Abnormal B-lymphoblasts in myelodysplastic syndromes and myeloproliferative neoplasms other than chronic myeloid leukemia

BACKGROUND

Lineage infidelity is characteristic of mixed phenotype acute leukemia and is also seen in blast phase of chronic myeloid leukemia (CML), myeloid/lymphoid neoplasia with eosinophilia and gene rearrangements, and subtypes of acute myeloid leukemia. Driver genetic events often occur in multipotent progenitor cells in myeloid neoplasms, suggesting that multilineage output may be more common than appreciated. This phenomenon is not well studied in myelodysplastic syndrome (MDS) and non-CML myeloproliferative neoplasms (MPN).

METHODS

We systematically evaluated phenotypic lineage infidelity by reviewing bone marrow pathology and flow cytometry (FC) studies of 1262 consecutive patients with a diagnosis of MDS and/or non-CML MPN. We assessed B- and T-cells in these patients by FC. When abnormal B-lymphoblast (ABLB) populations were detected, we additionally evaluated immature B-cells using a high sensitivity FC assay for B-lymphoblastic leukemia/lymphoma (B-ALL).

RESULTS

We identified 9 patients (7 MDS, 7/713, 1%; 2 non-CML MPN, 2/312, 0.6%; 0 in MDS/MPN) with low-level ABLB populations (0.012%-3.6% of WBCs in marrow) with abnormal immunophenotypes. Genetic studies on flow sorted cell populations confirmed that some ABLB populations were clonally related to myeloid blasts (4/6, 67%). On follow-up, ABLB populations in 8/9 patients remained stable or disappeared. Only 1 case progressed to B-ALL.

CONCLUSIONS

These findings demonstrate that phenotypically detectable abnormal immature B lineage output occurs in MDS and non-CML MPN, albeit rarely. While presence of ABLB does not necessarily reflect blast crisis, the underlying disease biology of our findings may ultimately be relevant to patient management and warrants further investigation.

Coping with glioblastoma: prognostic communication and prognostic understanding among patients with recurrent glioblastoma, caregivers, and oncologists

PURPOSE

Glioblastoma (GBM) is a devastating neuro-oncologic disease with invariably poor prognosis. Despite this, research shows patients have unrealistic perceptions of their prognosis, which may relate in part to communication patterns between patients, caregivers and oncologists. The purpose of this study was to examine communication processes and goals among patients, caregivers, and oncologists to elucidate drivers of prognostic understanding (PU) in the context of recurrent GBM.

METHODS

This was a prospective, multi-center study enrolling adult patients with GBM, caregivers, and oncologists, who independently reported the content of a specific discussion involving the disclosure of GBM recurrence. Communication processes and goals were characterized for each participant, and concordance between all dyads and patient-caregiver-oncologist triads were calculated.

RESULTS

Seventeen patient, caregiver, and oncologist triads were analyzed. At the individual level, three (17.6%) patients and 8 (47.1%) caregivers reported having discussed prognosis during the clinical encounter, as compared to ten oncologists (58.8%). Seven patients (41.2%) and 5 caregivers (29.4%), versus thirteen oncologists (76.5%) reported ever discussing prognosis or life expectancy at previous appointments. Generally, patient-caregiver concordance (i.e., both answered the same) regarding communication goals and processes was low. Triads showed limited concordant responses in discussing curability (n = 5), prognosis (n = 4), end-of-life treatment goals (n = 4), and ever discussing prognosis (n = 3).

CONCLUSION

Patients, caregivers and oncologists had discordant views regarding communication processes and prognostic goals, even when recalling a single discussion. This study highlights the importance of clear and frequent communication about prognosis, and the need for further research on communication and PU in the neuro-oncology setting.

PD-1 improves accurate detection of Sezary cells by flow cytometry in peripheral blood in mycosis fungoides/Sezary syndrome

BACKGROUND

Accurate Sezary cell detection in peripheral blood of mycosis fungoides/Sezary syndrome (MF/SS) patients by flow cytometry can be difficult due to overlapping immunophenotypes with normal T cells using standard markers. We assessed the utility of programmed death-1 (PD-1/CD279), a transmembrane protein expressed in some hematopoietic cells, for identification and quantitation of circulating Sezary cells among established markers using flow cytometry.

METHODS

50 MF/SS and 20 control blood samples were immunophenotyped by flow cytometry. Principal component analysis (PCA) assessed contributions of antigens to separation of abnormal from normal T cell populations. PD-1 was assessed over time in blood and bone marrow of available MF/SS cases.

RESULTS

Normal CD4+ T cells showed dim/intermediate to absent PD-1 expression. PD-1 in Sezary cells was informatively brighter (≥1/3 log) than internal normal CD4+ T cells in 39/50 (78%) cases. By PCA, PD-1 ranked 3rd behind CD7 and CD26 in population separation as a whole; it ranked in the top 3 markers in 32/50 (64%) cases and 1st in 4/50 (8%) cases when individual abnormal populations were compared to total normal CD4+ T cells. PD-1 clearly separated Sezary from normal CD4+ T cells in 15/26 (58%, 30% of total) cases with few and subtle alterations of pan-T cell antigens/CD26 and was critical in 6 (12% of total), without which identification and quantification were significantly affected or nearly impossible. PD-1 remained informative in blood/bone marrow over time in most patients.

CONCLUSIONS

PD-1 significantly contributes to accurate flow cytometric Sezary cell assessment in a routine Sezary panel.

Role of Flow Cytometric Immunophenotyping for Classic Hodgkin Lymphoma in Small Biopsy and Cytology Specimens

CONTEXT.—

The diagnosis of classic Hodgkin lymphoma (CHL) traditionally requires surgical tissue biopsy because of the paucity of diagnostic Hodgkin and Reed-Sternberg cells. Diagnosis can be challenging in small core needle and cytologic biopsies, which are increasingly used because of reduced costs and minimal invasiveness. Flow cytometric (FC) identification of Hodgkin and Reed-Sternberg cells is possible, but FC test efficacy is not well studied outside of validation settings, especially in small specimens.

OBJECTIVE.—

To assess the testing efficacy of FC performed on small biopsy and cytology specimens for the diagnosis of CHL.

DESIGN.—

We reviewed 131 patients with CHL and 459 patients without CHL during a 3-year period who underwent a small biopsy procedure, including core biopsy and/or cytology evaluation, with concurrent routine clinical FC testing for CHL, assessing performance of FC in small specimens.

RESULTS.—

Evaluating testing efficacy, sensitivity was 95.4% and specificity was 98.2%, whereas positive and negative predictive values were 92.2% and 99.0%, respectively. Although there were more false-positive results than compared with published validation studies, expert review identified distinct diagnostic pitfalls; awareness of these may improve testing efficacy.

CONCLUSIONS.—

Although FC diagnosis of CHL was historically considered unfeasible, our findings in a real-world clinical setting suggest that FC adds diagnostic value to small biopsy evaluation, reducing time to treatment, costs, and invasive excisional procedures.

Genetic Basis of Extramedullary Plasmablastic Transformation of Multiple Myeloma

In patients with multiple myeloma, plasmablastic transformation in the bone marrow is rare and associated with poor outcomes. The significance of discordant extramedullary plasmablastic transformation in patients with small, mature clonal plasma cells in the bone marrow has not been well studied. Here, we report the clinicopathologic, cytogenetic, and molecular features of 10 such patients (male/female: 6/4, median age: 65 y, range: 48 to 76 y) with an established diagnosis of multiple myeloma in the bone marrow composed of small, mature plasma cells in parallel with a concurrent or subsequent extramedullary plasmablastic transformation. Eight patients with available survival data showed an overall aggressive clinical course with a median survival of 4.5 months after the diagnosis of extramedullary plasmablastic transformation, despite aggressive treatment and even in patients with low-level bone marrow involvement. Pathologically, the extramedullary plasmablastic myeloma were clonally related to the corresponding bone marrow plasma cells, showed high levels of CMYC and/or P53 expression with a high Ki-67 proliferation index by immunohistochemistry and harbored more complex genomic aberrations including frequent mutations in the RAS pathway and MYC rearrangements compared with their bone marrow counterparts. In summary, although genetic and immunohistochemical studies were not uniformly performed on all cases due to the retrospective nature of this study, our data suggest that discordant extramedullary plasmablastic transformation of multiple myeloma has an aggressive clinical course and is characterized by frequent mutations in the RAS pathway and more complex genomic abnormalities.

Abstract 4248: Multispectral immunofluorescence identifies pS6 as a biomarker of intrinsic resistance to ruxolitinib in patients with relapsed/refractory T-cell lymphomas

Introduction: Peripheral and cutaneous T cell lymphomas (TCL) are highly heterogeneous diseases that in the relapsed/refractory (R/R) stage have poor outcome. JAK/STAT, Pi3K/AKT and MAP kinase signaling are commonly involved in the pathogenesis of these lymphomas, and the efficacy of small molecule inhibitors targeting these pathways is being assessed in phase II trials. However, biomarkers to define patients most likely to benefit from specific inhibitors are lacking and mechanisms of acquired resistance in TCLs have not been reported.

Methods: We are conducting two early phase trials in R/R TCL: 1) NCT02974647 targets JAK1/JAK2 with ruxolitinib (RUX, a JAK 1-2 inhibitor) and has enrolled 53 patients and 2) NCT02783625 targets Pi3K/AKT with duvelisib (DUV, a Pi3K gamma-delta inhibitor) in combination with either romidepsin or bortezomib and has enrolled 92 patients. We analyzed pre-, on and post- treatment biopsies with multiplex immunofluorescence (mIF) using the Vectra platform, and analyzed images for marker expression and cellular location using HALO software. We designed multiple mIF panels with 6 markers per slide, 3 identifying TCL cells based on disease-specific phenotypes (e.g. CD4+PD1+CD8- for angioimmunoblastic TCL), pSTAT3,5, pS6, and a macrophage marker (CD68). Areas of TCL involvement within biopsy slides were manually defined during image analysis based on mIF and comparison to clinical immunohistochemistry. Differences in marker expressions were analyzed with the Wilcoxon test using the program R. Results: We analyzed 53 biopsies from 39 patients with high-quality mIF images, of which 17 were from lymph nodes and 36 were from extranodal sites. Of 39 patients, 13 were treated with RUX (9 biopsies pre-, 7 on, 4 post- treatment) and 26 with DUV (20 biopsies pre-, 6 on, 10 post- treatment). Median number of total TCL cells in pre-treatment biopsies was 1041 (range, 97-6463) and median TCL cell fraction within involved areas was 27.86% (range, 5.12-88.02%). Median macrophage fraction within involved areas was 5.92% (range, 2.89-11.88%). For either agent, response to treatment was not associated with: 1) quantity of macrophages (p=0.1 for responders vs non-responders to DUV, p=0.53 for RUX), 2) average distance between TCL cells and closest macrophage, 3) TCL cell fraction within involved areas, or 4) fraction of TCL cells expressing pSTAT3/5 (Figure). In contrast, pS6 expression in <25% of TCL cells within pre-treatment biopsy completely distinguished responders from non-responders (Figure; p=0.02). Neither agent induced consistent changes in expression of pSTAT3/5 or pS6 at the on or post-treatment timepoints.

Conclusions: mIF is a feasible platform for biomarker discovery and translation in TCL, a set of lymphomas with heterogeneous immunophenotypes. pS6 expression in <25% of TCL cells may predict response to ruxolitinib, suggesting that activation of S6 kinase downstream of PI3K or MAP kinase, may overcome dependence on JAK/STAT signaling. This is also the first data suggesting that ruxolitinib responses involve a TCL cell-intrinsic mechanism of action. Based on these data, we are assessing the use of pS6 IHC as a clinically-validated biomarker in patients with TCL prior to ruxolitinib.

Citation Format: Paola Ghione, Alison Moskowitz, Priadarshini Kumar, Andrea Knezevic, Venkatraman Seshan, Eric Jacobsen, Jia Ruan, Johnathan Schatz, Sarah Noor, Patricia Myskowski, Helen Hancock, Theresa Davey, Obadi Obadi, Carlissa Onwasigwe, Nivetha Ganesan, Lauren Pomerantz, Christine Jarjies, Allison Sigler, Mark Geyer, Ariela Noy, David Straus, Natasha Galasso, Giorgio Inghirami, Steven Horwitz, David Weinstock, Travis Hollmann, Ahmet Dogan. Multispectral immunofluorescence identifies pS6 as a biomarker of intrinsic resistance to ruxolitinib in patients with relapsed/refractory T-cell lymphomas [abstract]. In: Proceedings of the Annual Meeting of the American Association for Cancer Research 2020; 2020 Apr 27-28 and Jun 22-24. Philadelphia (PA): AACR; Cancer Res 2020;80(16 Suppl):Abstract nr 4248.

Genetic basis for iMCD-TAFRO

TAFRO syndrome, a clinical subtype of idiopathic multicentric Castleman disease (iMCD), consists of a constellation of symptoms/signs including thrombocytopenia, anasarca, fever, reticulin fibrosis/renal dysfunction, and organomegaly. The etiology of iMCD-TAFRO and the basis for cytokine hypersecretion commonly seen in iMCD-TAFRO patients has not been elucidated. Here, we identified a somatic MEK2P128L mutation and a germline RUNX1G60C mutation in two patients with iMCD-TAFRO, respectively. The MEK2P128L mutation, which has been identified previously in solid tumor and histiocytosis patients, caused hyperactivated MAP kinase signaling, conferred IL-3 hypersensitivity and sensitized the cells to various MEK inhibitors. The RUNX1G60C mutation abolished the transcriptional activity of wild-type RUNX1 and functioned as a dominant negative form of RUNX1, resulting in enhanced self-renewal activity in hematopoietic stem/progenitor cells. Interestingly, ERK was heavily activated in both patients, highlighting a potential role for activation of MAPK signaling in iMCD-TAFRO pathogenesis and a rationale for exploring inhibition of the MAPK pathway as a therapy for iMCD-TAFRO. Moreover, these data suggest that iMCD-TAFRO might share pathogenetic features with clonal inflammatory disorders bearing MEK and RUNX1 mutations such as histiocytoses and myeloid neoplasms.

An essential role for vesicular glutamate transporter 1 (VGLUT1) in postnatal development and control of quantal size

Quantal neurotransmitter release at excitatory synapses depends on glutamate import into synaptic vesicles by vesicular glutamate transporters (VGLUTs). Of the three known transporters, VGLUT1 and VGLUT2 are expressed prominently in the adult brain, but during the first two weeks of postnatal development, VGLUT2 expression predominates. Targeted deletion of VGLUT1 in mice causes lethality in the third postnatal week. Glutamatergic neurotransmission is drastically reduced in neurons from VGLUT1-deficient mice, with a specific reduction in quantal size. The remaining activity correlates with the expression of VGLUT2. This reduction in glutamatergic neurotransmission can be rescued and enhanced with overexpression of VGLUT1. These results show that the expression level of VGLUTs determines the amount of glutamate that is loaded into vesicles and released and thereby regulates the efficacy of neurotransmission.

Permeation of tetracyclines through membranes of liposomes and Escherichia coli

Uptake of tetracycline (tc), 2-tetracyclinonitrile (CN-tc), and 9-(N, N-dimethylglycylamido)-6-demethyl-6-deoxytetracycline (DMG-DMDOT) by liposomes containing Tet repressor (TetR) and by Escherichia coli cells overexpressing TetR was examined. TetR specifically binds to tetracyclines, enhances their fluorescence and thereby allows selective detection of tetracyclines that have crossed the membranes. Analysis of the diffusion of tc and DMG-DMDOT into liposomes yielded permeation coefficients of (2.4 +/- 0.6) x 10-9 cm.s-1 and (3.3 +/- 0.8) x 10-9 cm.s-1, respectively. Similar coefficients were obtained for uptake of these tetracyclines by E. coli, indicating that diffusion through the cytoplasmic membrane is the rate-limiting step. The permeation coefficients translate into half-equilibration times of approximately 35 +/- 15 min and explain how efflux pumps can mediate resistance against tetracyclines. Furthermore, diffusion of CN-tc into liposomes was at least 400-fold slower than that of tc, indicating that the carboxamide group at position C2 is required for efficient permeation of tc through lipid membranes and thereby explaining the lack of antibiotic activity of CN-tc.

Nasal deformity and microform cleft lip in parents of patients with cleft lip

OBJECTIVE

To describe subtle nasal deformities and microform cleft lips in parents whose children have complete cleft lip deformities.

DESIGN

Clinical analyses of three parents whose children had complete cleft lips. Subtle nasal deformities and microform cleft lips were identified.

SETTING

An institutional general hospital: Manuel Gea González Cleft Lip and Palate Clinic in Mexico City, Mexico.

PATIENTS

The study first examined the parents of all complete and incomplete cleft lip-palate patients who were seen from March 1994 to February 1997 by the authors (n = 1000). We identified three patients, each of whom had one parent who showed signs of subtle nasal deformity and microform cleft lip.

INTERVENTIONS

None for the parents. Interventions in the children with cleft lips and palates were known.

MAIN OUTCOME MEASURES

Qualitative photographic analyses were performed. Nostril symmetry, septal deviation, nasal floor position, and orbicularis oris malinsertions were carefully examined.

RESULTS

Three of the evaluated parents had one alar cartilage caudally displaced and a deviated septum. One parent's nasal floor was depressed. Two parents also had evidence of a minimal orbicularis oris muscle fissure located in the upper lip.

CONCLUSION

Genetic evaluations of children with complete and incomplete cleft lips might also include thorough evaluation of their parents. Although small in size, this study of three case histories identified nasal and lip deformities in the patients' parents.

Maxillary growth in children after early facial bipartition

Facial osteotomies performed in young children are frequently associated with growth deficiencies, especially at the middle third of the face. This problem may be more severe when the initial deformity is associated with alveolar and palatal clefts. Orbital hypertelorism is a major congenital malformation requiring early correction. The resection of the ethmoid tissues located between the orbit and the medialization of the orbital skeleton through the intracranial approach modifies the exaggerated interorbital distance but does not correct the vertical shortness at the midline of the face. Also this procedure interferes with the sagittal growth of the maxilla possibly resulting from the horizontal osteotomy across the maxillae. The medial rotation of the two halves of the face performed by the intracranial approach or the subcranial approach simultaneously corrects the orbital hypertelorism and elongates the nose and the central segment of the face. Our experience with this procedure in infants and young children is analyzed. A series of nine patients with orbital hypertelorism associated with median and paramedian clefts underwent correction by hemifacial rotation. All patients were monitored from 6 to 10 years (mean, 7 years) and demonstrated normal sagittal growth of the maxillae.

Endurance exercise in the presence of heart disease

Although patients with heart disease have successfully completed marathon runs, the immediate cardiac effects of similar and greater distance endurance exercise competition are unknown. Two such cases are presented, demonstrating that vigorous exercise and extreme levels of fitness are not precluded in the cardiac patient.

Unilateral hyperlucent lung (Swyer-James syndrome) after severe Mycoplasma pneumoniae infection

An 11-year-old girl contracted pneumonia with consolidation of the left lower lobe, infiltrates in the lingula and left upper lobe, and a large left pleural effusion, accompanied by a Mycoplasma complement-fixation titer increasing to 1:16,384. Serial chest radiographs demonstrated resolution of the pneumonia and effusion, followed by development of a hyperlucent left lower lobe. This diagnosis was supported by abnormalities discovered by chest cinefluoroscopic examination and lung scans of ventilation and perfusion. Unilateral hyperlucent lung should be considered as a possible sequel to severe Mycoplasma pulmonary infection.

Changing erythrocyte populations in juvenile chronic myelocytic leukemia: evidence for disordered regulation

Fetal and adult erythrocyte characteristics were studied serially in a 30-mo-old female with juvenile chronic myelocytic leukemia. On presentation the erythrocytes exhibited predominantly fetal characteristics as indicated by 69% hemoglobin F (HbF), 1.1% hemoglobin A2 (HbA2), absent I antigen, and fetal levels of the erythrocyte enzymes, carbonic anhydrase I and II, glucose-6-phosphate dehydrogenase, hexokinase, pyruvate kinase, and lactate dehydrogenase; 100% of the erythrocytes present contained HbF. However, Orskov-Jacobs-Stewart hemolysis demonstrated that at least one adult characteristic was present. Seven months later HbF was 17%; I antigen and carbonic anhydrase I had increased to adult levels. The number of cells containing HbF had decreased to 30%. Further studies indicated that at least three new populations of red cells were present after 7 mo which had not previously been detected. Two of these populations exhibited a mixture of both fetal and adult characteristics. Such findings suggested that an ongoing disturbance of regulatory mechanisms was responsible for the variable expression of fetal versus adult erythrocyte characteristics.