SF3B1 Mutations Are Associated with Resistance to Non-Genotoxic MDM2 Inhibition in Chronic Lymphocytic Leukemia

Chronic lymphocytic leukemia (CLL) is a genetically and clinically heterogeneous malignancy affecting older individuals. There are a number of current treatment options for CLL, including monoclonal antibodies, targeted drugs, chemotherapy, and different combinations of these. However, for those patients who are intrinsically treatment resistant, or relapse following initial responses, novel targeted therapies are still needed. Targeting the mouse double-minute-2 human homolog (MDM2), a primary negative regulator of p53, is an appealing therapeutic strategy for non-genotoxic reactivation of p53, since the TP53 gene is in its wild-type state at diagnosis in approximately 90% of patients. Mutated SF3B1 and TP53 are both associated with more aggressive disease, resistance to therapies and poorer overall survival for CLL. In this study, we performed a screen for SF3B1 and TP53 mutations and tested RG7388 (idasanutlin), a second-generation MDM2 inhibitor, in a cohort of CLL primary patient samples. SF3B1 mutations were detected in 24 of 195 cases (12.3%) and found associated with poor overall survival (hazard ratio [HR] 2.12, p = 0.032) and high CD38 expression (median CD38 (%) 32 vs. 5; p = 0.0087). The novel striking finding of this study was an independent link between SF3B1 mutational status and poor response to RG7388. Overall, SF3B1 mutations in CLL patient samples were associated with resistance to treatment with RG7388 ex vivo, and patients with the wild type for both SF3B1 and TP53 are more likely to benefit from treatment with MDM2 inhibitors.

Non-genotoxic MDM2 inhibition selectively induces a pro-apoptotic p53 gene signature in chronic lymphocytic leukemia cells

Chronic lymphocytic leukemia (CLL) is a clinically heterogeneous hematologic malignancy. In approximately 90% of cases the TP53 gene is in its wildtype state at diagnosis of this malignancy. As mouse double-minute-2 homolog (MDM2) is a primary repressor of p53, targeting this protein is an attractive therapeutic approach for non-genotoxic reactivation of p53. Since the discovery of the first MDM2 inhibitor, Nutlin-3a, newer potent and bioavailable compounds have been developed. In this study we tested the second-generation MDM2 inhibitor, RG7388, in patient-derived CLL cells and normal cells, examining its effect on the induction of p53-transcriptional targets. RG7388 potently decreased viability in p53-functional CLL cells, whereas p53-non-functional samples were more resistant to the drug. RG7388 induced a pro-apoptotic gene expression signature with upregulation of p53-target genes involved in the intrinsic (PUMA, BAX) and extrinsic (TNFRSF10B, FAS) pathways of apoptosis, as well as MDM2. Only a slight induction of CDKN1A was observed and upregulation of pro-apoptotic genes dominated, indicating that CLL cells are primed for p53-dependent apoptosis. Consequently, RG7388 led to a concentration-dependent increase in caspase-3/7 activity and cleaved poly (ADP-ribose) polymerase. Importantly, we observed a preferential pro-apoptotic signature in CLL cells but not in normal blood and bone marrow cells, including CD34⁺ hematopoietic cells. These data support the further evaluation of MDM2 inhibitors as a novel additional treatment option for patients with p53-functional CLL.

A transfusion prescription template and other human factor interventions to improve balanced transfusion delivery in major haemorrhage due to trauma

OBJECTIVES

The aim of this study is to improve practice in the management of major haemorrhage, particularly in red cell to plasma transfusion ratios.

BACKGROUND

A review of the management of major haemorrhage in trauma in Newcastle Hospitals Trust in 2012-2013 showed good mortality outcomes but found that red cell : plasma transfusion ratios could be improved. Human factors techniques transferable from industry and the military were identified, and a package of interventions was implemented, including an intensive multidisciplinary team training programme and a new major haemorrhage prescription template.

METHODS/MATERIALS

We reviewed the management of all 243 adult trauma patients admitted with major haemorrhage to the Emergency Department in the Newcastle Hospitals Trust in the 4-year period from April 2012. We analysed clinical details, blood components transfused and patient outcomes and used Trauma Audit and Research Network data to correlate with injury severity and predicted survival.

RESULTS

Mean transfusion ratios of red cells to plasma improved from 1·5 : 1 and 1·6 : 1 in the first 2 years to 1·1 : 1 in the 2 years following implementation of the new measures. There was a statistically significant improvement in the delivery of a balanced transfusion, defined as a red cell : plasma ratio of <1·3 : 1 following the changes.

CONCLUSION

Simple changes to procedures, specifically implementation of a new major haemorrhage prescription template and multidisciplinary team training, have resulted in marked improvement in the ratio of red cells to plasma transfused to trauma patients with major haemorrhage or requiring emergency blood. The package of changes could be easily replicated in other health-care settings.

Age of platelet concentrates and time to the next transfusion

BACKGROUND

Storage time of platelet (PLT) concentrates has been negatively associated with clinical efficacy outcomes. The aim of this study was to quantify the association between storage time of PLT concentrates and interval to the next PLT transfusion for different types of PLT components, stored for up to 7 days and transfused to transfusion-dependent hematooncology patients with thrombocytopenia.

STUDY DESIGN AND METHODS

From a cohort of patients from 10 major Dutch hospitals, patients were selected whose transfusion patterns were compatible with PLT transfusion dependency due to hematooncologic disease. Mean time to the next transfusion and mean differences in time to the next transfusion for different storage time categories (i.e., fresh, <4 days; intermediate, 4-5 days; and old, >5 days) were estimated, per component type, using multilevel mixed-effects linear models.

RESULTS

Among a cohort of 29,761 patients who received 140,896 PLT transfusions we selected 4441 hematooncology patients who had received 12,724 PLT transfusions during periods of PLT transfusion dependency. Transfusion of fresh, compared to old, buffy coat-derived PLTs in plasma was associated with a delay to the next transfusion of 6.2 hours (95% confidence interval [CI], 4.5-8.0 hr). For buffy coat-derived PLTs in PAS-B and -C this difference was 7.7 hours (95% CI, 2.2-13.3 hr) and 3.9 hours (95% CI, -2.1 to 9.9 hr) while for apheresis PLTs in plasma it was only 1.8 hours (95% CI, -3.5 to 7.1 hr).

CONCLUSION

Our results indicate that the time to the next transfusion shortens with increasing age of transfused buffy coat-derived PLT concentrates. This association was not observed for apheresis PLTs.

PARP1 expression, activity and ex vivo sensitivity to the PARP inhibitor, talazoparib (BMN 673), in chronic lymphocytic leukaemia

In chronic lymphocytic leukemia (CLL), mutation and loss of p53 and ATM abrogate DNA damage signalling and predict poorer response and shorter survival. We hypothesised that poly (ADP-ribose) polymerase (PARP) activity, which is crucial for repair of DNA breaks induced by oxidative stress or chemotherapy, may be an additional predictive biomarker and a target for therapy with PARP inhibitors.

We measured PARP activity in 109 patient-derived CLL samples, which varied widely (192 – 190052 pmol PAR/10⁶ cells) compared to that seen in healthy volunteer lymphocytes (2451 – 7519 pmol PAR/10⁶ cells). PARP activity was associated with PARP1 protein expression and endogenous PAR levels. PARP activity was not associated with p53 or ATM loss, Binet stage, IGHV mutational status or survival, but correlated with Bcl-2 and Rel A (an NF-kB subunit). Levels of 8-hydroxy-2′-deoxyguanosine in DNA (a marker of oxidative damage) were not associated with PAR levels or PARP activity. The potent PARP inhibitor, talazoparib (BMN 673), inhibited CD40L-stimulated proliferation of CLL cells at nM concentrations, independently of Binet stage or p53/ATM function.

PARP activity is highly variable in CLL and correlates with stress-induced proteins. Proliferating CLL cells (including those with p53 or ATM loss) are highly sensitive to the PARP inhibitor talazoparib.

Familial pseudohyperkalemia in blood donors: a novel mutation with implications for transfusion practice

BACKGROUND

Familial pseudohyperkalemia (FP) is a dominantly inherited condition in which red blood cells (RBCs) have an increased cold-induced permeability to monovalent cations. Potassium leaks into the supernatant of all stored blood with time, but FP RBCs leak potassium more rapidly. We investigated two unrelated blood donors whose RBC donations demonstrated unexpectedly high potassium after 5 and 6 days' storage. We matched the observed pattern of RBC cation leak to a previously recognized family with FP (FP-Cardiff) and investigated the likely cause with targeted DNA analysis.

STUDY DESIGN AND METHODS

Cation leakage from the donor RBCs and from standard donor units was measured. DNA analysis of donors and family members with FP-Cardiff was performed. Allele frequencies were obtained from human variation databases.

RESULTS

Both implicated donors were found to have increased cold-induced potassium leak identical in pattern to affected members of the family with FP-Cardiff. We found a heterozygous substitution Arg723Gln in the ATP-binding cassette, Subfamily B, Member 6 protein that segregated with FP in the Cardiff family and was also present in both blood donors. Arg723Gln is listed in human variation databases with an allele frequency of approximately 1:1000.

CONCLUSIONS

We describe a novel FP mutation that may affect 1:500 European blood donors and causes rapid loss of potassium from stored RBCs. This finding has implications for neonates and infants receiving large-volume RBC transfusions. Genomic screening of donors could be used to identify donors with this mutation and potentially improve the quality and safety of donor units.

Female donors and transfusion-related acute lung injury: A case-referent study from the International TRALI Unisex Research Group

BACKGROUND

Although quantitative evidence is lacking, it is generally believed that the majority of cases of transfusion-related acute lung injury (TRALI) are caused by female blood donors. We aimed to examine the relation between female donors and the occurrence of TRALI.

STUDY DESIGN AND METHODS

We performed an international, multicenter case-referent study. TRALI patients who were diagnosed clinically, independent of serology or donor sex, and had received transfusions either only from male donors or only from female donors (unisex cases) were selected. The observed sex distribution among the donors of these TRALI patients was compared to the expected sex distribution, based on the relevant donor populations.

RESULTS

Eighty-three clinical TRALI cases were included; 67 cases received only red blood cells (RBCs), 13 only plasma-rich products, and three both. Among RBC recipients the relative risk (RR) of TRALI after a transfusion from a female donor was 1.2 (95% confidence interval [CI], 0.69-2.1) and among plasma-rich product recipients the RR was 19 (95% CI, 1.9-191). The p value for the difference between RBCs and plasma was 0.023.

CONCLUSION

Our data support the notion that plasma from female donors is associated with an increased risk of TRALI, while RBCs from female donors are not.

Strategies to reduce transfusion acquired vCJD

Variant Creutzfeldt-Jakob disease (vCJD) can be transmitted by transfusion. The risk depends on the number of infected donors in the community. An estimate of these numbers in a less genetically susceptible population, based on the epidemic seen so far, suggests a maximum of 300 more cases. From this, it is possible to predict a maximum of one transfusion acquired case in 3 years from plasma transfusion. Importation of plasma from outside the UK has been advocated to prevent these cases and would cost around £30 million per year. An alternative measure is to use the observed susceptibility and exposure to dietary vCJD by age, and to target low risk donors for the production of components such as fresh frozen plasma (FFP) and platelets. This will reduce the possible cases of plasma transfusion-acquired vCJD at little or no extra cost to the health service.

Transfusion-related lung injury

This paper describes the history and pathogenesis of TRALI and illustrates this with personal experience of the condition over 15 years at a single hospital. It discusses the contribution of transfusion to ALI seen in critically ill patients, and the effect of preventative measures taken in the UK.

Changing indications for red cell transfusion from 2000 to 2004 in the North of England

Falling donor numbers and the threat of transfusion-transmitted variant Creutzfeldt-Jakob disease may lead to shortages in the national blood supply. Knowledge of current patterns of transfusion and trends in usage will help predict future change in blood use. Our previous survey identified medical indications as the major reason for transfusion, but detailed information within this category was limited. We performed prospective surveys of indications for red cell transfusion for two 14-day periods in 2004 in the North of England, concentrating on medical reasons for transfusion. Data were obtained for transfusion indications of 9003 units, which accounted for over 99% of red cell issues from the regional blood centre during the study. In 2004, medical patients received 62% (5558 units) of all transfused units, surgical patients 33% (3001 units) and Obstetric & Gynaecology patients 5% (444 units). These figures compare with 52, 41 and 6% for Medicine, Surgery, and Obstetrics & Gynaecology in 1999/2000. The three largest uses of blood within the medical category were for patients with primary haematological disorders (18.2% of all transfused blood), for management of gastrointestinal haemorrhage (13.8%) and for patients with nonhaematological malignancies (8.8%). There has been a significant reduction in use of blood for surgical indications over the last 5 years, but an absolute increase in use of blood for medical indications. Lower transfusion triggers, education, use of cell salvage, the increasing price of a unit of red cells and changing population demographics may all have contributed to the reduction in surgical blood use. Promotion of good transfusion practice and alternatives to allogeneic transfusion should now focus on medical and surgical use of blood transfusion.

Recovery from post-operative anaemia

Acceptance of lower transfusion thresholds and shorter post-operative stays results in patients leaving hospital after surgery with lower haemoglobin (Hb) than previously. We undertook a prospective observational study to assess the haematological response to post-operative anaemia and to determine the utility of quality of life (QoL) measures in assessing the impact of anaemia on such patients. Thirty patients undergoing unilateral hip arthroplasty had blood samples taken and QoL questionnaires administered pre-operatively and at 7, 28 and 56 days post-operatively. Increased erythropoiesis was evident at day 7 post-operatively. Approximately two-thirds of the post-operative Hb deficit was corrected by day 28. There was evidence of functional iron deficiency in more than one-quarter of patients at day 56. QoL scores used did not show any relationship with Hb in the post-operative period. Red cell 2,3-diphosphoglycerate (2,3DPG) levels increased in proportion to the degree of post-operative anaemia. We concluded that substantial recovery of Hb occurs between day 7 and day 28 post-operatively. Complete recovery of Hb may be delayed beyond day 56 due to development of iron deficiency. Patients are at significant risk of developing post-operative iron deficiency depending on operative blood loss and pre-operative iron stores. Increased red cell 2,3DPG may offset the effect of anaemia on oxygen delivery. We found no evidence that anaemia produces a measurable effect on chosen QoL scores in the post-operative period.

Nitric oxide and blood: a review

Nitric oxide (NO) was identified as a physiological mediator of vascular tone in 1987. NO produced by endothelial cells causes vasodilatation and also inhibits platelet aggregation and leucocyte adhesion. Red cells metabolize NO to nitrate but may possibly carry and release, or even produce, NO in hypoxic conditions. NO physiology may have important implications for transfusion medicine, ranging from adverse effects of haemoglobin substitutes to preservation of stored platelets and to detrimental effects of stored red cells.

Long-term survival after blood transfusion: a population based study in the North of England

BACKGROUND

Blood transfusion may transmit infectious diseases with long incubation periods. Estimation of the risks of transmission of such disease requires know-ledge of long-term survival of transfused patients. No such information is available in the UK, where there is particular concern about possible transmission by trans-fusion of variant CJD.

STUDY DESIGN AND METHODS

Information on survival after transfusion and demographics was collected for all patients transfused during June 1994 in a population of 2.9 million served by a single blood center.

RESULTS

A total of 2899 patients were transfused with 10,760 units of RBCs (99% of RBCs issued during the study period). Follow-up to death or 5 years was completed for 98.2 percent, and 46.9 percent of all transfusion recipients were alive at 5 years; 41 percent of transfused RBC units and 36 percent of transfused FFP were given to patients who were alive at 5 years. Median age at transfusion was 67 years (mean, 60.9 years). Shorter patient survival was associated with increasing patient age, increasing numbers of RBC units transfused, trans-fusion of plasma or PLTs, and nonsurgical indications for transfusion.

CONCLUSIONS

Posttransfusion survival is lower than estimated in previous decades in other countries. This is probably due to a relative increase in use of transfusion for older patients and for medical indications. Our figures may be used to predict and stratify the risk of infections, such as variant CJD, amongst different groups of transfusion recipients.

Transfusion-related acute lung injury caused by two donors with anti-human leucocyte antigen class II antibodies: a look-back investigation

Transfusion-related acute lung injury (TRALI) is considered as one of the most important complications of blood transfusion. Previous look-back investigations have revealed unrecognized cases. We report two cases of TRALI in brief and the outcomes of transfusion in the recipients of previous components from the implicated donors. This look-back investigation was a retrospective case-note study assessing whether there were any untoward events associated with the previous transfusions. 18 patients were identified as having received a blood component transfusion from one of the two donors with anti-human leucocyte antigen (HLA) antibodies to antigens occurring frequently in the local population. One of the five patients receiving a unit of fresh frozen plasma had an evidence of TRALI, which was not diagnosed at the time. A second patient, who had been HLA typed and who carried a full match of antigens for the antibody specificities of the plasma received, had no evidence of a reaction. There were no documented reactions in 13 recipients of red cells in optimal additive (OA) solution. Cases of TRALI may go unrecognized. Not all patients with antibody/antigen concordance will develop clinical signs. Red cells in OA solution from donors with anti-HLA antibodies appear to have a low risk of causing clinically evident lung damage.

Single hospital experience of TRALI

BACKGROUND

TRALI is a serious adverse effect of blood transfusion. There is evidence that the condition is underrecognized and underreported.

STUDY DESIGN AND METHODS

This study was an observational study carried out in a single hospital.

RESULTS

Eleven cases of TRALI were recognized over 12 years. In 10 cases the implicated donor unit was FFP and in 1 case uncertain. All implicated donors were parous women. In 4 cases the presumed causative antibodies were to an HLA class II antigen only. Specific anti-neutrophil antibodies, possibly causative, were detected in 1 case only. Ten of the 11 cases required mechanical ventilatory support. Five persons died as a result of the TRALI. The observed incidence of TRALI caused by FFP is 1 in 7900 units transfused.

CONCLUSION

TRALI is the most common serious adverse effect of blood transfusion in our hospital. Antibodies to HLA class II antigens should be looked for routinely when investigating a possible case of TRALI.

'Tag and label' system for checking and recording of blood transfusions

Guidelines for checking and recording of blood transfusion mandate the use of a blood transfusion compatibility form. We have introduced and assessed a 'tag and label' system that does away with the compatibility form. A compatibility tag with a peel-off self-adhesive label is attached to the unit for transfusion. No compatibility form is issued to the site of the transfusion. The peel-off label is signed and fixed in patient notes at the time of transfusion. We have found the system easier to use and to be preferred by nursing staff administering transfusions. During 2 years, we have transfused over 100,000 blood components, including 70,000 units of red cells, and have not recognized any episode during which the wrong blood was transfused to a patient. Recording in the patient notes of units transfused has significantly improved compared with local and national figures in a previous survey. We conclude that it is possible to dispense with the compatibility form without compromising the safety of the transfusion process.

Management of transfusion-related acute lung injury with extracorporeal cardiopulmonary support in a four-year-old child

We report a case of successful management of transfusion-related acute lung injury (TRALI) with prolonged cardiopulmonary bypass support in a 4-yr-old patient undergoing elective cardiac surgery. TRALI was diagnosed clinically and immunologically by detection of reactive antibodies in a unit of fresh frozen plasma that had been administered to the patient. The aetiology and management of TRALI are briefly discussed and possible implications of this case for the management of TRALI are highlighted.

Where does blood go? Prospective observational study of red cell transfusion in north England

OBJECTIVE

To collect population based information on transfusion of red blood cells.

DESIGN

Prospective observational study over 28 days.

SETTING

Hospital blood banks in the north of England (population 2.9 million).

MAIN OUTCOME MEASURES

Indications for transfusion, number of units given, and the age and sex of transfusion recipients.

PARTICIPANTS

All patients who received a red cell transfusion during the study period. Data completed by hospital blood bank staff.

RESULTS

The destination of 9848 units was recorded (97% of expected blood use). In total 9774 units were transfused: 5047 (51.6%) units were given to medical patients, 3982 (40.7%) to surgical patients, and 612 (6.3%) to obstetric and gynaecology patients. Nearly half (49.3%) of all blood is given to female recipients, and the mean age of recipients of individual units was 62.7 years. The most common surgical indications for transfusion were total hip replacement (4.6% of all blood transfused) and coronary artery bypass grafting (4.1%). Haematological disorders accounted for 15.5% of use. Overall use was 4274 units per 100 000 population per year.

CONCLUSION

In the north east of England more than half of red cell units are transfused for medical indications. Demand for red cell transfusion increases with age. With anticipated changes in the age structure of the population the demand for blood will increase by 4.9% by 2008.

Transfusion-related alloimmune neutropenia: an undescribed complication of blood transfusion

Alloimmune neutropenia in neonates is rare. We describe severe and persistent neutropenia in a 4-week-old neonate, which arose within 2 h of a transfusion of blood that contained about 28 mL of plasma and in which strong antibodies against human neutrophil antigen 1b (HNA-1b) were subsequently identified. The infant was positive for HNA-1b. No other likely cause of neutropenia was discovered. We believe this complication of blood transfusion to be a previously unrecognised one, and have called the condition transfusion-related alloimmune neutropenia (TRAIN).

Effect of WBC reduction of transfused RBCs on postoperative infection rates in cardiac surgery

BACKGROUND

WBC-replete blood transfusion has been suggested as an independent cause of increased postoperative infection.

STUDY DESIGN AND METHODS

A total of 597 patients undergoing elective coronary artery or heart valve surgery were randomly assigned to receive plasma-reduced (PR), buffy coat-depleted (BCD), or WBC-filtered (WCF) RBCs in the event of requiring blood transfusion. Details of postoperative course were recorded. Further information was collected from the patient's general practitioner 3 months after discharge.

RESULTS

No significant difference in inpatient infection rates was observed among patients randomly assigned to receive PR, BCD, or WCF RBCs. When only those receiving transfusion were analyzed (n = 509), use of PR RBCs was associated with more events coded as infections (p < or = 0.05) compared with BCD or WCF RBCs. However, when events coded as urinary tract infections were excluded, there was no significant difference among the three groups. Follow-up performed after discharge showed no difference in readmission rates, but a higher reported rate of infection in those randomly assigned to receive WCF RBCs (p < 0.02).

CONCLUSION

No evidence has been found, analyzed by intention to treat, that use of WBC-reduced, BCD, or WCF RBCs reduces postoperative inpatient infection in patients undergoing cardiac bypass surgery.

The incidence of anti-Wra and Wra antigen in blood donors and hospital patients

A retrospective study of positive 37 degrees C indirect antiglobulin test (IAT) for compatibility following negative antibody screens in a hospital laboratory revealed an unexpectedly high incidence of Wra-incompatible units. Over the course of 1 month 1112 routine patients' samples containing no other atypical antibodies were tested for the presence of anti-Wra. Anti-Wra was found in 88 patients, an incidence of 7.9%. Testing of 5098 healthy blood donor samples found 54 donors positive for anti-Wra, an incidence of 1.06%. A survey of 5253 healthy blood donor samples for Wra antigen found only two Wra-positive samples, suggesting an incidence between 1 in 1000 and < 1 in 10,000. The significance of this finding is discussed in relation to the continuing use of an IAT compatibility test.

Comparison of plasma and serum for antibody detection using DiaMed microtubes

Atypical antibody detection in DiaMed microtubes using a low-ionic-strength saline (LISS) indirect antiglobulin technique (IAT) was assessed using both serum and plasma. During the first period of the study all atypical antibodies originally detected in serum were also detected in EDTA plasma with comparable reaction strengths. Two of 73 antibodies were not detected in citrated plasma. During the second period of the study all routine antibody screens were performed in both serum and EDTA plasma. More clinically significant antibodies were detected in EDTA plasma than in serum. More false positives and non-specific antibodies were also detected in EDTA plasma. It is concluded that EDTA plasma is a suitable medium for antibody detection using LISS IAT in DiaMed gel microtubes.

Automated blood grouping by gel technology

The ID-Sampler II, an automated liquid handling system, is designed specifically for use with current gel technology. It was found to be reliable, easy to use and fully alarmed, making it a 'walk-away' instrument. Over a three-month period samples for ABO/Rh(D) grouping, antibody screening and compatibility testing were tested in parallel with our routine microtitre plate and gel techniques. No ABO/Rh(D) errors occurred on the automated system and antibody screening results were comparable to our routine methods.

Pericardial extramedullary haemopoiesis in chronic myelomonocytic leukaemia

Chronic myelomonocytic leukaemia (CMML) is a myelodysplastic syndrome with a diverse clinical spectrum. A case of a 60 year old man with CMML who developed cardiac tamponade is reported. Cytological examination of the pericardial effusion fluid showed extramedullary haemopoiesis. Serous effusions are well recognised in association with this disease, but this seems to be the first reported case of extramedullary haemopoiesis resulting in a pericardial effusion in a patient with CMML.

Acute lymphoblastic leukemia of Burkitt type (L3) with a (14;18) and an atypical (8;22) translocation

A 67-year-old man had night sweats, tumor lysis syndrome, and typical histologic and immunophenotypic features of Burkitt-type acute lymphoblastic leukemia (ALL). Cytogenetic analysis showed a previously unreported karyotype, a combination of a (14;18) and an atypical (8;22) translocation.

Routine histological compared with immunohistological examination of bone marrow trephine biopsy specimens in disseminated neuroblastoma

The ability to detect infiltration in bone marrow biopsy specimens from patients with disseminated neuroblastoma was assessed by immunohistological and routine histological methods. Frozen cores from 33 staging procedures were tested with UJ13A and UJ127.11. Immunopositive tumour cells were found in 10 of 17 staging procedures in which tumour was detectable by routine histological methods. Positive cells or stromal material were also found in eight of 12 staging procedures in which distorted architecture and fibrosis, but no obvious tumour, had been noted. Paraffin wax embedded cores from 29 of the same staging procedures were tested with antibodies against neurone specific enolase and neurofilament. Only a single core reacted with anti-neurofilament antibody. Neurone specific enolase positive cells or stromal material were found in nine of 15 staging procedures in which obvious tumour was detectable. Although these immunohistochemical techniques proved inferior to routine histology in their ability to detect obvious tumour, the demonstration of immunopositive stromal tissue which was not frankly malignant supports the view that distorted, fibrotic marrow may reflect persistence of neuroectodermal tissue and justifies its distinction from normal marrow when reporting the response to treatment.

Bone marrow fibrosis in childhood acute lymphoblastic leukaemia

Bone marrow trephine biopsy specimens were obtained at diagnosis from 63 of 76 consecutively presenting children with acute lymphoblastic leukaemia (ALL). The association between marrow fibrosis and presenting features, including immunophenotype, was analysed. Reticulin was increased in 45 of 56 cases in which blasts expressed B lineage markers, but in only one of seven with T-ALL. A weak association was also found between marrow fibrosis and splenomegaly in those with common ALL. Marrow fibrosis is apparently associated with some examples of ALL of B cell lineage, but precisely which subtypes and whether the phenomenon is clinically important remain to be determined.

Haemolytic anaemia associated with splenic haemangiomata

We describe a 33 year old woman who developed unexplained haemolytic anaemia following renal transplantation and who was found to have multiple splenic haemangiomata. This case demonstrates that splenic haemangiomata may be a cause of haemolytic anaemia in the absence of abnormalities in coagulation.

Acute myeloid leukaemia developing in a patient with longstanding untreated chronic lymphocytic leukaemia

A patient with chronic lymphocytic leukaemia untreated for 5 years subsequently developed acute myeloid leukaemia. It is suggested that reduced immunocompetence is the likely mechanism in this case and may also be a contributory factor in those cases which have been ascribed to the use of alkylating agents or radiation.