First contributors in the history of leukemia

While the modern era of leukemia chemotherapy began recently, the recognition of leukemias has been mainly recorded in the second part of the nineteenth century. This brief historic review reports the first descriptions of the disease and the major advances in its history from its roots to the beginning of the twentieth century. Although most treatments for leukemia were ineffective until the middle of the twentieth century, it seemed of interest to review some pertinent exemples of the evolution in the knowledge of this disease (relied upon chronology as an organizing framework, while stressing the importance of themes), since our current knowledge about leukemia is still mainly based on the first accounts of scientific and medical discovery. Early in the nineteenth century, a small number of cases of patients with uncommon or peculiar alterations of the blood were published. Of the cases, four might suggest symptoms of chronic leukemia. The first published case was the detailed report prepared by John Hughes Bennett in the “Edinburgh Medical and Surgical Journal” October 1845. Leukemia gradually became accepted as a distinct disease and published case reports grew in number. Concomitantly, clinical and pathological description of the disease became more detailed.

PVSG and WHO vs European Clinical, Molecular and Pathological Criteria for prefibrotic myeloproliferative neoplasms

The Polycythemia Vera Study Group (PVSG), World Health Organization (WHO) and European Clinical, Molecular and Pathological (ECMP) classifications agree upon the diagnostic criteria for polycythemia vera (PV) and advanced primary myelofibrosis (MF). Essential thrombocythemia (ET) according to PVSG and 2007/2008 WHO criteria comprises three variants of JAK2^V617F mutated ET when the ECMP criteria are applied. These include normocellular ET, hypercellular ET with features of early PV (prodromal PV), and hypercellular ET due to megakaryocytic, granulocytic myeloproliferation (ET.MGM). Evolution of prodromal PV into overt PV is common. Development of MF is rare in normocellular ET (WHO-ET) but rather common in hypercellular ET.MGM. The JAK2^V617F mutation burden in heterozygous mutated normocellular ET and in heterozygous/homozygous or homozygous mutated PV and ET.MGM is of major prognostic significance. JAK2/MPL wild type ET associated with prefibrotic primary megakaryocytic and granulocytic myeloproliferation (PMGM) is characterized by densely clustered immature dysmorphic megakaryocytes with bulky (bulbous) hyperchromatic nuclei, which are never seen in JAK2^V617F mutated ET, and PV and also not in MPL⁵¹⁵ mutated normocellular ET (WHO-ET). JAK2^V617 mutation burden, spleen size, LDH, circulating CD34⁺ cells, and pre-treatment bone marrow histopathology are mandatory to stage the myeloproliferative neoplasms ET, PV, PMGM for proper prognosis assessment and therapeutic implications. MF itself is not a disease because reticulin fibrosis and reticulin/collagen fibrosis are secondary responses of activated polyclonal fibroblasts to cytokines released from the clonal myeloproliferative granulocytic and megakaryocytic progenitor cells in ET.MGM, PV and PMGM.

Management of adult Langerhans cell histiocytosis based on the characteristic clinical features

To find out the most appropriate management, clinical features of 18 cases of adult multisystem langerhans cell histiocytosis (LCH) have been analyzed. The patients comprising of 9 males and 9 females were median age of 36 years, ranging from 18-53 years at diagnosis. Regarding the initial symptoms, 7 patients (2 males and 5 females) showed central diabetes insipidus (CDI) and other endocrine symptoms with thickened pituitary stalk or a mass at the hypothalamic region. Additional 2 patients initiated the disease with CDI with no immediate diagnosis. In the remaining patients, the disease begun with single (n = 3) or multiple (n = 1) spinal bone lesion(s) in 4 patients (all males), with multiple bone lesions in 3 patients (1 male and 2 females), with single skull lesion in one female patient and with ambiguous symptoms including hypothyroidism in the remaining one male patient. We also recognized the correlation between pregnancy/childbirth and LCH in 4 patients. In terms of treatment, 9 patients received systemic immuno-chemotherapy alone, of which the majority received vinblastine-based chemotherapy while 4 received 2-chlorodeoxyadenosine. Five had a combination of immuno-chemotherapy with surgical resection or radiotherapy, 2 had immunotherapy alone, 2 had surgical resection followed by observation alone to date. Three patients received hematopoietic stem cell transplantation after extensive chemotherapy. In terms of outcome, 15 patients are alive (9 with active disease, 6 without active disease), with a median of 66 mo (range 17-166 mo), two died of disease while the remaining 1 lost to follow-up. Based on these results, we think that early diagnosis and rapid introduction of appropriate treatment are essential, in order to overcome the problems relevant to adult LCH.

Another look at the life of a neutrophil

Neutrophils are considered as the privates of the innate immune system. They are born in the bone marrow, migrate to the tissues where they kill putative intruders. After their job they are quickly removed from the battlefield by macrophages. This view of a predetermined pathway fitted nicely in their short lifespan of 5 h. However, recent studies indicated that their lifespan was in the order of several days. Recently, it became clear that neutrophils have functions beyond killing of pathogens. The reported half-life of 5 h is hardly compatible with those functions. Moreover, the organism actively invests in rescuing primed neutrophils from clearance by the body. It appears that their half-life is highly dependent on the method used to measure their life span. Here, we discuss the literature and show that neutrophils compartmentalize which could explain partially the differences reported for their lifespan. Moreover, the methodology to label neutrophils ex-vivo could have similar deteriorating effects on their lifespan as found for transfused red blood cells.

Contribution of new immunoglobulin-derived biomarkers in plasma cell dyscrasias and lymphoproliferative disorders

New assays for serum immunoglobulin (Ig) free and heavy chain quantification were developed for routine clinical practice. Serum free light chain (sFLC) assay was shown to improve detection, management and prognostication in all plasma cell dyscrasias. More precisely, sFLC measurements proved to be prognostic for the progression of monoclonal gammopathy of undetermined significance and smoldering multiple myeloma (MM), became markers of response and survival in amyloid light-chain amyloidosis and contributed to accurate follow-up of patients with light chain and non secretory MM. In addition, sFLC and they ratio (sFLCR) were shown useful for the prognosis and monitoring of intact Ig myeloma; their evaluation was incorporated in the new uniform response criteria. sFLC or sFLCR were also observed abnormal in B-cell non-Hodgkin lymphoma/chronic lymphocytic leukemia (CLL). Moreover, increased sFLC levels, summated sFLC or abnormal sFLCR predict shorter overall survival in early-stage CLL while increased sFLC constituted an independent, adverse prognostic factor for event-free and overall survival in diffuse large B-cell lymphoma and Waldenstrom’s macroglobulinemia. Clinical applications of heavy Ig chain separately (HLC) measurements are more recent and mainly concern MM in which HLC deriving ratios correlated with parameters of disease activity and constituted an adverse survival marker.

Aspirin responsive platelet thrombophilia in essential thrombocythemia and polycythemia vera

Essential thrombocythemia (ET) and polycythemia vera (PV) frequently present with erythromelalgia and acrocyanotic complications, migraine-like microvascular cerebral and ocular transient ischemic attacks (MIAs) and/or acute coronary disease. The spectrum of MIAs in ET range from poorly localized symptoms of transient unsteadiness, dysarthria and scintillating scotoma to focal symptoms of transient monocular blindness, transient mono- or hemiparesis or both. The attacks all have a sudden onset, occur sequentially rather than simultaneously, last for a few seconds to several minutes and are usually associated with a dull, pulsatile or migraine-like headache. Increased hematocrit and blood viscosity in PV patients aggravate the microvascular ischemic syndrome of thrombocythemia to major arterial and venous thrombotic complications. Phlebotomy to correct hematocrit to normal in PV significantly reduces major arterial and venous thrombotic complications, but fails to prevent the platelet-mediated erythromelalgia and MIAs. Complete long-term relief of the erythromelalgic microvascular disturbances, MIAs and major thrombosis in ET and PV patients can be obtained with low dose aspirin and platelet reduction to normal, but not with anticoagulation. Skin punch biopsies from the erythromelalgic area show fibromuscular intimal proliferation of arterioles complicated by occlusive platelet-rich thrombi leading to acrocyanotic ischemia. Symptomatic ET patients with erythromelalgic microvascular disturbances have shortened platelet survival, increased platelet activation markers β-thromboglobulin (β-TG), platelet factor 4 (PF4) and thrombomoduline (TM), increased urinary thromboxane B2 (TXB2) excretion, and no activation of the coagulation markers thrombin fragments F1+2 and fibrin degradation products. Inhibition of platelet cyclooxygenase (COX1) by aspirin is followed by the disappearance and no recurrence of microvascular disturbances, increase in platelet number, correction of the shortened platelet survival times to normal, and reduction of increased plasma levels of β-TG, PF4, TM and urinary TXB2 excretion to normal. These results indicate that platelet-mediated fibromuscular intimal proliferation and platelet-rich thrombi in the peripheral, cerebral and coronary end-arterial microvasculature are responsible for the erythromelalgic ischemic complications, MIAs and splanchnic vein thrombosis. Baseline platelet P-selectin levels and arachidonic acid induced COX1 mediated platelet activation showed a highly significant increase of platelet P-selectin expression (not seen in ADP and collagen stimulated platelets), which was significantly higher in JAK2^V617F mutated compared to JAK2 wild type ET.

Autologous lymphocytes infusion

The graft vs tumor effect produced by the infusion of allo-reactive lymphocytes is considered to be the main mechanism of action in the eradication of tumor cells only reported in allogeneic stem cell transplantation. We present a case of a lymphoma patient infused with his collected bystander lymphocytes from is stem cell autograft after failing to collect enough stem cells to proceed with autologous stem cells transplantation, resulting in tumor response with no treatment related toxicity. This case illustrates the concept of autologous lymphocyte infusion, suggesting the possibility of an autograft vs tumor effect, as an effort to parallel donor lymphocyte infusion in allogeneic stem cell transplantation to create a graft vs tumor effect by increasing donor lymphocytes in the patient.

Emerging immunological concepts in the pathogenesis of myelodysplastic syndromes

The involvement of T-lymphocytes in the pathogenesis of myelodysplastic syndromes (MDS) is now well documented by relevant clinical and experimental findings. This brief review will focus on the T-cell repertoire pattern typical of MDS patients as well as on the potential role exerted by specific T-cell subsets in this context. Future investigations should further explore the specific role played by different T-cell subsets in the bone marrow milieu typical of MDS, further clarifying which of the described changes represent either an epiphenomenon or rather a real causative factor in the pathogenesis of these disorders.

Circulating microparticles and microRNAs as players in atherosclerosis

Microparticles (MPs) are extracellular membrane vesicles released from normal, apoptotic and pathological cells following a process of detachment from cells of origin. MPs are typically defined by their size, exposure of phosphatidylserine, the expression of surface antigens, proteins and genetic material, originating from their donor cells, and as important vehicles of intercellular communication across numerous biological processes. MPs contain the major source of systemic RNA including microRNA (miRNA) of which aberrant expression appears to be associated with stage and progression of atherosclerosis. The involvement and influence of miRNA during the onset and progression of atherosclerotic disease have generated a lot of interest in assessing the feasibility of therapeutic regulation of miRNAs to manipulate them with a special focus on cardiovascular disease. We speculate on the future developments of MPs which contain miRNA as new therapeutic targets for proliferative vascular diseases such as atherosclerosis.

Bone marrow cell death and proliferation: Controlling mechanisms in normal and leukemic state

Bone marrow cell death and proliferation are regulated by multiple factors including genetic and epigenetic alterations of hematopoietic cells, crosstalk of hematopoietic cells with bone marrow mesenchymal cells through direct cell-cell interaction or cytokine/chemokine production, vascularity of the bone marrow, and interactions of sympathetic nerve system with hematopoiesis. Cell proliferation usually predominates over cell death in neoplastic processes such as leukemia and myeloproliferative neoplasms, while apoptotic processes also have a significant role in the pathogenesis of myelodysplastic syndromes. Recently, hematopoietic stem cells (HSCs) and leukemia stem cells (LSCs) have been identified and their characters on self renewal process, differentiation, cell dynamics and drug resistance have been implicated. Although most leukemia cells are initially sensitive to chemo- or radiotherapy, LSCs are resistant and considered to be the basis for disease relapse after initial response. HSCs and LSCs may use similar interactions with bone marrow microenvironment. However, bone marrow microenvironment called niche should influence the normal as well as malignant hematopoiesis in different manners. Recent studies have expanded the number of cell types constituting bone marrow niche and made the issue more complex. Since the majority of excellent and contributing studies on bone marrow niches have been performed in animal models, niches in human tissues are beginning to be localized and characterized. In this article, we summarize the relation of hematopoietic cells with niches and hope to point a hint to the novel strategy for treatment of malignant proliferation of hematopoietic cells.

Current viewpoints on platelet contribution to inflammation

Inflammation is an underlying feature of a variety of human diseases. Because inflammatory diseases are a major cause of morbidity and mortality in developed countries, understanding the interaction of the most important factors involved is an important challenge. Although platelets are widely recognized as having a critical role in primary hemostasis and thrombosis, basic and clinical evidence increasingly identifies these enucleated cells as relevant modulators, as both effector and target cells, of the inflammatory response. The cross-talk between platelets, endothelial cells and leukocytes in the inflammatory milieu mat be seen as a double-edged sword which functions not only as an effective first-line defense mechanism but may also lead to organ failure and death in the absence of counter-regulation systems. The molecular mechanisms involved in the reciprocal activation of platelets, endothelial cells and leukocytes are beginning to be elucidated. In the light of the existing data from experimental and clinical studies it is conceivable that platelet adhesion molecules and platelet mediators provide promising targets for novel therapeutic strategies in inflammatory diseases. The potentially adverse effects of these approaches need to be carefully addressed and monitored, including alterations in hemostasis and coagulation and particularly the impairment of host defense mechanisms, given the recently identified pivotal role of platelets in pathogen recognition and bacterial trapping. In this review we discuss the most important recent advances in research into the cross-talk between platelets and vascular cells during inflammation and the clinical consequences of these interactions.

Cost of allogeneic blood transfusion

Blood is a scarce and costly resource to society. Therefore, it is important to understand the costs associated with blood, blood components, and blood transfusions. Previous studies have attempted to account for the cost of blood but, because of different objectives, perspectives, and methodologies, they may have underestimated the true (direct and indirect) costs associated with transfusions. Recognizing these limitations, a panel of experts in blood banking and transfusion medicine gathered at the Cost of Blood Consensus Conference to identify a set of key elements associated with whole blood collection, transfusion processes, follow-up, and to establish a standard methodology in estimating costs. Activity-based costing (ABC), the proposed all-inclusive reference methodology, is expected to produce standard and generalizable estimates of the cost of blood transfusion, and it should prove useful to payers, buyers, and society (all of whom bear the cost of blood). In this article, we argue that the ABC approach should be adopted in future cost-of-transfusion studies. In particular, we address the supply and demand dilemma associated with blood and blood components; evaluate the economic impact of transfusion-related adverse outcomes on overall blood utilization; discuss hemovigilance as it contributes not to the expense, but also the safety of transfusion; review previous cost-of-transfusion studies; and summarize the ABC approach and its utility as a methodology for estimating transfusion costs.

MGUS: Proposal for outpatient management

The term monoclonal gammopathy of undetermined significance (MGUS) indicates the presence of a monoclonal protein (M-protein) without features of multiple myeloma, Waldenström’s macroglobulinemia, primary amyloidosis or malignant lymphoproliferative disorders (LPD). While several guidelines on the treatment of LPD exist, many doubts and perplexities still exist on who should treat a MGUS, when and how. Even where MGUS does not require any therapy, the risk of progression to a LPD is 1% per year. This risk does not diminish over time and persists even in patients (pts) whose condition has remained stable for decades, and a prolonged follow up is, therefore, recommended. We met primary care doctors to share and agree on criteria for the management of outpatients with MGUS. Our aim is to draw up guidelines or, at least, suggestions that may help to determine which MGUS pts could be cared for by the primary care doctor and which should be followed by the hematologist. We suggest that once a MGUS is diagnosed, the primary care physician will attend patients with M-protein < 15 g/L if IgG and pts with M-protein < 10 g/L if IgA or IgM, without end-organ damage and without signs and symptoms of LPD. However, a hematological evaluation is recommended for patients with M-protein IgG > 15 g/L, or M-protein IgA > 10 g/L, or IgM > 10 g/L, or any M-protein with end-organ damage (not attributable to any others causes) or with signs and symptoms of LPD, or rapidly increasing M-protein (> 5 g/L per year).

An exciting time to launch the World Journal of Hematology

This first issue of the World Journal of Hematology (WJH) marks the birth of a new member of the World Series Journal family and comes at one of the most exciting times in stem cell biology and translational medicine. The pace of discovery in the field of hematology has accelerated signeificantly in recent years, due to important scientific discoveries and new technologies for purification of hematopoietic stem cells and identification of specific stem cell biomarkers; whole genome sequencing using next-generation sequencing technology; and development of molecularly-targeted therapies, leading to the translation of highly promising science into advanced diagnosis and proven targeted therapies for hematopoietic disorders. The WJH is an open-access, peer-reviewed journal, which is officially published on June 6, 2012. The WJH Editorial Board consists of 102 experts in hematology from 26 countries. There is clearly a niche for this new journal, which provides access to all articles without boundaries to all internet users throughout the world. The WJH aims to provide rapid access to high impact publications in fundamental and clinical hematology, with multidisciplinary coverage, through an established system that is targeted at dissemination to the scientific community via online open-access.