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Ishiguro K, Sasaki Y, Takagi Y, Niinuma T, Suzuki H, Tokino T, Hayashi T, Takahashi T, Igarashi T, Matsuno Y. Aggressive variant of splenic marginal zone lymphoma characterized using a cancer panel test and treated with rituximab-containing chemotherapy: A case report. Medicine (Baltimore) 2020; 99:e21938. [PMID: 32871937 PMCID: PMC7458248 DOI: 10.1097/md.0000000000021938] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
RATIONALE Aggressive variant of splenic marginal zone lymphoma (AV-SMZL) is a very rare disease that is often associated with TP53 mutations and has a poor prognosis. On the other hand, recent advances in genome sequencing techniques enable us to understand the molecular characteristics of rare cancers such as AV-SMZL. Here we present a case of AV-SMZL analyzed using a genetic test. PATIENT CONCERNS A 66-year-old woman was admitted with splenomegaly and lymphocytosis. Computed tomography revealed marked splenomegaly without lymphadenopathy in any other areas. The serum soluble interleukin-2 receptor (sIL-2R) level was significantly elevated. Peripheral and bone marrow blood tests showed an increase in abnormal lymphocytes. DIAGNOSIS A splenectomy revealed an SMZL pattern with increased numbers of large cells and mitotic cells and a high Ki-67 positivity rate, which led to a diagnosis of AV-SMZL. Although TP53 mutation was not detected, mutations in NOTCH2, NCOA4, PTEN, EPHA3, and KMT2D were identified. Among these, the mutations in NCOA4, PTEN, and EPHA3 were novel pathogenic mutations in SMZL, which suggests they may be related to the aggressiveness and persistence of the disease. INTERVENTIONS The patient was administered a rituximab-containing regimen and rituximab-maintenance therapy. OUTCOMES The patient continues to exhibit a complete response. LESSONS This is a case of AV-SMZL in which a cancer panel test successfully detected genetic alterations that are potentially associated with its pathogenesis. These findings suggest that genetic analysis is useful for making diagnoses as well as for determining treatment strategies in AV-SMZL.
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Affiliation(s)
- Kazuya Ishiguro
- Department of Hematology, Tenshi Hospital
- Department of Molecular Biology, Sapporo Medical University School of Medicine
| | - Yasushi Sasaki
- Center for Medical Education, Sapporo Medical University
| | | | - Takeshi Niinuma
- Department of Molecular Biology, Sapporo Medical University School of Medicine
| | - Hiromu Suzuki
- Department of Molecular Biology, Sapporo Medical University School of Medicine
| | - Takashi Tokino
- Department of Medical Genome Sciences, Research Institute for Frontier Medicine, Sapporo Medical University School of Medicine
| | - Toshiaki Hayashi
- Department of Hematology, Teine Keijinkai Hospital, Sapporo, Japan
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Meacham PJ, Williams AM, Strawderman M, Baran AM, Archibald WJ, Wallace DS, Tschernia NP, Burack WR, Barr PM, Zent CS. Additional B-cell malignancies in patients with chronic lymphocytic leukemia/small lymphocytic lymphoma (CLL). Leuk Lymphoma 2020; 61:1636-1644. [PMID: 32175786 DOI: 10.1080/10428194.2020.1737690] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Family and migration studies suggest a genetic risk of developing chronic lymphocytic leukemia/small lymphocytic lymphoma (CLL). We hypothesized that CLL patients have an increased risk of additional clonally unrelated B-cell malignancies. To test this, we studied 467 CLL patients (2743 person-years (PYs)) at a single institution over 17 years. The incidence rate (IR) of any additional B-cell lymphoid malignancy was 10.9 per 1000 PYs (n = 30, 6.4%). Eighteen (4%) patients had a clonally unrelated B-cell malignancy (IR = 6.6 per 1000 PYs). Standardized incidence ratios (SIRs) were used to compare the incidence of additional clonally unrelated B-cell malignancies in CLL patients to the age- and sex-matched expected rates in the USA generated from the Surveillance, Epidemiology, and End Results (SEER) database. For the subset of 13 patients having data for comparison in the SEER database, the SIR was 5.41 (95% CI = 2.9, 9.3) which is supportive of our hypothesis.
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Affiliation(s)
| | | | | | | | | | | | | | - Walter Richard Burack
- Department of Pathology and Laboratory Medicine, University of Rochester Medical Center, Rochester, NY, USA
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3
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Defrancesco I, Zerbi C, Rattotti S, Merli M, Bruno R, Paulli M, Arcaini L. HCV infection and non-Hodgkin lymphomas: an evolving story. Clin Exp Med 2020; 20:321-328. [PMID: 32052244 DOI: 10.1007/s10238-020-00615-6] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2019] [Accepted: 02/07/2020] [Indexed: 12/11/2022]
Abstract
Hepatitis C virus infection represents a global health problem with 3% of population infected worldwide. Several epidemiological studies have shown an increased risk of B cell non-Hodgkin lymphomas in HCV-infected subjects with a wide geographic variability. The observation that HCV eradication by antiviral treatment is associated with successful lymphoma response provided the most convincing evidence for the causal role of HCV in lymphoma's development. According to the most accepted model, HCV-driven chronic antigenic stimulation may represent the major stimulus for lymphoma growth. Several evidences have led to recommend antiviral therapy (in the past interferon-based, now the new direct-acting antiviral agents) in the setting of asymptomatic indolent B cell lymphomas not requiring an immediate systemic treatment. The favourable profile of direct-acting antiviral agents supports the HCV eradication also in the setting of HCV-positive diffuse large B cell lymphoma; however, further studies are needed to assess the appropriate timing of these drugs in the treatment of aggressive lymphomas. Multidisciplinary management involving expert hepatologists is highly warranted.
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Affiliation(s)
| | - Caterina Zerbi
- Department of Molecular Medicine, University of Pavia, Pavia, Italy
| | - Sara Rattotti
- Division of Hematology, Fondazione IRCCS Policlinico San Matteo, Viale Golgi 19, 27100, Pavia, Italy
| | - Michele Merli
- Division of Hematology, University Hospital Ospedale di Circolo e Fondazione Macchi-Azienda Socio-Sanitaria Territoriale Sette Laghi, University of Insubria, Varese, Italy
| | - Raffaele Bruno
- Division of Infectious Diseases Unit, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy.,Department of Medical, Surgical, Diagnostic and Paediatric Science, University of Pavia, Pavia, Italy
| | - Marco Paulli
- Department of Molecular Medicine, University of Pavia, Pavia, Italy.,Anatomic Pathology Section, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Luca Arcaini
- Department of Molecular Medicine, University of Pavia, Pavia, Italy. .,Division of Hematology, Fondazione IRCCS Policlinico San Matteo, Viale Golgi 19, 27100, Pavia, Italy.
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Auat M, Cardoso CC, Santos-Pirath IM, Rudolf-Oliveira RCM, Matiollo C, Lange BG, da Silva JP, Dametto GC, Pirolli MM, Colombo MDHP, Santos-Silva MC. Evaluation of CD307a expression patterns during normal B-cell maturation and in B-cell malignancies by flow cytometry. CYTOMETRY PART B-CLINICAL CYTOMETRY 2018; 94:588-595. [DOI: 10.1002/cyto.b.21631] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/02/2017] [Revised: 01/14/2018] [Accepted: 02/20/2018] [Indexed: 11/06/2022]
Affiliation(s)
- Mariangeles Auat
- Postgraduate Program in Pharmacy of the Federal University of Santa Catarina; Florianópolis, Santa Catarina Brazil
| | - Chandra Chiappin Cardoso
- Clinical Analysis Division; University Hospital of the Federal University of Santa Catarina, Florianópolis; Santa Catarina Brazil
| | - Iris Mattos Santos-Pirath
- Postgraduate Program in Pharmacy of the Federal University of Santa Catarina; Florianópolis, Santa Catarina Brazil
- Clinical Analysis Division; University Hospital of the Federal University of Santa Catarina, Florianópolis; Santa Catarina Brazil
| | | | - Camila Matiollo
- Clinical Analysis Division; University Hospital of the Federal University of Santa Catarina, Florianópolis; Santa Catarina Brazil
| | - Bárbara Gil Lange
- Clinical Analysis Department of the Federal University of Santa Catarina, Florianópolis; Santa Catarina Brazil
| | - Jessica Pires da Silva
- Clinical Analysis Department of the Federal University of Santa Catarina, Florianópolis; Santa Catarina Brazil
| | | | - Mayara Marin Pirolli
- Hematology and Hemotherapy Center of Santa Catarina, Florianópolis; Santa Catarina Brazil
| | | | - Maria Claudia Santos-Silva
- Postgraduate Program in Pharmacy of the Federal University of Santa Catarina; Florianópolis, Santa Catarina Brazil
- Clinical Analysis Division; University Hospital of the Federal University of Santa Catarina, Florianópolis; Santa Catarina Brazil
- Clinical Analysis Department of the Federal University of Santa Catarina, Florianópolis; Santa Catarina Brazil
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5
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First-line treatment with bendamustine and rituximab, in patients with intermediate-/high-risk splenic marginal zone lymphomas. Med Oncol 2017; 35:15. [PMID: 29288421 DOI: 10.1007/s12032-017-1076-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2017] [Accepted: 12/27/2017] [Indexed: 01/18/2023]
Abstract
Splenic marginal zone lymphomas (SMZLs) are rare indolent B cell neoplasms that affect the spleen, bone marrow, and blood. Although they have an indolent course in the majority of patients, who have a median survival of 8-10 years, ∼ 30% may experience a worse outcome. The prognostic criteria of progression are lymph node and extra-nodal involvement, high lymphocyte counts, anaemia, and thrombocytopenia. The treatment of SMZLs include a "wait and watch strategy", splenectomy, and alkylating agents ± rituximab. We here describe data relating to 70 patients with intermediate-/high-risk SMZLs, who received rituximab/bendamustine as first-line treatment for a median of 60 days (range 1-75) after diagnosis. Sixty patients (86%) achieved a complete response (CR), and seven (10%) a partial response (PR). Three patients (4.3%) experienced disease progression (PD). The median duration of remission was 18 months. Side effects were generally mild. Our findings suggest that rituximab/bendamustine is a feasible treatment option in patients with intermediate-/high-risk SMZLs.
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Yi S, Li Z, Zou D, Xiong W, Li H, Cui R, Li C, Yan Y, Liu W, Lv R, Yu Z, Chen W, Xu Y, An G, Wang H, Ru K, Cheng T, Wang J, Qiu L. Del17p does not always significantly influence the survival of B-cell chronic lymphoproliferative disorders. Oncotarget 2017; 9:3353-3364. [PMID: 29423051 PMCID: PMC5790468 DOI: 10.18632/oncotarget.23261] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2017] [Accepted: 11/17/2017] [Indexed: 12/13/2022] Open
Abstract
B-cell chronic lymphoproliferative disorders (B-CLPD) comprise several entities with indolent clinical manifestations but heterogeneous survival. Cytogenetic aberrations are now the standard prognostic predictors in chronic lymphocytic leukemia (CLL) but have been less investigated in other subtypes of B-CLPD. In this study, we detected cytogenetic aberrations by fluorescence in situ hybridization (FISH) in 875 B-CLPD patients, based on a panel probes locating at 13q14, 11q22, 17p13 and CEP12. We identified del17p acted as the independent adverse cytogenetic predictor for overall survival (OS) in CLL. Del13q, del11q and del17p were adverse factors for OS in Waldenström's macroglobulinemia in the univariate analysis but lost their role in the multivariate analysis. Trisomy 12 acted as an independent poor factor for both marginal zone lymphoma (MZL) and unclassified B-CLPD (BCLPD-U) subtype. Del17p did not impact survival in MZL and BCLPD-U patients. These contrasting results indicate different roles of the same cytogenetic aberrations in the pathogenesis of each B-CLPD subtype. As del17p contributed to the poorest survival in CLL and desired extraordinary treatment strategy, the imitation of CLL strategy to other B-CLPD with del17p should be carefully advocated based on this study.
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Affiliation(s)
- Shuhua Yi
- State Key Laboratory of Experimental Hematology, Institute of Hematology and Blood Disease Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Tianjin, P.R.China
| | - Zengjun Li
- State Key Laboratory of Experimental Hematology, Institute of Hematology and Blood Disease Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Tianjin, P.R.China
| | - Dehui Zou
- State Key Laboratory of Experimental Hematology, Institute of Hematology and Blood Disease Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Tianjin, P.R.China
| | - Wenjie Xiong
- State Key Laboratory of Experimental Hematology, Institute of Hematology and Blood Disease Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Tianjin, P.R.China
| | - Heng Li
- State Key Laboratory of Experimental Hematology, Institute of Hematology and Blood Disease Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Tianjin, P.R.China
| | - Rui Cui
- State Key Laboratory of Experimental Hematology, Institute of Hematology and Blood Disease Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Tianjin, P.R.China.,Department of Hematology, Tianjin First Center Hospital, Tianjin, P.R.China
| | - Chengwen Li
- State Key Laboratory of Experimental Hematology, Institute of Hematology and Blood Disease Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Tianjin, P.R.China
| | - Yuting Yan
- State Key Laboratory of Experimental Hematology, Institute of Hematology and Blood Disease Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Tianjin, P.R.China
| | - Wei Liu
- State Key Laboratory of Experimental Hematology, Institute of Hematology and Blood Disease Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Tianjin, P.R.China
| | - Rui Lv
- State Key Laboratory of Experimental Hematology, Institute of Hematology and Blood Disease Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Tianjin, P.R.China
| | - Zhen Yu
- State Key Laboratory of Experimental Hematology, Institute of Hematology and Blood Disease Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Tianjin, P.R.China
| | - Weiwei Chen
- State Key Laboratory of Experimental Hematology, Institute of Hematology and Blood Disease Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Tianjin, P.R.China
| | - Yan Xu
- State Key Laboratory of Experimental Hematology, Institute of Hematology and Blood Disease Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Tianjin, P.R.China
| | - Gang An
- State Key Laboratory of Experimental Hematology, Institute of Hematology and Blood Disease Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Tianjin, P.R.China
| | - Huijun Wang
- State Key Laboratory of Experimental Hematology, Institute of Hematology and Blood Disease Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Tianjin, P.R.China
| | - Kun Ru
- State Key Laboratory of Experimental Hematology, Institute of Hematology and Blood Disease Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Tianjin, P.R.China
| | - Tao Cheng
- State Key Laboratory of Experimental Hematology, Institute of Hematology and Blood Disease Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Tianjin, P.R.China
| | - Jianxiang Wang
- State Key Laboratory of Experimental Hematology, Institute of Hematology and Blood Disease Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Tianjin, P.R.China
| | - Lugui Qiu
- State Key Laboratory of Experimental Hematology, Institute of Hematology and Blood Disease Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Tianjin, P.R.China
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Ghia P, Nadel B, Sander B, Stamatopoulos K, Stevenson FK. Early stages in the ontogeny of small B-cell lymphomas: genetics and microenvironment. J Intern Med 2017; 282:395-414. [PMID: 28393412 DOI: 10.1111/joim.12608] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
In this review, we focus on the mechanisms underlying lymphomagenesis in chronic lymphocytic leukaemia, follicular lymphoma, mantle cell lymphoma and splenic marginal zone lymphoma. The cells of origin of these small B-cell lymphomas are distinct, as are the characteristic chromosomal lesions and clinical courses. One shared feature is retention of expression of surface immunoglobulin. Analysis of this critical receptor reveals the point of differentiation reached by the cell of origin. Additionally, the sequence patterns of the immunoglobulin-variable domains can indicate a role for stimulants of the B-cell receptor before, during and after malignant transformation. The pathways driven via the B-cell receptor are now being targeted by specific kinase inhibitors with exciting clinical effects. To consider routes to pathogenesis, potentially offering earlier intervention, or to identify causative factors, genetic tools are being used to track pretransformation events and the early phases in lymphomagenesis. These methods are revealing that chromosomal changes are only one of the many steps involved, and that the influence of surrounding cells, probably multiple and variable according to tissue location, is required, both to establish tumours and to maintain growth and survival. Similarly, the influence of the tumour microenvironment may protect malignant cells from eradication by treatment, and the resulting minimal residual disease will eventually give rise to relapse. The common and different features of the four lymphomas will be summarized to show how normal B lymphocytes can be subverted to generate tumours, how these tumours evolve and how their weaknesses can be attacked by targeted therapies.
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Affiliation(s)
- P Ghia
- Division of Experimental Oncology, Università Vita-Salute San Raffaele and IRCCS San Raffaele Scientific Institute Milan, Milan, Italy
| | - B Nadel
- Aix-Marseille Université, CNRS, INSERM, CIML, Marseille, France
| | - B Sander
- Department of Laboratory Medicine, Division of Pathology, Karolinska Institutet and Karolinska University Hospital, Stockholm, Sweden
| | - K Stamatopoulos
- Institute of Applied Biosciences, Center for Research and Technology Hellas, Thessaloniki, Greece.,Department of Immunology, Genetics and Pathology, Science for Life Laboratory, Uppsala University, Uppsala, Sweden
| | - F K Stevenson
- Cancer Research UK Centre, Cancer Sciences Unit, University of Southampton Faculty of Medicine, Southampton General Hospital, Southampton, UK
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8
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Xochelli A, Oscier D, Stamatopoulos K. Clonal B-cell lymphocytosis of marginal zone origin. Best Pract Res Clin Haematol 2017; 30:77-83. [DOI: 10.1016/j.beha.2016.08.028] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2016] [Revised: 08/10/2016] [Accepted: 08/12/2016] [Indexed: 12/25/2022]
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9
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Sorigue M, Juncà J, Sarrate E, Grau J. Expression of CD43 in chronic lymphoproliferative leukemias. CYTOMETRY PART B-CLINICAL CYTOMETRY 2017; 94:136-142. [PMID: 28073173 DOI: 10.1002/cyto.b.21509] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/02/2016] [Revised: 12/27/2016] [Accepted: 01/06/2017] [Indexed: 01/25/2023]
Abstract
BACKGROUND CD43 has been used on histological samples for the differential diagnosis of lymphoproliferative disorders but there is scarce data on its use by flow cytometry (FC). We set out to characterize the expression of CD43 by FC in B-cell lymphoproliferative disorders and to determine its possible role in the differential diagnosis of these malignancies. METHODS We analyzed the expression of CD43 in clonal B-cell lymphoproliferative disorders with exclusive peripheral blood and/or bone marrow involvement based on their Moreau chronic lymphocytic leukemia (CLL) score with particular emphasis on Moreau CLL score 3 (MS3) cases, which often present a diagnostic challenge. The cohort included 433 CLL (score 4-5), 34 MS3 and 166 lymphoproliferative disorders with lower scores. RESULTS Generally, the higher the Moreau CLL score, the higher CD43-positivity (425/443 [96%] for CLL, 23/34 [67%] for MS3 and 18/166 [11%] for cases with lower scores). MS3 cases constituted 5.4% of all cases and were more frequently CD5, CD200, CD43-positive and had del(q13) than score 0-2 cases. Among MS3 cases, del(13q) cases were predominantly CD43-positive (12/13). CONCLUSIONS The frequency of CD43-positivity increases sharply with the Moreau score. MS3 cases seem to include both CLL and non-CLL lymphoproliferative disorders and CD43 could aid in the differential diagnosis between the two. However, studies analyzing the correlation between CD43 expression and the underlying biologic changes of these cases are warranted. © 2017 International Clinical Cytometry Society.
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Affiliation(s)
- Marc Sorigue
- Department of Laboratory Hematology, ICO-Badalona, Hospital Universitari Germans Trias i Pujol, Josep Carreras Leukemia Research Institute, Universitat Autonoma de Barcelona, Badalona, Spain
| | - Jordi Juncà
- Department of Laboratory Hematology, ICO-Badalona, Hospital Universitari Germans Trias i Pujol, Josep Carreras Leukemia Research Institute, Universitat Autonoma de Barcelona, Badalona, Spain
| | - Edurne Sarrate
- Department of Laboratory Hematology, Hospital Universitari Germans Trias i Pujol, Universitat Autonoma de Barcelona, Badalona, Spain
| | - Javier Grau
- Department of Laboratory Hematology, ICO-Badalona, Hospital Universitari Germans Trias i Pujol, Josep Carreras Leukemia Research Institute, Universitat Autonoma de Barcelona, Badalona, Spain
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10
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Merli M, Carli G, Arcaini L, Visco C. Antiviral therapy of hepatitis C as curative treatment of indolent B-cell lymphoma. World J Gastroenterol 2016; 22:8447-8458. [PMID: 27784957 PMCID: PMC5064026 DOI: 10.3748/wjg.v22.i38.8447] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2016] [Revised: 08/02/2016] [Accepted: 08/23/2016] [Indexed: 02/06/2023] Open
Abstract
The association of hepatitis C virus (HCV) and B-cell non-Hodgkin lymphomas (NHL) has been highlighted by several epidemiological and biological insights; however the most convincing evidence is represented by interventional studies demonstrating the capability of antiviral treatment (AT) with interferon (IFN) with or without ribavirin to induce the regression of indolent lymphomas, especially of marginal-zone origin. In the largest published retrospective study (100 patients) the overall response rate (ORR) after first-line IFN-based AT was 77% (44% complete responses) and responses were sustainable (median duration of response 33 mo). These results were confirmed by a recent meta-analysis on 254 patients, demonstrating an ORR of 73%. Moreover this analysis confirmed the highly significant correlation between the achievement of viral eradication sustained virological response (SVR) and hematological responses. Two large prospective studies demonstrated that AT is associated with improved survival and argue in favor of current guidelines’ recommendation of AT as preferential first-line option in asymptomatic patients with HCV-associated indolent NHL. The recently approved direct-acting antiviral agents (DAAs) revolutionized the treatment of HCV infection, leading to SVR approaching 100% in all genotypes. Very preliminary data of IFN-free DAAs therapy in indolent HCV-positive NHL seem to confirm their activity in inducing lymphoma regression.
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11
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Bendamustine and Rituximab, as First Line Treatment, in Intermediate, High Risk Splenic Marginal Zone Lymphomas of Elderly Patients. Mediterr J Hematol Infect Dis 2016; 8:e2016030. [PMID: 27413523 PMCID: PMC4928534 DOI: 10.4084/mjhid.2016.030] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2016] [Accepted: 06/12/2016] [Indexed: 11/08/2022] Open
Abstract
Background Splenic marginal zone lymphoma (SMZL) is a chronic B-cell lymphoproliferative disorder, comprising less than 2% of non-Hodgkin’s lymphomas, and affecting mainly middle-aged and elderly patients with a median survival of >10 years. The typical clinical features of SMZL include splenomegaly. Treatment should be patient-tailored and can range from a ‘watchful waiting’ approach for asymptomatic patients without cytopenias to surgery, localized radiation therapy or immuno/chemotherapies. Recently, the combination of rituximab and Bendamustine (R-Benda) has been defined as highly active in patients with follicular lymphomas, but little is known about the efficacy of R-Benda in SMZL. Aim of the study The purpose of this retrospective study was to report our experience on the efficacy of R-Benda as first line treatment in 23 consecutive elderly SMZL patients. Results All patients had a complete resolution of splenomegaly along with restoration of their blood counts. Nineteen patients (83%) achieved a complete response (CR) to therapy; three patients (13%) achieved a partial response (PR).Ten patients (43%) obtained molecular remission. Toxicities were mild and mainly haematological and result in dose reductions for fourteen patients. Conclusions Our data suggest a high activity and good tolerance of R-Benda, despite dose reduction due to potential toxicity.
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12
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Wulaningsih W, Holmberg L, Garmo H, Malmstrom H, Lambe M, Hammar N, Walldius G, Jungner I, Ng T, Van Hemelrijck M. Serum lactate dehydrogenase and survival following cancer diagnosis. Br J Cancer 2015; 113:1389-96. [PMID: 26469834 PMCID: PMC4815785 DOI: 10.1038/bjc.2015.361] [Citation(s) in RCA: 50] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2015] [Revised: 09/14/2015] [Accepted: 09/18/2015] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND There is evidence that high level of serum lactate dehydrogenase (LDH) is associated with poorer overall survival in several malignancies, but its link to cancer-specific survival is unclear. METHODS A total of 7895 individuals diagnosed with cancer between 1986 and 1999 were selected for this study. Multivariable Cox proportional hazards regression was used to assess overall and cancer-specific death by the z-score and clinical categories of serum LDH prospectively collected within 3 years before diagnosis. Site-specific analysis was performed for major cancers. Analysis was repeated by different lag times between LDH measurements and diagnosis. RESULTS At the end of follow-up, 5799 participants were deceased. Hazard ratios (HRs) and 95% confidence intervals (CIs) for overall and cancer-specific death in the multivariable model were 1.43 (1.31-1.56) and 1.46 (1.32-1.61), respectively, for high compared with low prediagnostic LDH. Site-specific analysis showed high LDH to correlate with an increased risk of death from prostate, pulmonary, colorectal, gastro-oesophageal, gynaecological and haematological cancers. Serum LDH assessed within intervals closer to diagnosis was more strongly associated with overall and cancer-specific death. CONCLUSIONS Our findings demonstrated an inverse association of baseline serum LDH with cancer-specific survival, corroborating its role in cancer progression.
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Affiliation(s)
- Wahyu Wulaningsih
- Division of Cancer Studies, Cancer Epidemiology Group, King's College London, Research Oncology, 3rd Floor, Bermondsey Wing, Guy's Hospital, London SE1 9RT, UK
| | - Lars Holmberg
- Division of Cancer Studies, Cancer Epidemiology Group, King's College London, Research Oncology, 3rd Floor, Bermondsey Wing, Guy's Hospital, London SE1 9RT, UK
- Department of Surgical Sciences, Uppsala University Hospital, Uppsala 751 85, Sweden
- Regional Cancer Centre, Uppsala 751 85, Sweden
| | - Hans Garmo
- Division of Cancer Studies, Cancer Epidemiology Group, King's College London, Research Oncology, 3rd Floor, Bermondsey Wing, Guy's Hospital, London SE1 9RT, UK
- Regional Cancer Centre, Uppsala 751 85, Sweden
| | - Håkan Malmstrom
- Department of Epidemiology, Institute of Environmental Medicine, Karolinska Institutet, Stockholm 171 77, Sweden
| | - Mats Lambe
- Regional Cancer Centre, Uppsala 751 85, Sweden
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm 171 77, Sweden
| | - Niklas Hammar
- Department of Epidemiology, Institute of Environmental Medicine, Karolinska Institutet, Stockholm 171 77, Sweden
- AstraZeneca R&D, Mölndal 431 50, Sweden
| | - Göran Walldius
- Department of Cardiovascular Epidemiology, Institute of Environmental Medicine, Karolinska Institutet, Stockholm 171 77, Sweden
| | - Ingmar Jungner
- Department of Medicine, Clinical Epidemiological Unit, Karolinska Institutet and CALAB Research, Stockholm 171 77, Sweden
| | - Tony Ng
- Richard Dimbleby Department of Cancer Research, Randall Division and Division of Cancer Studies, King's College London, London SE1 1UL, UK
| | - Mieke Van Hemelrijck
- Division of Cancer Studies, Cancer Epidemiology Group, King's College London, Research Oncology, 3rd Floor, Bermondsey Wing, Guy's Hospital, London SE1 9RT, UK
- Department of Epidemiology, Institute of Environmental Medicine, Karolinska Institutet, Stockholm 171 77, Sweden
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Oberley MJ, Fitzgerald S, Yang DT, Morgan A, Johnson J, Leith C. Value-based flow testing of chronic lymphoproliferative disorders: a quality improvement project to develop an algorithm to streamline testing and reduce costs. Am J Clin Pathol 2014; 142:411-8. [PMID: 25125633 DOI: 10.1309/ajcp0swzj6gbdhpf] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022] Open
Abstract
OBJECTIVES Flow cytometry is essential for the evaluation of lymphoproliferative disorders (LPDs) and their classification. Flow panels routinely incorporate a large array of antibodies, making testing complex and expensive; such panels are likely unnecessary in benign cases or those with straightforward diagnoses. Our aim was to develop a more cost-effective testing strategy based on a retrospective analysis of flow studies for possible LPDs in blood. METHODS We identified LPD frequencies and types, as well as associated results with patient age and absolute lymphocyte count. RESULTS We found that the likelihood of LPDs increased with patient age and absolute lymphocyte count and that CD5-positive LPD was the most common LPD diagnosed in our institution (71% of LPDs). Using these data, we devised flow-testing algorithms with a screening test for patients at low risk of disease and a focus on CD5-positive LPD detection, with reflexing as needed. CONCLUSIONS We project this approach will result in a 40% decrease in antibody utilization.
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Affiliation(s)
- Matthew J. Oberley
- Department of Pathology and Laboratory Medicine, Children’s Hospital of Los Angeles, Keck School of Medicine, University of Southern California, Los Angeles
| | - Sean Fitzgerald
- Department of Pathology, University of Texas Medical Branch, Galveston
| | - David T. Yang
- Department of Pathology and Laboratory Medicine, Children’s Hospital of Los Angeles, Keck School of Medicine, University of Southern California, Los Angeles
| | - Adam Morgan
- Department of Pathology, St Mary’s Hospital, Madison, WI
| | - Joyce Johnson
- Flow Cytometry Laboratory, University of Wisconsin Hospital and Clinics, Madison
| | - Catherine Leith
- Department of Pathology and Laboratory Medicine, University of Wisconsin, Madison
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14
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Prevalence and clinical significance of the MYD88 (L265P) somatic mutation in Waldenström’s macroglobulinemia and related lymphoid neoplasms. Blood 2013; 121:2522-8. [DOI: 10.1182/blood-2012-09-457101] [Citation(s) in RCA: 242] [Impact Index Per Article: 22.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
Key Points
Using a sensitive method, the MYD88 (L265P) mutation is detectable in all patients with Waldenström’s macroglobulinemia, therefore representing a hallmark of the disease. MYD88 (L265P) is also found in a substantial proportion of patients with IgM-MGUS.
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15
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Indolent B-cell lymphomas associated with HCV infection: clinical and virological features and role of antiviral therapy. Clin Dev Immunol 2012; 2012:638185. [PMID: 22956970 PMCID: PMC3432550 DOI: 10.1155/2012/638185] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2012] [Revised: 07/04/2012] [Accepted: 07/04/2012] [Indexed: 02/06/2023]
Abstract
The association between hepatitis C virus (HCV) infection and B-cell non-Hodgkin's lymphomas (NHL) has been demonstrated by epidemiological studies, in particular in highly endemic geographical areas such as Italy, Japan, and southern parts of United States. In these countries, together with diffuse large B-cell lymphomas, marginal zone lymphomas are the histotypes most frequently associated with HCV infection; in Italy around 20–30% cases of marginal zone lymphomas are HCV positive. Recently, antiviral treatment with interferon with or without ribavirin has been proved to be effective in the treatment of HCV-positive patients affected by indolent lymphoma, prevalently of marginal zone origin. An increasing number of experiences confirmed the validity of this approach in marginal zone lymphomas and in other indolent NHL subtypes like lymphoplasmacytic lymphoma. Across different studies, overall response rate was approximately 75%. Hematological responses resulted significantly associated with the eradication of the virus. This is the strongest evidence of a causative link between HCV and lymphomas. The aim of this paper is to illustrate the relationship between HCV infection and different subtypes of indolent B-cell lymphomas and to systematically summarize the data from the therapeutic studies that reported the use of antiviral treatment as hematological therapy in patients with HCV-associated indolent lymphomas.
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16
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Isobe Y, Tomomatsu J, Tsukune Y, Tsukada N, Sasaki M, Sugimoto K, Komatsu N. Diagnostic problems among chronic lymphocytic leukemia and other indolent B-cell leukemias in a Japanese population. Intern Med 2012; 51:1977-81. [PMID: 22864121 DOI: 10.2169/internalmedicine.51.7579] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
OBJECTIVE Japanese chronic lymphocytic leukemia (CLL) provides a diagnostic dilemma due to the low incidence and the heterogeneity shown in its morphology and immunophenotype. We clarified the diagnostic problems in Japanese CLL through our retrospective observation. METHODS Between 2006 and 2011, we found a total of 48 cases with CLL and other indolent B-cell leukemias. We made a diagnosis of true CLL based on clinical, laboratory, immunophenotypic and cytogenetic data. RESULTS Among the 48 cases, only 28 cases (58.3%) were diagnosed with true CLL. Morphologic evaluation using a forced-air dried preparation alone is not helpful to distinguish CLL from other indolent B-cell leukemias, including hairy cell leukemia, mantle cell lymphoma, lymphoplasmacytic lymphoma, and splenic marginal zone lymphoma. CLL immunophenotypic score should be more strictly applied in Japan than in Western countries. CONCLUSION Fluorescence in situ hybridization for CCND1/IGH, the presence of leukocytosis and lymphadenopathy at diagnosis, and the morphological evaluation using naturally air dried preparations are important clues to make a correct diagnosis of Japanese CLL.
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MESH Headings
- Asian People
- CD5 Antigens/metabolism
- Cytogenetic Analysis
- Humans
- Immunophenotyping
- In Situ Hybridization, Fluorescence
- Japan
- Leukemia, B-Cell/diagnosis
- Leukemia, B-Cell/genetics
- Leukemia, B-Cell/immunology
- Leukemia, Hairy Cell/diagnosis
- Leukemia, Lymphocytic, Chronic, B-Cell/diagnosis
- Leukemia, Lymphocytic, Chronic, B-Cell/genetics
- Leukemia, Lymphocytic, Chronic, B-Cell/immunology
- Leukemia, Prolymphocytic, B-Cell/diagnosis
- Lymphoma, B-Cell, Marginal Zone/diagnosis
- Lymphoma, Follicular/diagnosis
- Lymphoma, Mantle-Cell/diagnosis
- Oncogene Proteins, Fusion/genetics
- Retrospective Studies
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Affiliation(s)
- Yasushi Isobe
- Department of Hematology, Juntendo University School of Medicine, Japan.
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17
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Abstract
The somatically acquired V600E mutation of the BRAF gene has been recently described as a molecular marker of hairy cell leukemia (HCL). We developed an allele-specific PCR for this mutation and studied 62 patients with HCL, 1 with HCL variant, 91 with splenic marginal zone lymphoma, 29 with Waldenström macroglobulinemia, and 57 with B-cell chronic lymphoproliferative disorders. The BRAF V600E mutation was detected in all HCL cases and in only 2 of the remaining 178 patients. These 2 subjects had B-cell chronic lymphoproliferative disorders that did not fulfill the diagnostic criteria for HCL. Despite the positive PCR finding, the mutation could not be detected by Sanger sequencing in these 2 cases, suggesting that it was associated with a small subclone. We conclude that the BRAF V600E mutation is present in all patients with HCL and that, in combination with clinical and morphologic features, represents a reliable molecular marker for this condition.
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18
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Mulligan CS, Thomas ME, Mulligan SP. Monoclonal B-lymphocytosis: demographics, nature and subclassification in 414 community patients. Leuk Lymphoma 2011; 52:2293-8. [DOI: 10.3109/10428194.2011.598250] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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19
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Dronca RS, Jevremovic D, Hanson CA, Rabe KG, Shanafelt TD, Morice WG, Call TG, Kay NE, Collins CS, Schwager SM, Slager SL, Zent CS. CD5-positive chronic B-cell lymphoproliferative disorders: diagnosis and prognosis of a heterogeneous disease entity. CYTOMETRY PART B-CLINICAL CYTOMETRY 2010; 78 Suppl 1:S35-41. [PMID: 20568273 DOI: 10.1002/cyto.b.20546] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND The pathology and clinical course of patients with CD5+ chronic B-cell lymphoproliferative disorders, excluding those that present with typical chronic lymphocytic leukemia/small lymphocytic lymphoma (CLL) or mantle cell lymphoma, (i.e. CD5+B-CLPD) are poorly defined. METHODS We studied patients with CD5+B-CLPD to (1) more completely define the clinical features and pathology of CD5+B-CLPD, (2) compare these features to patients presenting with typical CLL, and (3) test the hypothesis that a subset of patients with CD5+B-CLPD could have a unique B-cell malignancy. RESULTS We identified 229 patients with CD5+B-CLPD. A definitive pathological diagnosis was made in all 61 (27%) CD5+B-CLPD patients with nonbone marrow (BM) biopsy specimens considered adequate for a comprehensive pathological examination. The most common diagnosis among these 61 patients was CLL (44%) followed by the leukemic phase of marginal zone lymphoma (34%), lymphoplasmacytic lymphoma (11%), diffuse large B cell lymphoma (8%), and high-grade B cell lymphoma not otherwise specified (2%). In contrast, among 168 patients without a non-BM tissue biopsy specimen, a specific diagnosis could be made on review of all available data in only 24 (14%) with 144 (86%) remaining "unclassified." CONCLUSIONS In patients with CD5+B-CLPD, a definitive diagnosis can be made on an adequate non-BM tissue biopsy suggesting that this entity does not include a novel disease. We recommend that all patients with CD5+B-CLPD should have a non-BM tissue biopsy to make a definitive diagnosis prior to initiation of treatment.
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Affiliation(s)
- Roxana S Dronca
- Division of Hematology, Mayo Clinic, Rochester, Minnesota 55905, USA
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20
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Costa ES, Pedreira CE, Barrena S, Lecrevisse Q, Flores J, Quijano S, Almeida J, del Carmen García- Macias M, Bottcher S, Van Dongen JJM, Orfao A. Automated pattern-guided principal component analysis vs expert-based immunophenotypic classification of B-cell chronic lymphoproliferative disorders: a step forward in the standardization of clinical immunophenotyping. Leukemia 2010; 24:1927-33. [PMID: 20844562 PMCID: PMC3035971 DOI: 10.1038/leu.2010.160] [Citation(s) in RCA: 92] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2010] [Revised: 06/09/2010] [Accepted: 06/17/2010] [Indexed: 12/21/2022]
Abstract
Immunophenotypic characterization of B-cell chronic lymphoproliferative disorders (B-CLPD) is becoming increasingly complex due to usage of progressively larger panels of reagents and a high number of World Health Organization (WHO) entities. Typically, data analysis is performed separately for each stained aliquot of a sample; subsequently, an expert interprets the overall immunophenotypic profile (IP) of neoplastic B-cells and assigns it to specific diagnostic categories. We constructed a principal component analysis (PCA)-based tool to guide immunophenotypic classification of B-CLPD. Three reference groups of immunophenotypic data files-B-cell chronic lymphocytic leukemias (B-CLL; n = 10), mantle cell (MCL; n = 10) and follicular lymphomas (FL; n = 10)--were built. Subsequently, each of the 175 cases studied was evaluated and assigned to either one of the three reference groups or to none of them (other B-CLPD). Most cases (89%) were correctly assigned to their corresponding WHO diagnostic group with overall positive and negative predictive values of 89 and 96%, respectively. The efficiency of the PCA-based approach was particularly high among typical B-CLL, MCL and FL vs other B-CLPD cases. In summary, PCA-guided immunophenotypic classification of B-CLPD is a promising tool for standardized interpretation of tumor IP, their classification into well-defined entities and comprehensive evaluation of antibody panels.
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MESH Headings
- Adult
- Aged
- Aged, 80 and over
- Antigens, CD/immunology
- Automation
- B-Lymphocytes/immunology
- B-Lymphocytes/pathology
- Female
- Flow Cytometry/methods
- Humans
- Immunoglobulin A/immunology
- Immunophenotyping/methods
- Leukemia, Lymphocytic, Chronic, B-Cell/immunology
- Leukemia, Lymphocytic, Chronic, B-Cell/pathology
- Lymphoma/immunology
- Lymphoma/pathology
- Lymphoma, Follicular/immunology
- Lymphoma, Follicular/pathology
- Lymphoma, Mantle-Cell/immunology
- Lymphoma, Mantle-Cell/pathology
- Male
- Middle Aged
- Predictive Value of Tests
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Affiliation(s)
- E S Costa
- Pediatrics Institute Martagão Gesteira—IPPMG, Federal University of Rio de Janeiro—UFRJ, Rio de Janeiro, Brazil
| | - C E Pedreira
- Faculty of Medicine and COPPE—Engineering Graduate Program, Federal University of Rio de Janeiro—UFRJ, Rio de Janeiro, Brazil
| | - S Barrena
- Cytometry Service, Department of Medicine and Cancer Research Center (IBMCC, University of Salamanca-CSIC), University of Salamanca, Salamanca, Spain
| | - Q Lecrevisse
- Cytometry Service, Department of Medicine and Cancer Research Center (IBMCC, University of Salamanca-CSIC), University of Salamanca, Salamanca, Spain
| | - J Flores
- Cytometry Service, Department of Medicine and Cancer Research Center (IBMCC, University of Salamanca-CSIC), University of Salamanca, Salamanca, Spain
| | - S Quijano
- Cytometry Service, Department of Medicine and Cancer Research Center (IBMCC, University of Salamanca-CSIC), University of Salamanca, Salamanca, Spain
| | - J Almeida
- Cytometry Service, Department of Medicine and Cancer Research Center (IBMCC, University of Salamanca-CSIC), University of Salamanca, Salamanca, Spain
| | | | - S Bottcher
- University of Schleswig-Holstein, Campus Kiel, Kiel, Germany
| | - J J M Van Dongen
- Department of Immunology, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - A Orfao
- Cytometry Service, Department of Medicine and Cancer Research Center (IBMCC, University of Salamanca-CSIC), University of Salamanca, Salamanca, Spain
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Juncà J, Moreno M, Mate JL, Milla F. Diagnóstico simultáneo de una leucemia aguda mieloide y un síndrome linfoproliferativo crónico, con amiloidosis AA como episodio final. Med Clin (Barc) 2010; 135:136-7. [DOI: 10.1016/j.medcli.2009.04.052] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2009] [Accepted: 04/14/2009] [Indexed: 11/27/2022]
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22
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Arcaini L, Pascutto C, Passamonti F, Bruno R, Merli M, Rizzi S, Orlandi E, Astori C, Rattotti S, Paulli M, Lazzarino M. Bayesian models identify specific lymphoproliferative disorders associated with hepatitis C virus infection. Int J Cancer 2009; 124:2246-9. [PMID: 19132749 DOI: 10.1002/ijc.24162] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
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23
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Hanson CA, Morice WG. The clinical and laboratory approach to the CD5/CD10 negative B-cell chronic lymphoproliferative leukemias. Am J Hematol 2008; 83:347-8. [PMID: 18383327 DOI: 10.1002/ajh.21188] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
MESH Headings
- Antigens, CD/analysis
- Antigens, Neoplasm/analysis
- B-Lymphocyte Subsets/chemistry
- B-Lymphocyte Subsets/pathology
- Bone Marrow Examination
- Disease Management
- Flow Cytometry
- Humans
- Immunophenotyping
- Leukemia, Lymphocytic, Chronic, B-Cell/diagnosis
- Leukemia, Lymphocytic, Chronic, B-Cell/drug therapy
- Leukemia, Lymphocytic, Chronic, B-Cell/pathology
- Multicenter Studies as Topic
- Neoplastic Stem Cells/chemistry
- Neoplastic Stem Cells/pathology
- Retrospective Studies
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