Bone marrow involvement in systemic lupus erythematosus

BACKGROUND

Besides peripheral cytopenias, bone marrow abnormalities, such as fibrosis, pure red cell aplasia and aplastic anemia have been reported in patients with systemic lupus erythematosus (SLE), suggesting that bone marrow may be a 25 target organ in SLE.

AIM

Our objective was to describe this bone marrow involvement.

METHODS

This registry is a nationwide retrospective study. Centers provided data concerning medical history, SLE manifestations, type of hematologic disorder, treatments and outcome. Bone marrow aspirations and/or biopsies were transferred for centralized review.

RESULTS

Thirty patients from 19 centers were included. Central hematologic manifestations comprised bone marrow fibrosis (n = 17; 57%), pure red cell aplasia (n = 8; 27%), myelodysplastic syndrome (n = 3; 10%), aplastic anemia and agranulocytosis (n = 1; 3% each). Bone marrow involvement was diagnosed concomitantly with SLE in 12 patients. Bone marrow biopsies showed fibrosis in 19 cases, including one case of pure red cell aplasia and one case of agranulocytosis and variable global marrow cellularity. Treatments included corticosteroids (90%), hydroxychloroquine (87%), rituximab (33%), intravenous immunoglobulins (30%), mycophenolate mofetil (20%) and ciclosporine (20%). After a median follow-up of 27 months (range: 1-142), 24 patients manifested complete improvement. No patient died.

CONCLUSIONS

This registry comprises the largest series of SLE patients with bone marrow involvement. It demonstrates the strong link between SLE and bone marrow fibrosis. Patients with atypical or refractory cytopenia associated with SLE should undergo bone marrow examination to enable appropriate, and often effective, treatment. Long-term prognosis is good.

Blood parameters of preterm neonates: postnatal evolution according to gestational age

INTRODUCTION

The blood count provides qualitative and quantitative essential information on bloodlines. Reference hematologic parameters have been established in children and neonates, but few data are available regarding the premature population during the first month of life. The main objective of this study was to establish normative values for blood parameters for premature infants born between 26 and <37 weeks of gestation, during the first month of life, taking into account gestational and postnatal age and treatments that can impact the threshold values.

METHODS

A single-center retrospective study was conducted based on the clinical and laboratory data of preterm infants born between January 1, 2012 and December 31, 2013 and hospitalized in the intensive care, neonatal, and maternity units of University Hospital of Saint Etienne (France). Data were collected by crossing the PMSI database (date of birth and gestational age), the administrative patient database (IPP), and the pre-analytical laboratory database. Anthropometric and clinical data were extracted for both mother and child. The samples were all made from central or peripheral venous blood. All blood parameters were taken into account.

RESULTS

The degree of prematurity is a factor greatly influencing the values of the blood parameters at birth. All three blood lines increase in proportion to gestational age. We were able to highlight for some blood parameters specific kinetic profiles according to gestational age.

CONCLUSION

Blood parameters of preterm neonates depend on both the degree of prematurity, postnatal age, and perinatal treatments. A good knowledge of these physiological variations may help target transfusion or therapeutic indications in everyday practice.

Expression and activity of caspases 1 and 3 in myelodysplastic syndromes

Myelodysplastic syndromes (MDS) are characterized by abnormal growth of committed progenitors in clonogenic assay, with reduced number of colonies and decreased colony/cluster ratio. It has been suggested that excessive apoptosis is the cause of marrow failure in MDS. We studied the expression of caspase-1 (interleukin-1beta-converting enzyme, ICE) and caspase-3 (CPP32/apopain) in marrow mononuclear cells, and the growth pattern of committed progenitors in a series of 83 MDS cases. The percentage of apoptotic cells as detected by TUNEL technique, and the percentage of caspase-3-positive cells were significantly higher in refractory anemia (RA) and RA with ringed sideroblasts (RAS) than in chronic myelomonocytic leukemia (CMML), refractory anemia with excess of blasts (RAEB) and RAEB in transformation (RAEB-T). Spontaneous growth of CFU-GM was associated with a higher percentage of blasts, and with a lower expression of caspase-3 and caspase-1. The yield of CFU-E, BFU-E, and CFU-GM (in the presence of growth factors) was decreased by comparison to normal marrow, but large individual differences were observed in all cytological categories. Inhibition of caspase-1 and caspase-3 activities by specific inhibitors resulted in a significant increase of the production of all types of colonies (up to 50-fold of control). In the presence of caspase-3 inhibitor, the number of BFU-E and CFU-E was in the range of normal values in most cases of RA and RAS. In addition, caspase-1 and -3 protease activities were detectable by fluorogenic assay in all cases studied. Western blot analysis confirmed the expression of caspase-3, including the cleaved (activated)-p17 form in most cases of RA/RAS analyzed. It is concluded that caspase-3 is implicated in the increased apoptosis observed in MDS and that inhibition of its activity can restore at least partially the growth of committed progenitors.

Expression of apoptosis-controlling proteins in acute leukemia cells

The expression of Bcl-2 family proteins (Bcl-2, Bcl-X, Bcl-XL, Bcl-Xs, BAX, BAD, MCL-1) and of Interleukin-1 converting enzyme (ICE)-related proteins (ICE, CPP32, ICH- 1) was analyzed in acute leukemia cells by flow cytometry. Most proteins studied were detectable in cell lines such as KG1a, HL60, K562 (myeloblastic), REH, RAJI and MOLT4 (lymphoblastic) and VAL (B-cell lymphoma). However, BCL-Xs and BAK were weakly expressed in K562, as were Bcl-X, BAD and BAK in the VAL line. In acute myeloid leukemia (66 cases studied), the proteins were expressed in most cases in a high percentage of cells, especially BAX and CPP32, without correlation with hematological characteristics. However, Bcl-2 was expressed in a higher percentage of cells in FAB M1 and M5 cases, and in CD34-positive cases, whereas Bcl-Xs was more frequently expressed in M3 cases. No differences were observed regarding fluorescence intensity. Higher percentages of Bcl-2-positive cells were associated with low remission rate, while expression of Bcl-Xs was predictive of high remission rate. In acute lymphoblastic leukemia (36 cases), all proteins studied were expressed in a majority of cases. Bcl-Xs was more frequently detected in T-cell type, and was also associated with a higher remission rate. These results suggest that apoptosis-controlling proteins may have a role in the pathogenesis and response to therapy of acute leukemia.

High expression of bcl-2 protein in acute myeloid leukemia cells is associated with poor response to chemotherapy

The BCL-2 proto-oncogene encodes a mitochondrial protein that blocks programmed cell death. High amounts of bcl-2 protein are found not only in lymphoid malignancies, but also in normal tissues characterized by apoptotic cell death, including bone marrow. Using a monoclonal antibody to bcl-2 protein, we analyzed 82 samples of newly diagnosed acute myeloid leukemia. The number of bcl-2+ cells in each sample was heterogeneous (range, 0% to 95%), with a mean of 23%. The percentage of bcl-2+ cells was higher in M4 and M5 types, according to French-American-British classification, and in cases with high white blood cell counts. bcl-2 expression was also correlated with that of the stem cell marker CD34. In vitro survival of leukemic cells maintained in liquid culture in the absence of growth factors was significantly longer in cases with a high percentage of bcl-2+ cells. High expression of bcl-2 was associated with a low complete remission rate after intensive chemotherapy (29% in cases with 20% or more positive cells v 85% in cases with less than 20% positive cells, P < 10(-5)) and with a significantly shorter survival. In multivariate analysis, the percentage of bcl-2+ cells (or the blast survival in culture), age, and the percentage of CD34+ cells were independently associated with poor survival.

Trisomy 12 in B-cell chronic lymphocytic leukemia: interphase study by in situ hybridization in 75 patients

Trisomy 12 is the most common cytogenetic abnormality in chronic lymphocytic leukaemia (CLL) and may be a prognostic indicator. In the present study, fluorescence in situ hybridization (FISH) is shown to be a method of choice for detection of trisomy 12 in interphase cells. Seventy-five cases of B-cell CLL were analysed with a chromosome 12 specific alpha satellite DNA probe and results compared with those from cytogenetic analysis. FISH showed the three hybridization spots characteristic of trisomy 12 in 32/75 patients (42.6%). Sixty-three patients were also studied by conventional cytogenetics: failure in 7 cases, normal karyotype in 28, trisomy 12 in 9 (14.3%) and in 19 cases abnormalities other than trisomy 12. In these same 63 patients, trisomy 12 was detected on 29 occasions by FISH (46%): in one case of failure by cytogenetic analysis, in 9 cases thought to have a normal karyotype, in 10 cases carrying abnormalities other than trisomy 12 and in all 9 cases showing trisomy 12 by conventional cytogenetic investigation. Correlation between trisomy 12 and the three stages of the Binet classification indicated an increasing proportion of trisomy 12 from stage A to stage C. It is concluded that fluorescence in situ hybridization is a powerful and sensitive technique for detection of trisomy 12 in CLL and although more cases will be required to confirm a correlation between the incidence of trisomy 12 and the stage of the disease, this link could be important from a prognostic point of view.

t(2;18) and t(18;22) variant chromosomal translocations in B cell malignancies

Variant translocations (2;18 and 18;22) are described in this review. The chromosomal and molecular findings of these translocation of BCL2 and their effect on possible BCL2 gene activation is discussed. Unanswered questions still remain and these include why this is so rare compared to the 25% incidence recorded for translocations in Burkitt's lymphoma. Further studies are obviously still needed in order to determine the true frequency of these findings and their distribution in the various B-cell disorders.

A case of myelodysplastic syndrome with abnormal megakaryocytes and ins(8;3)(q24;q21q26)

We report a 56-year-old male patient with refractory anemia with excess of blasts in transformation (RAEB-T) who had an ins(8;3)(q24;q21q26) as the sole chromosome abnormality in bone marrow (BM) cells. The findings of disturbed thrombocytopoiesis with numerous micromegakaryocytes suggest that it could be a variant of the classic ins(3;3)(q26;q21q26) described in hematologic malignancies with abnormal thrombopoiesis.

Comparison of a rehabilitation programme, a counselling programme and usual care after an acute myocardial infarction: results of a long-term randomized trial. P.RE.COR. Group

One hundred and eighty-two male post myocardial infarction patients under 65 years old were randomized 30 to 60 days after the acute event into a 6-week rehabilitation programme (RP), a counselling programme without exercise training training (CP) and usual care (UC). Follow-up visits and exercise tests on a bicycle ergometer were performed 2, 12 and 24 months after randomization. Baseline characteristics were identical in the three groups. The percentage of patients reaching the maximal heart rate at exercise test was higher in the RP group even after 2 years (UC = 24%, CP = 13%, RP = 50%, P = 0.001). The number of deaths at 2 years was respectively 4, 5 and 0 in the UC, CP and RP groups (P = 0.08). If UC and CP groups are combined and tested against RP the difference is statistically significant (P = 0.03). Reinfarction rates were similar in the three groups (UC = 10%, CP = 7%, RP = 7%). This study confirms that a rehabilitation programme seems worth recommending in young patients with uncomplicated myocardial infarction.

A complex t(3;8;17) involving breakpoint 8p11 in a case of M5 acute nonlymphocytic leukemia with erythrophagocytosis

The t(8;16)(p11;p13) is a recently described new chromosome rearrangement of acute nonlymphocytic leukemia (ANLL). It appears to be specifically associated with acute monoblastic (AML-M5) or unusual myelomonocytic leukemia with prominent erythrophagocytosis in the leukemic cells. A complex t(3;8;17)(q27;p11;q12) is reported in a case of acute monoblastic leukemia with erythrophagocytosis. Sixteen cases of this t(8;16) and two other variant translocations are reviewed. The pathogenetic mechanism of the variant translocations is discussed, suggesting that the der(8) is a consistent recombinant.

[The contribution of cytogenetics to the evaluation of residual disease in malignant hemopathies]

Autologous bone marrow transplantation is now a major tool in the treatment of human leukemias and lymphomas. Evaluation of residual disease by standard cytological methods is difficult. Cytogenetics provide clonal markers which are specific features of leukemic cells. Detection of minimal disease by chromosomal methods is possible in acute leukemias, it requires karyotyping of a few hundred metaphases from a short term culture. A preselection of the material to be examined will improve the degree of sensitivity of the method.

Prognostic factors in angioimmunoblastic lymphadenopathy

In order to identify prognostic factors in angioimmunoblastic lymphadenopathy (AIL), 30 directly diagnosed patients were prospectively followed for more than 42 months. Age and sex distribution, clinical and laboratory findings and evolution were not different from previously reported series. Median duration of survival was 24 months. Parameters associated with a longer survival in our series were localized adenopathies (P = 0.01) and the achievement of a remission (P less than 0.0001). Features associated with a shorter survival included drug exposure in relation to the onset of the disease (P = 0.02), rash (P less than 0.0001), lymph node eosinophilia (P = 0.03) and elevated serum lactic dehydrogenase (P = 0.03). Drug exposure and rash were, however, significantly dependent (P = 0.02). In addition, lymphopenia, the presence of circulating immune complexes, and the absence of polyclonal hypergammaglobulinemia may indicate a poor prognosis, although the significance level is not achieved in this short series. None of the parameters tested was significantly related to the lymphomatous transformation of AIL, which occurred in four cases. It is concluded that multicentric prospective studies of AIL are necessary in order to better define this disorder, to find prognostic factors, and to optimize therapy.

Persistence of t(4;11) in cytologically normal bone marrow treated ex vivo with Asta-Z

The chromosomal anomaly t(4;11) is closely related to a specific type of acute leukemia: occurrence in young children, hyperleukocytosis with a particular immunologic phenotype, and poor response to therapy. Allogeneic bone marrow (BM) transplantation has been done in a few cases. We report a case in which a complete remission was obtained after intensive therapy. Because no donor was available, an autologous BM transplantation was performed after purge ex vivo of the BM collection by Asta-Z. Relapse occurred at day 45.

Variant translocation in Burkitt's lymphoma: 8;22 translocation in a French patient with an Epstein-Barr virus-associated tumor

A variant translocation t(8;22)(q23;q11) has been found in tumor cells from a 19-year-old white man with an Epstein-Barr virus-associated Burkitt's lymphoma (BL). The tumor, which appeared 2 years after the patient had infectious mononucleosis, bore histopathological features characteristic of BL, although only the lymph nodes in the cervical region were involved. This case and some other recent cytogenetic observations of nonendemic BL emphasize the importance of chromosome #8 rearrangement in this B-cell-type lymphoma.

RBC filterability, oxygen saturation, ATP intracellular stock, and cerebral microcirculation

The filterability of erythrocytes through Nucleopore filters of 5 micrometer has been studied with a new device (Hemorheometer SPO1). A reliable and reproducible index of filterability (IF) can be obtained which depends only on the red blood cell deformability. The results showed an alteration of red blood cell deformability in some pathological circumstances like smoking and that deformability depends on the nature of haemoglobin, the ATP intracellar stock and the saturation of haemoglobin by oxygen. The cerebral microcirculatory consequences of alterations of red blood cell deformability has been studied in vitro by measuring whole blood filterability on 5 micrometer Nucleopore filters with the classical technic of Reid & Dormandy and in vivo by 99mTc cineangioscintigraphy and by determination of the regional cerebral blood flow by the 133Xenon inhalation technic. The results showed an increase of cerebral ascensional time and mean transit time of the cineangioscintigraphy and a decrease of regional cerebral blood flow in patients presenting with a decrease of whole blood filterability flow.