Low-burden TP53 mutations represent frequent genetic events in CLL with an increased risk for treatment initiation

TP53 aberrations predict chemoresistance and represent a contraindication for the use of standard chemoimmunotherapy in chronic lymphocytic leukaemia (CLL). Recent next-generation sequencing (NGS)-based studies have identified frequent low-burden TP53 mutations with variant allele frequencies below 10%, but the clinical impact of these low-burden TP53 mutations is still a matter of debate. In this study, we aimed to scrutinise the subclonal architecture and clinical impact of TP53 mutations using a sensitive, NGS-based mutation analysis in a 'real-world' cohort of 901 patients with CLL. In total, 225 TP53 mutations were identified in 17.5% (158/901) of the patients; 48% of these alterations represented high-burden mutations, while 52% were low-burden TP53 mutations. Low-burden mutations as sole alterations were identified in 39% (62/158) of all mutated cases with 82% (51/62) of these being represented by a single low-burden TP53 mutation. Patients harbouring low-burden TP53 mutations had significantly lower time to first treatment compared to patients with wild-type TP53. Our study has expanded the knowledge on the frequency, clonal architecture, and clinical impact of low-burden TP53 mutations. By demonstrating that patients with sole low-burden TP53 variants represent more than one-third of patients with TP53 mutations and have an increased risk for treatment initiation, our findings strengthen the need to redefine the threshold of TP53 variant reporting to below 10% in the routine diagnostic setting.

Beneficial Effect of Lenalidomide-Dexamethason Treatment in Relapsed/Refractory Multiple Myeloma Patients: Results of Real-Life Data From 11 Hungarian Centers

In Hungary, the cost of lenalidomide-based therapy is covered only for relapsed multiple myeloma (MM) patients, therefore lenalidomide is typically used in the second-line either as part of a triplet with proteasome inhibitors or as a doublet. Lenalidomide-dexamethasone is a standard treatment approach for relapsed/refractory MM, and according to recent large randomized clinical trials (RCT, the standard arm of POLLUX, ASPIRE, TOURMALINE), the progression-free survival (PFS) is expected to be approximately 18 months. We surveyed ten Hungarian centers treating MM and collected data of 278 patients treated predominantly after 2016. The median age was 65 years, and patients were distributed roughly equally over the 3 international staging system groups, but patients with high risk cytogenetics were underrepresented. 15.8% of the patients reached complete response, 21.6% very good partial response, 40.6% partial response, 10.8% stable disease, and 2.5% progressed on treatment. The median PFS was unexpectedly long, 24 months, however only 9 months in those with high risk cytogenetics. We found interesting differences between centers regarding corticosteroid type (prednisolone, methylprednisolone or dexamethasone) and dosing, and also regarding the choice of anticoagulation, but the outcome of the various centers were not different. Although the higher equivalent steroid dose resulted in more complete responses, the median PFS of those having lower corticosteroid dose and methylprednisolone were not inferior compared to the ones with higher dose dexamethasone. On multivariate analysis high risk cytogenetics and the number of prior lines remained significant independent prognostic factors regarding PFS (p < 0.001 and p = 0.005). Our results show that in well-selected patients Lenalidomide-dexamethasone can be a very effective treatment with real-world results that may even outperform those reported in the recent RCTs. This real world information may be more valuable than outdated RCT data when treatment options are discussed with patients.

Carboxiterminal pro-endothelin-1 as an endothelial cell biomarker in thrombotic thrombocytopenic purpura

Thrombotic thrombocytopenic purpura (TTP) is characterised by the deficiency of the von Willebrand factor (VWF) cleaving protease (ADAMTS-13). Although several observations indicate an important role of endothelial activation in the pathogenesis of TTP, no reliable endothelial activation markers are available in the clinical management of TTP. Our aim was to investigate the presence of endothelial activation in TTP and to determine its connections with disease activity, therapy and complement activation. We enrolled 54 patients (median age 40.5; 44 females) and 57 healthy controls (median age 34; 30 females),VWF antigen, carboxiterminal-pro-endothelin-1 (CT-proET-1), complement Factor H and complement activation products (C3bBbP and SC5b-9) were measured. In both the acute and remission phase of TTP we found increased CT-proET-1 and VWF levels, while Factor H levels decreased compared with healthy controls. In remission, however, the elevated CT-proET-1 levels showed 22 % decrease when compared with the acute phase in paired samples (p=0.0031), whereas no changes for VWF and Factor H levels were observed. We also found positive correlations between CT-proET-1 levels and alternative pathway activation markers (C3bBbP; p=0.0360; r=0.4299). The data we present here demonstrate a role of endothelium activation in patients with acute TTP. The finding that CT-proET-1 levels decreased in remission compared with the acute phase further supports endothelial involvement. In addition, we show that endothelial activation also correlated with the activation of the alternative complement pathway. The data suggest that complement and endothelium activation jointly contribute to the development of TTP episodes in patients with predisposition to TTP.

Common large partial VWF gene deletion does not cause alloantibody formation in the Hungarian type 3 von Willebrand disease population

BACKGROUND

Type 3 von Willebrand disease (VWD) is an autosomal recessive bleeding disorder, characterized by virtually undetectable plasma von Willebrand factor (VWF) and consequently reduced plasma factor VIII levels. Genetic mutations responsible for type 3 VWD are very heterogeneous, scattered throughout the VWF gene and show high variability among different populations.

METHODS

Twenty-five severe VWD patients were studied by direct sequencing of the 51 coding exons of the VWF gene. The total number of VWD type 3 families in Hungary is 24, of which 23 were investigated.

RESULTS

Fifteen novel mutations were identified in 31 alleles, five being nonsense mutations (p.Q1238X, p.Q1898X, p.Q1931X, p.S2505X and p.S2568X), four small deletions and insertions resulting in frame shifts (c.1992insC, c.3622delT, c.5315insGA and c.7333delG), one a large partial deletion (delExon1-3) of the 5'-region, four candidate missense mutations (p.C35R, p.R81G, p.C295S, p.C623T) and one a candidate splice site mutation (c.1730-10C>A). Six previously described mutations were detected in 17 alleles, including the repeatedly found c.2435delC, p.R1659X and p.R1853X. Only one patient developed alloantibodies to VWF, carrying a homozygous c.3622delT.

CONCLUSION

We report the genetic background of the entire Hungarian type 3 VWD population. A large novel deletion, most probably due to a founder effect, seems to be unique to Hungarian type 3 VWD patients with high allele frequency. In contrast to previous reports, none of the five patients homozygous for the large partial deletion developed inhibitors to VWF. This discrepancy raises the possibility of selection bias in some of the reports.

[Diagnosis, care, and therapeutic possibilities in intravascular B-cell lymphoma--a case report]

The cutaneous angiotropic lymphoma has a poor prognosis. The diagnosis and the treatment are usually late. The mortality rate is over 80% and the majority of patients die within a year because of the tumorous infiltration of parenchymal organs. The authors report here the medical history and follow up of a still living patient suffering from cutaneous angiotropic lymphoma which has been diagnosed sixty months ago. During the successful treatment course systemic treatment with psoralen ultraviolet A-rays, chlorambucil and cyclophosphamide-doxorubicin-vincristine-methylprednisolone chemotherapy was applied, and for the management of the last relapse, rituximab-cyclophosphamide-doxorubicin-vincristine-methylprednisolone polychemotherapy was used. On the basis of findings in this case a treatment using an anti-CD20 monoclonal antibody could be a promising therapeutic alternative in the management of angiotropic B-cell lymphoma which otherwise considered to be a rare entity.

Increased incidence of monoclonal B-cell infiltrate in chronic myeloproliferative disorders

A total of 106 trephine biopsy specimens with clinical, laboratory and pathology findings corresponding to chronic myeloproliferative disorders (CMPD) were analyzed to reveal the nature of the lymphoid infiltrate in the bone marrow. Histological investigation in 31 chronic myeloid leukemia (CML), 29 CMPDs not otherwise specified (CMPD-NOS), 28 essential thrombocytosis (ET), 15 polycythemia vera (PV) and three chronic eosinophilic leukemia/hypereosinophilic syndrome (CEL/HES) exhibited in 32% various amounts of lymphocytic infiltrate of sparsely to moderately diffuse or nodular types in the bone marrow, but the reactive or coinciding lymphomatous nature could not be revealed by histology alone in the majority of cases. PCR analysis of the immunoglobulin heavy chain (IgH) gene rearrangement was successfully performed in 81 out of the 106 DNA specimens extracted from formol-paraffin blocks. Out of the 81 samples with good-quality DNA, 18 gave a single or double discrete amplification band(s), which was reproducible only in four specimens. Sequencing finally proved monoclonal B-cell population of both pre- and postfollicular origin in all four samples (5%), one CML and three CMPD-NOS. Detailed clinical and pathological investigations indicated overt B-cell malignant lymphoma with clonal relationship to the CMPD in two out of these four patients. We conclude that detailed molecular analysis of IgH gene rearrangement in bone marrow samples of CMPD patients is needed to identify the true monoclonal B-cell infiltration, which-even without overt malignant lymphoma-may occur in this group of disorders. Modern Pathology (2004) 17, 1521-1530, advance online publication, 16 July 2004; doi:10.1038/modpathol.3800225.

Philadelphia chromosome and/or bcr-abl mRNA-positive primary thrombocytosis: morphometric evidence for the transition from essential thrombocythaemia to chronic myeloid leukaemia type of myeloproliferation

AIMS

The incidence, bone marrow morphology and genetic features of bcr+ essential thrombocythaemia were investigated.

METHODS AND RESULTS

Sixty-four consecutive patients meeting the criteria of essential thrombocythaemia have been investigated for bcr-abl rearrangement and chimera mRNA expression. Reverse transcriptase-polymerase chain reaction indicated bcr-abl expression in six patients, in two of whom large fraction of the blood and bone marrow cells proved to be positive for Philadelphia chromosome (Ph) by fluorescent in-situ hybridization (FISH) and conventional cytogenetic analysis. In the remaining four patients FISH analysis could not detect Ph+ cells among the blood cells, but in one of these four patients conventional cytogenetic analysis indicated a very small fraction (2%) of Ph+ mitoses in the bone marrow (bcr+ essential thrombocythaemia patients). In three of these four patients, X-chromosome-linked clonality assay showed that the disease is of uncommitted stem cell origin. During an average of 57 month long follow-up no transformation to chronic myeloid leukaemia type of disease or acceleration/blastic crisis could be observed in the four bcr+ essential thrombocythaemia patients. They did not differ significantly from typical essential thrombocythaemia patients in quantitative indices of bone marrow cellularity or the size of megakaryocytes. In these two parameters as well as in the total nucleolus organizer region area per nucleus, however, significant differences could be detected between these four as well as typical chronic myeloid leukaemia patients. Statistical analysis of the morphometric data obtained from all six Ph+ and bcr+ essential thrombocythaemia patients combined indicated a shift of the bone marrow morphology towards the chronic myeloid leukaemia type of myeloproliferation.

CONCLUSIONS

These investigations indicate that bcr+ essential thrombocythaemia is infrequent among essential thrombocythaemia patients, and this condition resembles essential thrombocythaemia more than chronic myeloid leukaemia. Various expansions of the Ph+ clone appear to lead to either essential thrombocythaemia or, rather, chronic myeloid leukaemia type of myeloproliferation; however, data in the present study do not indicate that bcr+ essential thrombocythaemia would be a form fruste variant of chronic myeloid leukaemia.

Intravascular B-cell lymphoma

Intravascular (angiotropic) lymphoma is a unique and rare cutaneous lymphoma in which the malignant T or B lymphoid cells proliferate within the lumens of small blood vessels, primarily in the skin and central nervous system. Erythematous, tender nodules, tumors, and telangiectases are the most common skin symptoms in addition to various neurologic signs. Progression of the disease produces secondary organ involvement with variable symptoms and can be fatal. We describe a case of a 74-year-old woman with edematous, infiltrated, orange-like skin with multiple telangiectases, generalized edema, severe weakness, and extremely high values of lactate dehydrogenase. Skin biopsy specimens revealed atypical large cells filling up the lumens of dermal capillaries. Immunohistochemical investigation results identified them as B cells with CD20, CD45, CD79a, Ki-67, and HLA-DR positivity. After administration of diuretics, colchicine, and systemic PUVA therapy, the patient lost her edema, her skin became tender and free of telangiectases, and laboratory alterations normalized. Because of heavy neuralgia in her legs, oral monochemotherapy was introduced with chlorambucil, and now the patient is in remission.

Coexistence of chronic myeloid leukemia and hairy cell leukemia of common clonal origin

The history of a forty year old patient is presented who was admitted with a clinical picture of chronic myeloid leukemia (CML). Laboratory findings, bone marrow morphology and molecular investigations supported this diagnosis, including b3/a2 as well as b2/a2 chimeric mRNA expression in support of a Philadelphia chromosome positive chronic myeloproliferation. In a fraction of the bone marrow content, however, an infiltrate different from that of CML could be seen. In addition, the morphology, cytochemistry, immunophenotyping and molecular analysis indicated that the coexisting neoplasia is hairy cell leukemia (HCL). Cell lineage specific interphase cytogenetic analysis proved a clonal relationship between the two neoplasias in a way that the HCL arose from one of the B-cells which, based on two cytogenetic markers, belonged to the original CML clone.

[Screening for carrier state of Haemophilia B using indirect genomic detection]

The authors report the first data having applied the indirect genomic diagnosis in carrier screening in Hungary. 22 patients with haemophilia B and female family members of 14 out of them were examined by PCR based restriction fragment length polymorphism analysis. The combined use of 3 intra- and 1 extragenic polymorphisms have been examined at the same population. DNA fragments, containing the single nucleotide change polymorphic site (Xmnl, Hhal, Taql), or the 50 bp insertion/deletion element (Dde) were amplified. The products were digested by the appropriate restriction digestion enzyme and were detected on agarose gel following ethidium-bromide staining. 20 siblings were interested in the determination of their carrier-state. 15 (75%) of them could get definite diagnosis. The carrier-state was established in 7 cases, excluded in 8 subjects. For the remaining 5 participants studied, the absence of the parental DNA sample caused uncertainty, while in 2 cases (10%) none of the analyzed RFLP was informative. The heterozygosity rate, the gene and haplotype frequency were also recorded and compared with the international data. The indirect methods have proved to be sufficient and well suitable for routine carrier testing. The results provide the basis of the subsequent prenatal diagnosis.

[Detection of minimal residual diseases in B-cell tumors using PCR specific for the immunoglobulin heavy chain gene]

In B-cell non-Hodgkin's lymphomas (NHL), clonal rearrangement of the immunoglobulin heavy chain (IgH) gene provides a useful marker for the detection of minimal residual disease (MRD) after treatment. To explore clinical usefulness of polymerase chain reaction (PCR) analysis of clonal IgH gene rearrangement in the detection of MRD a follow up study of 10 patients with B-cell NHL have been performed. At the time of diagnosis, tumor DNAs were PCR-amplified using sense primer specific for the heavy chain variable region (VH) and antisense primer specific for the heavy chain joining region (JH) of the IgH gene. The clonal rearrangement of IgH gene detected by PCR was used as clonal marker to determine MRD after treatment. In three cases, where clinical remission was not achieved, clonal IgH gene rearrangement was detected after the treatment. In seven cases, clinical remission was achieved after induction therapy but the PCR analysis revealed clonal IgH gene rearrangement in three of the cases. In all of the three cases, where MRD was detected by PCR, clinical relapse developed after 7-28 months of the therapy. In all cases that have relapsed, the IgH gene rearrangement was identical at the time of initial diagnosis and at the relapse. This study demonstrates that PCR analysis of clonal IgH gene rearrangement is a useful method to monitor and detect MRD before clinical relapse.

[Detection of t(14;18) chromosome translocation in follicular lymphoma by polymerase chain reaction]

In most cases of centroblastic/centrocytic follicular lymphomas the bcl-2 proto-oncogene (18q21) is translocated to the immunoglobulin JH region of chromosome 14 (14q32). About three quarters of the translocations are concentrated on the 3' nontranslated, a few hundred basepare-long region of bcl-2, the so called major breakpoint region (mbr), the remaining 20-25% is located about 30 kilobases downstream of bcl-2 coding sequences in the minor cluster region (mcr). The majority of the immunoglobulin breakpoints can be found in JH6-4 genes. The polymerase chain reaction method can detect the translocation already in a very few number of cells (> 10(3)). This very sensitive technique makes it possible to detect the translocation in lymphoid/lymphoma of peripheral blood and bone marrow that are missed by other diagnostic methods. This way one can perform a quick, early diagnosis, examine the result of treatments as well as detect the remissions and the possible relapses right at the beginning. All the advantages of this method contribute to a more successful treatment of follicular lymphoma. This present work describes a polymerase chain reaction technique which is capable of a detection of the t(14;18) translocation in a patient of centroblastic/centrocytic lymphoma, moreover shows how this translocation disappears after 4 week of radiotherapy of the patient.

[Bronchoalveolar lavage in the confirmation of pulmonary involvement in chronic lymphoid leukemia]

The authors made bronchoalveolar lavage (BAL) for explaining the origin of diffuse bilateral lung--infiltration in patients with chronic lymphoid leukaemia. On the base of lavage-fluid, the lung damage may be caused by leukaemic infiltration. The lesion has not changed by antibiotic therapy, but was radiologically cured after giving corticoids. The authors have not read about approaching chronic lymphoid leukaemic pulmonary infiltration by BAL. They call attention to the etiologic clarification of lung organs' complications in haematological aspects and outstanding role of BAL as a non-invasive method.

[Results of multicenter treatment of highly malignant non-Hodgkin's lymphomas]

One hundred and eleven consecutive patients with highgrade non-Hodgkin's lymphoma treated in three centres between 1983 and 1988 were analysed to assess the efficacy of different types of chemotherapy. The median age at presentation was 56.9 +/- 16.6 years. According to the Kiel classification histological subtypes were: centroblastoma (n = 45), immunoblastoma (n = 17), lymphoblastoma (n = 6), T cell lymphoblastoma (n = 9), histiocytoma (n = 2), and high grade unclassified (n = 32). Patients were clinically staged, 68 patients (61%) belong to stage I-II. and 43 had widespread disease (stage III-IV.). Remission was achieved in 81 cases [70 complete (CR) and 11 partial (PR) remission], 30 patients did not respond. The most effective modality of treatment was extended field irradiation completed with chemotherapy (81% CR, 7-year overall survival 65%) followed by ProMACE-COPP chemotherapy (67% CR, 4-year survival 40%) and CHOP-Bleo chemotherapy (65% CR, 7-year survival 25%). Age and histological subtype had no prognostic relevance, whereas clinical stage proved to have significant influence on remission and survival.

Comprehensive epidemiological and clinicopathological survey of Hodgkin's disease in Hungary

To determine the epidemiological pattern and some clinicopathological features of Hodgkin's disease in Hungary, the data of 233 consecutive patients with the disease from seven counties, diagnosed between January 1983 and July 1987, were analysed on the basis of data from four cancer centers. Large variations were noted in incidence rates between the different regions of Hungary. The epidemiological pattern seems to vary from those reported in developed and developing countries. A sharp rise in the incidence of Hodgkin's disease occurred at the end of the second decade of patients' lives. More of our Hodgkin's patients are at advanced clinical stages, with systemic symptoms and a histological type of mixed cellularity, at the time of diagnosis, than in the western hemisphere. On the average, there is a 6-month period between the appearance of the first sign or symptom and the diagnosis. There is a lack of data outlining the epidemiological differences in the pattern of Central Europa. The aim of this study is to supply data for the etiopathogenetic research of Hodgkin's disease, as there is an important task to improve the unfavourable home situation, and to strive for earlier diagnosis in this disease.

[Comprehensive epidemiologic and clinico-pathologic study of Hodgkin's disease]

To determine the epidemiologic pattern and some clinicopathologic features of Hodgkin's disease (HD) in Hungary, the data of 233 consecutive patients with HD, diagnosed between January 1983 and July 1987 from seven county were analysed on the basis of data from 4 cancer centers. Large variations have shown in incidence rates within different regions of Hungary. The epidemiologic pattern seems to vary from those reported in developed and developing countries. A sharp rise in HD incidence occurs already at the end of second decade. More Hodgkin's patients have advanced clinical stages, systemic symptoms, mixed cellularity histologic type at the time of diagnosis than in Western hemisphere. On the average, there is a six months period between the appearance of the first sign or symptom and the diagnosis. There is a lack of data outlining the epidemiologic difference in the pattern of Central Europe. The aim of this study was to supply data for the etiopathogenetic research of HD. There is an important task to improve the unfavourable home situation, to strive to earlier diagnosis in HD.