Search

Les recommandations de la Societe de Reanimation en Langue Francaise (SRLF) [1], publiees en 2002, concernant les limitations et arrets de therapeutiques actives en reanimation adulte, sont a ce jour une initiative unique qui a modifie les pratiques professionnelles des services de reanimation. Dans un contexte different, de nombreuses situations posent au quotidien, dans les services d’hematologie, le probleme de la proportionnalite des soins et d’une eventuelle obstination deraisonnable, encore appelee communement acharnement therapeutique. En hematologie comme dans d’autres disciplines, cette conduite therapeutique peut etre cause de souffrance chez les malades, leurs familles et les soignants eux-memes, et souleve de graves problemes ethiques. C’est pourquoi le premier objectif du groupe Ethique de la Societe Francaise d’Hematologie (SFH), cree par son conseil d’administration en fevrier 2004, a ete de proposer a la discipline une reflexion et des recommandations. Ce texte a ete redige en s’inspirant du texte de la SRLF [1], des reflexions et de l’experience des membres du groupe et des donnees de la litterature. Il sera presente aux membres du conseil d’administration de la SFH et diffuse au sein de la discipline « hematologie ». Ce projet est apparu particulierement necessaire avec l’apparition de nouveaux textes legislatifs (en particulier la loi du 4 mars 2002), l’avis n° 60 du Comite Consultatif National d’Ethique du 27 janvier 2000 intitule « Fin de vie, arret de vie, euthanasie », la publication des recommandations de la Conference de consensus de l’ANAES des 14 et 15 janvier 2004 sur l’Accompagnement des patients en fin de vie et de leurs proches et la proposition de loi n° 1882 du 30 novembre 2004 relative aux droits des malades et a la fin de vie. Ce texte est propose comme une incitation a la reflexion plutot que comme une serie de recommandations qui s’ajouteraient aux textes officiels actuels ou en cours d’elaboration.

hma.2011.0608 Auteur(s) : Chantal Bauchetet, Dominique Bordessoule, Philippe Casassus, Joel Ceccaldi, Morgane Cheminant, Christian Bastard, Philippe Colombat, Diane Damotte, Eric Fiat, Dominique Jaulmes, Jean-Pierre Jouet, Sandra Malak, Genevieve Margueritte, Sarah Morin, Alice Polomeni, Henri Rochant, Jean-Jacques Sotto JJSotto@chu-grenoble.fr, Marc Zandecki, Robert Zittoun Commission d’ethique de la Societe francaise d’hematologie Tires a part : J. Sotto Notre pratique quotidienne [...]

Resume Propos. – Decrire les principales caracteristiques et les modalites evolutives des anemies hemolytiques auto-immunes (AHAI) de l’adulte et evaluer la pertinence et la rentabilite des examens complementaires realises a la recherche d’une maladie sous-jacente. Methodes. – Etude retrospective (1980–2000) monocentrique. Criteres d’inclusion : âge superieur a 16 ans, AHAI definie par une anemie (hemoglobine ≤ 12 g/dl chez l’homme, a 11 g/dl chez la femme) de type hemolytique, associee a un test de Coombs direct positif et/ou la presence d’agglutinines froides a un taux significatif (≥ 1/500) et/ou apres avoir elimine toute autre cause d’hemolyse constitutionnelle ou acquise. Resultats. – Quatre-vingt-trois patients inclus (56 femmes, 27 hommes), d’âge moyen 56 ans (± 21) au diagnostic, repartis en 72 (87 %) AHAI a anticorps « chauds » et 11 (13 %) maladies des agglutinines froides. Duree moyenne de suivi egale a 48 mois (mediane : 22 mois). Parmi les 72 AHAI « chaudes », la specificite du test de Coombs direct etait : IgG + complement (43 %), IgG seul (32 %) ou complement seul (25 %), des agglutinines froides etaient associees (taux :1/60 a 1/512) dans 15 cas (20 %). Les anticorps antinoyaux (AAN) etaient positifs (taux ≥ 1/80) chez 33 % des patients testes. La presence d’une hypogammaglobulinemie sur l’electrophorese des proteines plasmatiques (EPP) etait significativement correlee a la presence d'un lymphome malin non hodgkinien (LMNH). La tomodensitometrie (TDM) thoracoabdominale, realisee chez la moitie des patients, retrouvait une anomalie autre qu’une splenomegalie dans 25 % des cas. La biopsie medullaire (BOM) etait anormale dans 7/26 cas (27 %) mais permettait de porter a elle seule le diagnostic de LMNH dans 1 seul cas. Sur les 72 AHAI « chaudes », 37 (51 %) etaient finalement considerees comme « secondaires »: LMNH (n = 14), Hogdkin (n = 1), connectivite (n = 14), prise medicamenteuse (n = 3), causes diverses (n = 5). Dans 6 cas sur 14 (43 %), le diagnostic d’AHAI precedait le diagnostic de LNH, avec des delais variant de 24 a 66 mois. Les reponses aux differents traitements etaient comparables dans les AHAI « primitives » et « secondaires ». Treize patients (15,6 %) sont decedes au total, de complications infectieuses (n = 5), du LMNH sous-jacent (n = 5), ou d’autres causes (n = 3). Conclusions. – Les AHAI s’associent a une maladie sous-jacente dans plus de la moitie des cas et elles peuvent preceder de plusieurs annees l’apparition d’un lymphome. En dehors d’une cause evidente, la realisation systematique de la recherche d’AAN, d’une EPP et d’une TDM thoracoabdominale se justifie. En cas de normalite de ces examens, la realisation systematique d’une BOM parait tres peu rentable.

A prospective study of autologous bone marrow or peripheral blood stem cell transplantation after intensive chemotherapy in myelodysplastic syndromes

Admission of patients with hematological malignancies to intensive care unit (ICU) raises recurrent ethical issues for both hematological and intensivist teams. The decision of transfer to ICU has major consequences for end of life care for patients and their relatives. It also impacts organizational human and economic aspects for the ICU and global health policy. In light of the recent advances in hematology and critical care medicine, a wide multidisciplinary debate has been conducted resulting in guidelines approved by consensus by both disciplines. The main aspects developed were (i) clarification of the clinical situations that could lead to a transfer to ICU taking into account the severity criteria of both hematological malignancy and clinical distress, (ii) understanding the process of decision-making in a context of regular interdisciplinary concertation involving the patient and his relatives, (iii) organization of a collegial concertation at the time of the initial decision of transfer to ICU and throughout and beyond the stay in ICU. The aim of this work is to propose suggestions to strengthen the collaboration between the different teams involved, to facilitate the daily decision-making process, and to allow improvement of clinical practice.

To describe the main characteristics and outcome of adult's acquired immune hemolytic anemias (AIHA). To analyse the relevance of the complementary tests performed for the search of an underlying disease.Retrospective (1980-2000) monocentric study.age above 16, AIHA defined by an hemoglobin level below 12 g/dl in men and 11 g/dl in women, with hemolysis and/or a positive direct Coombs test and/or the presence of cold agglutinins (threshold 1/500) and/or in the absence of any other cause.Eighty three patients included (56 women and 27 men), with a mean age of 56 years (+/- 22) at AIHA onset including: 72 patients (87%) with warm antibody AIHA and 11 (13%) with cold agglutinin disease. The mean follow-up was 48 months (median 22 months). Among the 72 patients with warm antibody AIHA, the specificity of autoantibodies was: IgG + complement (43%), IgG (32%) or complement alone (25%); cold agglutinins (titre from 1/60 to 1/512) were detected in 15 (20%) of the patients. Antinuclear antibodies were detected (threshold: 1/80) in 33% of the cases. Hypogammaglobulinemia on serum protein electrophoresis (SPE) was significantively associated with the presence of an underlying non-Hogkin lymphoma (NHL). The CT-scan of the the chest and abdomen which was performed in 50% of the patients, showed abnormalities other than a spleen enlargement in 25% of the cases. The medullar biopsy (MB) was abnormal in 7 of 26 cases (27%) but lead by itself to the diagnosis of NHL in a single case. Thrirty seven (51%) of warm antibody AIHA cases were finally considered to be "secondary" to an underlying disease namely: NHLs (n = 14), Hogkin's disease (n = 1) connective tissue disease (CTD) (n = 14), drug-induced AIHA (n = 3), miscellaneous (n = 5). In 6 out of 14 cases (43%) of NHL's associated AIHA, the onset of AIHA precedes the NHL from 22 to 66 months. The response rates to different therapeutic regimens did not significatively differ when "secondary" and "idiopathic" AIHA were compared. Overall, 13 patients (15.6%) died mainly from infectious complications (n = 5) or an underlying NHL (n = 5).In more than half of the cases AIHA are associated with an underlying disease and AIHA may precede the onset of a NHL for a long period. In the absence of a clinically apparent underlying disorder, testing for the presence of antinuclear antibodies, a SPE and a CT-scan must be systematic. Conversely, if no abnormalities are found, the relevance of a systematic MB at AIHA onset seems very low.

From the beginning of the century, autoimmune haemolytic anaemia (AIHA) was the first model of an auto-antibody mediated disease. Despite the variety of the clinical features, the diagnosis of AIHA provides few difficulties since the introduction of the popular Coombs' test. The clinical presentation of AIHA depends on the subclass type and on the thermal range activity of the causative auto-antibody, so that two main pictures occur usually: warm auto-antibody and cold auto-antibody types, the latter being less frequent than the former. In more than half the cases, AIHA is associated with another disease that must be considered more as the background of immune dysregulation than the cause of the disease. Systemic disorders, chronic lymphoid malignancy, primitive or acquired immunodeficiencies are the most common disorders associated with AIHA. Acute infections or drugs may give rise to acute transient AIHA. The clinical aspects and the links between AIHA and associated diseases are emphasised. No decisive advancement in therapy has arisen over the last decades. Some patients are still resistant to all therapeutic manoeuvres and may die. Much labour is to be done in order to discover more rational methods of therapy to restore a state of normal tolerance towards erythrocyte auto-antigens. Suppressing the production of pathogenic auto-antibodies by immunomodulation may be the first step of this task.

The CML 88 study was designed to evaluate the efficacy of maintenance therapy in a multicentric randomised protocol using IFN combined with low-dose Ara-C versus IFN alone, following an induction with IFN + HU. Between April 1988 and February 1991, 237 patients from 36 French Hematology Centres were entered in the study. Preliminary cytogenetic results show a slightly higher, although not statistically significant, proportion of major chromosomal responses, including complete cytogenetic remissions, in the IFN + Ara C arm.

We designed a randomized trial of IC with or without quinine, an agent capable of reverting the multidrug resistance (mdr) phenotype, in patients agedor = 65 years with high risk MDS. Patients were randomized to receive Mitoxantrone 12 mg/m2/d d2-5 + AraC 1 g/m2/12 h d1-5, with (Q+) or without (Q-) quinine (30 mg/kg/day). 131 patients were included. PGP expression analysis was successfully made in 91 patients and 42 patients (46%) had positive PGP expression. In PGP positive cases, 13 of the 25 (52%) patients who received quinine achieved CR, as compared to 3 of the 17 (18%) patients treated with chemotherapy alone (p = 0.02). In PGP negative cases, the CR rate was 35% and 49%, respectively in patients who received quinine or chemotherapy alone (difference not significant). In the 42 PGP positive patients, median Kaplan-Meier (KM) survival was 13 months in patients allocated to the quinine group, and 8 months in patients treated with chemotherapy alone (p = 0.01). In PGP negative patients, median KM survival was 14 months in patients allocated to the quinine group, and 14 months in patients treated with chemotherapy alone. Side effects of quinine mainly included vertigo and tinnitus that generally disappeared with dose reduction. Mucositis was significantly more frequently observed in the quinine group. No life threatening cardiac toxicity was observed. In conclusion, results of this randomized study show that quinine increases the CR rate and survival in PGP positive MDS cases treated with IC. The fact that quinine had no effect on the response rate and survival of PGP negative MDS suggests a specific effect on PGP mediated drug resistance rather than, for instance, a simple effect on the metabolism of Mitoxantrone and/or AraC.

We prospectively assessed autologous stem cell transplantation for consolidation treatment in a trial of intensive chemotherapy in high risk myelodysplastic syndromes (MDS). In this trial, patients aged 55 years or less with no HLA-identical sibling and achieving CR were scheduled to receive unmanipulated autologous bone marrow transplantation (ABMT) preceded by a consolidation chemotherapy course. Forty-two of the 83 patients aged 55 years or less included in the trial (51%) achieved CR. Three were allografted in CR. Twenty-four of the remaining 39 patients who achieved CR (62%) received ABMT (16 patients) or autologous peripheral blood stem cell transplantation (APSCT) (eight patients). Indeed, as bone marrow harvest was often insufficient, APSCT was subsequently proposed after mobilization by consolidation chemotherapy followed by G-CSF. The conditioning regimen combined cyclophosphamide and busulfan. ABMT and APSCT were performed 1-7 months (median 3) after CR achievement. Hematological reconstitution occurred in all patients and tended to be faster after APSCT than ABMT although not significantly. Three patients died from the procedure, nine relapsed after 2-26 months and 12 (50%) were still in CR after 8-55 months. In autografted patients, median Kaplan-Meier disease-free survival and survival were 29 and 33 months from the autograft, respectively. Thus, ABMT or APSCT can be performed in almost two-thirds of MDS patients who achieve CR with intensive chemotherapy. PBSC collection may yield higher numbers of stem cells than marrow collection in some cases, and could improve the percentage of MDS patients autografted in CR. Longer follow-up is required to determine if autograft will prolong CR duration in at least some patients.

We designed a randomized trial of IC with or without quinine, an agent capable of reverting the multidrug resistance (mdr) phenotype, in patients aged < 65 years with high risk MDS. Patients were randomized to receive Mitoxantrone 12mg/m2/d d2–5 + AraC 1g/m2/12h d1–5, with (Q+) or without (Q) quinine (30mg/kg/day). 131 patients were included. PGP expression analysis was successfully made in 91 patients and 42 patients (46%) had positive PGP expression. In PGP positive cases, 13 of the 25 (52%) patients who received quinine achieved CR, as compared to 3 of the 17 (18%) patients treated with chemotherapy alone (p=0.02). In PGP negative cases, the CR rate was 35% and 49%, respectively in patients who received quinine or chemotherapy alone (difference not significant). In the 42 PGP positive patients, median Kaplan-Meier (KM) survival was 13 months in patients allocated to the quinine group, and 8 months in patients treated with chemotherapy alone (p=0.01). In PGP negative patients, median KM survival was 14 months in patients allocated to the quinine group, and 14 months in patients treated with chemotherapy alone. Side effects of quinine mainly included vertigo and tinnitus that generally disappeared with dose reduction. Mucositis was significantly more frequently observed in the quinine group. No life threatening cardiac toxicity was observed. In conclusion, results of this randomized study show that quinine increases the CR rate and survival in PGP positive MDS cases treated with IC. The fact that quinine had no effect on the response rate and survival of PGP negative MDS suggests a specific effect on PGP mediated drug resistance rather than, for instance, a simple effect on the metabolism of Mitoxantrone and/or AraC.

Although the FAB classification of the myelodysplastic syndromes (MDS) allows to classify most patients, a few clinical patterns do not fit the FAB categories, including borderline forms with manifestations usually seen in other diseases and forms with atypical or unusual clinical or laboratory features that do not immediately suggest a MDS. Borderline forms are characterized by the presence of any of the following: high or very high platelet counts, myelofibrosis, bone marrow hypoplasia, eosinophilia, or systemic diseases such as relapsing polychondritis. Unusual or atypical forms include manifestations such as hemolysis, high reticulocyte counts, erythroblastopenia, or an abnormality of a single cell line such as isolated thrombocytopenia, isolated neutropenia, or isolated macrocytosis. The definitive diagnosis of these forms of MDS can require a number of investigations such as cytogenetic studies, bone marrow biopsy, and/or radionuclide evaluation, and may not be possible until the patient has been followed for some time.

Low-dose chemotherapy in myelodysplastic syndromes (MDS) gives overall limited results in high-risk MDS [1–3]. Intensive chemotherapy in MDS and secondary leukemias (i.e., acute myeloid leukemia, AML, following de novo or therapy-related MDS) gives lower complete remission (CR) rates and shorter CR duration than in de novo AML [4–11]. This may be due in part to a higher incidence of mdr gene expression in MDS than in de novo AML as mdr gene expression is associated in our experience, with very low CR rates with intensive chemotherapy [12]. These recent results suggested that the use of agents capable of reverting mdr gene expression could improve the CR rate in MDS and secondary leukemias.

Paroxysmal nocturnal haemoglobinuria (PNH) is a rare acquired disorder of haematopoietic stem cells. Although knowledge about the pathophysiology of the disease is increasing, no multivariate analysis of factors influencing survival has been undertaken, mainly because the disease is rare. We undertook such an investigation.Data were collected on 220 patients with PNH diagnosed over a 46-year period (1950-1995) from participating French centres. Diagnosis of the disease required, at least, an unequivocally positive Ham's test.The Kaplan-Meier survival estimate was 65% (SE 4) at 10 years and 48% (6) at 15 years after diagnosis. 8-year cumulative incidence rates of the main complications (pancytopenia, thrombosis, and myelodysplastic syndrome) were 15% (3), 28% (4), and 5% (2), respectively. Demographic data, presenting features, initial treatment, complications, and causes of death were similar to those previously reported. In multivariate analysis, seven factors were significantly associated with survival in patients with PNH. Poor survival was associated with the occurrence of thrombosis as a complication (relative risk 10.2 [95% CI 6-17], p0.0001), evolution to pancytopenia (5.5 [2.8-11], p0.0001), myelodysplastic syndrome or acute leukaemia (19.1 [7.3-50], p0.001), age over 55 years at diagnosis (4 [2.4-6.9], p0.0001), need for additional treatment (2.1 [1.3-3.6], p0.003), and thrombocytopenia at diagnosis (2.2 [1.3-3.8, p0.003). Better survival was shown for patients in whom aplastic anaemia antedated PNH (0.32 [0.14-0.72], p0.02). Factors associated in multivariate analysis with a high risk of thrombosis during the disease course were thrombosis at diagnosis (5.1 [2.5-10.6], p = 0.0002), age over 54 years (2.6 [1.5-4.6, p = 0.0014), and infection at diagnosis (2.6 [1.3-5.2], p = 0.0099). The risk factors for progression to pancytopenia were absence at diagnosis of anaemia (4.03 [1.3-12.2], p = 0.03) and neutropenia (2.45 [1.1-5.7], p = 0.03). The risk factors for development of myelodysplastic syndrome or acute leukaemia were abdominal pain crisis at presentation (10.5 [2.5-44.0], p = 0.004) and year of diagnosis after 1983 (8.45 [1.8-40.7], p = 0.004).This large number of cases permitted a detailed analysis of prognostic factors for the first time, in this rare disease. Estimates of PNH prognostic factors may serve as baseline data in the assessment of current and future treatments for this disease.

Managing new innovations in medicine is a particularly timely subject. There is an abundant history concerning over expectations resulting from the development of new treatments or diagnostic procedures, some shown to be less effective than promised, others even found to be dangerous. A new aspect to the question is the importance of economic pressures which require rational investment decisions when diffusing innovating technologies. In 1991, the Commission for the evaluation and diffusion of innovating technologies (CEDIT) at the University Hospitals of Paris (Assistance Publique-Hôpitaux de Paris) developed a programme aimed at better managing the distribution and use of polyvalent intravenous immunoglobulins (IgIV), a new promising therapeutic tool with both a high cost and a certain number of risks. The programme was designed to assist prescribers in elaborating better therapeutic strategies and to help hospital managers rationalize expenditures for IgIV. The results of this experience are presented here together with certain conclusions concerning the way management decisions can be applied to the diffusion of an innovation in health care.

Anaemia is frequently encountered in daily practice. With full knowledge of its pathophysiology a rational classification is possible allowing a suitable approach for diagnostic investigations. In a first stage, the data provided by blood counts, erythrocyte constants and reticulocyte counts guide the diagnostic rationale. In cases with microcytic and hypochromic anaemia, measurement of ferritin level separates iron deficiency anaemia from the so-called "inflammatory" anaemias. A high number of reticulocytes points to haemolytic anaemia. Among the many causes of haemolysis, one must first look for autoimmune haemolysis. Elsewhere, the clinical context and morphological red cell abnormalities point to a hereditary disease affecting the erythrocyte membrane, enzymes or globin content. Although rare, microangiopathic anemia with schizocytosis and paroxysmal nocturnal haemoglobinuria must not be misdiagnosed. Bone marrow examination remains the clue in non-regenerative normochromic, normo- or macrocytic anaemias. In difficult cases, other investigations, such as cytogenetics, isotopic examination and progenitor culture, may help in characterizing the anaemia. Serum erythroproietin essays and plasma transferrin receptor counts will soon figure among the methods used to explore anaemias.

We analyzed the functional status of the small CD8+/Leu-7+ T-lymphocytes that circulate in increased proportions in the blood of many allogeneic bone marrow transplant (BMT) patients. Purified CD8+/Leu-7+ T cells were tested for their effect on T-cell proliferative responses. In contrast to CD8+/Leu-7-T-lymphocytes, such cells behaved as suppressor cells for lectin-induced mitogenic responses of the donor's peripheral blood lymphocytes. However, they did not interfere with the in vitro responsiveness to specific stimuli such as protein purified derivative (PPD) or alloantigens. We demonstrate that CD8+/Leu-7+ T cells are resting pre-cytotoxic T-lymphocytes (CTL) that can be induced by mitogenic lectins to express their cytolytic program in a non-specific, non-major histocompatibility complex-restricted manner against phytohemagglutinin-treated lymphoblasts or K562 target cells. The lectin-triggered cytotoxicity was achieved within a few days, together with limited cell division. Our results suggest that circulating CD8+/Leu-7+ T cells from BMT recipients are in vivo primed CTL awaiting cellular activation.

The polymerase chain reaction (PCR) allows the detection of minimal amounts of nucleic sequences and has been successfully used to test for the chronic myeloid leukemia-specific bcr/abl transcripts. We studied blood samples from 17 patients who had undergone allogeneic bone marrow transplantation for CML, using a modified polymerase chain reaction-based assay for the detection of leukemic mRNA. This nested PCR technique was found to be highly sensitive, detecting the chimeric bcr/abl transcript in 16 of 17 patients including several long-term survivors. Cytogenetic techniques failed to detect Ph mitoses. The clinical significance of the persisting bcr/abl transcript for long periods following BMT is poorly understood and remains to be elucidated by further studies.

An 18 year old boy presented with microcytic hypochromic anemia. Erythrocytic abnormalities and family studies suggested congenital sideroblastic anemia (CSA), but atypical features included absence of clinical iron overload, scanty iron deposits in mitochondria of late erythroblasts and reticulocytes, and a high platelet count. An unusual adhesion between bone marrow macrophages and reticulocytes was observed by electron microscopy. Haematological response was seen following pyridoxine administration, thus fending support to the diagnosis of CSA.

We previously demonstrated that after allogeneic bone marrow transplantation (BMT) a subset of CD8, HNK1, and DR-positive T lymphocytes are able to inhibit CFU-GM and BFU-E growth with an HLA-DR restriction. In this study we investigated whether these cells, present in normal marrow in low concentration (less than 1%), play the same role. HNK1-positive sorted marrow cells forming rosettes (E+C) were able to inhibit BFU-E and CFU-GM growth when added back to the marrow E- C at a ratio of 1:10 (HNK1+ E+C/E-C) in a range from 40% to 60%. This inhibitory effect was also detected for a cellular ratio of 1:100, which is the normal marrow value for this subset of T cell. HNK1+ DR+- sorted E+C after double-immunofluorescent labeling also showed the same inhibitory activity as the HNK1+ E+C, whereas the negative fraction including all the other E+C had no detectable inhibitory activity. CD3 and CD8 antigens were also present on the membrane of these cells, as demonstrated in two cases by double-immunofluorescent labeling performed with anti-CD3 or anti-CD8 monoclonal antibodies (MoAbs) and HNK1 MoAb, respectively, and subsequent cell sorting. Blocking experiments, performed by adding in culture anti-CD4 and anti-CD8 MoAbs to HNK1+ T cells showed that only the last MoAb was able to prevent inhibition of hematopoietic colony growth. These results confirmed that one subset of CD3+, CD8+, HNK1+, and DR+ T cells was responsible for in vitro inhibition of normal hematopoiesis. In addition, this inhibition was genetically restricted to HLA-class II antigens, since in three co- culture experiments with unrelated bone marrow cells inhibition occurred only when cells with one haplo-identical HLA-DR antigen was added back to the culture. Indeed, this effect was really HLA-DR restricted, since in blocking experiments with different anti-HLA class II MoAbs (anti-DR, anti-DP, and anti-DQ MoAbs) only an anti-HLA-DR MoAb was able to prevent the colony growth inhibition by CD3+ HNK1+, or CD8+ HNK1+ E+C. In conclusion, the CD3+, HNK1+, CD8+, DR+ cells may be the T- cell subset able to inhibit normal hematopoiesis with an HLA-DR restriction.

Three allogeneic bone marrow transplantation patients who exhibited a suppressive subset of T cells for in vitro hematopoiesis have been investigated to determine whether this T cell suppressive effect was genetically restricted. In the three cases, T cells separated by sheep red cell rosetting inhibited blood colony-forming units granulocyte-monocyte (CFU-GM) and burst-forming unit erythroid (BFU-E) growth from the patients and from the bone marrow donors who were HLA identical, but not from randomly chosen unrelated subjects. In one case, cocultures were performed between the patient T cells and the T-depleted cells from eight siblings and from the mother. A marked inhibition (30 to 60%) of CFU-GM and BFU-E growth was found in the relatives who shared a haplo-identical HLA-DR 5. The same degree of suppression was found with respect to whether the siblings were homozygous or heterozygous for the HLA-DR 5 antigen, and whether or not they shared common class I antigens. This inhibition was totally abolished when a monoclonal antibody against HLA-DR was added, whereas a monoclonal antibody against class I histocompatibility antigen had no effect. To additionally demonstrate that this inhibition was mediated by a single HLA-DR haplotype, T cells from the patient were co-cultured with cells from three normal unrelated individuals, one with a phenotypically identical DR and two with only one haploidentical DR. Inhibition was similarly found in the subject exhibiting complete DR identity, and the subject with only the DR 5 haploidentical phenotype. These results demonstrate that a unique subset of T cells present in allogeneic bone marrow transplants specifically suppress differentiation of hemopoietic progenitors that bear one phenotypically haplo-identical HLA-DR antigen.

In a series of 40 patients with Budd-Chiari syndrome, 5 (12%) were found to be afflicted with paroxysmal nocturnal hemoglobinuria. The clinico-pathological features in these 5 patients and in 26 well-documented previously reported cases could be ascribed to three groups of increasing severity: thrombosis limited to small-sized hepatic veins with no or transient ascites, partial thrombosis of large-sized hepatic veins with chronic ascites, and complete thrombosis of large-sized hepatic veins with a life-threatening course. These three groups did not differ with regard to sex, age, and duration and characteristics of paroxysmal nocturnal hemoglobinuria. In view of the relationship between prognosis and the extent of hepatic vein obstruction, we suggest that early therapy directed toward limiting the extension of thrombosis, or toward dissolving formed thrombi, should improve the prognosis of this severe complication of paroxysmal nocturnal hemoglobinuria.

We have investigated the effect of 12-O-tetradecanoylphorbol-13-acetate (TPA) on iron uptake into human hematopoietic cell lines K562, U937, and HL-60. TPA inhibited both cell growth and iron uptake by these cell lines. This effect was rapid, which is typical of phorbol esters which are biologically active, and it occurred at very low concentrations of TPA. This effect of TPA was dependent upon an inhibition of the transferrin-binding capacity as estimated on intact cells. However, experiments with transferrin binding on cell samples dissolved in 1% Triton X-100 showed that TPA-treated cells exhibited a transferrin-binding capacity similar to that of control cells. On the basis of this result, it is suggested that TPA modified a part of transferrin receptors present in the cells; as a result of this modification, these receptors became unavailable for binding transferrin, but they remained physically present in the cell. Other compounds capable of inducing the differentiation of leukemic cells, such as dimethyl sulfoxide, butyrate, retinoic acid, and 1 alpha,25-dihydroxy-vitamin D3, did not acutely inhibit iron uptake. We also investigated the effect of TPA on transferrin receptors in a cellular system in which phorbol esters stimulate cell proliferation. At 16 X 10(-9) M, TPA markedly stimulated the proliferation of T-lymphocytes. However, in spite of this marked stimulation of cell proliferation, TPA-stimulated lymphocytes exhibited a transferrin-binding capacity much inferior to cells stimulated by other mitogens, such as phytohemagglutinin.

Graft-versus-host disease (GVHD) is the major complication of allogeneic HLA-identical bone marrow transplantation. GVHD is induced by the activation of mature T cells in the graft which react against minor antigens of the recipient. Mixed epidermal cell-lymphocyte cultures (MELC), which constitute an in vitro model of epidermal cell-lymphocyte interactions, make it possible to study the presentation of antigens to the lymphoid cells by epidermal Langerhans cells. We performed MELC in 66 patients who had received an HLA-identical bone marrow transplant for malignant blood disease. The bone marrow received by 29 recipients had been depleted of mature T cells, whereas 37 recipients had received a non-depleted bone marrow. A complete, uni- and multivariate statistical analysis was carried out on recipients of non-depleted bone marrow to evaluate the risk factors for acute and chronic GVHD. This study showed that MELC between donor and recipient was the most predictive parameter for the occurrence of GVHD. Other factors were a history of previous pregnancies in female donors and a diagnosis of chronic myelogenous leukaemia. These results may be of value in the selection of donors and for a better determination of the need for bone marrow depletion.

Treatment of acute lymphoblastic leukemia (ALL) in children with effective regimens including induction with vincristine, cytoxan, asparaginase, and prednisone followed by prolonged maintenance with various drug combinations results in complete remission (CR) rates of approximately 90%, with more than 50% of the patients being possibly cured [1]. Use of similar regimens in patients over 15 has, however, been far less successful [2]. During the last decade, considerable improvement has been achieved in the treatment of adult ALL using more intensive regimens, and several protocols including more aggressive induction with anthracyclines followed by intensive consolidation and multidrug maintenance over several years have yielded therapeutic results similar to those obtained in children [3–6] and possibly similar to those achieved by allogeneic bone marrow transplantation [7] with approximately 50% long-term survivors. These regimens, however, are very toxic and may not be suitable for all patients.

An authentic case of Waldenstrom's macroglobulinaemia without a tumoural syndrome is reported, with initial signs of peripheral pancytopenia. Complete and persistent remission appears to have followed multiple sequential chemotherapy. This very satisfactory and, according to data in the published literature, very rare result suggests that this type of treatment should be prescribed for all patients with macroglobulinaemia with poor prognostic clinical and histological characteristics.

In a series of 40 patients with Budd-Chiari syndrome, 5 (12%) were found to be afflicted with paroxysmal nocturnal hemoglobinuria. The clinico-pathological features in these 5 patients and in 26 well-documented previously reported cases could be ascribed to three groups of increasing severity: thrombosis limited to small-sized hepatic veins with no or transient ascites, partial thrombosis of large-sized hepatic veins with chronic ascites, and complete thrombosis of large-sized hepatic veins with a life-threatening course. These three groups did not differ with regard to sex, age, and duration and characteristics of paroxysmal nocturnal hemoglobinuria. In view of the relationship between prognosis and the extent of hepatic vein obstruction, we suggest that early therapy directed toward limiting the extension of thrombosis, or toward dissolving formed thrombi, should improve the prognosis of this severe complication of paroxysmal nocturnal hemoglobinuria.

The authors report 12 cases of acute leukemia observed after breast cancer. 4 patients received only adjuvant radiotherapy, whereas the other eight received both chemotherapy and radiotherapy. Acute leukemia appeared with a mean time of 5.5 years after the detection of breast cancer and was preceded in 7 cases by isolated pancytopenia during 4 months. Acute leukemias were always non lymphoblastic and myelofibrosis was very frequent. A complete remission was obtained at three patients out of the seven treated. The mean survival time was 5.6 months. The existence of acute leukemia after chemo-and/or radiotherapy poses several problems. The detection of patients with a high risk of leukemia by different methods such as cytogenetic, studies of dysmyelopoietic symptoms, is actually often too late occurring during preleukemia states of bad prognosis. We also need to know the exact incidence of secondary leukemia after treatment of breast carcinoma and the real benefit of such treatment.

Red blood cells from normal subjects and subjects with heterocellular hereditary persistence of fatal haemoglobin and beta-thalassaemia were fractionated according to density by centrifugation on a discontinuous gradient of Stractan II. F-cells were studied by immunofluorescence and their proportion was evaluated in each separated population. This approach has permitted to show that F-cells were preferentially distributed among high density erythrocytes. This phenomenon reflects a peculiar characteristic of F-cells.

Between September 78 and May 81, 13 adults (mean age 27± 7 years) with acute myeloid leukemia (AML) in 1st remission (n=11) or chronic myeloid leukemia (CML) in 2nd chronic phase, were given donor buffy coat cells, Cyclophosphamide (60 mg/kg×2), and low dose total body irradiation (TBI) as conditioning regimen for allogeneic bone marrow transplantation (BMT) from an HLA identical sibling donor.

The results of a combination chemotherapy trial (melphalan, CCNU, vincristine, cyclophosphamide) involving 28 patients with stage III (n = 21) or stage II (n = 7) multiple myeloma suggest a high response rate, with a mean 71% malignant cell destruction in 78.5% of the patients. A longer survival in responsive stage III patients as compared with patients treated with alkylating agents seems likely, but this can only be established by a randomized trial. Despite haematological side-effects, this combination therapy may be used in high risk patients, especially those resistant to a single alkylating agent and in whom the frequency, intensity and duration of responses appears to be the same as in previously untreated patients. In contrast, only one of the 7 patients treated for relapse after previous response to a single alkylating agent responded to the combination chemotherapy.

Twenty cases of acute monoblastic leukemia are studied according to definite criterias: cytology, cytochemical staining, lysozyme production. The study points out the tumoral characters: hematodermy, gingivitis, central nervous system leukemia and the lack of important bone marrow incompetence. 47 per cent of complete remissions are obtained with daunorubicin, aracytin combination therapy. Other useful chemical agents, and prospects for maintenance therapy are discussed.

The expression of transferrin receptors in human leukemic cell lines was investigated. Our results have clearly shown that heme, iron and protoporphyrin-IX may modulate the expression of Trf receptors: iron and heme induce a decrease in the number of Trf receptors; in contrast protoporphyrin-IX elicited a significant increase in the number of Trf receptors. On the basis of these data we suggest that the intracellular concentration of iron, heme and protoporphyrin-IX may represent the main factor involved in the regulation of the expression of Trf receptors.

We reviewed 213 consecutive adult pancytopenic patients to determine the frequency of underlying pathology, to analyze our diagnostic procedure, and to determine the value of peripheral blood data for diagnosis. Pancytopenia was defined as the association of hemoglobin level below 12 g/dl in males and 11.5 g/dl in females, leukopenia below 4 x 10(9)/L, and thrombocytopenia below 150 x 10(9)/L. The bone marrow aspirates were normo- or hypercellular in 140 cases (66%). Bone marrow biopsies, performed in 93 cases, documented the presence of myelofibrosis in 67 cases. Aplastic anemia was diagnosed in 10% of the cases. Malignant myeloid disorders (acute myeloid leukemias, myelodysplastic syndromes, acute myeloid disorders with myelofibrosis) represented 42% of the cases and various malignant lymphoid disorders 18%. Vitamin deficiencies accounted for 7.5% and nonhematological pathology 10% of the cases. The bone marrow aspirate was sufficient for the diagnosis in 55% of the cases, and the trephine biopsy was necessary in 30%. In the remaining cases, other complementary tests were necessary to achieve final diagnosis. A discriminant analysis, focused on the hemogram data, showed that parameters obtained by analysis of blood smears were helpful for the diagnosis, especially the presence or absence of blast cells and/or of abnormal lymphoid cells.