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Purpose: Protein kinase CK2 promotes multiple myeloma cell growth by regulating critical signaling pathways. CK2 also modulates proper HSP90-dependent client protein folding and maturation by phosphorylating its co-chaperone CDC37. Because the endoplasmic reticulum (ER) stress/unfolded protein response (UPR) is central in myeloma pathogenesis, we tested the hypothesis that the CK2/CDC37/HSP90 axis could be involved in UPR in myeloma cells.Experimental Design: We analyzed CK2 activity upon ER stress, the effects of its inactivation on the UPR pathways and on ER stress–induced apoptosis. The consequences of CK2 plus HSP90 inhibition on myeloma cell growth in vitro and in vivo and CK2 regulation of HSP90-triggered UPR were determined.Results: CK2 partly localized to the ER and ER stress triggered its kinase activity. CK2 inhibition reduced the levels of the ER stress sensors IRE1α and BIP/GRP78, increased phosphorylation of PERK and EIF2α, and enhanced ER stress–induced apoptosis. Simultaneous inactivation of CK2 and HSP90 resulted in a synergic anti-myeloma effect (combination index = 0.291) and in much stronger alterations of the UPR pathways as compared with the single inhibition of the two molecules. Cytotoxicity from HSP90 and CK2 targeting was present in a myeloma microenvironment model, on plasma cells from patients with myeloma and in an in vivo mouse xenograft model. Mechanistically, CK2 inhibition led to a reduction of IRE1α/HSP90/CDC37 complexes in multiple myeloma cells.Conclusions: Our results place CK2 as a novel regulator of the ER stress/UPR cascades and HSP90 function in myeloma cells and offer the groundwork to design novel combination treatments for this disease. Clin Cancer Res; 18(7); 1888–900. ©2012 AACR.

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Micro-Abstract In this limited retrospective analysis, we report on 52 “high risk” AL amyloidosis patients treated with first line bortezomib based chemotherapy. Achieving a hematological complete response (CR+VGPR) at day 30 confirmed its prognostic value. Nevertheless, patients who reached a suboptimal response (PR) at day 30 have a reasonable chances of survival, and do not necessarily need a change in therapeutic strategy even in the face of permissive clinical conditions. On the other hand, an early identification of NR patients should prompt a shift in therapy trying to improve the well-known dismal prognosis of these patients. We have also shown that even “high-risk” AL amyloidosis patients can be managed safely and effectively in a hematology ward. Purpose To assess the feasibility and the results of Bortezomib-based treatment of “high-risk” AL-amyloidosis patients in a hematology ward. Methods We report on 52 high-risk amyloidosis patients treated with first-line bortezomib-based chemotherapy. Results At day 30 from the beginning of the therapy, 23 patients (44%) achieved a hematological response (complete response plus very good partial response); 14 patients (27%) achieved a partial response; 15 patients (29%) were non-responders. After a median follow-up of 28.5 months, the survival rates were 18/23 (78%) for responders; 9/14 (64%) for partial responders and 3/15 (20%) for non-responders with a median overall survival of 43, 24 and 11 months, respectively (log-rank test: p Conclusions These results show that high-risk AL-amyloidosis patients can be managed safely and effectively in a hematology ward. A partial hematologic response may herald a later better response, organ response, and can allow a subsequent second-line therapy and a good survival.

POEMS syndrome is a disease due to underlying plasma cells (PC) dyscrasia. Because of its rarity, there are no established upfront or second-line therapies. Treatment is borrowed from other PC diso...

Dysfunctions of the immune system, both as hyperactivity or defect, may lead to the development of different diseases. Malignant transformation of cells involved in the immune regulation, such as i...

Multiple myeloma is a post-germinal center B-cell neoplasm, characterized by the proliferation of malignant bone marrow plasma cells, whose survival and proliferation is sustained by growth factors and cytokines present in the bone marrow microenvironment. Among them, IL-6 triggers the signal downstream of its receptor, leading to the activation of the JAK/STAT pathway. The atypical GTPase RhoU lays downstream of STAT3 transcription factor and could be responsible for mediating its effects on cytoskeleton dynamics. Here we demonstrate that RHOU is heterogeneously expressed in primary multiple myeloma cells and significantly modulated with disease progression. At the mRNA level, RHOU expression in myeloma patients correlated with the expression of STAT3 and its targets MIR21 and SOCS3. Also, IL-6 stimulation of human myeloma cell lines up-regulated RHOU through STAT3 activation. On the other hand, RhoU silencing led to a decrease in cell migration with the accumulation of actin stress fibers, together with a decrease in cyclin D2 expression and in cell cycle progression. Furthermore, we found that even though lenalidomide positively regulated RhoU expression leading to higher cell migration rates, it actually led to cell cycle arrest probably through a p21 dependent mechanism. Lenalidomide treatment in combination with RhoU silencing determined a loss of cytoskeletal organization inhibiting cell migration, and a further increase in the percentage of cells in a resting phase. These results unravel a role for RhoU not only in regulating the migratory features of malignant plasma cells, but also in controlling cell cycle progression.

Light chain amyloidosis is characterized by the progressive deposition of immunoglobulin light chains into the extracellular tissue, leading to organ dysfunction. Usually, it is associated with an underlying clonal plasma cell dyscrasia and rarely with chronic lymphocytic leukaemia. Herein, we described the first report of a patient with relapsed chronic lymphocytic leukaemia harbouring TP53 abnormalities who developed, histologically proven, systemic light chain amyloidosis who was treated with the PI3K inhibitor, idelalisib, and rituximab. Unfortunately, the patient had sudden death during sleep, likely caused by arrhythmia secondary to amyloid cardiomyopathy. Idelalisib was at least effective in reducing secretory free light chain, chronic lymphocytic leukaemia burden, and to improve the survival of patient.

Given its anti-angiogenic activity, lenalidomide may have a role in the treatment of POEMS (Peripheral neuropathy, Organomegaly, Endocrinopathy, Monoclonal plasma cell disorder and Skin changes) syndrome. This prospective, open-label, pilot study evaluated the combination of lenalidomide + dexamethasone (RD) in 18 POEMS syndrome patients (13 pre-treated, 5 newly-diagnosed but ineligible for high-dose therapy). Treatment consisted of six cycles of lenalidomide (25 mg/day for 21 days followed by 7 days rest) plus dexamethasone (40 mg/once a week). Patients responding after six cycles continued treatment until progression or unbearable toxicity. The primary endpoint was the proportion of patients with either neurological or clinical improvement. The RD combination was considered as deserving further evaluation if 9 of the first 15 patients responded. Ten responses were observed among the first 15 enrolled patients, meeting the primary endpoint. Fifteen of 18 patients (83%) completed six RD cycles: 13 (72%) patients responded and nine had both clinical and neurological improvement. Among the 15 patients who completed the six RD cycles, four were still on treatment after a 25-month follow-up. At 39 months of follow-up, all patients were alive with a 3-year progression-free survival of 59%. No patient discontinued RD for toxicity. Overall, the RD regimen showed a high incidence of prolonged symptoms improvement and was well tolerated in most POEMS patients.

We analysed specificity and sensitivity of confocal laser microscopy (CLSM) on tissue sections for a diagnosis of amyloidosis, in an attempt to reduce technical errors and better standardise pathological diagnosis. We first set up a protocol for the use of CLSM on this type of specimen, using a group of 20 amyloid negative and 20 positive samples. Of all specimens, 2, 4 and 8-μm sections were cut. Sections were stained with Congo red (CR) and thioflavin-T (ThT) and observed by cross-polarised light microscopy (CR-PL), epifluorescence microscopy (CRF-epiFM and ThT-epiFM) and CLSM (CRF-CLSM and ThT-CLSM). To validate the method in a diagnostic setting, we examined tissue samples from 116 consecutive patients with clinical suspicion of amyloidosis, selected from the period 2005 to 2014 from the database of the Pathology Unit of the University of Padua. The results were compared with those of transmission electron microscopy (TEM), which we consider as reference. We found that with CRF-CLSM, the false negative rate was reduced from 17 to 5%, while the sensitivity of detection increased to 12%. The results were in complete agreement with those of TEM ThT-CLSM; both sensitivity and specificity were 100%. Finally, ThT-CLSM results did not vary with section thickness, and small amounts of amyloid could even be detected in 2-μm sections. In conclusion, we found ThT-CLSM to be more sensitive as a screening method for amyloidosis than CR and ThT epifluorescence optical imaging. The method was easier to standardise, provided images with better resolution and resulted in more consistent pathologist diagnoses.

Light chain deposition disease (LCDD) is a rare plasma cell dyscrasia consisting of nonamyloidotic deposition of misfolded immunoglobulin light chain (LC) in tissues and organs. Heart involvement is a rare and late event in the course of the disease.1 Therefore, such a nonfibrillar deposition of LC in the myocardium has so far been described only in few endomyocardial biopsies. Potentially lethal ventricular arrhythmias and a nondiagnostic echocardiogram are 2 clinical hallmarks of the disease.1,2 In addition, no other in vivo imaging of the condition is presently available. A 52-year-old man was admitted to the emergency department for syncope at rest. ECG showed a sinus rhythm with negative T waves in inferolateral leads alternating with ventricular bigeminism and episodes of torsades de pointes triggered by R-on-T phenomenon (Figure 1A). The previous history included serum IgGκ + κ monoclonal gammopathies and nephrotic syndrome. The bone marrow biopsy showed 60% clonal plasma cells, and the kidney biopsy examination by immunofluorescence and immunoelectron microscopy was consistent with LCDD. Light microscopic finding of kidney biopsy showed glomeruli with increased mesangial cellularity and nodular expansion of mesangial matrix; mesangial nodules were positive at periodic acid Schiff and trichrome stain (Figure 2A …

POEMS syndrome is defined by Polyneuropathy, Organomegaly, Endocrinopathy, Monoclonal gammopathy and Skin changes. The vascular endothelial growth factor (VEGF) appears to play a key role in the pathogenesis of the syndrome, and its concentrations are deemed to correlate to disease activity. The aim of the present study was to verify whether other biochemical markers including serum free light chains (FLC) and heavy/light chains (HLC) would be of value in monitoring POEMS patients.Fifty-three serum samples were collected from seven POEMS patients at diagnosis and during a follow-up period (range 14–56 months). VEGF was measured using an ELISA method, while FLC and HLC concentrations were measured using Binding Site reagents on a BNII (Siemens) nephelometer.At diagnosis all patients presented high VEGF concentrations, while the κ/λFLC ratio (FLCr) was within the reference range. Four patients had abnormal HLC, HLCκ/HLCλ (HLCr) and FLC values. The relationship between the trend of VEGF and both HLC and FLC during the follow-up was analysed by means of Cohen’s κ coefficient. VEGF and HLC values displayed a significant κ-Cohen (0.537, p=0.002) in all chemotherapy-responder patients while in non-responders it did not. Conversely, in both responders and non-responders, VEGF and FLC values did not attain a significance on κ-Cohen analysis. In three out of four responders HLCr values increased, thus reflecting an improved clinical condition.The findings made in the present study indicate that HLC, either as intact immunoglobulin or as HLCr, may provide useful information, particularly in identifying responders and confirm that the role of FLC is unreliable in monitoring patients with POEMS syndrome.

Purpose: Protein kinase CK2 promotes multiple myeloma cell growth by regulating critical signaling pathways. CK2 also modulates proper HSP90-dependent client protein folding and maturation by phosphorylating its co-chaperone CDC37. Because the endoplasmic reticulum (ER) stress/unfolded protein response (UPR) is central in myeloma pathogenesis, we tested the hypothesis that the CK2/CDC37/HSP90 axis could be involved in UPR in myeloma cells. Experimental Design: We analyzed CK2 activity upon ER stress, the effects of its inactivation on the UPR pathways and on ER stress–induced apoptosis. The consequences of CK2 plus HSP90 inhibition on myeloma cell growth in vitro and in vivo and CK2 regulation of HSP90-triggered UPR were determined. Results: CK2 partly localized to the ER and ER stress triggered its kinase activity. CK2 inhibition reduced the levels of the ER stress sensors IRE1α and BIP/GRP78, increased phosphorylation of PERK and EIF2α, and enhanced ER stress–induced apoptosis. Simultaneous inactivation of CK2 and HSP90 resulted in a synergic anti-myeloma effect (combination index = 0.291) and in much stronger alterations of the UPR pathways as compared with the single inhibition of the two molecules. Cytotoxicity from HSP90 and CK2 targeting was present in a myeloma microenvironment model, on plasma cells from patients with myeloma and in an in vivo mouse xenograft model. Mechanistically, CK2 inhibition led to a reduction of IRE1α/HSP90/CDC37 complexes in multiple myeloma cells. Conclusions: Our results place CK2 as a novel regulator of the ER stress/UPR cascades and HSP90 function in myeloma cells and offer the groundwork to design novel combination treatments for this disease. Clin Cancer Res; 18(7); 1888–900. ©2012 AACR.

The aims of the study were to evaluate (i) the prevalence of MGUS in patients after liver transplantation (LT), (ii) the role of MGUS as a risk factor for malignancy and other medical complications after LT. One hundred and fifty consecutive patients were included in the study and followed prospectively after LT for more than 18 months. Eighteen patients had MGUS before LT, whereas 49 patients developed MGUS after LT ('de novo' MGUS). Thirty-six of these patients showed a MGUS along all the follow up after LT ('permanent' MGUS). In 31 patients, MGUS disappeared after LT ('transient' MGUS). No patient with MGUS developed B-malignant lymphoproliferative disorder and only one patient developed a myeloma after LT. Comparing patients with 'permanent' MGUS to patients with 'transient' MGUS or without MGUS after LT, the former group showed a higher rate of serious infections (30% versus 13%, P = 0.01), chronic kidney disease (CKD) (75% versus 44%, P = 0.001) and mortality (33% versus 17%, P = 0.04). Permanent MGUS was confirmed as an independent risk factor for serious infections and CKD by multivariate analysis. Permanent MGUS after LT does not entail a significant risk of malignancy, but it is associated with a higher risk of serious infections and CKD.

POEMS syndrome and amyloidosis are rare plasma cell diseases that share common features, including polyneuropathy. The aim of this study was to investigate serum vascular endothelial growth factor (sVEGF) in patients with amyloidosis and to evaluate changes in response to treatment. Twenty-five patients [17 primary light-chain amyloidosis (AL-A), 7 transthyretin amyloidosis (TTR-A), 1 senile wild-type TTR-A] were studied. sVEGF was analyzed by ELISA. Sera from 8 myeloma and 7 POEMS patients were also evaluated. The median sVEGF level was 420 pg/ml in AL-A and 179 pg/ml in TTR-A patients; this was significantly lower than in POEMS syndrome (median 2580 pg/ml, P = 0.0002 and 0.001, respectively). sVEGF of AL-A patients showed no changes in response to treatment. sVEGF was not increased in amyloid patients regardless of neuropathy, and did not mirror the course of the disease. sVEGF should be tested in patients with overlapping and atypical clinical features.

Chemokines and their receptors play a pivotal role in the regulation of B-lymphocyte trafficking. This study was aimed at investigating the pattern of chemokine receptor expression, including CCR1 to CCR3, CCR5 to CCR7, CXCR1 to CXCR5, and the migration ability of multiple myeloma (MM) plasma cells (PC). PC were recovered from the bone marrow (BM) of 29 MM patients, extramedullary sites of 10 patients and the BM of five controls. Flow cytometry analysis showed that the receptors mainly expressed on malignant BM PC were represented by CXCR4 (70% of patients), CCR1 (25%), CCR2 (25%), CCR5 (17%) and CXCR3 (20%), while other receptors were commonly lacking. The analysis performed on extramedullary (peripheral blood and pleural effusion) malignant PC demonstrated that the most represented receptors were CXCR4 (100%), CCR2 (66%) and CXCR1 (60%). The migratory capability of malignant PC at resting conditions identified three groups of patients with different migration (low, intermediate and high). As CXCR4 was the relevant chemokine receptor expressed by MM PC, its ligand CXCL12 induced their migration. These data suggest that malignant PC from MM display different chemokine receptor profiles and that CXCR4 is fully functional and might play a role in the spreading of the disease.

Immunoglobulin light chain (AL) amyloidosis is a plasma cell (PC) dyscrasia in which amyloid deposition from misfolded monoclonal immunoglobulin light chains adversely affects organ functions. Card...

Background AL amyloidosis is a rare plasma cell dyscrasia with multiorgan involvement. Good risk patients are candidate to high dose chemotherapy and autologous stem cell transplantation. However both transplantation and stem cell collection entail significant risk in such patients. Plerixafor is a novel mobilizing agent approved for use in “poor mobilizer” patients with lymphoma and multiple myeloma; experience in systemic amyloidosis patients is limited. Case Report We describe a case of spontaneous splenic rupture following administration of G-CSF and plerixafor in a patient with AL amyloidosis who previously underwent heart transplantation due to amyloid heart involvement. Results and Conclusion This is the first report of spontaneous splenic rupture following stem cell mobilization with G-CSF and plerixafor in AL amyloidosis. The role of plerixafor has to be established. AL amyloidosis patients undergoing stem cell mobilization need careful monitoring of signs and symptoms of spontaneous splenic rupture.

Large granular lymphocyte (LGL) leukemia is a chronic indolent leukemia. Microscopic evidence of cardiac involvement by leukemia is found in ≈30% to 40% of patients who have died of the disease.1 Most of the times it is diagnosed because of cardiac complications, such as pericardial effusion.2 A 21-year-old woman with history of lymphoproliferative T-cell disease (LGL leukemia CD4+) while on therapy with low dose methotrexate and corticosteroid was admitted to the Emergency Department with anasarca. LGL leukemia had been previously diagnosed by morphological, immunophenotypic, and molecular analysis of blood and bone marrow biopsy. An electrocardiogram showed sinus tachycardia with infero-lateral T-wave inversions. High-sensitivity troponin I was normal. Physical examination was notable for bilateral pleural effusions, hepato-splenomegaly, and ascites. Pulmonary embolism was ruled out by computed tomographic …

Objectives The clinical usefulness of serum free light chain (FLC) measurement in the management of patients with plasma cell proliferative disorders has been reported in several papers, and most clinical studies use the reference ranges declared by the manufacturer. The aim of the present study was to evaluate the reproducibility of FLCs immunoassay and to validate the reference range, before introducing it in routine setting. Design and methods Internal quality control materials and a pool of fresh serum samples were used to evaluate imprecision; 162 fresh sera from healthy blood donors were analyzed to evaluate the reference range for FLCs. In order to verify the κ/λ FLC ratio, 43 sera from patients with polyclonal hypergammaglobulinemia were tested. The FLC immunoassay was performed using a nephelometer with the Freelite reagents. Results The imprecision studies performed using a serum pool tested with two different lots of reagents showed a mean CV of 16.09% for κFLC and of 16.72% for λFLC. Lower CV%s and different mean values were found by calculating the results from each specific lot separately, while different results were obtained using the control materials provided by the manufacturer. In reference subjects, the 2.5–97.5th percentiles were found to be 4.52–22.33 and 4.84–21.88 mg/L for κFLC and λFLC, respectively. The range for κ/λ ratio (0.65–2.36) was validated with the values obtained from subjects with polyclonal hypergammaglobulinemia. In retesting 15 samples from blood donor subjects with a different lot of reagents, mean bias percentages of 17.60 for κFLC and 15.26 for λFLC were obtained. Conclusions These findings confirm the lot-to-lot variability of the FLC assays also in the measurement of polyclonal light chains, as well as the need to carefully validate the reference values.

POEMS (polyneuropathy, organomegaly, endocrinopathy, monoclonal gammopathy, and skin changes) syndrome is a rare multisystemic disease associated with plasma cell dyscrasia and increased serum or plasma vascular endothelial growth factor (VEGF) levels, the latter likely responsible for several POEMS syndrome manifestations. Whereas peripheral neuropathy is the main neurological feature and a mandatory diagnostic criterium, central nervous system involvement is less common except for papilledema and stroke. We recently reported the frequent occurrence at brain MRI of cranial pachymeningeal involvement ina series of POEMS syndrome patients. Meningeal histopathology revealed hyperplasia of meningothelial cells, neovascularization, and obstructive vessel remodeling without inflammatory signs pointing to a role of VEGF in the meningeal manifestations. Here, we report the dramatic pachymeningeal improvement in patients undergoing lenalidomide therapy. These findings support the therapeutic role of lenalidomide and might shed further light on the pathophysiology of the disease

Bone marrow stromal cell-fueled multiple myeloma growth and osteoclastogenesis are sustained by protein kinase CK2

Circulating Pentraxin 3 (PTX3) and vascular endothelial growth factor (VEGF) levels were measured longitudinally (mean follow-up 2 years) by ELISA in 6 patients with polyneuropathy, organomegaly, endocrinopathy, M-protein, skin changes (POEMS) syndrome and 16 controls. Expression of PTX3 was also assessed (immunohistochemistry) on sural nerve biopsies from POEMS and vasculitic neuropathy patients. No correlation was found between PTX3 and VEGF levels in POEMS or controls. Sural nerve biopsies from vasculitic neuropathy patients, but not those from POEMS syndrome, showed strong PTX3 staining. PTX3, expression of vessel inflammation/remodeling, and VEGF, crucial pro-angiogenic cytokine, appear to be independently regulated in POEMS syndrome.

Background : Chronic hepatitis C virus (HCV) infection is associated with a variety of extrahepatic disorders that may relate to direct or indirect effects of virus infection. Increased levels of soluble forms of tumor necrosis factor (TNF) receptors I and II, found in lymphoproliferative and infectious diseases, can interfere with TNF induced apoptotic cell death. The aim of the present study was to evaluate soluble TNF family receptors levels in lymphoproliferative disorders associated with HCV infection. Methods : One hundred and forty-nine subjects were studied, including 120 anti-HCV positive patients (60 without lymphoproliferative manifestations, 47 with type II cryoglobulinemia and 13 with low-grade B-cell non-Hodgkin's lymphoma (B-NHL)) and 29 anti-HCV negative subjects (19 with low-grade B-NHLs and ten normal controls). Results : Soluble forms of TNF receptor I, TNF receptor II and Fas were significantly higher in HCV positive patients compared with normal controls. The highest levels were found in patients affected by type II cryoglobulinemia or HCV positive lymphoplasmacytoid lymphomas (LP-NHLs), while HCV positive patients without type II cryoglobulinemia or with other B-NHLs had lower values ( P Conclusions : Among HCV infected individuals, very high levels of soluble TNF receptors are significantly associated with type II cryoglobulinemia and LP-NHLs, suggesting that they may be involved in these proliferative disorders.

Background Invasive fungal infections (IFI) are serious and life-threatening complications of hematological malignancies particularly in patients affected by acute myeloid leukemia and following hematopoietic stem cell transplantation. However, only few epidemiological data concerning fungal infections in chroniclymphoproliferativedisorders are available. In this work we aimed to identify the clinical and biological features of patients with chronic lymphocytic leukemia (CLL) affected by IFI. Methods We performed a single-center retrospective study based on the CLL patients referred to the Hematology Unit of University of Padua from 1983 to 2015. IFI were defined as infective events caused by yeasts ormouldsthat required inpatient management and/or intravenous antifungal therapies. We included only proven and probable IFI. Time to IFI (TIFI) and overall survival (OS) were calculated from the date of CLL diagnosis to IFI development or death (event), respectively, or last available follow-up (censored). Diagnostic work-up of fungal infection included blood cultures, serumgalactomannanantigen test for 3 consecutive days (cut-off 0.5), β-1,3-(D)-glucanand high resolution chest computed tomography andbronchoalveolarlavages when clinically indicated. We also collected the closest immunoglobulin (IG) levels data before the onset of each IFI or serious bacterial infective events. IGs measured during infections were not included in the analysis, because they could have been influenced by the infectious event. The last available serum IG levels were considered for patients who did not suffer from any IFI. Results 795 patients with CLL were recruited in this study. 60% were male and the median age at diagnosis and at IFI onset were 65 and 68 years, respectively. The median follow-up was 8.5 years and 316 patients required treatment during the follow-up. 11 out of 795 (1.4%) patients developed IFI during the follow-up. Among them, 7 patients (64%) had probable Aspergillosisand 4 had proven IFI (3 Aspergillusspp and 1 Candida kruseii) based on histological confirmation and/or microbiological isolation of the specific fungal agent. 9 patients wereBinet stage A, 2Binet B and noneBinet C at CLL diagnosis. The median lines of treatment were 5 ranging from 2 to 9. Six out of 11 (55%) patients showed high-risk cytogenetic by FISH analysis (11q or 17p deletion), 2 harbored complex karyotypes, 62% (5/8) hadunmutated IGVH gene. By Kaplan-Meyer analysis we showed that IFI occurred in 2.1% and 7.0% of the cohort after 10 and 20 years of follow-up, respectively (Figure 1A). However, considering the number of chemotherapy regimens, the estimated cumulative incidence of IFI was higher in patients who were treated with at least 4 lines of chemo-immunotherapy (10-year TIFI were 9.0% and 0.3%, p IFI occurrence was associated with a very poor prognosis. In fact, the median overall survival of patients who developed IFI was 125 months as compared to 250 months of the remaining cohort (Log-rank test, p=0.0001, Figure 1C). Since IFI was itself the main cause of death of these subjects. In multivariable analysis, patients with IFI had almost 10 times higher-risk of death (HR 10, p=0.0012) that other patients. We demonstrated that, at the time of IFI events, patients had lower levels of IG as compared to a group of 72 patients who had serious bacterial infections or to 712 subjects who did not have any infections. The medianIgGlevels were 4.11, 6.38 and 8.38 g/L for patients with IFI, bacterial infections and without history of infections, respectively (ANOVA test, p Conclusions Herein, we described the epidemiology of invasive fungal infections among a large cohort of CLL patients from a single institution over 32 years. We demonstrated that IFI significantly impacts on the survival of CLL patients and we provided evidence of the importance of previous chemo-immunotherapy and IG levels on the risk of developing IFI. Figure 1 Figure 1. Disclosures No relevant conflicts of interest to declare.

ABVD chemotherapy (adriamycin, bleomycin, vinblastine, dacarbazine) is considered the standard treatment for advanced Hodgkin lymphoma. However, pulmonary and cardiac toxicity rates due to bleomyci...

CK2 is a pivotal pro-survival protein kinase in multiple myeloma that may likely impinge on bortezomib-regulated cellular pathways. In the present study, we investigated CK2 expression in multiple myeloma and mantle cell lymphoma, two bortezomib-responsive B cell tumors, as well as its involvement in bortezomib-induced cytotoxicity and signaling cascades potentially mediating bortezomib resistance. In both tumors, CK2 expression correlated with that of its activated targets NF-κB and STAT3 transcription factors. Bortezomib-induced proliferation arrest and apoptosis were significantly amplified by the simultaneous inhibition of CK2 with two inhibitors (CX-4945 and K27) in multiple myeloma and mantle cell lymphoma cell lines, in a model of multiple myeloma bone marrow microenvironment and in cells isolated from patients. CK2 inhibition empowered bortezomib-triggered mitochondrial-dependent cell death. Phosphorylation of NF-κB p65 on Ser529 (a CK2 target site) and rise of the levels of the endoplasmic reticulum stress kinase/endoribonuclease Ire1α were markedly reduced upon CK2 inhibition, as were STAT3 phospho Ser727 levels. On the contrary, CK2 inhibition increased phospho Ser51 eIF2α levels and enhanced the bortezomib-dependent accumulation of poly-ubiquitylated proteins and of the proteotoxic stress-associated chaperone Hsp70. Our data suggest that CK2 over expression in multiple myeloma and mantle cell lymphoma cells might sustain survival signaling cascades and can antagonize bortezomib-induced apoptosis at different levels. CK2 inhibitors could be useful in bortezomib-based combination therapies.

Vitamin B12 deficiency causes a wide range of hematological, gastrointestinal, psychiatric and neurological disorders. Hematological presentation of cobalamin deficiency ranges from the incidental increase of mean corpuscular volume and neutrophil hypersegmentation to symptoms due to severe anemia, such as angor, dyspnea on exertion, fatigue or symptoms related to congestive heart failure, such as ankle edema, orthopnea and nocturia. Neuropsychiatric symptoms may precede hematologic signs and are represented by myelopathy, neuropathy, dementia and, less often, optic nerve atrophy. The spinal cord manifestation, subacute combined degeneration (SCD), is characterized by symmetric dysesthesia, disturbance of position sense and spastic paraparesis or tetraparesis. The most consistent MRI finding is a symmetrical abnormally increased T2 signal intensity confined to posterior or posterior and lateral columns in the cervical and thoracic spinal cord. Isolated peripheral neuropathy is less frequent, but likely overlooked. Vitamin B12 deficiency has been correlated negatively with cognitive functioning in healthy elderly subjects. Symptoms include slow mentation, memory impairment, attention deficits and dementia. Optic neuropathy occurs occasionally in adult patient. It is characterized by symmetric, painless and progressive visual loss. Parenteral replacement therapy should be started soon after the vitamin deficiency has been established.

A 46-year-old man with progressive visual loss underwent brain MRI showing multifocal nodular pachymeningeal thickening involving optic nerve meninges bilaterally and internal acoustic meatus dura mater (figure 1). Diffuse meningiomatosis was diagnosed and radiation therapy was given with symptom stabilization. Four years later, left hearing loss and right hypoacusia occurred, with slight transient improvement after high-dose dexamethasone. Serum immunoglobulin (Ig)G4 was increased. CSF analysis showed increased protein, oligoclonal IgG, plasma cells, and lymphocytes. Cerebral biopsy showed meningeal plasma-cell granuloma with IgG4-positive polyclonal plasma cells and B-lymphocyte infiltration (figure 2). IgG4-related disease was diagnosed.1 Rituximab was unsuccessful. IgG4-related disease is a fibroinflammatory, multiorgan condition characterized by tumefactive lesions and lymphoplasmacytic infiltrates rich in IgG4-positive plasma cells that may affect every organ; serum IgG4 may be elevated. Although IgG4-related disease with exclusive multifocal CNS localization is extremely rare and often misdiagnosed,2–4 it should be considered in the differential diagnosis of tumor-like intracranial lesions and hyperthrophic pachymeningitis.

We report on a young pregnant woman developing distal leg edema and hypoalbuminemia, who was lately diagnosed with AL amyloidosis. Fetal growth retardation led to a caesarian section in the 27th week of gestation. A live birth healthy female, 710 g weight, was admitted to the neonatal intensive care unit and survived. Thereafter the mother underwent specific chemotherapy achieving only a partial and transient response, and eventually died due to sepsis. Interestingly, amyloidotic material was found on the maternal but not on the fetal side of the placenta.Experimental data show suppression of AA amyloid formation during pregnancy and suggest a protective role of the placenta on the offspring. However, most reported cases deal with pregnant women diagnosed with AA amyloidosis associated with Familial Mediterranean Fever and describe growth retardation of the fetus, worsening renal function and preeclampsia.To the best of our knowledge, this is the first report of AL amyloidosis diagnosed in a pregn...

Polyneuropathy, organomegaly, endocrinopathy, monoclonal gammopathy, skin changes (POEMS) syndrome is a rare plasma cell disease. Vascular endothelial growth factor (VEGF) seems to play a pathogenic role. Peripheral neuropathy is the main neurological feature. Cranial pachymeningitis has occasionally been reported, but no histopathological studies have been performed. The authors extensively evaluated the central nervous system MRI in 11 patients (seven men, four women; mean age at diagnosis 54.45 years) with POEMS syndrome. In two patients, meningeal histopathology with staining for VEGF and VEGF receptor was performed, and pachymeningeal involvement characterised at histopathological, immunohistochemical and confocal microscopy levels. Nine patients presented with cranial pachymeningitis. One patient suffered from migraine, and none complained of cranial nerve palsies or visual loss. None showed any MRI signs of spinal pachymeningitis. No correlation was found with disease duration and VEGF serum level. Histopathology showed hyperplasia of meningothelial cells, neovascularisation and obstructive vessel remodelling, without inflammation. VEGF and VEGF receptor were strongly coexpressed on endothelium, smooth-muscle cells of arterioles and meningothelial cells. In conclusion, POEMS patients present a high prevalence of meningeal involvement. The histological changes, different from those present in chronic pachymeningitis of other aetiology, suggest a possible VEGF role in the pathogenesis of the meningeal remodelling.

The optimal treatment of advanced sporadic Burkitt lymphoma in adults is still a matter of debate. The salutary results of pediatric therapies did open the road for improving the adult outcome. Between May 1988 and March 2009, 71 consecutive patients—46 adults, 25 children—affected by Burkitt lymphoma/leukemia were treated with the same intensive pediatric protocol alternating vincristine, adriamycine and fractionated ciclophosphamide (phase A) with high dose methotrexate and high dose cytarabine (phase B) in four Italian institutions. Eighty-nine per cent of patients were in Stage III–IV or had L3 leukemia. Complete remissions were 67/71 (94.4%), 24/25 (96%) in children, and 43/46 (93.5%) in adults. Toxic deaths were 3/71 (4.2%), all in adults. There were nine relapses (one in children, eight in adults), all but one observed early. After a median observation of 94 months (range 23–275), the Event–Free Survival rate is 92% in children and 71.7% in adults (P = 0.067). The 23 more recent adults received also rituximab, without differences in outcome as compared to patients who did not. Our experience confirms that such an intensive pediatric-derived chemotherapy is feasible and improves the long-term outcome of adults with advanced Burkitt lymphoma. Am. J. Hematol., 2012. © 2011 Wiley Periodicals, Inc.

Light-chain amyloidosis [1] is a rare disease caused by a clonal plasma cell dyscrasia associated with multiorgan deposition of amyloidogenic immunoglobulin light chains. Autosomal dominant transthyretin amyloidosis (ATTR) is an even rarer disorder caused by amyloidogenic mutant alleles of TTR manifesting with progressive and fatal involvement of the peripheral nerves, ganglia, heart, kidney, and eyes. The specific therapy is orthotopic liver transplantation [2]. ATTR may be overlooked because of phenotypical variability [3], and also misdiagnosed as AL because of possible coexistence of monoclonal gammopathy and limited sensitivity/specificity of light chain immunostaining of biopsy specimens [4, 5]. We describe a patient with restrictive cardiomiopathy misdiagnosed as light chain AL amyloidosis, who was affected with ATTR associated with a novel p.Glu62Lys. The final diagnosis with immunogold electron microscopy was possible only in autoptic tissue. A 75-year-old man with type II diabetes, coronary artery disease, and no history of neurological or cardiological disorders presented with signs and symptoms of right-sided heart failure. Electrocardiogram revealed sinus rhythm, first degree A-V block, left anterior fascicular block, and Q waves at the inferior leads. At bidimensional echocardiogram, left ventricular wall thickening, mild systolic dysfunction, and restrictive diastolic pattern were found. Cardiac MRI findings were suggestive of amyloid deposition. Abdominal fat fine-needle aspiration was negative. Endomyocardial biopsy was positive at Congo Red stain and anti-k chain immunohistochemistry. Bone marrow biopsy was normal. A mild IgG/k monoclonal gammopathy was present (2.5 g/l); no Bence-Jones protein was detected, but a slightly abnormal j/k serum free light chain (sFLC) ratio was present. Cardiac troponin I (cTnI) was increased (0.21 lg/l, normal values 0–0.15) as well as NTproBNP (2,842 ng/l, nv 0-900); ALP was also elevated, suggesting a hepatic involvement. The patient was started on melphalan and dexamethasone, and the liver cholestasis enzymes normalized, but cTnI, NT-proBNP, and the j/k FLC chain ratio did not change. A shift to bortezomib-dexamethasone was not effective, and a possible hereditary amyloidosis was considered. Mutational analysis of the TTR gene demonstrated a heterozygous c.183G[A transition in exon 3 that substituted a glutammic acid with a lysine at residue 62 (p.Glu62Lys) of the mature protein; to the best of our knowledge, the nucleotide change was unreported. After re-evaluating the endocardial biopsy, immunohistochemistry demonstrated only a weak TTR positivity. Electronic supplementary material The online version of this article (doi:10.1007/s00415-012-6529-z) contains supplementary material, which is available to authorized users.

Background and objectives. Bendamustine in combination with rituximab has demonstrated a relevant clinical activity and a good toxicity profile in patients with mantle cell lymphoma (MCL). Cytosine arabinoside (Ara-C) is a key drug in induction chemotherapy regimens of young patients with MCL. In vitro studies have shown that bendamustine increases the cytotoxic effect of Ara‐C in leukemic blasts and lymphoma cells, and the two drugs display high synergistic activity when used in consecutive combinations. Clinically, it has recently been demonstrated that rituximab + bendamustine + Ara‐C (R-BAC) combination has a remarkable activity and is well tolerated both in untreated and in relapsed/refractory patients with MCL (Visco C et al. J Clin Oncol 2013 31:1442-1449). In the present study, we report data from an Italian single-center experience evaluating the efficacy and tolerability of R-BAC association in previously untreated MCL patients both eligible and ineligible for transplantation. Design and methods. From January 2009 to November 2014, 25 newly diagnosed patients with MCL (median 67 years; range 57-83 years) were treated with immunochemotherapy according to R-BAC schedule (Rituximab 375 mg/mq day 1; Bendamustine 70 mg/mq days 2, 3; Ara-C 500 mg/mq days 2-4) x 4 or 6 28-day cycles. All patients received G-CSF prophylaxis. Ninety-six percent of patients had stage III/IV disease; MIPI score was high in 24%, intermediate in 60% and low in 12%; in one patient it was not evaluable. Results. Twenty-two patients (88%) completed the scheduled treatment (4 or 6 cycles). The ORR was 88%: CR 84% (21 patients); PR 4% (1 patient); 1 patient was in SD, but he received only 1 cycle due to toxicity and died still in SD about three years later. Seven patients (28%) underwent autologous stem cell transplantation (ASCT); seven patients (28%) received rituximab maintenance for two years. Two patients (8%) experienced disease progression during first line therapy, both had intermediate MIPI score. After a median follow up of 33 months (range 4-65 months), the OS was 80% (one patient died for unrelated causes) and the PFS was 80%. At this time point, 19 (76%) and 1 (4%) patient were in CR and in PD, respectively. The latter patient is currently undergoing salvage chemotherapy. Patients who received either maintenance immunotherapy with rituximab or consolidation with ASCT after R-BAC (overall 56%) seemed to experience longer PFS and OS. In the ASCT group the OS was 100% at a median follow up of 23 months; in the rituximab maintenance group the OS was 71% at a median follow up of 41 months. In the group of patients that received R-BAC induction therapy only, the OS was 61% at a median follow up of 26 months (p=0.14, likely due to the low number). The most common adverse events (AEs) during R-BAC were hematological: grade 3-4 neutropenia (88%), grade 3-4 thrombocytopenia (64%) and grade 3-4 anemia (36%). The numbers of common grade 3/4 non hematological AEs in the study included: febrile neutropenia (28%), acute coronary syndrome (4%), lung infection (4%) and hyperglycemia (4%). No treatment-related mortality was observed, one patient died of secondary acute myeloid leukemia four years later from induction therapy. Conclusions. The present retrospective study confirms that R-BAC as frontline regimen in MCL is well tolerated and highly effective in ASCT ineligible patients and that it can be administered also in ASCT eligible patients as induction therapy. Moreover, our data suggest that a consolidation therapy (ASCT or maintenance immunotherapy) after R-BAC induction could improve the outcome. Disclosures No relevant conflicts of interest to declare.

Clonal plasma cell dyscrasia is considered causative of both POEMS syndrome and primary light chain amyloidosis (AL-A). Patients with POEMS syndrome and AL-A may share clinical features, ...

A case of lymphoma presenting with features shared by hairy cell leukemia (HCL) and its variant, intermediate lymphocytic lymphoma (ILL) and monocytoid B-cell lymphoma (MBCL) is described. Clinical presentation and the morphological findings observed in peripheral blood and in bone marrow biopsy suggested an HCL; however, the tartrate-resistant acid phosphatase negativity of peripheral blood lymphocytes, the histologic pattern observed in the spleen, and the immunophenotyping of peripheral blood, spleen and bone marrow neoplastic lymphocytes (expression of CD5 and lack of CD25), were strongly against this hypothesis. The clinical course was aggressive. This report emphasizes the concept of the equivocal presentation of some 'low-grade' B-cell lymphomas. It is further pointed out that, even with complete and exhaustive morphological and immunological analyses, atypical cases may be encountered.

Background Glycogen Synthase Kinase-3 (GSK-3) α and β are two serine-threonine kinases controlling insulin, Wnt/β-catenin, NF-κB signaling and other cancer-associated transduction pathways. Recent evidence suggests that GSK-3 could function as growth-promoting kinases, especially in malignant cells. In this study, we have investigated GSK-3α and GSK-3β function in multiple myeloma (MM). Methods GSK-3 α and β expression and cellular localization were investigated by Western blot (WB) and immunofluorescence analysis in a panel of MM cell lines and in freshly isolated plasma cells from patients. MM cell growth, viability and sensitivity to bortezomib was assessed upon treatment with GSK-3 specific inhibitors or transfection with siRNAs against GSK-3 α and β isoforms. Survival signaling pathways were studied with WB analysis. Results GSK-3α and GSK-3β were differently expressed and phosphorylated in MM cells. Inhibition of GSK-3 with the ATP-competitive, small chemical compounds SB216763 and SB415286 caused MM cell growth arrest and apoptosis through the activation of the intrinsic pathway. Importantly, the two inhibitors augmented the bortezomib-induced MM cell cytotoxicity. RNA interference experiments showed that the two GSK-3 isoforms have distinct roles: GSK-3β knock down decreased MM cell viability, while GSK-3α knock down was associated with a higher rate of bortezomib-induced cytotoxicity. GSK-3 inhibition caused accumulation of β-catenin and nuclear phospho-ERK1, 2. Moreover, GSK-3 inhibition and GSK-3α knockdown enhanced bortezomib-induced AKT and MCL-1 protein degradation. Interestingly, bortezomib caused a reduction of GSK-3 serine phosphorylation and its nuclear accumulation with a mechanism that resulted partly dependent on GSK-3 itself. Conclusions These data suggest that in MM cells GSK-3α and β i) play distinct roles in cell survival and ii) modulate the sensitivity to proteasome inhibitors.

Polyneuropathy, organomegaly, endocrinopathy, monoclonal gammopathy, skin changes (POEMS) syndrome and primary (AL) amyloidosis are two rare plasma cell disorders with heterogeneous, deceptive clinical features and severe prognosis. With the exception of autologous bone marrow transplantation for selected patients, the best therapeutic approaches are far from being settled and organ-response rates do not exceed 50% in AL amyloidosis and are fairly better in POEMS syndrome associated with localized osteosclerotic myeloma. Moreover, clinical evidence of therapy efficacy is delayed so that biological markers play a crucial role in monitoring diseases course and assessing therapy efficacy. We report on a 57-year-old woman with the unique coexistence of these two plasma cell disorders in whom the close monitoring of serum vascular endothelial growth factor (VEGF) and free light chains (FLC) helped to evaluate the response to melphalan and dexamethasone therapy.