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PURPOSE: While patients with early-stage Hodgkin lymphoma (HL) have an excellent outcome with combined treatment, the radiation therapy (RT) dose and treatment with chemotherapy alone remain questionable. This noninferiority trial evaluates the feasibility of reducing the dose or omitting RT after chemotherapy. METHODS AND MATERIALS: Patients with untreated supradiaphragmatic HL without risk factors (age ≥ 50 years, 4 to 5 nodal areas involved, mediastinum-thoracic ratio ≥ 0.35, and erythrocyte sedimentation rate ≥ 50 mm in first hour without B symptoms or erythrocyte sedimentation rate ≥ 30 mm in first hour with B symptoms) were eligible for the trial. Patients in complete remission after chemotherapy were randomized to no RT, low-dose RT (20 Gy in 10 fractions), or standard-dose involved-field RT (36 Gy in 18 fractions). The limit of noninferiority was 10% for the difference between 5-year relapse-free survival (RFS) estimates. From September 1998 to May 2004, 783 patients received 6 cycles of epirubicin, bleomycin, vinblastine, and prednisone; 592 achieved complete remission or unconfirmed complete remission, of whom 578 were randomized to receive 36 Gy (n=239), 20 Gy of involved-field RT (n=209), or no RT (n=130). RESULTS: Randomization to the no-RT arm was prematurely stopped (≥20% rate of inacceptable events: toxicity, treatment modification, early relapse, or death). Results in the 20-Gy arm (5-year RFS, 84.2%) were not inferior to those in the 36-Gy arm (5-year RFS, 88.6%) (difference, 4.4%; 90% confidence interval [CI] -1.2% to 9.9%). A difference of 16.5% (90% CI 8.0%-25.0%) in 5-year RFS estimates was observed between the no-RT arm (69.8%) and the 36-Gy arm (86.3%); the hazard ratio was 2.55 (95% CI 1.44-4.53; P

Cerebro-retinal microangiopathy with calcifications and cysts (CRMCC) or Coats plus syndrome is a pleiotropic disorder affecting the eyes, brain, bone and gastrointestinal tract. Its primary pathogenesis involves small vessel obliterative microangiopathy. Recently, autosomal recessively inherited mutations in CTC1 have been reported in CRMCC patients. We herein report an adolescent referred to our hospital following new seizures in a context of an undefined multisystem disorder. Cerebral imaging disclosed asymmetrical leukopathy, intracranial calcifications and cysts. In addition, he presented other typical CRMCC features i.e. a history of intrauterine growth retardation, skeletal demineralization and osteopenia, bilateral exudative vitreo-retinopathy reminiscent of Coats disease, recurrent gastrointestinal hemorrhages secondary to watermelon stomach and variceal bleeding of the esophagus due to idiopathic portal hypertension and telangiectatic and angiodysplasic changes in the small intestine and colon, and anemia due to recurrent bleeding and bone marrow abnormalities. The patient was diagnosed with Coats plus syndrome. CTC1 gene screening confirmed the diagnosis with the identification of heterozygous deleterious mutations. CRMCC due to CTC1 mutations has a broad clinical expressivity. Our case report illustrates the main possible associated phenotypes and their complications, demonstrating the need for a careful etiological search in order to initiate appropriate therapeutic and preventive measures.

International audience; After failure of erythropoiesis-stimulating agents (ESAs), lenalidomide (LEN) yields red blood cell (RBC) transfusion independence (TI) in 20-30% of lower-risk non-del5q myelodysplastic syndrome (MDS). Several observations suggest an additive effect of ESA and LEN in this situation. We performed a randomized phase III study in 131 RBC transfusion-dependent (TD, median transfusion requirement six RBC units per 8 weeks) lower-risk ESA-refractory non-del5q MDS. Patients received LEN alone, 10 mg per day, 21 days per 4 weeks (L arm) or LEN (same schedule) + erythropoietin (EPO) beta, 60,000 U per week (LE arm). In an intent-to-treat (ITT) analysis, erythroid response (HI-E, IWG 2006 criteria) after four treatment cycles (primary end point) was 23.1% (95% CI 13.5-35.2) in the L arm and 39.4% (95% CI 27.6-52.2) in the LE arm (P=0.044), while RBC-TI was reached in 13.8 and 24.2% of the patients in the L and LE arms, respectively (P=0.13). Median response duration was 18.1 and 15.1 months in the L and LE arms, respectively (P=0.47). Side effects were moderate and similar in the two arms. Low baseline serum EPO level and a G polymorphism of CRBN gene predicted HI-E. Combining LEN and EPO significantly improves erythroid response over LEN alone in lower-risk non-del5q MDS patients with anemia resistant to ESA

We evaluated the prognostic value of serum ferritin (SF) level at diagnosis in 318 newly diagnosed IPSS low and int 1 (lower) risk MDS patients included in the French MDS registry, who did not require RBC transfusions and had baseline SF level determination. Increased baseline SF level (>300 ng/ml) was correlated with male gender, more pronounced anaemia, and diagnosis of RARS but had no negative impact on progression to AML or survival.

Resume But de l’etude La grossesse chez la femme drepanocytaire est a haut risque maternel et fœtal. Notre objectif etait d’evaluer l’interet d’un programme transfusionnel prophylactique adapte, soit par des transfusions de globules rouges, soit par des echanges erythrocytaires automatises, chez des patientes drepanocytaires ayant des antecedents de complications obstetricales et/ou vaso-occlusives severes. Patientes et methodes Nous avons suivi 18 grossesses chez 14 patientes (12 SS, 1 SC, 1S/β-thalassemie). Sept avaient eu une ou plusieurs grossesses anterieures avec, dans neuf cas sur dix, des complications maternofœtales graves. Sept ont ete prises en charge des leur premiere grossesse en raison d’antecedents de complications drepanocytaires severes. Le but etait d’obtenir un taux d’hemoglobine anormale (hemoglobine S ou S + C) inferieur a 50 % et un taux d’hemoglobine entre 9 et 11 g/dL. Le choix entre transfusions simples et echanges erythrocytaires etait fonction du taux d’hemoglobine. Les echanges erythrocytaires ont ete realises a l’aide d’un separateur de cellules (Com. Tec, Laboratoires Fresenius). Dans dix cas, les patientes n’ont eu que des echanges erythrocytaires. Dans cinq cas, seules des transfusions simples ont ete realisees. Dans trois cas, les patientes ont beneficie successivement de transfusions et d’echanges erythrocytaires. Resultats Aucune complication maternelle grave et aucune mort fœtale ou perinatale n’ont ete observees. Dans un cas, l’accouchement a ete declenche a 36 semaines d’amenorrhee du fait d’une souffrance fœtale avec hypotrophie. Conclusion Les femmes atteintes d’un syndrome drepanocytaire majeur peuvent, meme en cas d’antecedents obstetricaux severes, mener a terme une grossesse sans grave complication obstetricale grâce a l’association d’une prise en charge precoce par une equipe multidisciplinaire et d’une politique transfusionnelle preventive adaptee.

Purpose: To assess whether abnormalities depicted by Thallium-201 scintigraphy can predict the occurrence of late cardiac complications in patients with Hodgkin's disease treated with mantle field radiation therapy. Methods and Materials: Thallium scintigraphy was performed in 49 patients at a median of 75 months after initial treatment (range 28–208 months). Initial treatment consisted in chemotherapy, given to two-thirds of the patients and mantle field radiation, delivered to all patients, using a 25-MV linear accelerator. Myocardial perfusion defects were observed in 78% of patients on thallium scintigraphy. These patients had their cardiac status reassessed at a median follow-up of 13.5 years after treatment. Results: Forty-two patients were assessable, as data on the cardiac status were missing in 7 patients. The majority of patients received at least 40 Gy, and 75% of them were treated with one field per day. The median follow-up of patients is 13.5 years (range 9–24.5). Eleven cardiac complications were observed in 9 patients (coronary artery disease [ n = 2], conduction-system abnormalities [ n = 3], valvular defects [ n = 5], and congestive heart disease [ n = 1]). The median 15-year actuarial incidence of cardiac complications was 21% (95% confidence interval of 9–40%). The positive and negative predictive value of thallium scintigraphy was 19% and 77%, respectively. The univariate analysis showed that the extent of left ventricle exposure to irradiation was an adverse prognostic factor, and chemotherapy administered before mantle field irradiation was of borderline significance. Conclusion: Thallium scintigraphy is not predictive of late cardiac complications. The extent of left ventricle exposure to radiation and possibly chemotherapy given before radiation treatment are adverse prognostic factors.

PURPOSE To compare progression-free survival (PFS), overall survival (OS), and toxicity of a doxorubicin-containing regimen administered alone or in combination with interferon alfa-2b (IFNalpha) in patients with low-grade follicular lymphoma (FL) and poor prognostic factors. PATIENTS AND METHODS Two hundred sixty-eight patients with advanced-stage FL received cyclophosphamide, doxorubicin, teniposide, and prednisone (CHVP) monthly for 6 months, then every 2 months for 12 months. After randomization, 242 patients were evaluated for efficacy: 119 received CHVP alone, and 123 also received IFNalpha at a dose of 5 million units three times weekly for 18 months. RESULTS After a 6-year median follow-up, the patients treated with CHVP + IFNalpha showed significantly longer median PFS than those who received CHVP alone (2.9 years v 1.5 years, respectively; P = .0002) and significantly longer median OS (not reached v 5.6 years, respectively; P = .008). Although some side effects, which included neutropenia, asthenia, fever, elevated serum transaminase levels, flu-like symptoms, and thrombocytopenia, were more frequently observed in patients who received the combination regimen, these reactions were moderate. IFNalpha was withdrawn because of toxicity in 10% of the patients, and a dosage reduction or temporary suspension was required in 28%. CONCLUSION With long-term follow-up of 6 years, these results confirm that the addition of IFNalpha to a doxorubicin-containing regimen for patients with advanced-stage and clinically aggressive FL not only increased PFS, as in most other similar trials, but also prolonged OS. Toxicity was moderate. The beneficial effects of this combined chemotherapy and IFNalpha regimen on OS probably reflect the selection of FL patients with poor prognostic factors.

Summary Background Blastic plasmacytoid dendritic cell neoplasm (BPDCN) is a rare disease characterized by malignant proliferation of a contingent blastic plasmacytoid dendritic cell. This rare entity is recognized mostly by cutaneous spreading, or not having a leukaemic component. The prognosis is very poor. Objectives To study a large cohort of 90 patients with BPDCN, to define additional symptoms to form a correct diagnosis earlier, and to manage such patients accordingly. Methods We retrospectively reviewed BPDCN cases registered in the French Study Group on Cutaneous Lymphoma database between November 1995 and January 2012. Ninety patients were studied. Demographic data, clinical presentation, initial staging and outcome were recorded. Results The group contained 62 male and 28 female patients (sex ratio 2·2). Their ages ranged from 8 to 103 years at the time of diagnosis (mean 67·2 years). Three major different clinical presentations were identified. Sixty-six patients (73%) presented with nodular lesions only, 11 patients (12%) with ‘bruise-like’ patches and 13 (14%) with disseminated lesions (patches and nodules). Mucosal lesions were seen in five patients (6%). The median survival in patients with BPDCN was 12 months. Conclusions We here distinguish three different clinical presentations of BPDCN. A nodular pattern is a more common feature than the originally reported ‘bruise-like’ pattern. Despite the fact that BPDCN may initially appear as a localized skin tumour, aggressive management including allogeneic bone marrow transplantation should be considered immediately, as it is currently the only option associated with long-term survival.

A sixty-year old female was referred to the Internal Medicine Department for the treatment of a diffuse high-grade non Hodgkin's lymphoma. She presented episodes of fever in context of neutropenia (neutrophils 0.35 x 10(9)/1 from 1.6 x 10(9)/1 white blood cells). Hemoglobin level was 8.2 g/dl and platelets 132 x 10(12)/1. A monoclonal IgM-Kappa protein (48 g/l) was detected in her serum. A direct antiglobulin test on the red cells proved positive with anti-C3d but not with anti-IgG antiglobulin, due to the presence of an IgM cold antibody with a serological anti-i specificity. The IgM antibody was found on the patient's neutrophils as well as in her serum. The antibody recognized all neutrophils tested in conventional serological tests whether the neutrophil phenotypes in systems NA, NB, and 5. It was demonstrated that it recognized the i antigen expressed on the neutrophils. These results suggest that a cold agglutinin anti-i might be responsible for neutropenia in some patients.

The reactivation of varicella-zoster virus occurs in immunocompromised patients, especially in cases of hematological malignancy. Disseminated reactivation could involve digestive tract with life-threatening condition.A 76-year-old woman, with a history of chronic lymphocytic leukemia, presented with left hypochondrium pain, and a vesicular rash with hemorrhagic shock that revealed an hemorrhagic gastritis due to varicella-zoster virus. The literature review identified 28 additional cases of gastrointestinal mucosal damage during reactivation of varicella-zoster virus. Mortality is 40%. We report here the first case in the course of low-grade lymphoid malignancy.Acute gastrointestinal symptoms in immunocompromised patients should evoke a varicella-zoster virus reactivation with gastrointestinal involvement. This clinical manifestation, although rare, should not be ignored because of its severity.

Thirty-nine patients with untreated acute promyelocytic leukemia (APL) were randomly allocated to receive rubidazone (zorubicin) 200 mg/m2/d, days 1 to 4 plus cytarabine (Ara C) 200 mg/m2/d, days 1 to 7 (arm A, 21 patients), or amsacrine (Amsa) 150 mg/m2/d, days 1 to 4 plus Ara C 200 mg/m2/d, days 1 to 7 (arm B, 18 patients). Prophylaxis of disseminated intravascular coagulation was made by platelet transfusions and heparin. In case of leukemic resistance, patients received a second course with 2 days of rubidazone (arm A) or Amsa (arm B) and 3 days of Ara C. Patients who achieved complete remission (CR) received three consolidation courses with the two drugs used for induction and maintenance therapy for 3 years. Two patients in arm A and one in arm B were allografted in first CR. Initial characteristics were similar in both arms. In arm A, 18 patients (86%) reached CR, two had hypoplastic death, and one had leukemic resistance after two courses. In arm B, 12 patients (66%) achieved CR, two had early death (CNS bleeding, one case; ventricular fibrillation, one case), and four had resistant leukemia after two courses. The difference in CR rate between the two arms was not significant. In arm A, disease-free survival (DFS) showed a plateau at 54.3% after 34 months (95% confidence interval [CI], 32.1% to 74.9%), with eight CRs longer than 34 months. In arm B, DFS was significantly shorter (P less than .03), showing a plateau at 16.7% after 38 months (95% confidence interval, 4.7% to 44.6%), and only two prolonged CRs were seen. The difference in DFS remained significant after censoring allografted patients and patients who died in CR (one in arm A, two in arm B). Our results suggest that Amsa-Ara C combinations may be inferior to anthracycline-Ara C combinations in the treatment of APL, because they seem to provide shorter DFS and, possibly, a higher incidence of initial leukemic resistance. However, studies with larger numbers of patients are required.

Maternal and fetal risk is often high during pregnancy in sickle cell disease. Our objective was to evaluate the benefits of a transfusion program adapted to each pregnant patient, either by red cell transfusion or by automated red cell exchange, in sickle cell patients with a history of serious obstetrical and/or sickling complications.We managed 18 pregnancies in 14 patients (12 SS, 1 SC, 1 S/b-thalassemia), seven of whom had a history of one or more pregnancies, with severe maternofetal complications in nine out of 10 cases. The other seven patients were pregnant for the first time and were in care because of a history of severe sickling complications. The aim was to achieve a proportion of abnormal hemoglobin (hemoglobin S or S+C) below 50% and a hemoglobin level between 9 and 11 g/dL. The choice between transfusion and red cell exchange was made in the light of the hemoglobin level. Red cell exchange was done using a Fresenius Com. Tec blood cell separator. Patients had red cell exchange in 10 cases, and transfusions in five cases. In three cases, patients had successive transfusions and red cell exchange.No serious maternal complication was observed. No fetal or perinatal death occurred. In one case, delivery was induced at 36 weeks of gestation because of fetal distress and hypotrophy.Our study suggests that women with severe sickle cell disease, even if they have a serious obstetrical history, can carry their pregnancy to term, without major obstetric complications, through a combination of early management by a multidisciplinary team and a suitable policy of prophylactic transfusion or automated red cell exchange.

We report a 61-yr-old kidney transplant recipient with human Parvovirus B19 (HPV B19) infection presenting as a severe pancytopenia 1 month after transplantation. Bone marrow aspiration revealed severe erythroid hypoplasia with giant and dystrophic proerythroblasts. Bone marrow cells were positive for HPV B19 DNA detected by polymerase chain reaction (PCR). Pancytopenia resolved shortly after administration of intravenous immunoglobulins. Nineteen cases of HPV B19 infection in organ transplant recipients have been so far reported in the literature. Immunocompromised patients should be considered at risk from developing symptomatic HPV B19 infections. In such patients, specific anti-HPV B19 IgM and IgG antibodies may be absent or transient and therefore their negativity cannot rule out the diagnosis of HPV B19 infestation. Bone marrow smear morphological findings may suggest the diagnosis but testing for viral DNA by PCR is mandatory. Patients may spontaneously recover. However, since specific anti-viral therapy is not currently available, intravenous immunoglobulin administration appears to be the more efficacious treatment.

PURPOSE The aim of this phase II trial was to assess the efficacy of fludarabine monophosphate in untreated and pretreated mantle-cell lymphomas (MCL). PATIENTS AND METHODS Fifteen patients with MCL were included in the study. In two cases, fludarabine was the first-line therapy, the second in four cases, the third in five cases, and the fourth in four cases. The diagnosis of MCL was based on the criteria of the European Lymphoma Task Force (ELTF), with morphologic, immunologic, and cytogenetic data. Patients were treated with intravenous fludarabine 25 mg/m2/d for 5 days every 4 weeks. RESULTS Toxicity of fludarabine was mild: World Health Organization (WHO) grade 3 and 4 granulocytopenia occurred in 15 of 56 assessable cycles (cy) (27%), there was no grade 3 or 4 thrombocytopenia, one grade 3 bacterial lung infection, and no treatment-related death. There were five partial responses (33%) but no complete response. The duration of these responses was short and ranged from 4 to 8 months. CONCLUSION These results suggest that fludarabine can be moderately effective in the treatment of MCL. Fludarabine appears to be far less effective than in chronic lymphocytic leukemia (CLL) and follicular non-Hodgkin's lymphoma (NHL). Therefore, fludarabine should be evaluated in association with other chemotherapeutic agents in MCL.

The effectivness of interferon alpha (IFN) for the treatment of chronic myelogenous leukemia (CML) during the chronic phase is now well established. Several studies have shown that IFN produces hematologic remission in 60% to 80% of patients [1]. In some studies the achievement of complete hematologic response within 3 months seems to represent a significant factor which correlates with a cytogenetic response [2]. Also, the treatment with IFN resulted in suppression of the Ph-positive cells population which was complete in 7% to 25% of the patients [3, 4]. A major cytogenetic response (i.e., less than 35% Ph-positive cells) was noted in 35 to 45% of the patients. Such cytogenetic response was not only complete but also prolonged for periods ranging between 2 and 8 years [5].

We report the case of a patient with chronic phase CML who exhibited, in the same cells, beside the Philadelphia chromosome, an additional translocation between the other chromosome 9 and one of the chromosomes 12 [t(9;12)(p13;q24.1)]. Complete cytogenetic remission with disappearance of both karyotypic abnormalities was achieved after 18 months treatment with low dose (1.4 x 10(6) U/m2/day) recombinant alpha-interferon and has been sustained with maintenance therapy for 68+ months (actual follow-up). Clonality at diagnosis and recovery of polyclonal hematopoiesis in complete cytogenetic remission were demonstrated using the polymorphism at the human androgen receptor gene (Humara) locus on chromosome X. The role of the additional translocation in the response to low dose alpha-interferon therapy remains hypothetical.

In the present study, we report the case of a patient displaying an abnormal chromatin clumping (ACC) syndrome, a rare disease which shares features with both myeloproliferative and myelodysplastic disorders. Although various non specific cytogenetic abnormalities have been observed in ACC, the presence of a Ph1 chromosome has not been reported. In our patient, despite a lack of Ph1, PCR analysis of blood and bone marrow samples revealed a BCR-ABL rearrangement. These results indicate that at least some cases of ACC syndrome could represent a form of Ph1-negative chronic myeloid leukaemia.

No significant progress has been achieved in the treatment of multiple myeloma. Indeed, the reference combination Melphalan-Prednisone, introduced in 1970’s by Alexanian affords a median survival of between 20 and 44 months and between 20 and 26 months, exclusively for stage III disease [1].

The authors report a complex case in which chronic lymphoid leukaemia was associated with leiomyoblastoma of the digestive tract and cutaneous thrombosing vasculitis with serum anti-cardiolipin antibodies. They discuss a new physiopathogenetic mechanism of vasculitis in blood diseases.

The authors report 3 pregnancies in 3 patients with essential thrombocythemia. In the 3 cases, the course of the pregnancy was successful, with normal delivery in 2 cases, and premature delivery of a live fetus because of an abruptio placentae in the third case. From these 3 cases and a review of the literature, the authors analyse the fetal and maternal risks of pregnancy in these patients and the potential usefulness of preventive treatments (platelet antiaggregating drugs, anticoagulants). Besides, in these 3 cases a steadily decrease in blood platelet counts was observed during pregnancy with a nadir just before delivery followed by a sharp increase in the days following delivery. These findings may give some useful information on the regulation of thrombopoiesis.

We recently demonstrated that IL-2 is produced by reactive T cells in CD25-positive malignant lymphomas (ML). Using in situ hybridization, we investigated IL-6 mRNA expression in these CD25-positive ML. The ML tested included 9 anaplastic large cell lymphomas and 3 B-diffuse large cell lymphomas. Five CD25-negative ML were studied as controls. We show that IL-6 producing cells are present in all these ML. The density of positive cells was heterogeneous from case to case. However 3 cases of CD25-positive ML showed a dramatically higher density of IL-6 producing cells (70, 50, 43 producing cells per 10,000 cells, respectively) as compared to the other 9 cases of CD25-positive ML (mean 6.03 +/- 2.1 per 10,000). Morphological and topographical data suggested that several types of cells including fibroblasts, lymphocytes, macrophages and endothelial cells may synthesize IL-6. A combination of immunohistochemistry and in situ hybridization showed that reactive T cells and endothelial cells express the IL-6 gene whereas CD30-positive ML cells do not express this gene. Previous studies showed that IL-6 was capable to induce IL-2 receptor expression as well as production of IL-2 and stimulation of lymphomatous cells growth. Our present results indicate that the paracrine production of this cytokine may play a role in the proliferation of malignant lymphomas.

The association between thrombocytopenic thrombotic purpura (TTP) and infectious or multisystem disease, pregnancy, transplantation, drugs and toxins is well known. The onset of TTP in the course of neoplasm is rarely described. The authors report one case of TTP associated with prostatic tumor. TTP preceded the discovery of neoplasm by 12 months. Moreover, TTP showed an original course with four recurrences despite antiplatelet and hormonal therapies; the successive regressions were obtained with less and less effort, as TTP was discovered at an early stage.

We conducted a randomized multicenter trial comparing low-dose cytarabine (LD ARA-C) (20 mg/m2 for 21 days) with an intensive chemotherapy (rubidazone [a daunorubicin-derived agent], 100 mg/m2 for 4 days, ARA-C 200 mg/m2 for 7 days) in 87 patients over 65 years of age with de novo acute nonlymphocytic leukemia (ANLL). Forty-one patients received LD ARA-C and 46 received intensive chemotherapy. The number of complete remissions (CRs) but also of early deaths was higher in the intensive chemotherapy group, while partial remissions (PRs) and failures were more frequent in the LD ARA-C group (P less than .001). Infectious complications during induction treatment were more numerous and more severe in the intensive chemotherapy group (P less than .01). Patients treated with LD ARA-C required fewer RBC transfusions (P less than .02), fewer platelet transfusions (P less than .01), and had a shorter hospital stay for induction treatment (P less than .01). Overall survival and CR duration were not significantly different in either group. In the LD ARA-C group, the survival of patients with PR and those of patients in CRs was identical. We conclude that in a selected group of elderly patients with de novo ANLL a higher number of CRs may be obtained with intensive chemotherapy, but that with LD ARA-C, the number of early deaths is lower, and long-lasting PRs are obtained, resulting in a similar overall survival.

The authors report the results of a chemotherapy regimen of methyl-GAG, etoposide and prednimustine in 21 elderly patients (median age = 78 years) with aggressive non-Hodgkin's lymphoma. Sixteen patients responded (11 complete remissions, 5 partial remissions) with minor toxic side-effects. This regimen could be proposed for patients whose age and/or cardiovascular status prohibit treatment with usual anthracycline-containing chemotherapy programs.

We report the case of a patient with chronic lymphocytic leukemia (CLL) who developed fatal intravascular autoimmune hemolytic anemia (AIHA) after fludarabine treatment. He had previously received several treatments including two courses of fludarabine. The direct antiglobulin test (DAT) was negative at diagnosis but was found to be positive with anti-IgG after the first fludarabine treatment. When the patient was treated again with fludarabine nine months later, the DAT became positive with anti-IgG and anti-C3d antiglobulins after the second course of treatment. Abrupt, fatal intravascular hemolysis occurred after the third course. The occurrence of severe AIHA in CLL patients treated with fludarabine has been reported by several authors. Physicians should be aware of the risk of severe AIHA in CLL patients with a history of AIHA or positivation of the DAT during previous fludarabine administration, or in case of secondary fixation of complement to the red cell membrane occurring during fludarabine treatment.

The association between thrombocytopenic thrombotic purpura (TTP) and infectious or multisystem disease, pregnancy, transplantation, drugs and toxins is well known. The onset of TTP in the course of neoplasm is rarely described : only 7 cases have been reported (5 cases of gastric adenocarcinoma, 1 case of breast carcinoma and 1 case of carcinoma with unknown primary site). The authors report the first case of TTP associated with prostatic tumor.

Procedures are described for the isolation of a mast cell growth factor (MCGF) from medium conditioned by mitogen-activated splenic leukocytes (CM). Although optimal conditions for the production of MCGF in CM are identical to those for the production of T cell growth factor (TCGF), MCGF can be dissociated from TCGF after the first stage of purification on a DEAE-cellulose column. MCGF elutes from the column in the breakthrough fraction, whereas TCGF binds avidly to DEAE and is eluted only at high salt concentration. MCGF also differs from TCGF with respect to m.w. (as estimated by Sephadex G-150 chromatography) and sensitivity to trypsin. In addition, MCGF is produced by the murine myelomonocytic leukemia WEHI-3 and the radiation induced thymic lymphoma LBRM-33 cells, whereas TCGF is produced only by the latter in the presence of a mitogen. Another hemopoietically active factor, granulocyte colony-stimulating factor (G-CSF) present in media conditioned by WEHI-3 and LBRM-33 cells, however, shares a number of properties with MCGF. Although studies with purified or partially purified MCGF have thus far failed to reveal a correlation between MCGF and G-CSF, further biochemical analyses are necessary to dissociate MCGF from G-CSF.

A feeder layer independent long-term in vitro culture system for murine mast cells is described. Concanavalin A-activated murine splenic leukocyte-conditioned medium, prepared under conditions optimal for T cell growth factor production, has been found also to contain a growth-promotion activity for murine mast cells identified by their morphology, characteristic ultrastructure of the granules, positive reactions with toluidine blue and alcian blue, presence of receptors for IgG and IgE, as well as presence of histamine, serotonin, L-Dopa, 5-hydroxytryptophan, and sulfated products within the cytoplasm. After 2 to 3 wk of culture in the presence of the conditioned medium, mast cell lines were established from various sources initially devoid of matured mast cells. Such sources included spleen and bone marrow of athymic nude mice, long-term cultured marrow cells as well as T cell-depleted normal marrow. Cultured mast cells are absolutely dependent upon the conditioned medium-derived growth factor(s) for growth and viability. Death ensues within 24 hr in the absence of the factor(s). Established mast cell lines have been maintained in exponential growth for over 1 yr by passaging in the conditioned medium every 3 to 7 days.

We describe three patients with chronic autoimmune thrombocytopenia who exhibited transient remission during viral infection (varicella, hepatitis B, and influenza virus pneumopathy). In two patients, a male homosexual and an hemophiliac, thrombocytopenia was associated with AIDS-related complex. The third patient had classic idiopathic thrombocytopenic purpura. The mechanism of these rare remissions is discussed.

We report the case of a patient treated for Hodgkin's disease (stage IIIEA) by combination of chemotherapy (MOPP regimen) and total nodal irradiation. Five months after the completion of radiotherapy the patient presented with a relapse of his Hodgkin's disease and simultaneous occurrence of diffuse non Hodgkin's lymphoma in a different lymph node territory. The relationship between these two malignancies is discussed and the literature is reviewed.

In 3 patients with ANLL, chemotherapy including high or conventional doses of Ara-C had been ineffective. However subsequent treatment with low-dose (LD) Ara-C induced a PR or CR which were sustained with regular LD Ara-C reinduction courses. Survival of the 2 patients with PR was 24 and 8 months respectively. The patient with CR was alive 18 months after a bone marrow graft. In 2/3 cases, the cytogenetic abnormalities initially detected disappeared with treatment. These observations suggest that the cellular mechanism of action of LD Ara-C is different from that of HD Ara-C, but do not favour a differentiating action of LD Ara-C. LD Ara-C can be prescribed as a salvage therapy even after failure of high or conventional doses.

Supernatants from mouse spleen leukocytes stimulated by concanavalin A or from a secondary MLC between donor and recipient of a skin allograft can induce in bone marrow cells an exponential growth of mononuclear cells with cytoplasmic basophilic granules. These cells can be maintained in liquid suspension culture for up to 6 months. They lack the properties of T or b lymphocytes, monocytes or macrophages. They have the morphological features of mast cells or basophils; the cytoplasmic granules are metachromatic for toluidine blue, alcian blue-positive at pH 0.3 and contain histamine. In addition, these cells bind monoclonal mouse IgE. They may be considered as cells of the basophil-mast cell lineage.

We have studied in detail the effects of cholera toxin (CT), its pentameric B-chain subunit (toxoid) and the A-promoter chain on the differentiation of hemopoietic progenitor cells. Murine marrow cells were treated either with CT or its subunits. After stimulation with either the multilineage growth factor (multi-CSF; also called interleukin 3 or HCGF) or other hemopoietic regulators (colony-stimulating factors, or CSF), the clones grown in semisolid collagen cultures were scored in situ. Pluripotent stem cells (CFU-S) and multilineage (mixed CFU) or lineage-restricted progenitors (CFU-c) were estimated. We found that CT sensitivity is gradually gained by cells through the stepwise differentiation processes (i.e., CFU-S less than multilineage CFC less than committed CFC less than maturing cells). CT also has a selective, dose-dependent inhibitory effect (1 microM to 1 pM) on hemopoietic lineages (basophil-mast cells less than megakaryocytes less than neutrophils less than monomacrophages). These phenomena were obvious when the clonal growth was supported by multi-CSF but, interestingly, were not observed when lineage-restricted CSF were used. They furnished additional evidence that multi-CSF activates cells in a specific manner. This growth factor involved in progenitor cell self-renewal control may contribute to maintaining, on maturing cells, characteristics that are normally the attributes of progenitors.

Abstract 2916 Background: Increased serum ferritin (SF) level has been associated with worse overall survival (OS) in lower risk MDS, presumably though iron overload in vital organs including the heart and liver (Cazzola, NEJM 2005, Malcovati, JCO 2005, Garcia-Manero G et al. Leukemia 2008). However, those high levels are generally associated with RBC transfusion requirement (Malcovati, JCO 2007, Sanz, Blood (ASH 2008 : Abstract 640). High SF level has also been reported in non transfused lower risk MDS, and attributed mainly to ineffective erythropoiesis, but its prognostic value in this context is unclear. We evaluated the prognostic value of SF level at diagnosis in lower risk non transfusion dependent (TD) MDS patients included in the GFM registry of MDS. Methods: We selected in the GFM Registry (1900 pts included between mid 2003 and 2010), 485 newly diagnosed IPSS low and int 1 (lower) risk MDS patients (pts), not transfused during the first 6 months of follow-up, who had a baseline SF level (normal values 20–300 ng/ml), and no other cause of increased SF, including infection and liver disease (due in particular to alcohol abuse). Pts with SF < 20ng/mL were excluded. The prognostic value of SF for AML progression and OS was analyzed. Results: Median age of the 485 pts was 77 years (range 29–103), with 53.8% males. WHO classification was RA 21.5%, RCMD 23.5%, RARS 23%, RCMD-RS 0.5%, RAEB-1 22% and 5q- syndrome 5%. Karyotype according to IPSS was fav (61%), int (10%), unfav (2%), not available (17%). IPSS was 0 (44%), 0.5 (31%), 1 (8%), ND (17%). The median level of SF was 276ng/ml (range 20–5558) with 225 (46%), 145 (30%) and 47(10%) pts having SF>300ng/ml, >500ng/ml and >1000ng/ml respectively (resp.). In univariate analysis, male gender (P=0.0005), Hb level100μm3 (P=0.02), erythroblasts >30% in bone marrow (P=0.008), serum (s) EPO level>100IU/l (P=0.04), RARS (P300ng/ml) while karyotype, IPSS, % marrow blasts, reticulocytes, platelets showed no correlation. In multivariate analysis, sEPO level>100IU/l and RARS were significantly associated with higher SF level. As the SF threshold of 1000ng/mL is often proposed to start chelation therapy, prognostic analyses were also made for that level. Hb level 100 were associated with SF >1000 ng/ml in univariate analysis, while only Hb level 5-year OS was 77% and 85% in pts with baseline SF300ng/ml resp. (p=0.7) and 81% vs 92% for SF1000ng/ml, resp. (p=0.11) and 5-year cumulative incidence of AML transformation was 2.2% and 3.3% for pts with SF300ng/ml resp (P=0.69), and 3% and 0% for pts with SF1000ng/ml resp (P=0.86). Conclusions: Increased baseline SF level in non transfusion-dependent lower risk MDS is correlated with a few baseline characteristics including more severe anemia, a diagnosis of RARS and higher baseline serum EPO level, but is not significantly correlated with outcome. Disclosures: Fenaux: CELGENE: Honoraria, Research Funding; JANSSEN CILAG: Honoraria, Research Funding; AMGEN: Honoraria, Research Funding; ROCHE: Honoraria, Research Funding; GSK: Honoraria, Research Funding; NOVARTIS: Honoraria, Research Funding; MERCK: Honoraria, Research Funding; CEPHALON: Honoraria, Research Funding.