Terminal deletions of long arm of chromosome 13 are rare and poorly characterized by cytogenetic studies, making for difficult genotype-phenotype correlations. We report two siblings presenting generalized epilepsy, intellectual disability, and genitourinary tract defects. Array CGH detected a 1.3 Mb deletion at 13q34; it contains two protein-coding genes, SOX1 and ARHGEF7, whose haploinsufficiency can contribute to the epileptic phenotype.

Acute monoblastic leukemia (AMoL) is characterized by cells with highly undifferentiated morphology. Cytochemistry with non-specific esterases is negative in up to 20% of cases. Immunophenotyping by flow cytometry has an essential role in diagnosing such a subtype of leukemia and a multiparametric approach with a wide monoclonal antibody panel is necessary. We describe a case of AMoL with morphology resembling either plasma blasts or very immature erythroblasts. Diagnosis was made by alpha-naphtyl-acetate esterase staining and with immunophenotyping, which was made with a wide monoclonal antibody panel. Blasts were positive for monocytic markers. Most of leukemic cells, however, were positive for Glycophorin-A. The presence of Glycophorin-A, which is considered as a specific marker of the erythroid lineage, has never been reported previously in cases of AMoL. This peculiar immunophenotype might be interpreted as deriving from a common myelo-erythroid precursor undergone leukemic transformation.

We present on a new case of myelodysplastic syndrome characterized by array Comparative Genomic Hybridization.This technique confirmed the monosomy 7, detected by conventional cytogenetics, and revealed also a deletion on the short arm of chromosome 12.This deletion extends for about 14.8 Mb and breaks ETV6 gene.12p deletion extents in hematological malignancies may vary, but the minimally deleted region almost invariably contains ETV6, that is considered the main candidate tumor suppressor genes within the region for tumor progression.It has been shown that levels of ETV6 were significantly decreased in cases with 12p13 deletions, whereas expression of other genes in the deleted region, like BCL2L14, LRP6, DUSP16 and GPRC5D, did not show any variation, independently of their copy number status.This observation strengthens the fact that ETV6 may play a potential role in the tumorigenesis process.The role of ETV6 in our patient myelodysplastic syndrome is showed by his clinical history and his poor prognosis.

Persistent polyclonal B-cell lymphocytosis (PPBL) is a rare clinical condition, characterized by a persistent, generally moderate lymphocytosis, generally due to stimulation of central memory B-lymphocytes, and by a moderate increase of polyclonal IgM. In some patients, slight or moderate splenomegaly is observed. A variable percentage of circulating, bone marrow and splenic lymphocytes display an abnormal nucleus (generally bilobated) or are binucleated. The clinical course is benign in most cases and transformation into splenic B-cell lymphoma occurs in few cases. In the current paper we report the first case of pregnancy in PPBL. Our patient became pregnant 18 months after diagnosis. In the course of pregnancy, a marked down-regulation of lymphocytosis (from 6 × 10(9)/L to 2.1 × 10(9)/L) and a decrease in B-lymphocyte number was observed (from 3.6 × 10(9)/L to 1 × 10(9)/L), mainly due to a marked reduction in the percentage and absolute number of central memory B-cells. Such modifications were similar to those described in normal pregnant women. One year after the delivery of a healthy female baby, the number of total lymphocytes and B-lymphocytes showed an inverse behavior, with a new expansion of central memory B-cells. Our case shows that a normal pregnancy can occur in patients with PPBL and that pregnancy can induce marked modifications in B-lymphocyte kinetics and phenotype.

sponse to therapy, such as VGPR or PR, was assessed according to the criteria of the International Myeloma Working Group [4] adding the criterion sCR [5] . Multiparameter flow cytometry was performed by means of a FACSCanto II cytometer (Becton Dickinson) equipped with two lasers (488 and 633 nm). A fiveor sixcolor method was carried our using the following monoclonal antibody (MoAb) combinations: CD138/FITC, CD38/PE, CD19/PE-Cy.7, CD27/APC, CD45/APC-Cy.7, for tube 1; CDF138/FITC, CD38/PE, CD20/PerCP-Cy5.5, CD19/PE-Cy.7, CD117/APC, CD45/PE-Cy.7, for tube 2; CD138/FITC, CD38/PE, CD19/PE-Cy.7; CD56/APC, CD45/APC-Cy.7, for tube 3; cyK/FITC, cyλ/PE, CD138/ PerCP-Cy5.5, CD18/PE-C7.7, CD38/APC, CD45/APCCy.7, for tube 4, and CD38/FITC, CD229/PE, CD138/ PerCP-Cy5.5, CD19/PE-Cy.7, CD45/CD45/APC-Cy.7 for tube 5. The CD229 MoAb was purchased from R&D Systems (clone 249936). For cyK and cyλ detection, rabbit F(ab’) 2 anti-human polyclonal antibodies, purchased from Dako, were used, and cell permeabilization was made by the FIX&PERM kit (An Der Grub Bio Research). All the remaining MoAbs were purchased from Becton Dickinson. Five hundred thousand events/tube were acquired, and data were registered and elaborated by the FACSDiva software (Becton Dickinson). Flow cytometer setting procedures were made by an automated method, using BD Cytometer Setup and Tracking Beads (Becton The SLAM family of membrane receptors consists of nine members (CD229, CD48, CD48-H1, CD84, CD150, CD244, BLAME, CS1 and NTB-A), which are involved in Tand NK-cell activation, but they also show a role in Blymphocyte function [1] . CD229 is an interesting member of the SLAM family. In humans, this molecule has been found to be widely distributed during B-cell development. Its expression appears to increase progressively during bone marrow maturation, and significant upregulation has been detected on the surface of tonsil plasma cells (PCs) [2] . Some interesting findings have shown that CD229 is constantly present on the surface of human bone marrow PCs, being expressed in myeloma cell lines, multiple myeloma (MM) and monoclonal gammopathies of uncertain significance (MGUS). Thus, CD229 has been proposed as a novel target for the diagnosis and treatment of MM [3] . In the current paper, we report our experience in a series of patients suffering from MGUS and MM examined by flow cytometry. After obtaining informed consent, we evaluated bone marrow samples from 54 patients: 14 patients diagnosed with MGUS and 40 with MM. The patients with MM were evaluated at diagnosis (n = 8) and after an achieving stringent complete response (sCR; n = 8), or either a partial response (PR) or a very good PR (VGPR) after therapy (n = 24). The main characteristics of our patients are shown in table 1 . The degree of reReceived: November 27, 2014 Accepted after revision: February 16, 2015 Published online: August 15, 2015

Conventional cytogenetics continues to have a fundamental role in the classification and risk scoring of myelodysplastic syndromes (MDS). Nevertheless, non-informative karyotypes represent up to 20% of cases. Some different molecular methods, not included in the routinary diagnostic workup, such as aCGH or mutational analysis, could be able to detect new abnormalities and improve the subtyping of MDS.

Hematogones are precursors of B-lymphocytes detected in small numbers in the bone marrow. Flow cytometry is the most useful tool to identify hematogones and, so far, 4-color methods have been published. In addition, flow cytometry is used in the diagnosis and follow-up of lymphomas. We developed a flow cytometric 7-color method to enumerate hematogones and to assess B-lymphocyte clonality for routine purposes. We evaluated 171 cases of B-cell non-Hodgkin lymphomas, either at diagnosis or in the course of follow-up. By our diagnostic method, which was carried out by the combination K/λ/CD20/CD19/CD10/CD45/CD5, we were able to detect hematogones in 97.6% of samples and to distinguish normal B-lymphocytes, neoplastic lymphocytes and hematogones in a single step. The percentage of hematogones showed a significant inverse correlation with the degree of neoplastic infiltration and, when bone marrow samples not involved by disease were taken into consideration, resulted higher in patients during follow-up than in patients evaluated at diagnosis.

Central nervous system (CNS) involvement in multiple myeloma (MM) is uncommon. Among its possible presentations, leptomeningeal involvement of MM, also termed central nervous system myelomatosis (CNS-MM) is rare and is characterized by the presence of neoplastic plasma cells in the cerebrospinal fluid (CSF). So far, 187 cases of CNS-MM have been reported : the great majority of them were diagnosed by cytological assays and flow cytometry was used in only eight cases. We describe a case of CNS-MM in a 62-year-old woman, previously treated with chemotherapy (VTD) and autologous peripheral blood hematopoietic stem cell transplantation for stage IIIB IgG-λ MM. After achieving a very good partial response, the patient showed progression of disease, with an extramedullary localization. During administration of second-line therapy, the patient showed severe neurological symptoms. MRI resulted negative. Diagnosis of CNS-MM was made by multiparameter flow cytometry, which showed the presence of CD56(+) plasma cells in a CSF sample, in the absence of plasma cell leukemia. In this paper we also present a review of the eight previous cases of CNS-MM diagnosed by flow cytometry. We found that the application of flow cytometry in cases of MM with neurological symptoms allows a rapid diagnosis of CNS-MM and provides useful information about plasma cell phenotype (including CD56 expression). Some cases of CNS-MM are characterized by normal MRI. In addition, some evidences deriving from the review of literature suggest that CSF monitoring by flow cytometry in such cases might be used to evaluate the efficacy of drugs capable of crossing the blood-brain barrier.

Clinical Practice Points•Acute myeloid leukemia (AML) associated with fms-related tyrosine kinase 3 (FLT3) internal tandem duplication mutation has an increased relapse rate and a reduced overall survival.•Here we report 3 cases of advanced refractory AML treated using sorafenib alone or in association with chemotherapy, at a standard dose of 400 mg twice daily. All the patients had been previously treated with several chemotherapy lines and their status was complicated by severe infectious disease.•After sorafenib treatment, clinical complete remission but not molecular remission was achieved in all cases. Median duration of the response of these patients was relatively short (40 days), but in 1 patient it was possible to continue the therapy at the reduced dose of 600 mg daily as a bridge to allogeneic stem cell transplantation.•We confirm that sorafenib is active in FLT3 mutated AML and we suggest that this drug could be used in more precocious stages of this disease to achieve a deeper hematological response as a bridge to bone marrow transplant. •Acute myeloid leukemia (AML) associated with fms-related tyrosine kinase 3 (FLT3) internal tandem duplication mutation has an increased relapse rate and a reduced overall survival.•Here we report 3 cases of advanced refractory AML treated using sorafenib alone or in association with chemotherapy, at a standard dose of 400 mg twice daily. All the patients had been previously treated with several chemotherapy lines and their status was complicated by severe infectious disease.•After sorafenib treatment, clinical complete remission but not molecular remission was achieved in all cases. Median duration of the response of these patients was relatively short (40 days), but in 1 patient it was possible to continue the therapy at the reduced dose of 600 mg daily as a bridge to allogeneic stem cell transplantation.•We confirm that sorafenib is active in FLT3 mutated AML and we suggest that this drug could be used in more precocious stages of this disease to achieve a deeper hematological response as a bridge to bone marrow transplant.

We examined the efficacy of cyclosporin A (CsA) in 50 patients with myelodysplastic syndrome (MDS) consisting from 47 of RA, 1 of RARS, and 2 of RAEB. These patients showed various marrow cell types including hypo-, normo-, and hypercellularity. Patients belonged to the following International Prognostic Scoring System (IPSS) risk groups: 4 of low, 41 of intermediate-1, and 5 of intermediate-2. The median CsA dose was 4.58 mg/kg, and treatment responses were classified according to the International Working Group (IWG) criteria. Hematological improvement (HI) was observed in 30 (60%) patients, and all of them were belonged to RA. In the patients with RARS or RAEB, no efficacy was observed. Four (8%) of the responders achieved partial remission (PR) with granulocytes ≥1500 μl−1, Hb >11 g/dl and platelets ≥100,000 μl−1. Higher response rate (53%) was shown in erythroid lineage (HI-E) compared to platelet (HI-P, 36%) or neutrophil lineage (HI-N, 35%). When we analyzed the correlation between the response to CsA therapy and the karyotype or HLA type, there were significantly more responders with good karyotype or DRB1∗1501 than with intermediate/poor karyotypes or with other HLA types. These results indicate the usefulness of CsA therapy for MDS patients with any marrow cellularity, especially for erythroid lineage and patients with good karyotype or DRB1∗1501.

Waldenström macroglobulinemia and multiple myeloma are mature B-cell neoplasms deriving from post-germinal cells at different stages of differentiation. The simultaneous presentation of Waldenström macroglobulinemia and multiple myeloma in the same patient is a very rare phenomenon and, so far, only two cases have been described. We report the case of a 75-year Caucasian female patient, with a silent clinical history, who presented with anemia and two different monoclonal proteins (IgMκ and IgGκ). The trephine biopsy showed the presence of a dual population, represented by small lymphoplasmacytoid cells and by plasma cells, which infiltrated the bone marrow with a clearly different pattern. Both immunohistochemistry and flow cytometry demonstrated the biclonal origin such neoplastic cells, since lymphoplasmacytoid cells resulted IgMκ while plasma cells were IgGκ. This biclonal pattern was further confirmed by the demonstration of a different IgH gene rearrangement of the two neoplasms. The patient was treated with bortezomib, dexamethasone and rituximab, achieving partial remission of both Waldenström macroglobulinemia and multiple myeloma. After a 30-month follow-up, she is in stable disease. Multiple myeloma has been described in association with other indolent B-cell neoplasms, mostly chronic lymphocytic leukemia, while Waldenström macroglobulinemia can be followed by diffuse large B-cell lymphoma in some instances, after chemotherapy. The association of Waldenström macroglobulinemia and multiple myeloma seems to be very rare. Our study shows that an integrated diagnostic work-up is very useful in such cases, with an interesting role for flow cytometry. [J Clin Exp Hematop 53(1): 29-36, 2013].

About 5% of adult B-cell acute lymphoblastic leukemias (B-ALL) are characterized by t(4;11)(q21;q23), which confers peculiar features to this B-ALL subtype, including a very immature immunophenotype and poor prognosis. We describe the case of a 21-year-old female who presented with B-ALL carrying the t(4;11)(q21;q23) and blasts positive for CD19, TdT, CD79a, CD38, HLA-DR. Before completing the Hyper-CVAD (hyperfractionated cyclophosphamide, vincristine, doxorubicin, and dexamethasone) therapy regimen, the B-cell leukemic clone still was detected, but an additional leukemic clone appeared, with morphology and immunophenotype (CD13, CD33, CD64, CD38, CD56, CD15, CD4dim) compatible with derivation from the myeloid/monocytic lineage. Karyotype showed the co-existence of three cell lines, with persistence of t(4;11)(q21;q23) and appearance of +8,+12,+13 and two der(4). The patient died because of disseminated intravascular coagulation. Our report describes a rare, possible evolution of such a subtype of B-ALL, with transformation into mixed phenotype acute leukemia in the course of therapy. This finding suggests a blast cell derivation from a common lymphoid/monocytic precursor leading to a final bilineal acute leukemia.