A 66-year-old Chinese man was referred for a hematological opinion in 2002 following the incidental discovery of a platelet count of 845 3 10/1 with a normal hemoglobin concentration and white cell count and no splenomegaly. Following bone marrow aspiration and trephine biopsy, a diagnosis of essential thrombocythemia was made. Cytogenetic analysis was normal. JAK2 V617F was detected. The patient was managed with hydroxycarbamide and aspirin. His clinical course was generally uneventful apart from a gastrointestinal hemorrhage in 2010. In 2012, following a period of poor compliance with therapy, he was hospitalized with severe community acquired pneumonia, a cerebral infarct and a platelet count ranging between 415 and 511 3 10 /1. A blood film showed dysplasia of all granulocyte lineages. Neutrophils were hypogranular and had hypolobated and abnormally shaped nuclei; some had cytoplasmic vacuolation (top left and bottom right). In addition, there were some macropolycytes and these showed dysplastic features such as hypogranularity (top right) and abnormal nuclear forms. All eosinophils were nonlobulated and showed a variable degree of hypogranularity (top left and bottom right). Basophils had reduced granule numbers, giant granules, and irregularly disposed granules (bottom left and right). During the episode of pneumonia, left shift was present (myelocytes, promyelocytes, and blast cells). Following recovery the dysplasia persisted but immature cells were no longer present. Granulocytic dysplasia is most often recognized in the neutrophil lineage. Eosinophil dysplasia as a feature of a myeloid neoplasm can be difficult to distinguish from the often striking cytological abnormalities in reactive eosinophilia. However, in this patient the uniform lack of lobulation in addition to the variable granule deficiency gave clear evidence of dysplasia. Because of their relative infrequency and the tendency of their granules to dissolve, basophils are not often recognized as dysplastic. However, in this patient all basophils were strikingly abnormal. The patient now has a platelet count well controlled by hydroxycarbamide but is mildly anemic (Hb 118 g/l). Myelodysplastic evolution in essential thrombocythemia may be prognostically adverse and may be the forerunner of leukemic transformation [1,2].

High-dose melphalan followed by autologous haematopoietic stem cell transplantation (ASCT) became part of the standard of care for most patients with multiple myeloma (MM) under the age of 65 years in the mid-to-late 1990s (Attal et al, 1996; Barlogie et al, 1997). While two smaller single-institution studies from the US reported better progression-free survival (PFS) but comparable overall survival (OS) in black compared with white MM patients following ASCT (Saraf et al, 2006; Verma et al, 2008), a recent large study by the Center for International Blood and Marrow Transplant Research (CIBMTR) did not observe any significant differences in PFS, OS, relapse rate, or non-relapse mortality (Hari et al, 2010). No systematic study has compared the outcome of Asians with blacks or whites. To address this gap in the literature, we evaluated the characteristics and outcomes of all MM patients who underwent a first ASCT at Hammersmith Hospital (HH), later Imperial College Healthcare NHS Trust (ICHNT), over a 16year period. This patient population came from a large multiethnic community of almost two million people in an equalaccess healthcare system. We identified all patients with MM who underwent a first ASCT at HH/ICHNT between 1994, when the ASCT programme for MM was initiated, and 2009. Over the study period, HH/ICHNT was the tertiary referral centre for haematopoietic stem cell transplantation for Northwest London. The 2001 UK Census recorded a Northwest London population of 1Æ73 million, consisting of 1Æ13 million whites (65%), 0Æ35 million Asians (20%), 0Æ15 million blacks (9%) and 0Æ1 million others (6%). Patients diagnosed with MM by primary and secondary healthcare providers who were considered eligible for ASCT were referred to HH/ICHNT upon completion of induction therapy. In accordance with the 2001 Census, we classified patient ethnicity as white (British, Irish, or other white ethnic background), black (Caribbean, African, or other black), or Asian (Indian, Pakistani, Bangladeshi, Middle Eastern, or other Southeast Asian). A reduced dose of melphalan was used at the transplant physicians’ discretion in patients over the age of 65 years, those with severe renal impairment, or those with other co-morbidities. Tandem ASCT was performed in patients considered to have chemorefractory disease. Responses were defined based on previously published criteria (Blade et al, 1998). Groups were compared using a Mann–Whitney test for continuous data and a Chi-squared test for categorical data. Probabilities for OS and PFS were calculated according to the Kaplan–Meier method and differences were tested with the log-rank test, and all analyses were carried out using the Statistical Package for the Social Sciences (spss) software (version 12.0.1, IBM, New York, NY, USA). P-values < 0Æ05 were deemed statistically significant. A total of 363 patients with a diagnosis of MM underwent a first ASCT at HH/ICHNT between 1994 and 2009. Of those, 270 (74Æ4%) were white, 56 (15Æ4%) were black, and 37 (10Æ2%) were Asian (Table I). There were no significant differences between the three ethnic groups in terms of gender, age, immunoglobulin

A 56-year-old male presented to the emergency department with a 1-month history of feeling unwell with abdominal pain, night sweats, anorexia, and weight loss. A right iliac fossa mass was detected on ultrasonography. CT scan demonstrated mediastinal, extensive retroperitoneal, and abdominal lymphadenopathy, together with a 7-cm mass in the region of the cecum. Blood results revealed normal hemoglobin, a white cell count of 29.8 × 109/L, neutrophils of 15 × 109/L, and platelets of 121 × 109/L. The lactate dehydrogenase was markedly raised at 9,647 IU/L. The blood film demonstrated medium- to large-sized mononuclear cells with basophilic cytoplasm, vacuolation, and multiple nucleoli. Peripheral blood immunophenotyping revealed the abnormal cells (25–30% of all cells) to be positive for CD19, CD10, and lambda light chain and negative for CD5 and CD23. The bone marrow aspirate showed large abnormal lymphoid cells with variation in cell and nuclear size. These cells had basophilic cytoplasm with multiple vacuoles and multiple small basophilic nucleoli (Fig. 1a–c). Immunophenotype of the bone marrow aspirate revealed a B-cell population that was positive for CD19, CD20, CD79a, CD10, CD24, CD27, CD81, FMC7, surface Ig, and lambda light chain. A bone marrow trephine biopsy showed replacement by sheets of medium- to large-sized lymphoid cells. These cells showed mild nuclear irregularity and granular chromatin and multiple small nucleoli (Fig. 1d,e). The tumor cells were positive for CD20 (Fig. 1f), CD10 (Fig. 1g), B-cell lymphoma (BCL)6 (focal; Fig. 1h), BCL2 (Fig. 1i), CD38 (Fig. 1j), and MUM1 (Fig. 1k) and were negative for CD44, TdT, cyclin D1, CD5, CD43, and EBER. Ki-67 was expressed in >95% of cells (Fig. 1l). G-banded chromosome analysis revealed the presence of t(8;14)(q24;32) that was confirmed by FISH to be IGH-MYC fusion positive (Fig. 1m). A subclone carrying a der(2)t(2;7)(p1?3;q?11.2) (Fig. 1n) was negative for an IGK rearrangement by FISH (not shown). A further subclone had add(13)(q34), and FISH demonstrated that the additional material of unknown origin had replaced the distal part of chromosome 13, resulting in loss of the green telomeric signal (Fig. 1o). FISH using probes for IGH/BCL2 and BCL6 showed normal signal patterns (not shown). A diagnosis of BCL, unclassifiable with features intermediate between diffuse large BCL and Burkitt lymphoma, or BCLU (DLBCL/BL), was made. This is currently a provisional entity in the WHO 2008 classification [1]. In contrast to BL, cases of BCLU (DLBCL/BL) have an admixture of medium- and large-sized cells, and more often have additional cytogenetic abnormalities (MYC-Complex karyotype). A proportion of cases harbor BCL2, BCL6, or CCND1 translocations, in addition to carrying a MYC translocation, comprising the so-called “double-hit” lymphomas [2]. This latter subgroup has a particular dismal prognosis with a median survival of 4–6 months; patients are often refractory to therapy, and remissions are short lived. Morphology, immunohistochemistry, and molecular markers may further help distinguish this entity from BL [3]. Though conventional cytogenetics and FISH did not detect a BCL2 rearrangement in our patient, BCL2 expression was detected on trephine sections. Although accurate diagnosis and distinction from BL is challenging, it is crucial for appropriate prognostication and management of this condition. In keeping with the highly aggressive nature of BCLU (DLBCL/BL) disease, our patient developed acute kidney injury as a result of spontaneous tumor lysis syndrome for which he was treated with fluids and rasburicase. He was transferred to the intensive care unit and required hemofiltration, subsequent intubation, and ventilation. Emergency chemotherapy with mitoxantrone and prednisolone were administered with little response. Despite subsequent treatment with Rituximab-chemotherapy and organ support, on day 3 of chemotherapy he continued to deteriorate and died of disease progression and multiorgan failure.

Limited data are available on immunologic responses to primary H1N1 infection in patients with hematologic malignancies. We present a prospective, case-surveillance study of such patients with real-time polymerase chain reaction (RT-PCR) confirmed H1N1-influenza who presented to our institution between September 2009 and January 2010. Ninety-two patients presented with influenza-like symptoms, and 13 had H1N1 infection confirmed by RT-PCR, including 4 allogeneic stem cell transplant recipients (1 with acute myelogenous leukemia, 1 with chronic lymphoblastic leukemia [CLL], 1 with non-Hodgkin lymphoma, and 1 with chronic myelogenous leukemia), 5 patients with multiple myeloma following autologous stem cell transplantation, 1 patient with multiple myeloma perimobilization, 2 patients with NHL post chemotherapy, and I patient with CLL. All 13 patients required hospitalization. Six (43%) were admitted to the intensive care unit (ICU), of whom 4 (67%) died. We evaluated B cell and T cell responses to H1N1 infection prospectively in these patients compared with those in 4 otherwise healthy controls. Within 12 weeks of diagnosis, only 6 of 11 patients developed seropositive antibody titers as measured by hemagglutination-inhibition or microneutralization assays, compared with 4 of 4 controls. H1N1-specific T cells were detected in only 2 of 8 evaluable patients compared with 4 of 4 controls. H1N1-specific T cells were functional, capable of producing interferon gamma, tumor necrosis factor alpha, and CD107a mobilization. Furthermore, CD154 was up-regulated on CD4(+) T cells in 3 of 4 controls and 2 of 2 patients who had both B cell and T cell responses to H1N1. Post-H1N1 infection, 5 of 8 patients developed seasonal influenza-specific T cells, suggesting cross-reactivity induced by H1N1 infection. These data offer novel insights into humoral and cell-mediated immunologic responses to primary H1N1 infection. Biol Blood Marrow Transplant 17: 632-639 (2011) (C) 2011 American Society for Blood and Marrow Transplantation

AIMS:Asteroid B cells are a component of normal thymus. It is currently unclear whether these cells are identifiable in T cell lymphoblastic leukaemia/lymphoma (T-ALL/LBL) of the thymus. The aim of this study was to identify asteroid B cells both in thymic and extrathymic tissue involved by T-ALL/LBL. METHODS AND RESULTS:Thymic, lymph node (LN) and bone marrow trephine biopsy (BMTB) samples from eight patients with T-ALL/LBL were reviewed. All had been investigated by immunohistochemistry and one by fluorescent in situ hybridization (FISH). The BMTB samples of two of eight T-ALL/LBLs and LN sample in one of them showed the presence of asteroid-shaped B cells with dendritic cytoplasmic processes. These B cells also expressed CD23 and the features were akin to the unique thymic asteroid B cells. Both patients had aggressive/resistant disease. Cytogenetic analysis in one showed a complex translocation involving the T cell receptor beta (TCRB) gene at 7q35 and a distal region of 9q known to harbour the NOTCH1 gene. CONCLUSION:This is the first report of T-ALL/LBL documenting the presence of an asteroid B cell-rich microenvironment at bone marrow and LN sites. In this small subset, T-ALL/LBL cells are possibly dependent upon asteroid B cells, and whether targeting of asteroid B cells with anti-CD20 monoclonal antibody in such cases will result in clinical benefit remains to be determined.

BACKGROUND:In 2009 the declaration by the World Health Organization of a global pandemic of influenza-H1N1 virus led to a vaccination campaign to ensure protection for immunocompromised patients. The goal of this study was to determine the efficacy of the 2009 H1N1 vaccine in patients with hematologic malignancies.DESIGN AND METHODS:We evaluated humoral and cellular immune responses to 2009 H1N1 vaccine in 97 adults with hematologic malignancies and compared these responses with those in 25 adult controls. Patients received two injections of vaccine 21 days apart and the controls received one dose. Antibody titers were measured using a hemagglutination-inhibition assay on days 0, 21 and 49 after injection of the first dose. Cellular immune responses to H1N1 were determined on days 0 and 49.RESULTS:By day 21 post-vaccination, protective antibody titers of 1:32 or more were seen in 100% of controls compared to 39% of patients with B-cell malignancies (P<0.001), 46% of allogeneic stem cell transplant recipients (P<0.001) and 85% of patients with chronic myeloid leukemia (P=0.086). After a second dose, seroprotection rates increased to 68%, (P=0.008), 73%, (P=0.031), and 95% (P=0.5) in patients with B-cell malignancies, after allogeneic stem cell transplantation and with chronic myeloid leukemia, respectively. On the other hand, T-cell responses to H1N1 vaccine were not significantly different between patients and controls.CONCLUSIONS:These data demonstrate the efficacy of H1N1 vaccine in most patients with hematologic malignancies and support the recommendation for the administration of two doses of vaccine in immunocompromised patients. These results may contribute towards the development of evidence-based guidelines for influenza vaccination in such patients in the future.

A 44-year-old man with relapsed HIV-associated stage IV nodular sclerosing Hodgkin's disease underwent high-dose therapy with autologous stem cell transplantation. The transplant was uncomplicated and the patient remains in complete remission at 59 months. Autologous stem cell transplantation is safe in HIV patients and can achieve long-term durable remissions in Hodgkin's disease.

The development of lymphoma in chronic inflammatory conditions has been a topic of great interest. Studies in inflammatory bowel disease (IBD) have demonstrated conflicting results and it is often difficult to disassociate disease severity, disease duration and the risk attributable to drug exposure. Recently presented results from the very large French population based CESAME study suggest a doubling of the risk of lymphoma in patients with IBD, with the majority of cases occurring in association with immunosuppressive therapy. Similarly, a meta-analysis of previous cohort studies concluded that the risk of lymphoma is increased four-fold in patients with IBD on thiopurine treatment (azathioprine and 6-mercaptopurine) compared to those not receiving such therapy. Such analyses cannot demonstrate causation, and it is possible that an increased lymphoma risk relates to more active underlying disease rather than thiopurine therapy, an interpretation supported by results from studies in IBD patients unexposed to such treatment.

This chapter addresses the impact of the disease and disease status on the outcome of stem-cell transplantation. In consideration of the other topics addressed within this volume we have elected to focus on allogeneic rather than autologous transplantation. Furthermore we have not tried to be comprehensive and discuss the role of disease status in all conditions amenable to allografting, but rather to review the evidence that exists for selected haematological malignancies. Where possible we have made some clear recommendations, but where evidence is less clear we have indicated the ongoing controversies.

This course is designed for haematologists and histopathologists with a special interest in haematopathology.The course focuses on the cellular and molecular pathology of the haemopoietic and lymphoid system and has a strong emphasis on microscopy and interpretation.The Special Guest Speaker is Daniel Catovsky (London).