On behalf of the BHS Lymphoproliferative Disease Committee 2017: M. André, C. Bonnet, D. Bron, A. Camboni, C. Caron, S. Debussche, H. Demuynck, V. De Wilde, V. Delrieu, D. Dierickx, R. Firescu, C. Jacquy, A. Janssens, J. Lemmens, M. Maerevoet, F. Offner, L. Schauvliege, W. Schroyens, S. Snauwaert, J. Somja, C. Springael, T. Tousseyn, E. Van Den Neste, V. Van Hende, A. Van Hoof, V. Vergote, G. Verhoef, I. Vrelust, and K.L. Wu

INTRODUCTION:Detection of mutations in patients with myeloid neoplasms (MNs) has shown great potential for diagnostic and prognostic purposes. Next-generation sequencing (NGS) is currently implemented for the diagnostic profiling of the four major MN subgroups. METHODS:First, we validated the targeted NGS approach using the TruSight Myeloid panel. Next, we screened 287 patients with a clinical suspicion of MN and 61 follow-up patients with documented MN. RESULTS:Validation of the NGS workflow resulted in maximal precision, accuracy, sensitivity, and specificity for gene variants with an allele frequency of at least 5% and a minimal read depth of 300. In our diagnostic screen, we identified at least one somatic mutation in 89% of patients with proven MN. Of the 155 newly diagnosed MN cases, 126 (81%) showed at least one mutation, confirming clonality. Moreover, the co-occurrence of mutated genes in the different MN subentities facilitates their classification and justifies the diagnostic use of a pan-myeloid panel. Furthermore, several of these mutations provide additional prognostic information independently of traditional prognostic scoring systems. CONCLUSION:Pan-myeloid targeted NGS fits elegantly in the routine diagnostic approach of MNs allowing for an improved diagnosis, subclassification, and prognosis.

Objectives:We evaluated azacitidine (Vidaza®) safety and efficacy in patients with myelodysplastic syndrome (MDS), acute myeloid leukaemia (AML), and chronic myelomonocytic leukaemia (CMML), in a real-life setting. Treatment response, dose, and schedule were assessed.Methods:This non-interventional, post-marketing survey included 49/50 patients receiving azacitidine at 14 Belgian haematology centres from 2010–2012. Treatment-emergent adverse events (TEAEs), including treatment-related TEAEs, and serious TEAEs (TESAEs) were recorded throughout the study. Treatment response [complete response (CR), partial response (PR), haematological improvement (HI), stable disease (SD), treatment failure (TF)) and transfusion-independence (TI) were evaluated at completion of a 1-year observation period (1YOP) or at treatment discontinuation, and overall survival (OS), at study conclusion.Results:The median age of patients was 74·7 (range: 43·9–87·8) years; 69·4% had MDS, 26·5% had primary or secondary AML, and 4·1% had CMML. Treatment-related TEAEs, grade 3–4 TEAEs, and TESAEs were reported in 67·3%, 28·6%, and 18·4% of patients, respectively. During 1YOP, patients received a median of 7 (1–12) treatment cycles. Treatment response was assessed for 38/49 patients. Among MDS and CMML patients (n = 29), 41·4% had CR, PR, or HI, 41·4% had SD, and 17·2% had TF. Among AML patients (n = 9), 44·4% had CR or PR, 33·3% had SD, and 22·2% had TF. TI was observed in 14/32 (43·8%) patients who were transfusion-dependent at baseline. Median (95% confidence interval) OS was 490 (326–555) days; 1-year OS estimate was 0·571 (0·422–0·696).Conclusions:Our data support previous findings that azacitidine has a clinically acceptable safety profile and shows efficacy.

We report the case of a 46-year-old man who presented with the hypogranular variant of an acute promyelocytic leukaemia (APL). RT-PCR analysis for detection of the t(15;17) fusion transcript confirmed the cytological findings by demonstrating a bcr-3 type PML/RARalpha rearrangement. According to the WHO-classification, this leukaemia fulfilled the criteria for 'Acute promyelocytic leukaemia with t(15;17)(q22;q12)'(1). Immunophenotyping revealed a leukaemic population with an aberrant expression of markers. Besides the presence of the expected immunophenotypic markers in APL (CD45 with low density, CD13+, CD33+, CD15-, CD117+ and MPO+), the population showed a positivity for CD34, CD2 and HLA-DR for at least a part of the malignant promyelocytes. Since the expression of these three markers, all together, is rather unique, we reviewed the literature to prove the relationship of this specific immunophenotype with morphology, clinical and molecular findings.

Since 2004, the US Food And Drug Administration and the European Medicine Agency are giving warnings about cocaine adulterated with levamisole. Levamisole is primarily used as an anti-helminthic. One of the side-effects of levamisole is a decreased bone marrow function. Herein we describe the first case of agranulocytosis and neutropenic fever due to cocaine adulterated with levamisole reported in Europe.

Although infections due to fungal pathogens are rare, the incidence of such infections has increased over the last few decades, mainly because of growing populations of immunocompromised patients. We report a case of a Phialemonium curvatum fungaemia in a woman with a history of a peripheral stem-cell transplantation. The case is analysed with 20 other cases described in the literature since 1986. Adequate therapeutic management is becoming increasingly important for immunode-pressed patients, in light of a broadened therapeutic choice of antifungals. Therefore precise and timely identification of fungi is needed. Therapeutic options with regard to Phialemonium fungaemia are also discussed.

We present a case of a 44 year old male with pyoderma gangrenosum (PG) presenting simultaneously with diagnosis of acute leukemia. His skin disease was stabilized with corticosteroids and most lesions cleared after chemotherapy-induced remission of the malignancy, but the largest lesion remained necrotic. Surgical treatment of the large necrotic ulcer included debridement followed by split-thickness skin graft while maintaining corticoid therapy. Unfortunately, relapse of the pyoderma gangrenosum with bullous lesions heralded relapse of the ultimately fatal malignancy. This case illustrates: 1. PG presenting simultaneously with a haematologic malignancy 2. Relapse with atypical bullous lesions with return of the malignancy and 3. The use of surgical modalities in managing patients with PG, a disease notorious for surgical complications.

OBJECTIVE:The aim of this study was to investigate the epidemiology and antibiotic susceptibility profiles of isolated bacterial organisms in relation to empiric treatment of neutropenic fever over a 15-year period.METHODS:All patients with or at risk for febrile neutropenia and treated in the hematology ward of the Antwerp University Hospital during 1994-2008 were prospectively included. Skin, blood, and urine cultures were taken. Oral quinolone prophylaxis was started in patients with neutropenia without fever. Empiric starting therapy consisted of amikacin in combination with cefepime.RESULTS:A total of 3624 bacteria were isolated. The most common pathogens were coagulase-negative Staphylococci (46%), followed by Escherichia coli (25%), Enterobacteriaceae (15.6%), Staphylococcus aureus (7.2%), and Pseudomonas aeruginosa (3.8%). The balance between Gram-positive and Gram-negative bacteria remained stable, with a majority of Gram-positive bacteria. A shift from oxacillin-sensitive to oxacillin-resistant coagulase-negative Staphylococci was observed. Regarding susceptibility patterns, no vancomycin resistance was detected in coagulase-negative Staphylococci or in S. aureus. The E. coli susceptibility rates remained stable. However, 66% of bloodstream infections were ciprofloxacin-resistant. A reduced susceptibility of P. aeruginosa strains to meropenem was noticed.CONCLUSIONS:Improvement in antibiotic susceptibility of inducible Enterobacteriaceae following a switch of empiric antibiotic therapy was maintained 15 years after starting the latter treatment. Further improvement in antibiotic susceptibility of these bacteria to ceftazidime was observed, but continuous vigilance is warranted.

The statistical analysis was supported with a grant from the quality fund at Jessa Hospital, Hasselt, Belgium. The authors would like to thank Dr I Gyssens, infectious diseases, for revision of manuscript, and Dr R Saenen and Dr L Luyten, medical registration, for providing patient data.

To date, Wilms' tumor protein (WT1) is acknowledged as a valuable target for active specific immunotherapy in several solid and hematological malignancies, such as leukemia. Preclinical data from our laboratory and that of Hans Stauss have already shown that WT1 RNA-electroporated dendritic cells (DC) stimulate WT1-specific T cells in vitro (Van Driessche A et al. Leukemia 2005; 19:1863–1871). Therefore, we started a phase I/II dose-escalation trial in which patients with acute myeloid leukemia (AML) in remission received intradermal injections with WT1 RNA-loaded DC. Feasibility, safety and immunogenicity of the vaccine were investigated. Seven patients received four biweekly DC vaccines. A delayed-type hypersensitivity (DTH) test was performed 2 weeks following the last vaccination. Patients underwent an apheresis and monocytes were isolated using CD14-labeled magnetic beads by CliniMACS. DC were generated in 6-day cultures in clinical-grade medium supplemented with serum, GM-CSF and IL-4 and maturated with PGE2 and TNF-a. Keyhole limpet hemocyanin (KLH) was added during maturation as a CD4+ helper antigen. Mature DC were harvested, electroporated with WT1 mRNA and used as vaccines. Patients were monitored for minimal residual disease (MRD) by analyzing WT1 RNA expression in peripheral blood by qRT-PCR. When the patient was HLA-A2+, tetramer staining was performed to detect WT1-specific CD8+ T cells. Before and after the vaccination cycle, peripheral blood was collected for immunomonitoring purposes. There was successful DC generation and vaccine production in all patients selected. No serious adverse events or toxicity was seen and all vaccinations were well tolerated. A decrease in WT1 RNA expression was observed during the course of the vaccination in 3/5 patients who had an increased WT1 mRNA level in peripheral blood at the start of DC vaccination. A vaccine-specific immune response was demonstrated in 7/7 patients by an in vivo DTH reaction both to KLH as well as to WT1. By tetramer analysis, detectable levels of WT1-specific CD8+ T cells could be demonstrated during the course of the vaccination both in the peripheral blood as well as in the expanded DTH-infiltrating T cells from the skin biopsies. Preliminary data from immunomonitoring in pre- and post-vaccination T cell samples from 3 patients show a mixed T helper (Th)1/Th2 response towards the KLH and the WT1 protein following vaccination. We conclude that vaccination of AML remission patients with WT1 RNA-loaded DC is feasible and safe. Furthermore, the vaccine elicits anti-vaccine T-cell responses in vivo and a decrease in WT1 RNA expression levels was observed during MRD monitoring in some vaccinated patients.