OBJECTIVE:Individuals with HIV experience an increased risk of lymphoma, making this an important cause of death among people with HIV. Nevertheless, little is known regarding the underlying genetic aberrations, which we therefore set out to characterize. DESIGN:We conducted next-generation panel sequencing to explore the mutational status of diagnostic lymphoma biopsies from 18 patients diagnosed with lymphoma secondary to HIV infection. METHODS:Ion Torrent next-generation sequencing was performed with an AmpliSeq panel on diagnostic lymphoma biopsies from HIV-associated B-cell lymphomas ( n  = 18), comprising diffuse large B-cell lymphoma ( n  = 9), classic Hodgkin lymphoma ( n  = 6), Burkitt lymphoma ( n  = 2), follicular lymphoma ( n  = 1), and marginal zone lymphoma ( n  = 1). The panel comprised 69 lymphoid and/or myeloid-relevant genes, in which either the entire coding sequence or a hotspot region was sequenced. RESULTS:Among the 18 lymphomas, we detected 213 variants. The number of detected mutations ranged from 4 to 41 per tumor distributed among 42 genes, including both exonic and intronic regions. The most frequently mutated genes included KMT2D (67%), TNFAIP3 (50%), and TP53 (61%). Notably, no gene was found to harbor variants across all the HIV-associated lymphomas, nor did we find subtype-specific variants. While some variants were shared among patients, most were unique to the individual patient and were often not reported as malignant genetic variants in databases. CONCLUSION:Our findings demonstrate genetic heterogeneity across histological subtypes of HIV-associated lymphomas and thus help elucidate the genetics and pathophysiological mechanisms underlying the disease.

Trine Engelbrecht Hybel , Maja Ølholm Vase , Kristina Lystlund Lauridsen, Marie Beck Enemark, Michael Boe Møller, Court Pedersen, Gitte Pedersen, Stephen Hamilton-Dutoit , Niels Obel, Carsten Schade Larsen, Francesco d’Amore and Maja Ludvigsen Department of Hematology, Aarhus University Hospital, Aarhus, Denmark; Department of Clinical Medicine, Aarhus University, Aarhus, Denmark; Department of Pathology, Aarhus University Hospital, Aarhus, Denmark; Department of Pathology, Odense University Hospital, Odense, Denmark; Department of Infectious Diseases, Odense University Hospital, Odense, Denmark; Department of Infectious Diseases, Aalborg University Hospital, Aalborg, Denmark; Department of Infectious Diseases, Copenhagen University Hospital, Copenhagen, Denmark; Department of Infectious Diseases, Aarhus University Hospital, Aarhus, Denmark

Post-transplant lymphoproliferative disorders (PTLDs) are lymphoid proliferations that can arise as a complication to organ transplantation [1,2]. When compared with sporadically occurring lymphoma...

Presentation with severe acute kidney injury due to cast nephropathy (CN) is a medical emergency in multiple myeloma (MM), with high risk of dialysis-dependent renal failure and death. Accrual of patients with CN into interventional studies is difficult, while phase III trials exclude patients with severe renal insufficiency. Real-world data are warranted. We assessed 2252 patients from the population-based Danish Multiple Myeloma Registry (DMMR) who were diagnosed between 2013 and 2017. We identified 204 patients with clinically-suspected CN, defined as serum creatinine concentration >177 μmol/L and serum free light chain (sFLC) concentration >1000 mg/L at the time of diagnosis. The median age was 72 years. Thirty-one percent of patients presented with dialysis-dependent renal failure. Kidney biopsies were performed in 19% of patients and showed CN in 74% of cases. Despite prompt initiation of bortezomib-based therapy in 94% of patients, 33% of patients died in the first year after diagnosis. Compared with the rest of the patients in the DMMR with symptomatic MM, patients with clinically-suspected CN had worse overall survival (OS) irrespective of transplant eligibility. Achievement of renal recovery was associated with deep reductions of involved sFLC. Achievement of very good partial response or better in the first line of therapy and/or deep reduction of involved sFLC at 3 months after initiation of therapy were associated with superior OS. In conclusion, MM patients presenting with clinically-suspected CN have an alarmingly high one-year mortality when treated with current standards of care. Early and deep hematologic response is crucial for survival.

INTRODUCTION Myeloma cast nephropathy (CN) is the most common form of monoclonal immunoglobulin-mediated kidney disease, resulting from the precipitation of excessive amounts of monoclonal serum free light chains (sFLC) and causing around 70% of the cases of dialysis-dependent renal failure in multiple myeloma (MM)(Heher et al. 2013; Nasr et al. 2012; Sanders et al. 1991). In patients with acute renal failure, the finding of a high sFLC concentration with an abnormal sFLC ratio raises the clinical suspicion of CN (Hutchison et al. 2011). Although the histopathologic diagnosis of CN is established by renal biopsy, in routine clinical practice, the diagnostic yield of this procedure is often outweighed by the urgent need of anti-myeloma treatment and the risk of procedure-related complications. Recruitment of patients with CN into clinical trials is challenging and therefore real-world data on clinically suspected CN are necessary to understand the clinical characteristics, treatment and prognosis of these patients (Bridoux et al. 2017; Hutchison et al. 2019). METHODS We searched the population-based Danish Multiple Myeloma Registry for patients diagnosed with MM according to the International Myeloma Working Group criteria between 1st of January 2013 and 31st of December 2017 with a serum creatinine concentration of 200 µg/L or higher and a sFLC concentration of 1000 mg/L or higher at diagnosis. We conducted a retrospective patient chart review in eight Danish centers and assessed baseline characteristics, biopsy results, and overall survival. Anti-myeloma treatment, sFLC levels and renal function were registered during the first 12 months after MM diagnosis. RESULTS We identified 181 patients (176 with accessible clinical records). The median age was 72 years, the median serum creatinine was 384 µg/L, the median involved sFLC concentration was 5960 mg/L and dialysis dependent renal failure was present in 35%. Pre-myeloma estimated glomerular filtration rate (eGFR) was available in 80%, the median eGFR was 66 ml/min/1.73 m2. A kidney biopsy was carried out in 21% of patients and showed CN in 70% of cases. The median time from first sFLC measurement to initiation of therapy was 4 days. The number of lines of therapy ranged between zero and six. 173 patients received one, 35 patients received two and 14 patients received three lines of therapy during the first 12 months from diagnosis. High-dose melphalan with autologous stem cell transplantation (HDT-ASCT) was carried out in 45 (26%) patients. Bortezomib was administered as part of the first-line regimen in 163 (94%) patients. The most common first-line regimens were bortezomib-dexamethasone (n=67) and cyclophosphamide-bortezomib-dexamethasone (n=46). The first line of therapy resulted in very good partial response or better in 50% (Figure 1A), but was discontinued due to death, toxicity or progressive disease in 38% of patients. Dialysis dependency, eGFR and involved sFLC concentration were assessed at the end of the first cycle, at three months, six months and 12 months after initiation of therapy. At all these time points, achievement of renal recovery was associated with the magnitude of reduction of involved sFLC (Figure 1B). The median overall survival was 3.3 years (Figure 1C). At 12 months after diagnosis, 68% of patients were alive and 15% were dialysis dependent. Reduction of the initial involved sFLC concentration to ≤ 10% at three months was strongly associated with longer OS in a multivariate cox regression analysis adjusted for age and HDT-ASCT; hazard ratio 0.42, p=0.003. CONCLUSION In conclusion, we assessed a population-based cohort of newly diagnosed MM patients presenting with a serum creatinine of 200 µg/L or higher together with a sFLC of 1000 mg/L or higher. Although CN could have been clinically suspected in these cases, a kidney biopsy was only performed in one fifth of the population. Bortezomib-based therapy was initiated quickly and resulted in deep responses in most patients. Approximately one third of patients died within a year from MM diagnosis. Achievement of early and deep reduction in involved sFLC resulted in longer OS. Figure 1 Disclosures Szabo: Janssen: Consultancy. Vangsted:Takeda: Membership on an entity's Board of Directors or advisory committees; Jansen: Honoraria; Celgene: Honoraria; Sanofi: Membership on an entity's Board of Directors or advisory committees; Oncopeptides: Membership on an entity's Board of Directors or advisory committees. Plesner:Celgene: Consultancy; AbbVie: Consultancy; Genmab: Consultancy; Oncopeptides: Consultancy; Takeda: Consultancy; Janssen: Consultancy, Research Funding.

At HIV-1 infection, the binding of the viral envelope proteins to CD4+ is essential for viral transmission, and this process is facilitated by interaction with the highly conserved host lectin, galectin-1 (Gal-1) [1–3]. Within the tumor microenvironment, Gal-1 is expressed by both tumor and stromal cells where it promotes tumor immune escape and favors hypoxia-driven angiogenesis [4–6]. In sporadically occurring Hodgkin lymphoma, high Gal-1 expression at diagnosis is associated with poorer treatment response [7], and high soluble Gal-1 (sGal-1) correlates with adverse disease characteristics [8]. Previous studies have shown that targeted inhibition of Gal-1 prevents tumor-induced immunosuppression [9,10] and inhibits tumor growth and metastasis in various tumor models [6,11–13]. Recently, we published a proteomic profiling study of pretreatment serum samples from HIV-infected patients, identifying several differentially expressed proteins associated with lymphoma development [14]. In this cohort, we have now evaluated serum levels of sGal-1 and correlated this with clinical parameters, including lymphoma development. In addition, we have investigated the intratumoral expression and prognostic value of Gal-1 in HIV-associated lymphomas, and, for comparison, sGal-1 serum levels in 30 healthy blood donors [15] Circulating sGal-1 levels were measured using a time-resolved immunofluorometric assay and immunohistochemistry and the evaluation of tumoral Gal-1 expression were performed as described previously [7,14,15]. Pretreatment sGal-1 serum levels were assessed in 19 HIV-positive individuals at time of HIV diagnosis. There were no sex-related differences (P = 0.450) and sGal-1 levels neither correlate with peripheral CD4+ cell count nor with viral load at HIV diagnosis (ρ = −0.491 P = 0.852 and ρ = −0.009 P = 0.974, respectively). HIV-infected individuals had significantly lower levels of sGal-1 compared with healthy controls (43.6 vs. 84.9 ng/ml; P < 0.001; Fig. 1a). Within the entire study cohort (healthy controls and HIV-infected individuals), those patients who would later develop lymphoma also had significantly lower levels of sGal-1 at time of HIV-diagnosis (Fig. 1b; P = 0.016). There was no significant difference in sGal-1 within the HIV cohort (Fig. 1c, P = 0.130).Fig. 1: Serum galectin-1 (Gal-1) levels in HIV-infected individuals and controls. The line indicates the median and the box indicates the 25th and 75th percentiles. Whiskers are upper and lower adjacent values.(a) HIV-infected individuals had significantly lower levels of soluble Gal-1 at the time of HIV diagnosis compared with healthy controls (P < 0.001). (b) Soluble Gal-1 at the time of HIV diagnosis in HIV-infected individuals with subsequent lymphoma compared with the remaining cohort (healthy controls and HIV-infected individuals without lymphoma) (P < 0.016). (c) Differences in Gal-1 serum levels in HIV-infected individuals who did or did not develop lymphoma (P < 0.130).A cut-off value of 2.4 ng/ml generated by receiver operating curve (ROC) analysis separated HIV-infected individuals who later developed lymphoma from the remaining cohort of HIV patients and controls with a specificity of 82% and a sensitivity of 100%. Based on this cut-off value, 13 (31%) HIV-infected patients were allocated to the low sGal-1 group, including all future lymphoma patients (N = 5). Tumoral Gal-1 expression correlated positively with a proinflammatory signature of the microenvironment, including the macrophage marker CD68, the cytotoxic markers CD8 and granzyme B, as well as the activation marker CD30 [CD68 (ρ = 0.740; P < 0.001), CD8 (ρ = 0.379; P = 0.027), granzyme B (ρ = 0.579; P < 0.001) and CD30 (ρ = 0.467; P = 0.006)]. Clinical features of the cohort included in the tissue microarray have been described previously [14]. Gal-1 was widely expressed in all lymphoma subtypes. Based on a ROC generated cut-off value for high vs. low intratumoral Gal-1 expression, 59% (N = 10) of diffuse large B-cell lymphoma (DLBCL) patients had a high level of intratumoral Gal-1 expression (>24.8% positive cells). In the total lymphoma cohort (all diagnoses), two-thirds of the patients (N = 22; 65%) were high expressers. This latter group more often had nodal disease and B-symptoms (P = 0.006). Gal-1 did not correlate with tumoral Epstein–Barr virus (EBV) status, EBV latency type, international prognostic index (IPI), clinical stage, or cell of origin. In HIV-associated DLBCL, patients with higher levels of intratumoral Gal-1 expression had a significantly better outcome with a 5-year overall survival of 70.0% (95% confidence interval 32.9–89.2%) vs. 14.3% (95% confidence interval 0.7–46.5%). In a multivariate analysis, adjusting for IPI and rituximab treatment, both Gal-1 expression (P = 0.021) and IPI (P = 0.049) retained an independent prognostic value. HIV infection has a profound influence on the host immune system including altered cytokine and protein expression years prior to lymphoma diagnosis [14,16–18]. Gal-1 is secreted by most immune cells [19] and the significantly lower levels of sGal-1 in newly diagnosed HIV-infected individuals (compared with healthy controls), as found in our study, may reflect the dramatically altered immune constitution of these patients. This may lead to a proinflammatory although nonefficient T-cell response, ultimately leading to lymphoma development. We found a relatively high intratumoral expression of Gal-1 in our cohort of HIV-associated DLBCL, as compared with the immunocompetent setting [20]. This may partly reflect different evaluation techniques, but inherent disparities in lymphoma microenvironment may also be involved [21,22]. Gal-1 is largely produced by macrophages [23]. The correlation between high Gal-1 expression and improved outcome in HIV-associated DLBCL may therefore be explained by a higher level of macrophages because they have been shown to improve the efficacy of antibody-driven immunotherapy [24]. In conclusion, the results of our study indicate that Gal-1 is significantly associated with risk of lymphoma in HIV-infected individuals and may represent an attractive future target for the management of HIV-associated lymphoma. Acknowledgements The authors wish to thank Erik Hagen Nielsen, Vibeke Ellerup Jensen, and Kristina Lystlund Lauridsen for expert technical assistance, and Betina S. Sørensen for facilitating access to healthy donors samples. Conceived and designed the study: M.Ø.V., M.L., C.S.L., F.d’A. Provided study material: G.A.R., I.P., G.P., C.S.L., M.B.M., K.B., S.H.D. Performed the experiments: R.H., M.L. Analyzed data: M.Ø.V., M.L., B.H., P.W.D. Wrote the paper: M.Ø.V. and M.L. Final editing and approval of the manuscript: all authors. The work was supported by unrestricted grants from Dagmar Marshalls Foundation, Manufacturer Einer Willumsen's Memorial Foundation, The Harboe Foundation, The Krista and Viggo Petersens Foundation, Fonden til Lægevidenskabens fremme, Director Emil C. Hertz and his wife Inger Hertz Foundation, The Foundation of 17 December 1981, Architect Holger Hjortenberg and wife Dagmar Hjortenberg's Foundation; Frits, Georg, and Marie Cecilie Glud's Foundation, Danish Diabetes Academy supported by the Novo Nordisk Foundation, Inger and Max Wørzner's Memorial Foundation, and The MEMBRANES Center at Aarhus University. Conflicts of interest There are no conflicts of interest.

investigated. We hypothesized that rituximab‐based therapy would improve survival in B‐cell–mediated AID‐associated lymphoma, given its beneficial clinical effect in AID. We aimed to examine the association between pre‐existing AIDs and B‐NHL and the possible influence of AIDs on NHL outcome. Methods: In this hospital‐based case‐control study in Hadassah– Hebrew University Medical Center, we recruited 435 newly‐diagnosed adult (>18 years) CD20+ B‐NHL patients diagnosed 2009 to 2014 and 414 controls frequency‐matched by age and sex to cases. The study is based on questionnaires in Hebrew, English, and Russian that included sociodemographic variables, medical information including a history of AIDs and medications; pathology confirmation; and chart review. We examined the association between NHL and AIDs in general, B‐ and T‐cell–mediated AIDs and autoimmune thyroid diseases, using logistic regression, reporting odds ratios (OR), and 95% confidence intervals (CI). In the second part of the study, we compared overall (OS) and relapse‐free survival (RFS) in B‐NHL patients with and without AID. We constructed Kaplan‐Meier curves for univariate analysis, and multivariable Cox regression models adjusting for important patient and disease characteristics such as Ki67% staining, international prognostic index score (IPI), and histological subgroup. Results: B‐NHL risk was associated with the presence of AIDs (OR = 1.98; 95% CI, 1.01‐3.9) especially those mediated by B‐cell activation (OR = 5.97; 95% CI, 2.3‐15.6). The strongest association was observed for marginal zone lymphoma (OR = 13.2, 95% CI, 4.02‐43.6). Time to relapse for all B‐NHL patients with AIDs was significantly shorter (mean of 49.21 months [±3.22]) than for patients without AID (mean of 59.74 months [±1.62]), hazard ratio (HR) = 1.7 (95% CI, 1.03‐2.79), after adjusting for IPI, Ki67% staining, and histological subgroup. Specifically in DLBCL, in which >99% received rituximab‐based therapy, both RFS and OS were adversely affected by the presence of B‐cell mediated AIDs with HR = 7.84 (95% CI, 2.86‐21.5) and 3.99 (95% CI, 1.24‐12.6), respectively (see figure). Conclusions: Beyond the well‐known association between AIDs and B‐NHL (particularly AIDs mediated by B‐cell activation), we found in addition that AID is an adverse prognostic factor in B‐cell lymphoma. AID‐associated B‐NHL patients have poorer outcomes. Specifically, B‐cell mediated AID results in inferior RFS and OS in DLBCL, suggesting that rituximab‐based therapy does not provide adequate coverage for the subgroup of patients. Further exploration of molecular subtypes and mechanisms of resistance of B‐NHL associated with AID is warranted.

Post-transplant lymphoproliferative disorder (PTLD) incidence is difficult to determine, mainly because both early and other lesions may go unrecognized and unregistered. Few studies have included systematic pathology review to maximize case identification and decide more accurately PTLD frequency after long-term post-transplantation follow-up. A retrospective population-based cohort study including all kidney transplant recipients at two Danish centres (1990-2011; population covered 3.1 million; 2175 transplantations in 1906 patients). Pathology reports were reviewed for all patient biopsies to identify possible PTLDs. Candidate PTLDs underwent histopathological review and classification. Seventy PTLD cases were identified in 2175 transplantations (3.2%). The incidence rate (IR) after first transplantation was 5.4 cases per 1000 patient-years (95% CI: 4.0-7.3). Most PTLDs were monomorphic (58.5%), or early lesions (21.5%). Excluding early lesions and patients <18 years, IR was 3.7 (95% CI: 2.9-5.5). Ten patients with PTLD were retransplanted, 2 developing further PTLDs. Post-transplant patient survival was inferior in patients with PTLD, while death-censored graft survival was not. Using registry data together with extensive pathological review and long follow-up, a rather high incidence of PTLD was found.

Introduction. HIV infected individuals have an increased risk of developing lymphoma compared to sex- and age matched non-immunocompromised control population and approximately 2% of HIV infected individuals developed lymphoma (Gopal et al, J Natl cancer Inst 2013). Our group has been among the first who identified novel serum protein markers present at time of HIV diagnosis, which were predictive of subsequent lymphoma development (Vase et al, AIDS 2016). Galectins are important regulators of cell adhesion, apoptosis, cell cycle, and mRNA processing. Galectin-1 (Gal-1) is a known lectin-binding protein able to mediate Th2 skewed microenvironment in lymphomas (Juszczynski et al, Proc Natl Acad Sci U S A 2007; Cedeno-Laurent et al, Blood 2012), and facilitates HIV-infection (Sato et al, Ann N Y Acad Sci 2012). Increased serum Gal-1 levels were correlated to increased tumor burden and adverse clinical features in Hodgkin lymphoma (HL) (Kamper et al, Blood 2011; Ouyang et al, Blood 2013) and low Gal-1 levels were associated with an increased risk of chronic graft-versus-host disease in patients with hematologic malignancies treated with non-myeloablative hematopoietic stem cell transplantation (Petruskevicius et al, BMT 2016). In this study, we investigated whether the serum level of Gal-1 at the time of HIV diagnosis was predictive for subsequent lymphoma development.

Clinical relevance of galectin-1 in hematologic malignancies treated with non-myeloablative hemopoietic stem cell transplantation

Objective: HIV-infected individuals have an increased risk of developing lymphoma. We sought to identify markers predictive of lymphoma development by comparing protein expression patterns in serum obtained at the time of HIV diagnosis from patients who later developed malignant lymphoma or benign lymphadenopathy, with samples from patients with no subsequent history of neoplasia.Design: All patients were identified retrospectively from the Danish HIV cohort.Methods: Serum samples (N = 21), obtained at time of HIV diagnosis, were subjected to high-resolution two-dimensional gel electrophoresis. Differentially expressed proteins were identified by liquid chromatography-tandem mass spectrometry. A tissue microarray, containing diagnostic HIV-lymphoma tissue samples (N = 40), was used to investigate immunohistochemical expression of markers in tumoural lesions.Results: Fourteen differentially expressed protein spots were detected. Using principal components analysis, spots containing immunoglobulin J chain, apolipoprotein A-I, procollagen C-endopeptidase enhancer-1 and complement C4-A were associated with lymphoma development (P < 0.0001). Serum amyloid A-2 was increased almost 10-fold in patients with subsequent lymphoma compared with patients without subsequent lymphoma. In the tissue microarray, amyloid A was widely expressed, and high expression showed a tendency towards inferior outcome (log-rank 0.073).Conclusion: We identified several differentially expressed protein spots present already at the time of HIV diagnosis. Analysis of biological differences correlating to lymphoma development at this early stage of a possible malignant transformation may lead to the identification of predictive markers. Further investigation of the potential clinical application of differentially expressed proteins as risk stratification markers for monitoring HIV-positive individuals is warranted. Copyright (C) 2016 Wolters Kluwer Health, Inc. All rights reserved.

Introduction. HIV infected individuals have an increased risk of developing lymphoma even in the era of combined antiretroviral therapy. Galectin-1 (Gal-1) is known to promote various immunomodulatory functions, including Treg expansion (Dalotto-Moreno et al, Cancer Res 2013), promotion of tolerogenic dendritic cells (Ilarregui et al, Nat Immunol 2009) and apoptosis of fully-differentiated effector T-cells (Toscano et al, Nat Immunol 2007). In the context of cancer, Gal-1 is expressed on both tumor cells and cells in the tumor microenvironment, and is usually associated with immune privilege, tumor escape and hypoxia-driven angiogenesis (Juszczynski et al, Proc Natl Acad Sci 2007; Cedeno-Laurent et al, Blood 2012). Previously, high intratumoral Gal-1 levels have been suggested as an unfavorable outcome predictor in patients with classical Hodgkin lymphoma (cHL) (Kamper et al, Blood 2011). Furthermore, several in vitro studies revealed the benefit of Gal-1 inhibition with regards to overcoming treatment resistance e.g., after anti-VEGF and anti-CD20 therapy (Croci et al, Cell 2014; Lykken et al, Blood 2016). Thus, Gal-1 inhibition may prospectively be an important tool in lymphoma treatment. In this study, we have investigated the Gal-1 expression in pre-therapeutic tumoral tissue samples from patients with HIV-associated lymphoma and its correlation to clinicopathological features at lymphoma diagnosis.

Post-transplant lymphoproliferative disorders (PTLDs) are potentially fatal, often Epstein-Barr virus (EBV)-driven neoplasias developing in immunocompromised hosts. Initial treatment usually consists of a reduction in immunosuppressive therapy and/or rituximab with or without chemotherapy. However, patients who relapse do poorly, and new treatment options are warranted. With the introduction of the immunoconjugate brentuximab vedotin, the CD30 antigen has become an effectively targetable molecule. Therefore, we investigated the frequency and level of CD30 expression in PTLDs. We identified 108 patients with PTLDs diagnosed during 1994-2011, of whom 62 had adequate paraffin-embedded tissue for tissue microarray construction. Immunohistochemical expression of CD30 was consistently detected in all types of PTLD (overall 85.25%), including the monomorphic subtypes, and was correlated with a more favorable outcome. For diffuse large B-cell lymphoma (DLBCL)-type PTLD this was regardless of EBV status, and remained significant in multivariate analysis. Cell-of-origin had no independent prognostic value in our series of DLBCL PTLD.

Background. Posttransplant lymphoproliferative disorder (PTLD) is a feared complication to organ transplantation, associated with substantial morbidity and inferior survival. Risk factors for PTLD include T cell-depleting induction therapy and primary infection or reactivation of Epstein-Barr virus. Possible associations between certain HLA types and the risk of developing PTLD have been reported by other investigators; however, results are conflicting. Methods. We conducted a retrospective, population-based study on 4295 Danish solid organ transplant patients from the Scandiatransplant database. Having identified 93 PTLD patients in the cohort, we investigated the association of HLA types with PTLD, Epstein-Barr virus status and time to PTLD onset. The outcomes survival and PTLD were evaluated using Cox regression; mismatching, and the PTLD-specific mortality were evaluated in a competing risk analysis. Results. Risk of PTLD was associated with male sex (odds ratio, 1.70; 95% confidence interval, 1.07-2.71), and, in women, HLA-DR13 conferred an increased risk (odds ratio, 3.22; 95% confidence interval, 1.41-7.31). In multivariate analysis, HLA-B45 and HLA-DR13 remained independent predictive factors of PTLD. Mismatching in the B locus was associated with a reduced risk of PTLD (P < 0.001). Overall survivalwas poor after a PTLD diagnosis and was significantly worse than that in the remaining transplant cohort (P < 0.001). Conclusions. Our data indicate risk-modifying HLA associations, which can be clinically useful after transplantation in personalized monitoring schemes. Given the strong linkage disequilibrium in the HLA region, the associations must be interpreted carefully. The large size, virtually complete ascertainment of cases and no loss to follow-up remain important strengths of the study.

BACKGROUND Transformation of indolent lymphomas (IL) to an aggressive histology (TIL) often results in a rapid clinical course, treatment refractoriness and shortened survival. Although rituximab-containing regimens (R-chemo) have become standard of care in CD20-positive TIL, the role of autologous stem-cell transplantation (ASCT) is still debated. The purpose of this study was to determine whether the outcome of TIL patients improved if they, at transformation, also received ASCT. Furthermore, we investigated the outcome of cases with histologically low- and high-grade components diagnosed either simultaneously or after a period of overt indolent disease. We also analyzed, whether prior rituximab treatment during the indolent course of the disease affected outcome after transformation. PATIENTS AND METHODS Eighty-five patients (≤68 years) with histologically confirmed TIL were included. Five-year overall (OS) and progression-free survival (PFS) were calculated. Selected parameters were tested in a multivariate analysis. All analyses were conducted on three cohorts: (i) whole cohort (all TIL), (ii) patients with co-existing evidence of both indolent and aggressive histology at diagnosis (Composite/discordant TIL) and (iii) patients transformed after prolonged prior indolent disease (sequential TIL). RESULTS Fifty-four patients (64%) received ASCT consolidation and 31 (36%) did not. Within the 'all TIL' cohort, the 5-year OS and PFS for R-chemo + ASCT versus R-chemo alone, were 67% versus 48% (P = 0.11) and 60% versus 30% (P = 0.02), respectively. Furthermore, in 'Composite/discordant TIL' R-chemo + ASCT showed no impact on OS (76% versus 67%; P = 0.66) or PFS (71% versus 62%; P = 0.54). Conversely, R-chemo + ASCT improved the outcome of 'sequential TIL' (OS 62% versus 36%; P = 0.07; PFS 53% versus 6%; P = 0.002), regardless of prior rituximab therapy. The beneficial effect of ASCT was significantly higher in patients who had not received rituximab at IL stage. CONCLUSIONS ASCT improved the outcome in sequential, but not composite/discordant TIL. The beneficial impact of ASCT was greater in patients, who were rituximab-naïve at transformation.

Background: PTLD comprises a diverse spectrum of hematological conditions, ranging from early lesions, characterized by reactive-like proliferations, to monomorphic lesions, resembling overt lymphoma. Â In most cases, the lesions are believed to arise as the result of reduced immune surveillance secondary to the use of immunosuppressive drugs post-transplant. This view is supported by the observation that PTLDs, particularly those characterized by early or polymorphic lesions, may regress spontaneously upon reduction of the immunosuppressive treatment. Studies in sporadic lymphomas have identified distinct microenvironmental characteristics, predictive of the clinical behavior, but data is scarce in the immunocompromised setting. Therefore, the aim of this study was to investigate the tumor microenvironment in a population-based cohort of PTLD.

Background: A potential link between breast implants and anaplastic large-cell lymphoma (ALCL) has been suggested. Methods: We examined lymphoma occurrence in a nationwide cohort of 19,885 Danish women who underwent breast implant surgery during 1973–2010. Standardized incidence ratios (SIR), with 95% confidence intervals (CI), for ALCL and lymphoma overall associated with breast implantation were calculated. Results: During 179,246 person-years of follow-up, we observed 31 cases of lymphoma among cohort members. No cases of ALCL were identified. SIRs for ALCL and lymphoma overall were zero (95% CI, 0–10.3) and 1.20 (95% CI, 0.82–1.70), respectively. Conclusions: In our nationwide cohort study, we did not find an increased risk of lymphoma in general, or ALCL in particular, among Danish women who underwent breast implantation. However, our evaluation of ALCL risk was limited by the rarity of the disease. Impact: Our results do not support an association between breast implants and ALCL and are consistent with other studies on cancer risk and breast implants. Cancer Epidemiol Biomarkers Prev; 22(11); 2126–9. ©2013 AACR.

In 2004, a 60-year-old male was hospitalized with weight loss and attack-like episodes of septic fever accompanied by chills, rigors and subsequent profound fatigue. He had a previous history of severe asthma and hypereosinophilia treated with steroids, β2-agonist inhalations and oral methotrexate with modest clinical effect. Physical examination was normal. Blood tests showed mild thrombocytopenia (110 × 109/l), leucopenia (2.8 × 109/l) and IgG hyperglobulinaemia (74 g/l). Repeated blood cultures and viral antigens (cytomegalovirus, Epstein-Barr, hepatitis A, B and C and HIV) were negative. Echocardiography was normal. A CT scan revealed a moderate splenomegaly. The bone marrow (BM) was hyperplastic with moderate plasmacytosis and eosinophilia but no malignant infiltration. A liver biopsy showed reactive inflammatory changes.After a period of waxing and waning, in 2007, the clinical symptoms worsened and the patient was readmitted. A new BM biopsy still showed hyperplasia with plasmacytosis. Due to progressive splenomegaly, the patient was referred to our institution, where a diagnostic splenectomy was performed (spleen weight 1.5 kg, 27 × 15 × 9 cm). A histopathological examination of the spleen revealed a diffuse small lymphocytic infiltration within the red pulp, morphologically and immunophenotypically consistent with primary splenic marginal zone lymphoma (SMZL), i.e. small, mature, mononuclear cells with some plasmacytic differentiation, CD79A+, CD20+, CD5–, CD10–, cyclin D1–. The proliferation rate (Ki-67) was low at <10%. Immunohistochemistry for light-chains λ and ĸ, on splenic tissue (fig. 1), was consistent with ĸ light-chain restriction, although PCR-based clonality analysis on archival splenic tissue was not able to confirm this finding.No pathological lymph nodes, nor evidence of extranodal involvement, were found (CT scan). A diagnosis of primary SMZL was made. Upon observation alone, the constitutional symptoms decreased significantly until 2008, when the febrile attacks reappeared. A new CT scan showed no signs of lymphoma progression. Based on persistent IgM paraproteinaemia (7 g/l) and constitutional symptoms, it was decided to initiate B-cell targeting with rituximab intravenously once weekly over 4 weeks followed by quarterly maintenance for 2 years. In November 2010, the patient developed Escherichia coli septicaemia treated with antibiotics. On that occasion, a positron emission tomography/CT and a new BM biopsy did not reveal any evidence of lymphoma. Instead, Leishmania amastigotes were detected in BM macrophages and in the extracellular matrix (fig. 2). A retrospective review of all previous bioptic material (BM ×2, liver, spleen) detected Leishmania amastigotes in all specimens. A thorough travel history covering the previous 2 decades revealed several visits, often twice a year starting in 1993, to the Mediterranean basin, areas endemic for Leishmania infantum. A diagnosis of chronic visceral leishmaniasis (VL) was made. Treatment with liposomal-bound amphotericin B led to rapid symptom clearance and BM normalization. However, a few months later, the patient was readmitted with uremic symptoms and severely impaired renal function (creatinine 530 µmol/l, urea 30 mmol/l, estimated glomerular filtration rate 9 ml/min). A renal biopsy demonstrated the presence of Leishmania amastigotes in the kidney parenchyma, consistent with residual parasitosis (fig. 2). The diagnosis was further confirmed by PCR and in vitro cultivation of the parasite. Sequencing-based molecular typing identified the species as L. infantum [1]. The patient was retreated with liposomal-bound amphotericin B followed by oral miltefosine. At the last follow-up in September 2011, he was asymptomatic and in good general condition.SMZL is characterized by significant splenomegaly, either isolated or in combination with BM involvement. Chronic antigenic stimulation by microbial agents has been proposed as a possible pathogenetic mechanism in a variety of MZL, e.g., Helicobacter pylori in gastric MZL [2], Chlamydia psittaci in ocular MZL [3], Borrelia burgdorferi in cutaneous MZL [4], Campylobacter jejuni in immunoproliferative small intestinal disease [5] and hepatitis C virus in SMZL [6]. Leishmaniasis is caused by flagellated protozoa of the genus Leishmania and is transmitted to humans by the bite of a sandfly vector [7]. Infection occurs in three clinical forms – cutaneous, visceral or mucocutaneous – depending on the Leishmania species and the immune response of the host. VL is a systemic disease with gradually onsetting fever, pancytopenia, hepatosplenomegaly and weight loss. The incubation period can range from weeks up to a year. Once patent, VL is fatal if left untreated. L. infantum is the most important causative agent of VL as well as of autochthonous cutaneous leishmaniasis in Europe and is also present in asymptomatic human carriers [8]. It is highly prevalent in the widespread reservoir host, the domestic dog [1,7]. VL is a frequent opportunistic infection in HIV-infected immunodeficient individuals but uncommon in cancer patients [9]. A few cases of VL in patients with already well-established malignant lymphoma [10,11] have been reported. Here, we report a case of SMZL developed after years of visceral Leishmania infection. This raises the suspicion of a possible correlation between the two conditions, which may represent different steps of clonal selection, in the context of a chronic lymphoproliferative process. The moderate splenomegaly, recognized years before the histologically verified lymphoma diagnosis, is more likely to reflect chronic VL than a pre-existing primary splenic lymphoma, unrecognized and untreated for several years, leading to immunodeficiency and subsequent Leishmania infection. Organ and tissue-specific immune responses against the Leishmania parasite have been shown in rodents [12]. In these models, parasites rapidly multiply in the liver, from where they are cleared, as granulomas gradually arise. In contrast, parasites' growth is slow in BM and particularly in the spleen, allowing for a longer persistence of the parasites in these organs. Intrasplenically, the parasites enter and activate macrophages of the marginal zone, which in turn, inducing a cytokine-mediated (e.g., interleukin-10) permissive environment, fail to evoke an optimal antigen-specific response [12]. Furthermore, the parasites specifically activate latent tumor growth factor-β, thereby facilitating their survival in the primary macrophages. This sustained antigenic stimulation not only triggers polyclonal B-cell proliferation, but also attracts neutrophils with subsequent release of reactive oxygen species. The mutagenic potential of reactive oxygen species (point mutations, rearrangements, deletions) and the prolonged proliferation of chronically stimulated B cells are likely to induce DNA double-strand breaks and translocations often translating into an activation of the nuclear factor-ĸB pathway. This pathway is essential for controlling B-cell proliferation, and its persistent activation is known to increase the risk of B-cell malignancies. Gastric MZL has been described as an example hereof [13]. The recognition of VL as a potentially SMZL-inducing disorder is useful for an improved understanding and management of both diseases.

Abstract Abstract 5202 We here report the observation of the development of a splenic marginal zone lymphoma (SMZL) after years of active chronic visceral Leishmania (VL) infection, implying a possible pathogenic link between these two conditions, where the neoplastic process is preceded by a prolonged period of chronic antigen stimulation. In 2004, a 60-year old male developed attack-like episodes of septic fever with chills, rigor and subsequent profound fatigue. He had a 4 years previous medical history of severe asthma-like symptoms and hypereosinophilia. A bone marrow (BM) and liver biopsy were inconclusive. A whole-body computed tomography showed a moderately enlarged spleen. No evidence of bacterial, fungal or viral infection was found; the symptoms persisted, although mitigated, with occasional exacerbations over the following 3 years. By 2007 the patient was admitted again and a new BM biopsy was taken, still showing reactive changes. Due to increased splenomegaly, a diagnostic splenectomy was performed. Examination of the spleen revealed a primary splenic marginal zone lymphoma (SMZL). In 2010 the patient was admitted with septicaemia and constitutional symptoms. A BM biopsy showed the presence of numerous Leishmania amastigotes and a retrospective review of all previous biopsies (since 2004) identified Leishmania amastigotes in all of them. In fact, a thorough travel history covering the previous two decades revealed several visits, often twice a year, to the Mediterranean basin, e.g. Greece and Malta, areas endemic for Leishmania infantum (L. infantum). Visceral Leishmaniasis is a frequent opportunistic infection in HIV-infected immunodeficient individuals but uncommon in cancer patients, and only a few cases of VL in patients with already well-established malignant lymphoma have been reported. Chronic antigenic stimulation by microbial pathogens has been proposed as a pathogenetic factor in a variety of marginal zone lymphomas. Tissue specific immune responses toward Leishmania parasites have been shown in rodents, and the spleen is a ‘safe harbor’ for the long-term persistence of visceralizing Leishmania. Sustained antigenic stimulation with upregulation of critical signaling pathways may result in prolonged polyclonal B-cell proliferation, and a subsequent increased risk of malignant transformation. This case is the first to provide evidence for a possible link between chronic antigen stimulation by long-lasting L. infantum infection and the development of a SMZL. Disclosures: No relevant conflicts of interest to declare.