The B cell receptor

The B-cell receptor

The B-cell receptor is a multimeric complex formed by the assembly of a surface immunoglobulin homodimer and a non-covalently-bound heterodimer Igα/Igβ (CD79A/CD79B). Low expression of the B-cell receptor is the hallmark of lymphocytes in chronic lymphocytic leukaemia.[23]

The mechanisms accounting for poor expression of the B-cell receptor in chronic lymphocytic leukaemia remain elusive. With the exception of one report of mutation in CD79B,[24] no genetic defects in B-cell-receptor components have been recorded.[25] and [26] By contrast with their poor expression at the membrane level, transcription and intracellular synthesis of components of the B-cell receptor are normal,[26] and [27] but they cannot be assembled and transported from the endoplasmic reticulum to the cell surface because of a folding and glycosylation defect of the μ and CD79A chains, although not of the CD79B chain. Poor expression of the CD22 molecule in B-cell chronic lymphocytic leukaemia cells was also shown to result from a folding defect arising in CD79A.[28]

Most B-cell chronic lymphocytic leukaemia cells express CD5 and IgM/IgD and, thus, have a mantle zone-like phenotype of naive cells that, in normal conditions, express unmutated immunoglobulin genes.[29] However, 50–70% of cases of chronic lymphocytic leukaemia have somatic mutations of IGHV genes,[30] as if they had matured in a lymphoid follicle. Presence or absence of somatic mutations is associated with particular IGHV genes. Specific alleles of the IGHV1-69 gene [31] and the IGHV4-39 gene have an unmutated profile.32 Subsequently, workers have reported [32] that more than 20% of patients with chronic lymphocytic leukaemia carry stereotypic B-cell receptors.[33], [34] and [35] Of note, the IGHV3-21 gene shows strikingly homologous IGHV and IGLV gene rearrangements and is associated with poor prognosis, whether expressed in a mutated or unmutated form.[36] and [37] These results strongly suggest that a common antigen epitope is recognised by these highly homologous molecules. With respect to the epitope recognised, research has shown that unmutated chronic lymphocytic leukaemia cells express highly polyreactive antibodies, whereas most mutated ones do not.[38] and [39] Infections with encapsulated organisms might be a trigger for development of chronic lymphocytic leukaemia, and work has shown that individuals with a history of pneumonia are significantly more likely to develop chronic lymphocytic leukaemia than are people without this history, and that the risk increases with number of attacks.[40] and [41]

When stimulated through the B-cell receptor pathway, the response of chronic lymphocytic leukaemia cells is impaired. Low expression of the B-cell receptor correlates with reduced induction of protein tyrosine kinase activity and defective intracellular calcium mobilisation and tyrosine phosphorylation.[42] Individuals have differing responses to IgM ligation, related to IGHV gene status. Findings of one study showed that chronic lymphocytic leukaemia cells expressing unmutated IGHV genes had a better response in most cases to stimulation via the B-cell receptor than did cells expressing mutated IGHV genes.[43]

Unexpectedly, high amounts of ZAP70—a receptor-associated protein tyrosine kinase usually found in T cells and natural killer cells but not in normal circulating B cells—are detected in most patients with unmutated chronic lymphocytic leukaemia.[44] Chronic lymphocytic leukaemia B cells that express ZAP70 are more likely to respond to IgM crosslinking with increased tyrosine phosphorylation and calcium flux than are those that do not express ZAP70. This effect might happen for any or all of the following reasons. First, after B-cell receptor ligation, ZAP70 undergoes tyrosine phosphorylation and becomes associated with surface immunoglobulin and CD79B.[45] Second, ZAP70 mediates inhibition events that terminate the signalling response.[46] Finally, ZAP70 expression is associated with advantageous survival responses because of enhanced access to proliferation centres.[47] Altogether, expression of ZAP70 in chronic lymphocytic leukaemia allows effective IgM signalling in B cells, which might lead to an aggressive disease course.

The apparently anomalous expression of ZAP70 in chronic lymphocytic leukaemia cells is not accounted for completely. Heat-shock protein 90 (HSP90) is a molecular chaperone that catalyses the conformational maturation of many signalling proteins in cancer, known collectively as clients. With inhibitors of HSP90, Castro and colleagues [48] showed that ZAP70 is a client protein in tumour cells, but not in T cells, from patients with ZAP70-positive chronic lymphocytic leukaemia, suggesting that the presence of ZAP70 is an oncogenic event. On the other hand, ZAP70 is expressed at various stages of B-cell maturation and in other B-cell malignant diseases. It is present in normal pre-B cells and pro-B cells and in acute leukaemias derived from them.[49] By studying normal tonsillar cells, Nolz and coworkers [50] and Cutrona and colleagues [51] detected ZAP70-positive B cells, concentrated particularly in germinal centres. ZAP70 seems to be coexpressed with other activation markers. In chronic lymphocytic leukaemia, higher amounts of ZAP70 are expressed by lymph-node cells than by circulating cells.[52] In turn, high levels of ZAP70 expression lead to increased sensitivity to chemokine migratory signals.[53] Whether expression of ZAP70 in chronic lymphocytic leukaemia cells is a result of frequent visits to proliferation centres or is the cause of enhanced access to them is still not clear.

Another unexpected molecule expressed by a subset of chronic lymphocytic leukaemia B cells is CD38. In the B-cell compartment, CD38 is not a lineage marker, but this molecule is expressed at times during B-cell development when cell-to-cell interactions are crucial.[54] Examples include an early bone-marrow precursor cell, cells in the germinal centre, and plasma cells.[55] In chronic lymphocytic leukaemia, expression of CD38 predominates in patients with unmutated IGHV genes and is associated with poor prognosis.18 Expression of CD38 in chronic lymphocytic leukaemia B cells favours B-cell growth and survival through sequential interactions between CD38 and CD31 and between CD100 and plexin B1 (PLXNB1).[56]

The activation-induced cytidine deaminase (AICDA), a B cell-restricted enzyme needed for somatic mutation and isotype switching, is upregulated in unmutated chronic lymphocytic leukaemia cells.[57], [58] and [59] Although evidence exists that AICDA expression could be confined to a small proportion of the clone,[60] AICDA seems to be functional, since unmutated cases of chronic lymphocytic leukaemia can generate isotype-switched transcripts and proteins and mutations in the pre-switch μ region.[57] Upregulation of AICDA could be associated with loss of target specificity, resulting in mutations in non-immunoglobulin genes such as BCL6, MYC, PAX5, and RHOH, which are linked to aggressive disease.[61] and [62]

References

23 F Vuillier, G Dumas and C Magnac et al., Lower levels of surface B-cell-receptor expression in chronic lymphocytic leukemia are associated with glycosylation and folding defects of the mu and CD79a chains, Blood 105 (2005), pp. 2933–2940.

24 AA Thompson, JA Talley and HN Do et al., Aberrations of the B-cell receptor B29 (CD79b) gene in chronic lymphocytic leukemia, Blood 90 (1997), pp. 1387–1394.

25 B Payelle-Brogard, C Magnac, FR Mauro, F Mandelli and G Dighiero, Analysis of the B-cell receptor B29 (CD79b) gene in familial chronic lymphocytic leukemia, Blood 94 (1999), pp. 3516–3522.

26 A Alfarano, S Indraccolo and P Circosta et al., An alternatively spliced form of CD79b gene may account for altered B-cell receptor expression in B-chronic lymphocytic leukemia, Blood 93 (1999), pp. 2327–2335.

27 B Payelle-Brogard, C Magnac, A Alcover, P Roux and G Dighiero, Defective assembly of the B-cell receptor chains accounts for its low expression in B-chronic lymphocytic leukaemia, Br J Haematol 118 (2002), pp. 976–985.

28 B Payelle-Brogard, G Dumas, C Magnac, AI Lalanne, G Dighiero and F Vuillier, Abnormal levels of the alpha chain of the CD22 adhesion molecule may account for low CD22 surface expression in chronic lymphocytic leukemia, Leukemia 20 (2006), pp. 877–878. )

29 V Pascual, YJ Liu, A Magalski, O de Bouteiller, J Banchereau and JD Capra, Analysis of somatic mutation in five B cell subsets of human tonsil, J Exp Med 180 (1994), pp. 329–339.

30 HW Schroeder Jr and G Dighiero, The pathogenesis of chronic lymphocytic leukemia: analysis of the antibody repertoire, Immunol Today 15 (1994), pp. 288–294.

31 TJ Kipps and DA Carson, Autoantibodies in chronic lymphocytic leukemia and related systemic autoimmune diseases, Blood 81 (1993), pp. 2475–2487.

32 N Chiorazzi and M Ferrarini, B cell chronic lymphocytic leukemia: lessons learned from studies of the B cell antigen receptor, Annu Rev Immunol 21 (2003), pp. 841–894.

33 K Stamatopoulos, C Belessi and C Moreno et al., Over 20% of patients with chronic lymphocytic leukemia carry stereotyped receptors: pathogenetic implications and clinical correlations, Blood 109 (2007), pp. 259–270.

34 BT Messmer, E Albesiano and DG Efremov et al., Multiple distinct sets of stereotyped antigen receptors indicate a role for antigen in promoting chronic lymphocytic leukemia, J Exp Med 200 (2004), pp. 519–525.

35 F Ghiotto, F Fais and A Valetto et al., Remarkably similar antigen receptors among a subset of patients with chronic lymphocytic leukemia, J Clin Invest 113 (2004), pp. 1008–1016.

36 G Tobin, U Thunberg and A Johnson et al., Somatically mutated Ig V(H)3-21 genes characterize a new subset of chronic lymphocytic leukemia, Blood 99 (2002), pp. 2262–2264.

37 M Thorselius, A Krober and F Murray et al., Strikingly homologous immunoglobulin gene rearrangements and poor outcome in VH3-21-using chronic lymphocytic leukemia patients independent of geographic origin and mutational status, Blood 107 (2006), pp. 2889–2894.

38 O Pritsch, C Magnac, G Dumas, C Egile and G Dighiero, V gene usage by seven hybrids derived from CD5+ B-cell chronic lymphocytic leukemia and displaying autoantibody activity, Blood 82 (1993), pp. 3103–3112.

39 M Herve, K Xu and YS Ng et al., Unmutated and mutated chronic lymphocytic leukemias derive from self-reactive B cell precursors despite expressing different antibody reactivity, J Clin Invest 115 (2005), pp. 1636–1643.

40 T Hamblin, Is chronic lymphocytic leukemia a response to infectious agents?, Leuk Res 30 (2006), pp. 1063–1064.

41 O Landgren, JS Rapkin and NE Caporaso et al., Respiratory tract infections and subsequent risk of chronic lymphocytic leukemia, Blood 109 (2007), pp. 2198–2201.

42 F Michel, H Merle-Beral, E Legac, A Michel, P Debre and G Bismuth, Defective calcium response in B-chronic lymphocytic leukemia cells: alteration of early protein tyrosine phosphorylation and of the mechanism responsible for cell calcium influx, J Immunol 150 (1993), pp. 3624–3633.

43 S Lanham, T Hamblin, D Oscier, R Ibbotson, F Stevenson and G Packham, Differential signaling via surface IgM is associated with VH gene mutational status and CD38 expression in chronic lymphocytic leukemia, Blood 101 (2003), pp. 1087–1093.
44 A Rosenwald, AA Alizadeh and G Widhopf et al., Relation of gene expression phenotype to immunoglobulin mutation genotype in B cell chronic lymphocytic leukemia, J Exp Med 194 (2001), pp. 1639–1647.

45 L Chen, J Apgar and L Huynh et al., ZAP-70 directly enhances IgM signaling in chronic lymphocytic leukemia, Blood 105 (2005), pp. 2036–2041.

46 S Gobessi, L Laurenti, PG Longo, S Sica, G Leone and DG Efremov, ZAP-70 enhances B-cell-receptor signaling despite absent or inefficient tyrosine kinase activation in chronic lymphocytic leukemia and lymphoma B cells, Blood 109 (2007),

47 SJ Richardson, C Matthews and MA Catherwood et al., ZAP-70 expression is associated with enhanced ability to respond to migratory and survival signals in B-cell chronic lymphocytic leukemia (B-CLL), Blood 107 (2006), pp. 3584–3592.

48 JE Castro, CE Prada and O Loria et al., ZAP-70 is a novel conditional heat shock protein 90 (Hsp90) client: inhibition of Hsp90 leads to ZAP-70 degradation, apoptosis, and impaired signaling in chronic lymphocytic leukemia, Blood 106 (2005), pp. 2506–2512.

49 M Crespo, N Villamor and E Gine et al., ZAP-70 expression in normal pro/pre B cells, mature B cells, and in B cell acute lymphoblastic leukemia, Clin Cancer Res 12 (2006), pp. 726–734.

50 JC Nolz, RC Tschumper, BT Pittner, JR Darce, NE Kay and DF Jelinek, ZAP-70 is expressed by a subset of normal human B-lymphocytes displaying an activated phenotype, Leukemia 19 (2005), pp. 1018–1024.

51 G Cutrona, M Colombo and S Matis et al., B lymphocytes in humans express ZAP-70 when activated in vivo, Eur J Immunol 36 (2006), pp. 558–569.

52 J Boelens, J Philippe and F Offner, B cells from lymph nodes express higher ZAP-70 levels than B-CLL cells from peripheral blood, Leuk Res 31 (2007), pp. 719–726.

53 SJ Richardson, C Matthews and MA Catherwood et al., ZAP-70 expression is associated with enhanced ability to respond to migratory survival signals in B-cell chronic lymphocytic leukemia (B-CLL), Blood 107 (2006), pp. 3584–3592.

54 F Malavasi, A Funaro, S Roggero, A Horenstein, L Calosso and K Mehta, Human CD38: a glycoprotein in search of a function, Immunol Today 15 (1994), pp. 95–97.

55 S Deaglio, K Mehta and F Malavasi, Human CD38: a (r)evolutionary story of enzymes and receptors, Leuk Res 25 (2001), pp. 1–12.

56 S Deaglio, T Vaisitti and L Bergui et al., CD38 and CD100 lead a network of surface receptors relaying positive signals for B-CLL growth and survival, Blood 105 (2005), pp. 3042–3050.

57 P Oppezzo, F Vuillier and Y Vasconcelos et al., Chronic lymphocytic leukemia B cells expressing AID display dissociation between class switch recombination and somatic hypermutation, Blood 101 (2003), pp. 4029–4032.

58 P Oppezzo, G Dumas and AI Lalanne et al., Different isoforms of BSAP regulate expression of AID in normal and chronic lymphocytic leukemia B cells, Blood 105 (2005), pp. 2495–2503.

59 H McCarthy, WG Wierda and LL Barron et al., High expression of activation-induced cytidine deaminase (AID) and splice variants is a distinctive feature of poor prognosis chronic lymphocytic leukemia, Blood 101 (2003), pp. 4903–4908.

60 E Albesiano, BT Messmer, RN Damle, SL Allen, KR Rai and N Chiorazzi, Activation induced cytidine deaminase in chronic lymphocytic leukemia B cells: expression as multiple forms in a dynamic, variably sized fraction of the clone, Blood 102 (2003), pp. 375–382.

61 SS Sahota, Z Davis, TJ Hamblin and FK Stevenson, Somatic mutation of bcl-6 genes can occur in the absence of V(H) mutations in chronic lymphocytic leukemia, Blood 96 (2000), pp. 1089–1095.

62 L Reininger, C Bodor and A Bognar et al., Richter's and prolymphocytic transformation of chronic lymphocytic leukemia are associated with high mRNA expression of activation-induced cytidine deaminase and aberrant somatic hypermutation, Leukemia 20 (2006), pp. 1089–1095.

High White Counts

Patients and doctors get very worried about high white counts. Need they be?

I remember one holiday weekend spending days at the hospital with a young 13-year old boy with priapism - a prolonged and painful penile erection - caused by a high white count. What happens in these cases is that the blood vessels get blocked by aggregated white blood cells, so that normal circulation is prevented. We connected the lad up to a cell separator and performed leucocytapheresis on him to rapidly lower the white count. He also had to have a surgical procedure to decompress the organ, but I'm glad to say this combination of treatments was successful and sexual function was restored, although since his disease was chronic myeloid leukaemia (CML)in the days before imatanib and matched unrelated bone marrow transplantation, he eventually succumbed to blast transformation of his disease.

Priapism is a well known complication of CML but is seldom seen in other types of leukemia. It is one version of the leukostasis syndrome. Other features include rapidly progressive breathing difficulties and mental problems. It is thought to be caused very sticky bits of white cells and platelets forming aggregates and thrombi, and blocking the circulation. Some authors distinguish this from the hyperviscosity syndrome which produces similar effects because the blood becomes very viscous or treacly (thick and sticky, not actually sweet). This can be due to high cell content (either red or white) or high protein content (especially IgM or immune complexes). Nowadays, patients are seldom allowed to get high white cell counts except in CLL. The question everybody asks is whether hyperviscosity can occur in CLL. I think that the answer is probably in exceptional cases both hyperviscosity and leukostasis can occur.

Looking back over the old literature, my old mate Eric Preston reported three cases from Sheffield in 1978. The white counts were 500, 647 and 1000 respectively. The symptoms of hyperviscosity were relatively minor, but they did resolve after leucocytapheresis. These three patients did have raised blood viscosity measurements, but the authors noted that CLL does not raise the viscosity by as much as other leukemias for a given white count. There is another report from Kurlander and colleagues of a patient with a white count of 901 who had retinal hemorrhages, which can be a feature of hyperviscosity, though this patient also had hyperkalemia (a high potassium level) and kidney failure, which could also have caused them. Then in 1985 Maria Baer from Nashville reported a study of 16 CLL patients with white counts over 500. In one of them, with a white count of 968 there was a full blown hyperviscosity syndrome with headache, double vision, loss of balance, slurred speech, deafness and other neurological signs, which all recovered after leucocytapheresis (in America people talk about leukapheresis which implies that the machine takes the whiteness out of the blood, like a reverse washing machine). A second patient had what were in retrospect features of hyperviscosity, but she was treated as if she had leukemic meningitis and died. A third patient had retinal hemorrhages, but these can be caused by a lot of different things including high blood pressure. The 16 high white counts were drawn from a series of 210 patients in Nashville.

One of the problems about the early CLL papers is that before good immunophenotyping we could not be sure that the patient actually had CLL – it could have been mantle cell lymphoma or a variant. A study from Sweden published in 1992 said this:

In order to evaluate the effects of different cell types of leukaemic cell origin on skin capillary circulation we have studied patients with (a) chronic lymphocytic leukaemia (CLL) (n = 6) and (b) acute non-lymphocytic leukaemia (ANLL) (n = 6) or chronic granulocytic leukaemia (CGL) (n = 5). Capillary blood cell velocity (CBV) in fingernail-fold capillaries was measured by videophotometric capillaroscopy. After a 1-min arterial occlusion at the finger base, the post-occlusive reactive hyperaemia was evaluated by measuring the peak (p) CBV and the time to pCBV. In patients with ANLL/GGL, both resting CBV and pCBV were lower than in healthy control subjects. In the CLL patients these values were not significantly different compared to controls.

More recently there have been occasional patients with very high white counts due to CLL that have caused either hyperviscosity or leukostasis, but they are so rare that they are almost certain to be reported in the literature.

In Paris in 1988:
A 50 year old man with chronic lymphocytic leukemia (CLL) and extreme hyperleukocytosis (600 x 10(9)/liter) presented with a respiratory distress syndrome, congestive heart failure with cardiomegaly, endotoxic shock and anuria. Examination revealed nodes in all areas and hepatosplenomegaly; laboratory studies showed hypoxemia and a chest X-ray diffuse bilateral alveolar infiltrates. He was treated twice by leukapheresis using a cell separator. This procedure removed 10.1 x 10(10) white blood cells with marked clinical improvement and resolution of air-space diseases over the subsequent 48 hours.

In Germany in 1991
An 82-year-old woman with CLL developed acute neuropsychiatric signs (confusion, disorders of speech and vision) together with ataxic gait and left hemiparesis mainly affecting the lower limb. Her white count was 1,300, most of the cells being morphologically atypical lymphocytes. Significant reduction of leucocyte count with considerable improvement in clinical signs was achieved after three doses of vincristine and prednisone together with one cycle of COP

In the Netherlands in 1996
The authors mistook pulmonary infiltrates with CLL cells for leukostasis. The white count was only 153.

In Poland in 1999
A severe leukostasis syndrome was observed in a case of CLL with peripheral lymphocyte count of 1,120. Typical symptoms of respiratory and central nervous system were developed (tachypnoe, hypoxia, headache, slurred speech, somnolence and confusion). Leukapheresis decreased the lymphocyte count to 305 rapidly and reversed the leukostasis syndrome.

And in Israel in 2002
We describe a 73-year-old woman who presented with newly diagnosed CLL, leukostasis, and hyperleukocytosis (2000 x 10(9)/l), affecting the respiratory and nervous system. We hypothesize that in our patient the extreme number of circulating lymphocytes resulted in an abnormal accumulation of lymphocytes possibly causing stasis and occlusion of a larger vessel, which resolved after leukapheresis.

In CLL patients with high white counts there are usually other reasons to begin treatment, but in patients without symptoms there should be no urgency to begin treatment just because the white count has reached 100 or 200 or 300 or 400 or even 500 because of the possibility of leukostasis or hyperviscosity. This makes CLL different from other types of leukemia, where a high white count carries its own dangers.

CLL: Diagnosis and Pathophysiology

Clinical diagnosis of chronic lymphocytic leukaemia is defined by absolute lymphocytosis of at least 5×109/L mature-appearing lymphocytes and an appropriate immunophenotype (figure). [13] These characteristics distinguish chronic lymphocytic leukaemia from mantle-cell lymphoma and splenic marginal-zone lymphoma, the diseases that most frequently mimic chronic lymphocytic leukaemia. [14] In a few individuals, tumour is confined to lymph nodes or other tissues without blood or bone marrow involvement. In these people, the disorder is known as small lymphocytic lymphoma: histological findings and immunophenotype are identical to chronic lymphocytic leukaemia and management should be the same.[15] Individuals without involvement of lymph nodes or other tissues, who have a population of small lymphocytes immunophenotypically similar to chronic lymphocytic leukaemia cells in blood or bone marrow below the threshold necessary for diagnosis of chronic lymphocytic leukaemia, are designated as having monoclonal B-cell lymphocytosis.[16] Molecular and cellular markers have been identified that could predict disease progression. In particular, the mutational profile of immunoglobulin genes[17] and [18] and some cytogenetic abnormalities [19] show strong prognostic value. However, these biological differences do not separate chronic lymphocytic leukaemia into two different disorders; it remains one disease with heterogeneous features. [20]

Pathophysiology

Despite the ready availability of tumour cells in chronic lymphocytic leukaemia, up to now, very little has been known about the pathophysiology of the disease. The cells themselves are remarkably inert in vitro. Most, if not all, cell lines attributed to chronic lymphocytic leukaemia are either from patients with mantle-cell lymphoma masquerading as chronic lymphocytic leukaemia or B-cell lymphoblastoid lines from contaminating normal lymphocytes. [21] Until the past few years, no animal model had existed for chronic lymphocytic leukaemia. The TCL1 transgenic mouse develops a CD5+ B-cell lymphoproliferative disease that serves as a model for aggressive forms of chronic lymphocytic leukaemia but not for the frequent indolent form. [22]

The discovery that the mutational status of IGHV genes affects profoundly the prognosis of chronic lymphocytic leukaemia has acted as such a spur to our understanding of the disease's pathology, but full review of this topic is not possible within the space confines of this Seminar. Instead, we will concentrate on three topics: the B-cell receptor; genetic abnormalities revealed by interphase cytogenetics; and the balance between proliferation and apoptosis.

References

13 JL Binet, F Caligaris-Cappio and D Catovsky et al., Perspectives on the use of new diagnostic tools in the treatment of chronic lymphocytic leukemia, Blood 107 (2006), pp. 859–861.

14 E Matutes, K Owusu-Ankomah and R Morilla et al., The immunological profile of B-cell disorders and proposal of a scoring system for the diagnosis of CLL, Leukemia 8 (1994), pp. 1640–1645.

15 HK Muller-Hermelink, E Montserrat, D Catovsky and NL Harris, Chronic lymphocytic leukaemia/small lymphocytic lymphoma. In: ES Jaffe, NL Harris, H Stein and JW Vardiman, Editors, World Health Organization classification of tumours: pathology and genetics of tumours of haematopoietic and lymphoid tissues, IARC Press, Lyon (2001), pp. 127–130.

16 GE Marti, AC Rawstron and P Ghia et al., Diagnostic criteria for monoclonal B-cell lymphocytosis, Br J Haematol 130 (2005), pp. 325–332.

17 TJ Hamblin, Z Davis, A Gardiner, DG Oscier and FK Stevenson, Unmutated Ig V(H) genes are associated with a more aggressive form of chronic lymphocytic leukemia, Blood 94 (1999), pp. 1848–1854.

18 RN Damle, T Wasil and F Fais et al., Ig V gene mutation status and CD38 expression as novel prognostic indicators in chronic lymphocytic leukemia, Blood 94 (1999), pp. 1840–1847.

19 H Döhner, S Stilgenbauer and A Benner et al., Genomic aberrations and survival in chronic lymphocytic leukemia, N Engl J Med 343 (2000), pp. 1910–1916.

20 T Hamblin, Chronic lymphocytic leukaemia: one disease or two?, Ann Hematol 81 (2002), pp. 299–303.

21 HG Drexler, WG Dirks, Y Matsuo and RA MacLeod, False leukemia-lymphoma cell lines: an update on over 500 cell lines, Leukemia 17 (2003), pp. 416–426.

22 R Bichi, SA Shinton and ES Martin et al., Human chronic lymphocytic leukemia modeled in mouse by targeted TCL1 expression, Proc Natl Acad Sci USA 99 (2002), pp. 6955–6960.

TP53: is it such a big deal?

Everyone knows that p53 abnormalities bode ill for patients with CLL. Generally such leukemias are resistant to fludarabine, cyclophosphamide, chlorambucil, penatastatin, cladribine, and rituximab. Although responsive to high dose steroids and Campath and sometimes to Revlimid, most patients with this abnormality have very short survivals. The data on this come from randomized clinical trials like LRF CLL4. However, not all patients need treatment and these trials lack representation from unreated patients. So I have examined my database for patients with del 17p (the chromosomal abnormality that most commonly causes p53 deletion. Have a look at these graphs:





What they tell us is that patients with mutated IgVH genes who also have del 17p usually don't require treatment, just like other patients with mutated IgVH genes.

Epidemiology of CLL

The incidence of chronic lymphocytic leukaemia varies with the age and sex structure of the population. Analysis of the Surveillance, Epidemiology, and End Results (SEER) database notes the US incidence as being 3·5 per 100 000 per year (men 5·0, women 2·5).[1] In the Leukaemia Research Fund data collection study, researchers gathered data from individual haematologists responsible for laboratories covering about a third of the population of England and Wales and reported an incidence of chronic lymphocytic leukaemia in the UK of 6·15 per 100 000 per year, although this value concealed a variation between 1·3 and 13·7 per 100 000 per year in different health districts, dependent largely on how interested the local haematologist was in the disease.[2] Since, in our experience, more than three-quarters of patients with chronic lymphocytic leukaemia are discovered because of an incidental blood count, the exact prevalence of the disease depends clearly on how assiduous is the case finding.

Chronic lymphocytic leukaemia is rare in people younger than 50 years, but after this age a fairly rapid rise in incidence takes place. According to SEER data, the median age for diagnosis of the disease is 70 years for men and 74 years for women, and median age at death is 76 years and 81 years, respectively. White American individuals have a slightly higher incidence than those of African-American origin (3·9 vs 2·8 per 100 000 per year), but in American people of Chinese, Japanese, and Filipino extraction, incidence is about five times lower, even in those who have adopted a fully American lifestyle.[3] Early data put the incidence of chronic lymphocytic leukaemia in Jewish people at twice that of non-Jewish North American individuals.[4]

Chronic lymphocytic leukaemia can arise in families.[5] and [6] First-degree relatives of patients with the disease are three times more likely to have chronic lymphocytic leukaemia or another lymphoid neoplasm than the general population.[7] With a four-colour flow-cytometric assay, Rawstron and colleagues [8] noted that 3·5% of healthy individuals older than 40 years had a population of monoclonal lymphocytes in their blood, with the immunophenotypic characteristics of chronic lymphocytic leukaemia cells, at concentrations lower than 3·5×109/L; in first-degree relatives of patients with familial chronic lymphocytic leukaemia, the prevalence of such cells is between 13·5% and 18%.[9] and [10] The relation between subclinical chronic lymphocytic leukaemia and full-blown disease is a matter of intense investigation in several laboratories.

No consistent evidence is available to link chronic lymphocytic leukaemia with environmental exposure to either radiation or chemicals, except in the case of agricultural workers and herbicides. On Jan 23, 2003, the US National Academy of Sciences' Institute of Medicine published a report concluding that there is “sufficient evidence of an association between exposure to Agent Orange, a herbicide used in Viet Nam, and the development of chronic lymphocytic leukaemia”. [11] Although ionising radiation has traditionally been absolved from causing chronic lymphocytic leukaemia, recent studies have suggested that this may be unwarranted.[12]

References
1 National Cancer Institute, SEER cancer statistics review 1975–2001 http://seer.cancer.gov/csr/1975_2001/

2 RA Cartwright, SM Bernard and CC Bird et al., Chronic lymphocytic leukaemia: case control epidemiological study in Yorkshire, Br J Haematol 56 (1987), pp. 79–82.

3 NS Weiss, Geographical variation in the incidence of the leukemias and the lymphomas, Natl Cancer Inst Monogr 53 (1978), p. 139.

4 B MacMahon and EK Koller, Ethnic differences in the incidences of leukemia, Blood 12 (1957), pp. 1–10.

5 MS Linet, ML Van Natta and R Brookmeyer et al., Familial cancer history and chronic lymphocytic leukemia: a case-control study, Am J Epidemiol 130 (1989), pp. 655–664.

6 GS Sellick, D Catovsky and RS Houlston, Familial chronic lymphocytic leukemia, Semin Oncol 33 (2006), pp. 195–201.

7 J Cuttner, Increased incidence of hematologic malignancies in first degree relatives of patients with chronic lymphocytic leukemia, Cancer Invest 10 (1992), pp. 103–109.

8 AC Rawstron, MJ Green and A Kuzmicki et al., Monoclonal B lymphocytes with the characteristics of “indolent” chronic lymphocytic leukemia are present in 3·5% of adults with normal blood counts, Blood 100 (2002), pp. 635–639.

9 AC Rawstron, MR Yuille, J Fuller, M Cullen, B Kennedy and SJ Richards, Inherited predisposition to CLL is detectable as subclinical monoclonal B-lymphocyte expansion, Blood 100 (2002), pp. 2289–2290.

10 GE Marti, P Carter and F Abbasi et al., B-cell monoclonal lymphocytosis and B-cell abnormalities in the setting of familial B-cell chronic lymphocytic leukemia, Cytometry B Clin Cytom 52 (2003), pp. 1–12.

11 Committee to review the health effects in Vietnam veterans of exposure to herbicides (fourth biennial update), Veterans and Agent Orange: 2002, National Academic Press, Washington, DC (2003), pp. 373–377.

12 TJ Hamblin, Have we been wrong about ionizing radiation and chronic lymphocytic leukemia?, Leuk Res 32 (2008), pp. 523–525.

Obama

"If Barack gets past the primary," said the Rev. Jeremiah Wright to the New York Times in April of last year, "he might have to publicly distance himself from me. I said it to Barack personally, and he said yeah, that might have to happen."

Calculating or what?

BBC caught out regurgitating propaganda

Remember before the fall of the Soviet union when Gorbachev was captured by the KGB and held in Georgia he said that he only knew what was happening because he listened to the BBC? The BBC can no longer be trusted to tell the truth about what is happening in the world.

In a news item on March 7, following the Mercaz Harav Yeshiva attack, the BBC showed a bulldozer demolishing a house, while correspondent Nick Miles told viewers: "Hours after the attack, Israeli bulldozers destroyed his family home. Later, mourners set up Hamas and Islamic Jihad banners nearby."

The house, however, was not demolished; the BBC was embarrassed when news reports from other broadcasters showed the east Jerusalem home intact and the family commemorating their son's actions.

Last week, the BBC apologized live on its news program, admitting it had used footage of another house being demolished.

News anchor Geeta Guru-Murthy said: "Now, we would like to clarify a report we heard at this hour last Friday about the attack by a Palestinian gunman on a Jewish seminary in Jerusalem. In the report, the day after the attack, BBC World said that the gunman's home in east Jerusalem had been demolished by the Israeli authorities. That was not correct, and the images broadcast were of another demolition."

The fabrication was exposed by Boston-based media monitor CAMERA, which revealed that the images used by the BBC were similar to photos taken by the Palestinian news agency Maan from the demolition of the house belonging to Islamic Jihad leader Muhammad Shehadeh in Bethlehem on March 7.

In a second incident, in a news item entitled "Israel jets strike northern Gaza" on March 14 on their News Web site, the BBC reported that Israel was deliberately targeting civilians in an operation targeting Kassam rocket launch sites in Gaza, and claiming that the United Nations secretary-general had described it as an attack on civilians.

"The Israeli air force said it was targeting a rocket firing team... UN Secretary-General Ban Ki-moon has condemned Israel's attacks on Palestinian civilians, calling them inappropriate and disproportionate," the report said.

In a letter to the BBC, Manchester Jewish community member Jonathan Hantman wrote,

"It is one-sided for the report to describe Israel's operations as 'attacks on civilians' while not describing the Palestinian rocket attacks, to which Israel was responding, as 'attacks on civilians' or 'acts of terrorism.'"

Hantman also pointed out that Ban's attributed comments were made weeks earlier to the UN Security Council and not in reference to that particular attack. He added that it was also wrong to mention the UN secretary-general's condemnation of Israel without mentioning his condemnation of Palestinian rocket attacks in the same statement.

"Ban's statement, made some two weeks ago, did not refer to yesterday's attack and did not describe Israel's operations on Gaza as 'attacks on civilians,'" Hantman noted. "He did, however, describe Palestinian rocket attacks as 'acts of terrorism.'"

In his statement to the UN Security Council on March 1, Ban said: "While recognizing Israel's right to defend itself, I condemn the disproportionate and excessive use of force that has killed and injured so many civilians, including children... I condemn Palestinian rocket attacks and call for the immediate cessation of such acts of terrorism."

Apologizing for the error, the BBC said in its response, regarding the speech: "We accept we should have made reference to what [Ban] said about Palestinian rocket attacks as well as to the 'excessive use of force' by Israel. We have amended the report, also removing the reference to Israeli 'attacks on civilians.'"

I have repeatedly said that I am not a Zionist nor a Jew. I do not believe that there is a divine right for the Jews to build a nation in Palestine. I think that blowing up the King David Hotel in 1948 was a terrorist act for which there was no justification. However, the world is the way it is and no amount of violence on behalf of the Palestinians is going to change it. Some members of the BBC have fallen for the Palestinian cause and regularly swallow whole the stories put out by their well-oiled propaganda machine. One would have thought that the fuss over the faked photographs from last year's Hezbollah war in Lebanon would have taught the BBC a lesson.

Third day: Nathaniel's tale

Cowed, we sat in that upper chamber and considered our options. Some of the women had gone to the grave before daybreak and found it empty. It certainly was empty, Cephas and Jonah had gone to confirm, but was it the right grave? We never saw where they had buried him so we just have the women’s word for it. One of women said she had actually seen him, but who can believe a woman? They’ll see things that aren’t there and say the first thing that comes into their head. Quite rightly the Law regards the testimony of a woman as less than believable.

Then there were those two who were on their way home to Emmaus. They fell in with this travelling preacher who conned his way into a meal at their expense. After they’d had a few they somehow got it into their heads that it was Jesus that they were eating with. I ask you, if they didn’t recognize him when they were sober how are we going to believe what they think they saw when they were sozzled? They burst in on us while we were here in John Mark’s house. To me they didn’t look in control of themselves.

The inner three – Jacob and Jonah Bar-Zebedee and Cephas – then said, “Yes, we know, Cephas has seen him too.”

That was news to me. Why were they keeping it to themselves? Cephas is one for shooting his mouth off, saying the first thing that comes into his head. He said nothing to Andrew, even, and now others come in saying, “We have seen the Lord,” and good old Cephas, not wishing to be beaten, claims, “I saw him first.”

You know me, I’m a straight talker. The Lord himself called me an Israelite in whom there is no guile. Not like our father Israel – there was a real trickster. Well, I grant you that the whole thing is highly suspicious. Nobody in their right mind would believe a hysterical woman and Cephas is an impulsive idiot. But I am someone who doesn’t put his name to something unless I’m sure it’s true. I am not joshing you. This is exactly what happened.

We had the locked the door after Cleopas and his mate gatecrashed the meeting. We were still arguing over what they had told us when suddenly Jesus stood in the midst of us. The door hadn’t opened; it was still locked. He just said, “Shalom,” the way that you do when you greet someone. My goodness, it was a shock. He wasn’t there and then he was there. If it was a trick, I can’t work out how he did it. There was nowhere he could have been concealed.

Of course, some of them thought he was a ghost. But he offered his hands and I felt them. They were real flesh and blood. You could even see the holes in his wrists where the nails went through. Same with his feet. He even ate a fish sandwich.

Then he said it again, “Shalom,” but this time it wasn’t a greeting. He was emphasizing the meaning. “My peace I give to you.” And, do you know, we felt it. After all the worry and turmoil of the last few days this tremendous feeling of calm came over us. I was struck by the enormity of it. It was wonderful to see him, of course, but he had been dead and now he is alive!

All he had been telling us at last made sense. When I first met him I had been contemplating our father Israel’s dream at Bethel. He knew what I was thinking. It was as though he could read my mind. I knew then that he was the son of God. Now he has revealed himself. Great things are going to happen. You see, the peace he offered us was peace with God. Ever since Adam sinned God had dealt with us under sufferance. We had to keep killing lambs and bulls, even pigeons to show that we submitted to his judgement. And on that condition his judgement was held at bay.

I keep thinking of that old servant song, “The punishment that brought us peace was upon him…the LORD has laid on him the iniquity of us all.” The Rabbis have argued down the ages about who the servant was supposed to be, but it’s all clear now. The servant is the son of God. Even the resurrection is predicted. I never saw it before, but what else can “After the suffering of his soul he will see the light of life and be satisfied” mean? So much that he said to us makes sense now. “In a little while you will see me no more, and then after a little while you will see me.” What else could that mean? Why didn’t we realize it at the time? And the best of it is this: because he is alive, the punishment is complete. Death has spat him out. He was too big to swallow.

He blew on us, as if to say take my breath into the whole world. It’s no longer a secret. Death is defeated; the last enemy is conquered. Something great is surely coming.

Second day

We have had these periods of silence before. There is nothing you can do about it; you just have to wait. On Andros III the moons are so arranged that the orbiter is out of contact with the ground station for a little under 24 earth-hours every nineteen weeks. Captain Newman could explain the physics of it if he were here, but I am a mere physician and everyone knows that we become doctors because we can’t do the math.

How I got to be alone on a small shuttle at the back end of the Galaxy is a long story. For now, let’s just say that I happened to be in the shuttle bay loading medical equipment when the main ship exploded and my orbiter was flung clear. If I knew how to fly the thing I might try to go somewhere, but not having the navigation skills I know neither where I would be coming from or where I would be going to. I just have to wait until I get into radio contact again.

That’s if there is anyone to get in contact with. The honey virus epidemic has affected three quarters of the colonists and although I now have the vaccine ready I’m reliant on the radio beam to guide me down to the survivors. If that were all, I would be happy to sit it out. In just under twenty-four hours I would be able to lock on to the beam and the computer would fly the thing down to them. The thing is, I don’t understand why the ship exploded. And if I don’t know that then I’m not sure it’s safe to go down there at all.

~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~

It’s been six hours now. I’ve tried to sleep but sleep won’t come. For some reason the only books on the computer are what they used to call ‘chick lit’ – historical classics by Jane Austen and Helen Fielding. Don’t they realize that there are still some male doctors? Another eighteen hours to go. The computer has beaten me at 3D chess seventeen times and I’m tired of Suicide Sudoku. I keep coming back to the explosion.

All I can remember is absolute panic. People were screaming over the radio. The whole ship was shaking. I jumped into the orbiter and slammed the hatch. Then everything went black and I passed out. When I awoke, twenty minutes had passed. I was alone and everything was silent. Through the upper port I could see Iskios, the largest moon, but through the other ports, nothing but stars.

Was the explosion some sort of accident? Or was it the result of enemy action? We’ve been fighting against the Kathgoros for centuries now. They seldom reach this far out in the Galaxy, but Captain Newman is an important person. It would be a fine coup for them to take him down if they could locate him. There have been rumors that the Kathgoros are behind the honey virus; certainly there have been signs of their activity wherever it has turned up throughout the Empire, but there has never been any conclusive evidence that they engineered it. They are like that, though. Elusive. If only they would stand and fight, I’m sure that we could defeat them. There used to be a term for it – asymmetric warfare.

We don’t even know what they look like. They’re shape-shifters, of course. They seem to be able to take on the shape of any human for a limited time – usually for less than an hour, but they seldom need more to spread their chaos. People are deceived by them and once they have their hooks into us, we seem to swallow all sorts of poison as if it were true.

~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~

I must have dozed off. Another three hours have gone by. I was playing “Parto, parto, ma tu ben mio” from La clemenza di Tito on the audio and I drifted into sleep. It’s six centuries since Mozart wrote it and it still has the power to calm the anxious heart. It was supposed to goad Sesto into starting the revolution, but Mozart is a soother not a goader.

We are no longer in the shadow of Iskios, but now Jragma shields us from the planet. After Jragma it will be Aspia and so on. Nearly fifteen hours of it.

I was always suspicious of Judy. That’s Judy Skaros, Newman’s PA. She gave herself airs, that one. Newman is a great man, no doubt about it. He was the brains behind the new vaccine, I just followed his instructions. But what is Judy? Just a glorified secretary. She organized his appointments, kept him on schedule; but she controlled who could see him. He was always accessible if you could get past her, always welcoming. He always had something interesting to say; a new way of looking at your problem. I thought she was taking bribes. Some of the people who got to se him latterly were really the dregs. Oh, they were rich enough, but how did they get their money? And she seemed dress more sharply every time I saw her. You don’t get that rich as a captain’s PA.

Not that I had much time for any of his unit. He seemed to attract losers. That Peter Ceffus was about the best of them, but he was always shooting his mouth off. He was going to do this; he was going to beat that; I reckon he’d be nowhere without Newman.

Anyway that’s one explanation. If the Kathgoros did get to Newman I suspect Judy had a hand in it.

~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~

If the Kathgoros blew up the ship it probably isn’t safe to go own to the surface. They would only risk the ship if they wanted to wipe out the colonists. They are probably down there waiting right now.

On the other hand it could all have been an accident. I’m assuming the ship was totally destroyed, but perhaps the damage was limited to my part and I was launched automatically in the orbiter. In which case perhaps the rest are fine and they think that I am the only lost one. But if that is the case why haven’t they come looking for me? Perhaps the ship was disabled but not damaged. Why then not send a shuttle to find me? But I was in the shuttle bay, perhaps that’s where the damage occurred and they can’t launch another shuttle. Yes, perhaps that’s it. In another 12 hours I come out of radio silence and everyone will know where I am. I’ll be rescued.

~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~

This waiting is killing me. Time seems flexible. When you are enjoying yourself it travels at light speed but waiting stretches it. I keep looking at my chronometer. I can’t believe that only two minutes has passed. If I only knew what I was waiting for. The longer the radio silence persists the more I expect disaster. Should I attempt to fly this thing? It can’t be that difficult. If only I had worked harder at the math. Molecular engineering is no pushover; it can’t be that difficult to work out co-ordinate geometry. But where to start?

Of course, the computer does most of the flying; all I have to do is punch in the co-ordinates of the start and finish, but that’s what I don’t know. Without a solid reference point I’m helpless. I’d just be wasting fuel and I need the fuel to re-generate the oxygen. I can certainly survive longer if I don’t go anywhere, but what’s the point of surviving if I don’t go anywhere?

Kathgoros means ‘accuser’ in English. The accuse us of contaminating the Galaxy. They were here before us, of course, but I can’t see how that gives them squatters’ rights. Surely there is room in the Universe for both of us? They seem to think that the presence of humans spoils things for everyone else. Their ambition seems to be to confine us to ‘Prisonship Earth’.

Captain Newman isn’t everybody’s cup of tea. A lot of the corporations don’t like him. They say his ways diminish profits. But then, the government isn’t that keen on him either. They appreciate his general law-abiding principles, but they don’t like his being free of their control. They see him as loose canon. They certainly didn’t approve of his coming to Andros III. They have problems much closer to home and they want him there. They though this was a foolhardy mission – they’d cast the colonists adrift.

Newman couldn’t resist a lost sheep. So he came. We worked on the vaccine together and by now we should be down on the planet inoculating everyone. Instead, I’m stuck in this stupid orbit and he’s been blown to smithereens. I would certainly carry on the vaccinations if it were possible, but somehow I think it’s a lost cause. What a waste of a brilliant potential: to perish on a mercy mission to a few thousand backwoodsmen. It won’t even merit a footnote in galactic history. I doubt if more than one person in a million on Earth has even heard of Andros III.

~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~

It won’t be long now. In half an hour I shall come out of the shadow of Sabano and be able to see the planet. This has been the longest 24 hours in my life. I’ve imagined every scenario. I think it’s most likely that the radio silence will continue. The ship will be completely gone and all its crew killed. I expect that the colony will be destroyed and if anyone is waiting for me it will be the Kathgoros. More likely, no-one will be there. I, only I, will be left. I have enough oxygen to last 3 days, or three hours if I attempt to fly the thing down to the planet. If I try that, most likely I will crash. I have a small chance of making it, but I suppose even a 1% chance is better than the certain death of staying up here. On the other hand, if I do survive the flight I shall be alone on an unpopulated. planet. Why wait forty years for death if there is no prospect of company? This far out in the Galaxy the prospect of further colonists is remote. What a choice!

~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~

Ten minute ago Captain Newman ‘beamed’ aboard. I thought that technology was impossible, a figment of the imagination of sci-fi writers of the twentieth century. Don’t ask me for an explanation. He suddenly appeared in the co-pilot’s seat, smiled at me, set the co-ordinates, fired up the engine and set us going. The he said, “I’ll see you later,” and disappeared again.

The orbiter seems to be approaching the planet on an orderly course. No doubt in time I will get an explanation.

Violent death

The accompanying document has recently come to light among the scrolls and papyri found near the Wadi Qumran. Unlike the majority of these documents, it was written in Latin and it may therefore be an attempt by local Bedouin to cash in on these discoveries. The Bedouin tribe of Ta’ammireh is well known for its cunning and sharp business practices, so it may well be a forgery. I have made a rough translation which I present for your judgement.

Report of post-mortem examination of prisoner MCMLXVII known as Yeshua Ben-Adam.

Hail Tiberius Caesar!

The body is that of a male Sephardic Jew aged between XXX and XL years, of average build and swarthy complexion. The hair is long and plaited and the beard unkempt. There are numerous facial injuries as detailed below.
(i) swelling over both eyebrows.
(ii) torn right eyelid.
(iii) large swelling and discoloration below right eye.
(iv) swollen nose, the nostrils filled with old blood clot.
(v) triangular shaped wound on right cheek with apex pointing towards nose (this appears to have arisen from an attempt to pluck out the prisoner’s beard)
(vi) swelling of left cheek.
(vii) swelling and contusion of left side of jaw.
(viii) IX separate puncture wounds in the scalp arranged in a ring around the crown of the head. The longest of these admits a probe the distance of the terminal bone of a man’s thumb.

On the dorsal surface of the body there are numerous wounds extending from the shoulders, across the back and buttocks down to the backs of the thighs. Each wound is slightly longer than the terminal bone in a man’s thumb and dumbbell shaped. They are arranged in groups of III and extend diagonally across the back in both directions. I counted CXVII separate wounds. These wounds are consistent with a scourging with a flagra properly administered.


There is an area the size of a man’s hand over the right shoulder which shows blistering and abrasions. Over one part of the knees are numerous excoriations.

There are puncture wounds in both wrists consistent with a large nail having been hammered through the skin crease between hand and wrist. In both cases the wound has passed between the small bones of the wrist without damaging them, but in both cases it has transected the median nerve. There is an exit wound on the back of the wrist.. There are similar wounds in each foot. In this case the wound passes between the proximal ends of the second and third metatarsals.

There is one further would. There is an elliptical slit the length of a man’s thumb between the ribs V and VI on the right hand side of the front of the chest. It is clear that blood has flowed from this. Unusually for those executed by crucifixion in the province of Judea no bones are fractured.

Internal examination was most interesting for the findings in the thorax. The left pleural cavity was filled with a straw colored fluid with some blood streaks. There was enough of this fluid to half fill a centurion’s helmet which I was leant for the purpose. The left lung showed contusions on the surface and was collapsed. The cut surface was frothy. I have seen such fluid before in prisoners who have died following a flogging.

The left pleural cavity contained very little fluid. Presumable it had drained through the wound in the anterior chest wall. I examined the track of this wound, the depth of which was about the breadth of a man’s hand. The wound passed through the pleural cavity, through the collapsed lung and into the right atrium of the heart which was empty of blood. The wound could have been made by a Roman soldier’s short lance.

The other organs of the body showed no gross abnormalities apart from the fact that all were covered with small petechiae and there was a good deal of unaltered blood in the bowel. A curious finding was the complete absence of clotted blood. Indeed blood flowed freely from the vessels when cut. I collected a sample of blood in an earthenware jar and although I stored it for several hours the blood would not coagulate. I have noticed this finding before in prisoners who have met a violent death. I would like to propose that such blood be collected and instilled into those who, because of a deficiency of blood, are weak and cowardly.

I find the cause of death to be suffocation caused by accumulation of fluid in the thorax during judicial crucifixion. Owing to the inability of the blood to coagulate it is possible that the lance wound occurred post-mortem and thus was both blood and pleural fluid lost from the body.

I would finally like to protest at the treatment of this prisoner. Although the wounds to the back and limbs are consistent with scourging and crucifixion properly and legally carried out, the wounds to the head are a different matter. There is no doubt in my mind that this prisoner was illegally beaten while in custody. Eye witness testimony suggests that this took place not only in the custody of the Roman Procurator, but also in that of the Tetrarch Herod Antipas and indeed in the custody of the Jews themselves.

This, Sir, is not what Roman justice is about. I should further like to protest that I was prevented from continuing my examination of the body by its disappearance. I have no doubt that this was ‘engineered’ by someone in authority to cover up evidence of penal atrocities. Despite extensive enquires I have been unable to find any trace of the corpse.

Signed Lucas Mortico, state pathologist.

The document has an addition in a different hand:
File. No further action. Not to be referred to higher authority. Lucas Mortico to be posted to Britannia or somewhere equally cold and unpleasant.

Signed: Pilatus, Procurator of Judea.


I think that this document is highly unlikely to be genuine, but it is interesting to note that the Soviets also observed the inability of blood to clot in those meeting a violent end. Apparently something triggers the fibrinolytic enzymes. They are on record as using cadaver blood donations to bolster their transfusion service in the time of Joseph Stalin.

Maundy story

Ward rounds were occasions of terror. In our short white coats we trooped behind the gods and demi-gods and tried to escape notice. Sir John Perkins was especially terrifying. He was tall, grey-haired and always dressed in black; black jacket and waistcoat, black trousers with a fine pin-stripe and sword-edge creases and black shoes reflecting their surroundings like a looking glass. Finely spoken and austere, his slim presence brought silence to the room as we waited for wisdom to emerge from his thin lips.

In those days we had Nightingale wards; long narrow rooms with beds lined up on either side, each with its own set of curtains. Half an hour before Sir John arrived Sister Carstairs had every patient settled in bright white sheets, hospital corners immaculate. Every bed was square with its fellow, every surface polished, every odour dispelled.

On this particular morning curtains were drawn around a bed at the far end of the ward. Sir John’s eye fixed upon it first. “An emergency, Sister? Is someone in need of my attention?”

Sister Carstairs looked unaccustomedly flustered, “A visitor, Sir John, an interloper. A brief admission from Casualty because they were short of beds. A lodger, merely. Gone tomorrow.”

“Nevertheless…” said Sir John and marched to the end of the ward and pulled back the curtains to reveal O’Brien. Those of us who had done stints in Casualty recognised O’Brien. The Irish drunk was a frequent visitor, but it was rare for him to con his way into a bed for the night.

Once the curtains were drawn the smell became noticeable and as Sir John drew back the bedclothes it intensified. “So, Patrick,” said Sir John, “It’s the feet, is it?”

It was the feet. O’Brien was wearing a hospital gown that left his legs exposed. He was not an attractive man; unshaven, obese, unwashed, hairy and malodorous. His feet were black with ingrained dirt and his ankles ulcerated. Sir John stripped off his jacket and handed it to Keith Pritchard, his Senior Registrar. He turned on his heel and marched in his shirtsleeves to the sluice. Shortly afterwards he reappeared with a towel wrapped around his waist and carrying a yellow plastic bowl filled with warm water. He set it down on the floor and kneeling before O’Brien proceeded gently to wash his feet. He took the towel and dried them. “Some talcum powder, Sister, I think.” he said.

Then he dismissed us; the students, the junior doctors, the nurses, almoner and the rest.
“Some coffee, perhaps, Sister Carstairs?” and he and she retired to her office.

Six months later Sir John Perkins died of lung cancer. We had not known that he smoked. He was succeeded as consultant surgeon at that famous teaching hospital by Keith Pritchard who learned from Sir John how to dress well and how to inspire respect in his students. He later became Surgeon to the Queen. Tony Baldini, the Senior House Officer, also became a consultant surgeon. He had learned to terrify his students and was notorious for humiliating them in front of their friends. Liam Murphy, my friend who had cowered with me at the back of the crowd, became a consultant obstetrician in Cork and the father of seven children, all boys. Sister Julia Carstairs never married. I learned never to think of myself as better than my patients.

That pig Paul.

The evangelist was scheduled to take a religious education lesson in a girls' secondary school. As he walked into the classroom he was greeted by the teacher who said, "We have decided that St Paul was male chauvinist pig."

After shooting upwards an arrow prayer for help he asked the girls, "How many of you would like to be married and have a family?" All their hands shot up.

"How many would like to marry a man like your father?" All the hands stayed down.

"Why not?" One girl suggested, "He expects my mum to wash and iron his clothes, to cook his meals and wash up the dishes, to do his shopping for him, to wait on him hand and foot. He's turned her into his house-slave."

"Who would like to marry a man like this? His love is patient, his love is kind. His love never envies, he is never rude. He is never proud; he does not boast. His love is not easily angered. His love keeps no record of wrongs. His love hates evil and loves the truth. His love always protects, always trusts, always hopes always keeps on tyring. His love never fails."

Every hand shot up.

"That's the kind of man that St Paul recommends."

I am grateful to Ian Leitch for the story.

Dying well.

Some people have horrible deaths. The author of this article suggests that it is all down to money, but I don't accept that. Money doesn't buy care, only the semblance of care. It's like relying on a prostitute for love; it may look like love, but it is all an act that finishes when the money runs out.

Arthur Hugh Clough's 'Thou shall not kill but needst not strive officiously to keep alive' was meant ironically, but it was written at a time when physicians could do next to nothing to prolong life anyway. I have noticed in my younger colleagues an unwillingness to let go. It's as if a patient's death is a personal insult. I believe doctors are generally terrified of their own deaths and as a consequence fear death of a patient. Thus they fail to prepare patients for their deaths and persist with useless treatments to a point when they are causing harm rather than benefit.

They have forgotten the part of their job that is about relieving suffering. There is also an unwarranted reticence to use morphine in proper doses. For Christians the doctrine of double effect – relieve the suffering even if it shortens life - should absolve them from responsibility for a patient's death.

Some would blame Christian ethics for this cruel attitude to the dying. They suggest that a belief that life must be preserved at all costs condemns patients to prolongation of their suffering, but it is not Christian ethics that are responsible for the callousness of health providers. Christians are supposed to be patient, kind, loving, good, faithful, gentle, peaceful, joyful and self-controlled. Other attitudes are perversions. Dame Cecily Saunders, the mother of the modern hospice movement understood that.

Blood Diamond

On Saturday night we watched Blood Diamond, the thriller set in Sierra Leone starring Leonardo DiCaprio. As a thriller it was excellent fun. Usually the action in these things is interrupted for what we used to call as kids, 'kissing bits'. Blood Diamond was mercifully free of these. The language was rather ripe - no doubt the film-makers would say that it reflects reality. I never thought that thrillers had to reflect reality.

The civil war in Sierra Leone began in 1991 and was fueled by the illegal exprt of diamonds. It was ended in 2000 following the intervention of British troops .

This took place during a short window when it was seen as acceptable to interfere in the internal workings of another country

Retirement

Today I took the notes of all my private patients into the hospital and distributed them among my colleagues. While there I reported two bone marrow biopsies that have been sitting in my in-tray. That's it. Finished.

When I got home my wife said, "On to pastures new?"

"More like pastors new," I said. I have just been asked to chair a search committee looking for a new pastor at the Church. Two of our pastors are leaving this year and our first task is to find a minister for pastoral care.

Androcles, you never can tell.

This week we watched two more of the GBS plays. 'Androcles and the Lion' starred Billy Connolley as Androcles, Anna Calder Marshall as Lavinia and Bernard Bresslaw as Ferrovius. Michael Holdroyd directs. This is a gentle and rather lightweight production originally produced for BBC Schools and not broadcast for 21 years. The story is based on the Aesop fable and written by Shaw to demonstrate different types of Christians.

Rather more fun was 'You never can tell' an early comedy (1897). The only reviewer on Amazon, was not impressed, but I rather approved of it. Robert Powell starred with Cyril Cusack and there was an appearance of Warren Clarke as a young and rather good looking man. He now plays Andy Dalziel in Dalziel and Pascoe as a plug ugly policeman.

New Clinical Trials

I was at the UKCLL Forum Clinical Trials Meeting yesterday. Here are some of the trials up and running or in development in the UK.

CLL6 is in preparation. It needs funding from the Health Technology Assessment Board. It asks a question about cost, namely, do we need such a large dose of rituximab. It compares FCR with FCmini-r + mitoxantrone in a non-inferiority study. This is a randomized phase II study. The dose of rituximab in mini-r is 100mg as opposed to 500mg/sq meter for FCR. Such a small dose can be given quicker and save time an money in the hospital. With small doses there is also the possibility of sc delivery which also saves money.

The use of mini-r derives from the work of Ron Taylor about which I have reported previously. Antigen shaving means that higher doses of rituximab have no CD20 to latch on to. If FCr+M is not inferior to FCR in response rate then a three way randomization of FCR v FCr+M v FCRM would be undertaken. Obviously the pharmaceutical companies will not fund a mini-r trial in case it is as good as full doses and their sales were gut to a fraction of present sales.

Since the German trial shows FCR to be better than FC (although this is from the Roche website and not from a peer reviewed publication) trials with FC as the comparator are non-starters now. However we do not expect publication of the German CLL8 until ASH this year and peer review won't happen to 2009. Therefore NICE will not pronounce until 2010/11. British patients will therefore not get rituximab until then.

As a consequence Roche have offered to fund a FCR v FCRM trial in the UK (using oral FC). This would enable British CLL patients to get free rituximab until NICE pronounces. It could also be seen as an interference ploy by Roche to prevent the mini-r trial from accruing. A cynic might suggest that Roche might be lobbying HTA to stop the funding for mini-r. There is certainly a message coming down from National Cancer Research Institute (NCRI) that they want to encourage participation in industry sponsored trials. Industry also has an interest in demonstrating that FCR with oral FC is as good as with iv FC.

In this context I ought to report that Pete Hillmen's phase II study showed that FCM-R was better than FCM in terms of response rate and quality of response. Historically, we know that FCM produces equivalent responses to FCR is separate phase II trials.

On the question of trials for older patients and those with co-morbidities, we looked at teh possibility of bendamustine trials. However, we thought that this was rather like going back to driving a Trabant when you had previously driven a Ford Focus. We decided to stick with chlorambucil, though given at a proper dose of 70mg/sq m/month rather than the 40mg/sq m/month used in American trials. Roche is supporting a phase II trial using this dose of chlorambucil with rituximab in conventional doses. 50 patients will be recruited in a maximum of 12 months. So far 10 sites are actively recruiting with 11 patients registered. CLL7 might be a randomized phase III comparing Chlorambucil plus or minus rituximab, but GSK have offered an alternative randomized phase III using ofatumumab (HuMax CD20) instead of rituximab.

CLL8 looks at the Campath consolidation question. The aim of this trial is to determine the rate of achieving MRD negativity as determined by 4 color flow cytometry in patients with low levels of MRD following conventional therapy or who relapse at MRD level after a previous MRD negative remission; and to assess the safety of alemtuzumab in the MRD positive setting. The recent CALGB trial had 5 deaths after Campath which has put the wind up Bayer, who bought Schering AG. However, this degree of toxicity is anomalous and may be a reflection on the community oncologists entering patients in that trial.

MRD positive patients will receive alemtuzumab 3 times a week for a total of 6 weeks. Patients whose CLL has disappeared will stop treatment. Patients whose CLL levels have not changed since before the start of treatment will stop treatment. Responding patients who have detectable CLL at the end of 6 weeks will continue treatment for 6 more weeks. MRD negative patients will be monitored every 3 months until they become MRD positive at which point they will be eligible to receive treatment with alemtuzumab.

Up to 54 patients will be recruited over a two year recruitment period and so far 15 patients are registered.

CLL206 is a phase II trial of Campath and high dose methylprednisolone in 17p deleted cases. There was a high MRD negative response rate and this will come to publication shortly. CLL10 asks a Revlimid question in the same group. Even MRD negative patients relapse so Revlimid maintenance will be examined in this study.

CLL203 ask a Revlimid question in high risk p53 or ATM deleted patients. The principle aims of the study would be to determine 1. Response (according to 2008 IWCLL criteria plus MRD eradication, 2. Safety and dosing schedule, 3. Time to next treatment. This question has been a thorny question with us. We have looked at the possible use of FC, FCR, rituximab, alemtuzumab and now Revlimid in this context. The figures for this group are so bad, however, that we feel that something must be done. Rituximab does not depress the immune system nor cause DNA damage - though it does have other unpleasant side effects.

We are also considering an FC plus or minus ofatumumab trial in relapsed disease. This would be commercially sponsored and therefore iv FC, which is a disadvantage, but would cost nothing and give us something to offer until NICE looks at FCR. It competes directly with the FCR plus or minus luxililimab trial, but this is not generally popular in the UK.

Travails of the NHS

Multi-disciplinary teams (MDT) are the means by which the NHS seeks to eliminate mavericks and make sure that patients receive the best treatment. The idea is that every new patient is discussed by a group of specialists and decisions are taken by several heads being put together.

Recently a patient with CLL appeared in a district hospital with a lymphocyte count of over a million. Prognostic markers were done and the patient was found to have a p53 deletion. The MDT was consulted and recommended that possible courses of treatment were alemtuzumab or leucapheresis. The local team instead decided to use CHOP. The following week the patient had a lymphocyte count of 1.2 million. The Hb was only 4g/dl. Again different members of the MDT recommended different courses of action. One consultant, who has an international reputation in the treatment of this disease and who chairs the committee that draws up treatment guidelines, again recommends alemtuzumab. He is aware that the patient has large lymph nodes, but the urgent element for treatment is the severe bone marrow suppression and surely this needs to be remedied before worrying about the lymph nodes. Instead, the local team decide on leucapheresis despite the low Hb and the patient dies while connected up to the cell separator.

Another patient, a young bodybuilder, appears with enlarged lymph nodes from his CLL. He too has a p53 deletion. The correct treatment is clearly alemtuzumab and high dose steroids. Because there is no specific budget for this, the case has to be put to the primary care trust (PCT). This group of public health doctors, GPs and pharmacists of course knows nothing about CLL. So they read the literature. "I have been reading about this subject for two hours" says one, "I am now an expert in the condition." "Campath is contraindicated where there are bulky nodes," says another. "Where are the guidelines recommending this?" asks another. My friend produces a recent paper and admits that the guidelines do not yet recommend this, but the ones in preparation will. He knows because he has the job of writing them. Of course a prophet is not without honor save in his own country. Eventually they are part persuaded and will pay for two courses of the drug.

Both examples of inappropriate bureaucracy hindering treatment.

Another example. The European Clinical Trials directive decrees that the same standard of oversight should be applied to academic trials as to pharmaceutical trials. So the MHRA dispatches inspectors to hospitals to examine the notes to ensure that the protocol has been properly followed. One famous hospital is taken to task because for one patient there is no record in her notes that she has been counselled about taking effective contraception during her chemotherapy. The patient is 73 years old.

A man from Zimbabwe has a blood test which shows a white count of 20,000 and a platelet count of 7. The cells are typical acute promyelocytic leukemia (APML) cells. This disease is curable if treated but he is in imminent danger of bleeding to death if he is not treated. This is explained to him, but he declines admission to hospital. The doctor realizes that he is probably an illegal and reassures him that he is not going to snitch to the authorities. He still refused to come into hospital. A week later his 'brother' brings him into the A&E department unconscious and then leaves him. He dies a few hours later; he has had a cerebral hemorrhage. the address his 'brother' has left is a false one.

I am so glad I no longer work for the NHS

stem cell transplants - a personal history

I was first involved in a bone marrow transplant (BMT) in 1970. We attempted to transplant bone marrow into a toddler with aplastic anemia from an identical twin. It did not take and the child dies. Such a transplant is called a syngeneic transplant and I have never been involved in one since.

In 1983 I got involved in a an autologous bone marrow transplant (ABMT). This was a woman with untreatable ovarian cancer. The idea was to increase the dose of chemotherapy that we gave her. The most sensitive tissue to the toxicities of the alkylating agents is bone marrow, so we thought we could take this out of the equation by storing it in the fridge while she had a big dose of melphalan. The technology worked but the chemotherapy did not damage the cancer.

In 1985 I was given a grant to pursue the idea of ABMT in lymphoma. We had access to Campath - at that time a rat monoclonal antibody. The problem with ABMT in lymphoma is that there is often lymphoma in the bone marrow, so we thought we would be able to launder the marrow with Campath to clean out the lymphoma. This was more successful and we did our first CLL/SLL transplant in 1985. He was cured of his CLL/SLL but died 13 years later of lung cancer.

We transplanted several other patients at this time and some of these were very successful ans some are still alive. For patients with very heavily contaminated bone marrow, even Campath could not get it clean. We then saw a paper by Martin Korbling who described a patient with Burkitt lymphoma who had been treated by a stem cell transplant using stem cells harvested from the peripheral blood (PBSCT). We thought we could try the same thing, especially since I was President of the European Society for Haemapheresis at this time and new all about harvesting cells from the blood.

In fact stem cells had been harvested from the blood before in chronic myeloid leukemia, but that was thought to be a special case, where the disease seemed to consist of bone marrow spilling out into the blood. No-one had suspected that you could get marrow stem cells from the blood in other diseases.

In 1986 we had a patient whose bone marrow was solid with lymphoma (mantle cell lymphoma in fact) We were trying a new chemotherapy regimen, IMVP16, and we had the idea that during the recovery phase from the chemotherapy, stem cells might shower into the peripheral blood as they had with Korbling's case. Sure enough, we had an assay for bone marrow progenitor cells (CFU-GM) as after chemotherapy we found large numbers of these cells appearing. By this time Chris Juttner in Adelaide had done a stem cell transplant in AML so we went ahead in our patient. It was a great success and we put him into a complete remission that lasted for 18 months. This was the first PBSCT in the UK and we think the third or fourth in the world. We did two further such transplants and then published the three cases in a paper in the B J Haem. The important finding was that the neutrophils recovered much more quickly after a PBSCT than after an ABMT, 15 days compared to 24.

We then started doing autografts in myeloma. Having already given high doses of melphalan in this disease and nursing patients through 6 weeks of pancytopenia, we though we would be able to manage this safely. In order to generate the stem cell harvest we had to give 7g per square meter of cyclophosphamide, a huge dose, but the patients negotiated this safely. Again this was very successful, though others were worried about the large dose of chemotherapy, we found that we were able to harvest enough stem cells to do a double autograft in some patients.

Then an Italian group published the fact that instead of chemotherapy you could generate stem cells in the blood by giving the growth factors G-CSF or GM-CSF the whole field took off. In fact, even allogeneic transplants used peripheral blood stem cells as a preference. Because bone marrow transplants and peripheral blood stem cell transplants tend to get lumped together a new term was coined - human stem cell transplants (HSCT) which encompasses both.

We did our first allograft in 1985. She was a young mother with high count acute lymphoblastic leukemia. This disease has a terrible prognosis and we decided that she needed a transplant. Because the past 4 transplants that we had sent to London had all died of the procedure we decided that we couldn't do worse if we did it ourselves. In fact we did rather better, because at least the patient got home for a while. Unfortunately, she developed graft versus host disease and then interstitial lung disease and died a few months later. I met her daughter a few months ago. there were no recriminations; she though that we had done the best for her mum. She left the hospital in a white Rolls Royce in a blaze of publicity.

In this case her sister had been the donor - it was a matched sibling transplant. We went on to do several more transplants which were more successful, but unfortunately the powers that be decided that resources should be concentrated in a different center.

When I started going to Kings College Hospital, I linked up with the biggest transplant center in the UK, one run by my old research fellow who had done our first allograft with us back in 1986. The majority of transplants done there are matched unrelated transplants (MUD) where the donors come from a volunteer donor panel. Sometimes these are known as volunteer unrelated donor transplants (VUD). To some extent this has made transplants more available, but still, because most hematologic diseases occur in older patients, most are unsuitable for standard transplants.

I remember going to a lecture about 10 years ago when the lecturer proposed that transplants work not by rescuing patients after a massive dose of chemotherapy, but by an immune attack on the tumor, the so-called graft-versus-leukemia effect. Therefore it wasn't really necessary to blast the patient with radiotherapy, simply to immunosuppress him enough for the graft to become established. This 'mini-tranplants' began. These are sometimes known as reduced intensity conditioning (RIC) transplants, and sometimes non-myeloablative grafts. There are various regimens used for the conditioning. In Seattle they use low-dose total body irradiation, but in other centers they rely on a small dose of fludarabine to immunosuppree, and in the UK they often use Campath. Patients up to the age of 70 can be safely transplanted, which brings patients with MDS and CLL into the transplantable range.

Still to be solved is the problem of ethnic minority volunteer donors. One solution seems to be cord-blood donors. Cord blood doesn't need to be so tightly matched and one or two mismatches are often perfectly acceptable. This extends the number of possible donors and even with patients who are half Serb and half Nigerian a donor can be found. Kings has started a cord blood program. Often the graft is not large enough for an adult transplant and in these cases two cords must be used. Only one will transplant, but the second sustains the first while it is expanding. One disadvantage of cord transplants is the risk of EBV driven lymphomas which occurs in 20%. The risk can be elimnated if rituximab is given with the graft, but this will likely make the recipient hypogammaglobulinemic for life.

Transplants are getting better all the time but the problems are not yet solved. There are patients that sail through the procedure with little problem, for others the procedure is lethal. We know some of the factors that influence outcome, but not all. Because the risk is uncertain we are reluctant to recommend it except where the alternative is definitely worse, but often that is a matter of judgement.

FCRL2; a new prognostic marker for CLL

In a forthcoming issue of Blood there will be an article on FCRL2, a new prognsotic factor for CLL.

The discovery that patients with chronic lymphocytic leukemia (CLL) who showed somatic hypermutation of their immunoglobulin heavy chain variable region genes (IGHV) lived on average three times longer than those who did not (1, 2) revolutionized the study of CLL and has greatly influenced the design and understanding of clinical trials. Assaying for such mutations seems complicated and the prospect is sufficiently intimidating to deter most routine laboratories from offering the test. Instead there has been a search for a surrogate marker, especially one that can be assayed by a familiar technique such as flow cytometry.

Originally, the expression of CD38 looked promising (1), but that was shown to be discordant with IGHV mutations in up to 30% of cases; so much so that it could be regarded as an independent prognostic factor. Moreover it could change during the course of the disease (3). Gene expression profiling of the two subtypes of CLL suggested that the Syk family tyrosine kinase gene ZAP-70 was the best discriminator between them (4), but translating this finding into a flow cytometry test has proved troublesome and none of the many possible assays has gained universal acceptance. One commonly used assay shows only 77% concordance with IGHV mutations (5).

The immunoglobulin superfamily is a large group of cell surface and soluble proteins that share structural features with immunoglobulin molecules, and includes receptors, co-receptors and co-stimulatory molecules. The well-known receptors for the Fc portion of immunoglobulin are members of this family. Recently a large family of Fc receptor-like molecules (FCRL) with preferential expression on B lymphocytes has been discovered (6). Genes coding for them localize to chromosome 1q21. There is no convincing evidence that they bind immunoglobulin and so far they lack ligands. In a coming issue of Blood, Li and colleagues have demonstrated that some of the FCRL are expressed more densely on CLL cells from patients with mutated IGHV genes than on those from patients with unmutated IGHV genes. A flow cytometric assay using a monoclonal antibody against FCRL2 and measuring mean fluorescence intensity (MFI) discriminated between CLL cells with mutated and unmutated IGHV genes with a concordance of 94.4%. Among 107 patients with CLL, median time to first treatment was more than four times as long for patients whose cells expressed FCRL2 with an MFI ratio of 4.2 or greater. FCRL2 seems to be stably expressed over time.

Should measurement of FCRL2 expression replace IGHV mutations as a prognostic marker? We must first see confirmation of these results in a rather larger series of patients, but given that DNA sequencing is cheaply available from commercial sources and that matching the sequence to the database is performed by a computer program, one wonders why so few laboratories have established the assay for IGHV mutations. In any event discordances between the various prognostic markers and the clinical picture promise to give us a clearer insight into why some cases of CLL progress and some do not.

References

1. Damle RN, Wasil T, Fais F et al. Ig V gene mutation status and CD38 expression as novel prognostic indicators in chronic lymphocytic leukemia. Blood. 1999;94:1840-1847.
2. Hamblin TJ, Davis Z, Gardiner A, Oscier DG, Stevenson FK. Unmutated Ig V(H) genes are associated with a more aggressive form of chronic lymphocytic leukemia. Blood. 1999;94:1848-1854.
3. Hamblin TJ, Orchard JA, Ibbotson RE et al. CD38 expression and immunoglobulin variable region mutations are independent prognostic variables in chronic lymphocytic leukemia, but CD38 expression may vary during the course of the disease. Blood. 2002;99:1023-1029.
4. Wiestner A, Rosenwald A, Barry TS et al. ZAP-70 expression identifies a chronic lymphocytic leukemia subtype with unmutated immunoglobulin genes, inferior clinical outcome, and distinct gene expression profile. Blood. 2003;101:4944-4951.
5. Rassenti LZ, Huynh L, Toy TL et al. ZAP-70 compared with immunoglobulin heavy-chain gene mutation status as a predictor of disease progression in chronic lymphocytic leukemia. N Engl J Med. 2004;351:893-901.
6. Davis RS. Fc receptor-like molecules. Annu Rev Immunol. 2007;25:525-560.

Mrs Warren's Profession (1972)

We watched another GBS play on Saturday night. Mrs Warren's profession is of course the oldest one. Her highly educatd feminist daughter treats her with disdain, not because she made her money that way, but because she continues to run brothels for her 35% return on investment now that she has made her money.

Acting again wonderful - I remember this one from when it was first broadcast. Penelope Wilton, stole the show as the daughter, but James Grout was Morse's boss and Robert Powell was Zeffirelli's Jesus.

LOST and the Gospel

Religious law is all the same. Whether it is Jewish law, Shariah law or Puritan law; it is designed to make the strong look good and the weak look wicked. When the disciples 'harvested' corn on the Sabbath (Matt 12:1) the Pharisees accused them of unlawfulness. Exodus 31:15 says that anyone who does any work on the Sabbath must be put to death. Jesus, who fulfilled the Law completely must have been expected to start stoning Peter, James and John and the rest. Instead he condemns the Pharisees. Treating them like schoolchildren he mocks them, "Haven't you read your Bible?" Then he quotes three Old Testament examples concerning Prophet, Priest and King. The King is King David who ate the Shew Bread (that should not have been eaten except by the priests) when he was on the run from Saul at Nob. The Priests are of course kept especially busy on the Sabbath. The Prophet is Hosea from whom Jesus quotes, "I desire mercy, not sacrifice." (Hos 6:6). That passage from Hosea begins, "Come let us return to the LORD," but I fear that our churches turn sinners away with their emphasis on respectability.

I have been watching the TV series, LOST on DVD. I have almost finished up to the end of the third season. Some might find it low-brow trash and that I should be reading 'Wuthering Heights' and 'The Millon the Floss' but I find it compulsive stuff.

For those who don't know, the premise is that a flight from Sydney to Los Angleles goes down over the Pacific, but there are survivors that turn up on a mysterious island (that looks a bit like rural Hawaii). The island has many mysterious powers: a paraplegic begins to walk, a cancer patient is cured. It also has many strange artefacts, signs of some sort of peace project with strange scientific experiments from the 1980s. However, of more importance is the presence of the 'Others', inhabitants who steal the survivors' children and some of their number who were on a list. Those left behind mostly seem to be very flawed characters. Many are murderers, but others have other besetting sins like gluttony, theft, lying, hatred of parents and adultery. Nevertheless, despite their evil deeds they seem to be very engaging characters and as we see their back-stories we see that there are often extenuating circumstances for their behaving as they did.

On particular character, Mr Eko, is apparently a Nigerian Catholic priest (Eko is thw name of the settlement that eventually became Lagos). In his back-story we learn that as a boy gangsters came into his village stealing children as recruits. His younger brother was ordered to shoot an old man or be killed himself. To save his brother, Eko takes the gun and shoots the old man himself. this begins his life as a gangster while his brother, Yemi, becomes a priest.

Eko now a fully fledged gangster leader asks Yemi to help him smuggle heroin by giving him a large number of Virgin Mary statues to hide it in, and also the use of the plane, in return for a large sum of money. When Yemi refuses, Eko threatens to burn the church down if he doesn't sign documents that allow him and his henchmen to appear as priests. Yemi reluctantly agrees. However as they try to board the plane Yemi is shot by the army and Eko mistaken for a real priest; he returns as Yemi's replacement to the village. Here, he commits further 'justifiable' homicides. Eventually he finds himself among the survivors on the island. Even here he cannot keep from killing. Eventually seeking absolution he sees an apparition of his dead brother who urges him to confess and repent. His reply is, "I have nothing to confess. I did what I had to do." Then appears the 'monster' which kills him.

Goodness knows what this series is about. The island apparently does not represent purgatory or Hell. But it does bring home certain undeniable points, 1 All have sinned and fallen short of the glory of God. 2 Most of us can point to extenuating circumstances to excuse our sin. 3 Excuses won't wash. 4 We are responsible for our own behavior.

Paul sums up how we should behave in Colossians chapter 3:Therefore, as God's chosen people, holy and dearly loved, clothe yourselves with compassion, kindness, humility, gentleness and patience. Bear with each other and forgive whatever grievances you may have against one another. Forgive as the Lord forgave you. And over all these virtues put on love, which binds them all together in perfect unity.

That way we will accept sinners into our churches, churches who don'y are like hospitals that turn away patients.

Psalm 25

I imagine David wrestling in prayer. He is lonely and afflicted (v16) and as he pleads for himself he keeps reminding himself of how great God is.

No one whose hope is in you will ever be put to shame v 3
You are God my savior v 5
Your love and mercy are from of old v6
You are good and upright v7-8
The LORD is loving and faithful v10
The LORD confides in those who fear him v14

So in this context he prays for protection (v2,20), direction (v4-5), preservation (v21) and forgiveness (v11,18).

Is he too self absorbed? We are often taught to pray for ourselves last; that others should come first. Just so, but at times we are cast down, depressed and hardly able to continue. At these times we can restore our hope by reciting the attributes of our God and claiming his promises. So David climaxes his prayer with a demand that God redeems Israel (and remember that the Church is the Israel of God). Demand? Too strong a word? I would have put 'plea' but that becomes too speculative and plaintive. God's response is sure; we do not have to beg, merely to ask. 'Demander' in the French sense.

Asymetric warfare

Late last month, a young female bomber was shot as she approached some shops in central Baghdad. The Iraqi soldier who drew his gun hesitated as the bomber, hands raised, insisted that she wasn't armed. The soldier and a shop owner finally opened fire as she dashed for the stores; she was knocked to the ground but still managed to detonate the bomb, killing three and wounding eight. Had the soldier and other bystanders not called out a warning to others -- and had they not shot her before she could enter the shops -- the death toll certainly would have been higher. Had he not hesitated, it might have been lower.

As more women and children are recruited by their mothers and their religious leaders to become suicide bombers, more women and children will be shot at -- some mistakenly. That too is part of the grand plan of our enemies. They want us to kill their civilians, who they also consider martyrs, because when we accidentally kill a civilian, they win in the court of public opinion. One Western diplomat called this the "harsh arithmetic of pain," whereby civilian casualties on both sides "play in their favor." Democracies lose, both politically and emotionally, when they kill civilians, even inadvertently. As Golda Meir once put it: "We can perhaps someday forgive you for killing our children, but we cannot forgive you for making us kill your children."

The traditional sharp distinction between soldiers in uniform and civilians in nonmilitary garb has given way to a continuum. At the more civilian end are babies and true noncombatants; at the more military end are the religious leaders who incite mass murder; in the middle are ordinary citizens who facilitate, finance or encourage terrorism. There are no hard and fast lines of demarcation, and mistakes are inevitable -- as the terrorists well understand.

ALAN M. DERSHOWITZ, 2008

Moral equivalence

Moreover, it should be expected that when criminals unlawfully attack a state, and the state responds, the criminals will suffer more casualties than the state. The ratio of criminals to police wounded in any democratic society should be high. A low ratio would represent a failure of law enforcement. The same is true of a military response to terrorism.

Those who suggest a moral equivalence between the terrorist targeting of civilians and the traditional response to terrorism – which always carries the risk of accidentally killing noncombatants – actually encourages the use of terrorism. … Those who focus on body counts, without distinguishing between the deliberate targeting of civilians and the inadvertent killing of some civilians along with terrorists, play directly into the hands of those who employ terrorism as a tactic for securing the moral high ground.

Alan M. Dershowitz (2002), Why Terrorism Works, Yale University Press, New Haven p.85

Israelis attack Hamas

Once more the BBC is attacking the Israeli government for invading Gaza and killing 100 Palestinians, only 90 of which were terrorists (or as the BBC prefers to call them, "militants"). The provocation for the Israeli invasion was rockets fired into Israel hitting Ashkelon some 20km into Israel.

As I remember when I was a very small boy Germany fired rockets at London and the British response was to firebomb Dresden.

The Geneva convention declares it a war crime to use civilians as human shields behind which to fire on an enemy in the hope of deterring the enemy from returning fire. Hamas are doing this in Gaza just as Hezbollah did in Lebanon. There sems to be no cry from the BBC that the war criminals in Gaza be brought to trial in the Hague.

The Geneva convention also states that it is not a war crime to kill civilians when retuirning fire on an enemy who uses human shields - or at least the crime is committed by those using thr human shields and not by those returning fire. Yet Edward Stourton this morning on the 'Today' programme spoke of Israel coming under universal condemnation for its action.

It is certainly possible to argue that it was wrong to establish a Jewish state in Palestine 60 years ago. It is a complex argument, but it does not deal in present day realities.

In some ways my position is similar to what it was over the Iran/Iraq war - a plague on both your houses. I have no interest in who wins the argument. I do not see the return of the Jews to Jerusalem as a fulfillment of prophesy as some American evangelicals do. If it involved the conversion of the Jews, I might be more impressed. Nevertheless, If I were living in the middle east I should prefer to live under the form of government present in Israel rather than the one in Palestine. I fail to understand why the BBC endorses a criminal government in Gaza over a democratic one in Israel.

The end of Mark

I don't suppose you know who Agur is. I certainly didn't. Although the Proverbs are attributed to Solomon, the last two chapters are the Sayings of Agur and the Sayings of King Lemual.

In Proverbs 30:5-6 Agur says: Every word of God is flawless; he is a shield to those who take refuge in him. Do not add to his words, or he will rebuke you and prove you a liar.

Scripture is complete. I remember making a cup of tea for my parents when a small child. I thought I would experiment with flavors and added a small teaspoonful of mustard to each cup. It was not a success.

Some have deliberately added to the Bible. An example would be extra conditions for salvation such as the prayers of saints or the intercession of Mary, good works. The sects have extra books like the Book of Mormon or Science and Health with Key to the Scriptures. Other have eliminated part of Scripture. They don't have to be physically cut out pages, just disparage them. The creation? An ancient Hebrew myth disproved by Darwin. Jonah? A folk tale. The miracles? Sleight of hand or hypnotism. The resurrection? Meant to be interpreted spiritually.

Sometimes the alteration to Scripture has been accidental. An error of transplantion - it's not easy to get it completely right. Words change their meaning over time and even tracing etymology does not always help. How about copying errors? The famous "wicked" Bible had "Thou shalt commit adultery" and an early edition of the NIV had 'immoral' instead of 'immortal'.

Prior to 1947 it was assumed that many copying errors had crept into Scripture over the years like Chinese whispers, but the Dead Sea Scrolls have shown us that Scripture is remarkably free of mistakes. Over 1000 years from the DSC to the Masoretic text the Old Testament books were copied accurately.

So where does that leave the end of Mark? The earliest Manuscripts end at Mark 16:8. The rest of the chapter is written in a different style. It speaks of Mary Magdalene as if she were being introduced for the first time rather than having been a major character in the previous chapters. It is really a summary of what is found in the other gospels. But is also contains contentious promises that do not hold up: picking up snakes and drinking poison. I know that there are various groups in America that pick up snakes as part of their worship, and indeed you can immunize against snake venom so as to be unaffected, but even pastors in these churches are sometimes killed by the bites of rattlesnakes. I know St Paul was bitten by a snake without ill effect, but someone else was cured by Peter's shadow. It is dangerous to generalize from the particular if your only warrant is a passage added 400 years after the gospel was first written.

To my mind, the most compelling evidence for the later interpolation of Mark 16:9-20 is seen in the structure of the gospel.

Mark 1 to 6:29 starts and finishes with John the Baptist. Jesus is established as the Messiah.
Mark 6:30 to 8:21 is topped and tailed with the feeding miracles. The first Jewish, the second, gentile. The gospel is not just for the Jews but for all mankind
Mark 8:22 to 10:52 is contained within the healing of two blind men. The disciples have eyes but will not see.
Mark 11-13 begins with the cleansing of the Temple and ends with the prediction of the destruction of the Temple. Temple worship is to cease. The sacrifice of animals was but a picture of the sacrifice of Christ.
Mark 14 begins with Mary anointing Jesus and ends with her going to anoint his body and finding no body there. Jesus the anointed one; prophet priest and King.

There it is complete. There is no need for an extra coda. It is complete and flawless.

Wuthering Heights

I have never read 'Wuthering Heights'. Last night I watched the DVD of the ITV version starring Robert Cavanagh and Orla Brady. It is highly praised by reviewers.

If the performances are good then the story must be tosh. Normally I am a sucker for period dramas. I watch 'Lark Rise to Candleford' every Sunday and have enjoyed every Charles Dickens dramatization. Elizabeth Gaskell, George Eliot, Jane Austen - bring 'em on. Bur 'Wuthering Heights' left me cold and looking at my watch. Neither Heathcliff nor Cathy interested me as characters. Both are thoroughly unpleasant and what is supposed to be a great love story came across as petulant selfishness.

Ps 119:15

I meditate on your precepts and consider your ways.

Meditation got a bad press with the Maharishi and 'transcendental meditation'. I never quite knew what that meant. I gather it is something about thinking about the sound of one hand clapping. An impossibility, of course, but the idea seems to be that by thinking of the absurd we disengage our mind from logic and consequence and engage in pure thought without reference points.

Utter hogwash, of course, and certainly not what the Bible means by meditation. Rather than running the mind in neutral we are expected to work hard. Wikipedia has this, "The Old Testament book of Joshua sets out a form of meditation based on scriptures: "Do not let this Book of the Law depart from your mouth; meditate on it day and night, so that you may be careful to do everything written in it, then you will be prosperous and successful" (Joshua 1:8). This is one of the reasons why bible verse memory is a practice among many evangelical Christians."

Again they are missing the point. Although it is a fine thing to memorize scripture verses it is far better to know the Bible and understand it. Being sylable perfect is rather beside the point with so many versions around.

Meditation is about thinking deeply about a subject and a Christian meditates by thinking deeply about the Bible. It is unhurried thought, seeking to understand meaning. I know a lot of people who can recite the 23rd Psalm but apart from knowing that it is often read at funerals they couldn't tell you what it means.

Nor is it a matter of what the commentaries say. They will tell you the technical side of exegesis but they say little of what it means to me or you.

Here is how to meditate on Scripture. Ask yourself the following questions:

What does the passage tell me about God?

What does the passage tell me about living?

What does the passage tell me about my life, here and now?

The Devil's Disciple

Watched another GBS play last night. The Devil's Disciple is set in a town in New Hampshire at the time of the American Revolution. It was a rather better production the than the previous two I commented on. It was remarkable for the performance of Patrick Stewart (John Luc Picard) with long hair and the apt aphorism of GBS, "The British soldier can only be defeated by the British War Office."

Why ciclosporin works in AIHA

As far as I can find, ciclosporin (or cyclosporin) was first used to treat autoimmune hemolytic anemia in Germany in 1986. (Pogglittsch and colleagues, Wien Med Wochenschr. 1986;136:567-70).

Some readers have expressed surprise that ciclosporin, which is best known for acting to prevent the rejection of transplants – a T-cell function, should be thought useful for a disease caused by antibodies. However, all IgG antibodies are produced because of an interaction of B-cells with T-cells. T-helper cells are required to make IgG antibodies.

My first experience of using ciclosporin in this way came in 1995 when we seemed to be experiencing an epidemic of hemolytic anemia in our CLL patients. I noticed they were all multiply treated patients and all had received fludarabine. It was this that prompted me to write about hemolytic anemia triggered by fludarabine. (Myint et al, Br J Haematol. 1995;91:341-4). I knew, of course, about the early paper by Dameshek demonstrating that radiation or chlorambucil could trigger hemolytic anemia in CLL, but, quite honestly, that seemed to have been a rather rare event in my experience.

As it happened, about this time I attended a lecture by Ethan Shevak, who introduced me to the idea of regulatory T cells (later published as Shevach et al. Novartis Foundation Symposium 1998; 215:200-211). This is what he told us: mice thymectomized on the third day of life develop a wide spectrum of organ specific autoimmune diseases depending on the strain. Reconstitution of these mice with CD4+ CD25+ T cells from normal mice prevents the development of disease. These cells can also prevent the transfer of disease by autoantigen-specific cloned T cells derived from neonatally thymectomized mice. Elimination of CD4+ CD25+ T cells, which constitute 5-10% of peripheral CD4+ T cells, leads to spontaneous development of various autoimmune diseases.

In other words young animals have the capacity to make antibodies against themselves, but this capacity is kept in place by a population of T cells that are CD4 positive and CD25 positive. These cells are known as regulatory T cells – these days they are further identified by being Fox3P positive. They suppress autoreactive T cells by specifically inhibiting the production of IL-2, an action that seemed to me to be remarkably like that of ciclosporin.

Regulatory T cells are very susceptible to killing with chemotherapeutic agents compared to the CD4+ CD25 negative subset, and Fludarabine is particularly toxic to them.

Ciclosporin is thought to bind to the cytosolic protein cyclophilin (immunophilin) of immunocompetent lymphocytes, especially T-lymphocytes. This complex of ciclosporin and cyclophylin inhibits calcineurin, which under normal circumstances is responsible for activating the transcription of interleukin-2.

It occurred to me that cyclosporin might mimic the function of regulatory T cells in denying interleukin-2 to T-helper cells. Faced with hemolysis following fludarabine that was uncontrollable by standard treatments, I thought it worth trying ciclosporin on theoretical grounds, as well as being supported by the empirical evidence that it had worked in anecdootal cases in the literature.

When we were designing the LRF CLL4 trial I took on the role of giving advice to investigators who were confronted with uncontrolable AIHA following fludarabine. My advice was almost always to try ciclosporin. After his retirement, Danny Catovsky had a sabbatical in Houston and I believe that he passed on our success with ciclosporin to MDACC. Certainly, Mike Keating now recommends ciclosporin for the treatment of AIHA in CLL.