From www.bloodjournal.org by guest on June 18, 2017. For personal use only. Inverse Expression of bcl-2 Protein and Fas Antigen in Lymphoblasts in Peripheral Lymph Nodes and Activated Peripheral Blood T and B Lymphocytes By Tadashi Yoshino, Eisaku Kondo, Liu Cao, Kiyoshi Takahashi, Kazuhiko Hayashi, Shintaro Nomura, and Tadaatsu Akagi Toexamine the regulatorymechanismofapoptosisin bcl-2 protein and less Far antigen. This inverse expression lymphoid cells, expression both of bcl-2 protein and Fas antiof bcl-2protein and Far antigen was also shown in activated gen was investigated in reactivelymphnodes, in resting from peripheral blood. These T and B lymphocytes (PBLs), and inPBLs stimlymphocytes from peripheral blood lymphoblasts fell into apoptosisdose-dependently in the ulated with pokeweed mitogen, interleukin-4 (IL-4) + antipresence of anti-Fas monoclonal antibody, but resting lymIgM antibody, IL-2 + anti-CD3 antibody, phytohemagglutinin phocytes that expressed both bcl-2 protein and Far antigen + phorbol myristate acetate using immunohistochemistry did not undergo apoptosis. These findings suggest that beland flow cytometry. Germinal center cells expressed a large2 expression prevents the apoptosis of lymphoid cells inamount of Fas antigen, which is associatedwith the inducduced by tha Fas antigen-dependent mechanism and that tion of apoptosis in lymphoid cell lines, in contrast to the apoptosis of lymphocytes is exquisitely controlled, at least lack of bcl-2 protein as an apoptosis inhibitor. On the other in part, by regulationof the bcl-2 and Far genes. hand, mantle zone lymphocytes expressed a high level of 0 1994 by The American Society of Hematology. P ROGRAMMED CELL DEATH or apoptosis plays an important role in the physiologic turnover of normal cells, in morphogenisis in embryonic development, and in metamorphosis.’.’ In the immune system, immature thymic T cells and B blasts in germinal centers undergo apoptosis in response to antigenic and other stimuli, including glucocorticoids and irradiati~n.~.~ Anti-Fas monoclonal antibody MOA^)^ and anti- APO- 1 MoAb6 reportedly induce apoptotic cell death in sensitive cell lines in vitro. Molecular cloning of these apoptosisinducing regulators has shown that Fas antigen and APO-l antigen are identical and belong to the tumor necrosis factor receptor (TNFR)/nerve growth factor receptor (NGFR) family.’ The bcl-2 protein, which was originally implicated in Bcell lymphomagenesis through its activation by the t( 14; 18) chromosomal translocation, prevents apoptosis in hematopoietic cells (reviewed by Kor~meyer’.~). We” and another group” have shown that germinal center cells (GCCs) in the lymph node lack bcl-2 protein, despite the expression of abundant bcl-2 transcripts. The regulatory mechanism of expression of these two proteins in normal lymphoid cells remains unclear. Here, we studied Fas antigen expression in GCCs and in peripheral blood lymphocytes (PBLs) stimulated with mitogen andother stimulators. In particular, bcl-2 protein expression was investigated, and we showed the inverse expression of bcl-2 protein and Fas antigen in GCCs in reactive lymph nodes and lymphoblasts. Both bcl-2 protein and Fas antigen From the Department of Pathology, Okayama University School of Medicine, Okayama; and the Department of Pathology, Osaka University School of Medicine, Suita, Japan. Submitted July 12, 1993; accepted November 23, 1993. Address reprint requests to Tadashi Yoshino, MD, Department of Pathology, Okayama University School of Medicine, Shikata-cho 25-1. Okayama, 700,Japan. The publication costs of this article were defrayed in part by page charge payment. This article must therefore be hereby marked “advertisement” in accordance with 18 U.S.C. section 1734 solely to indicate this fact. 0 1994 by The American Society of Hematology. 0006-4971/94/8307-0017$3.00/0 1856 may participate in clonal deletion and selection of lymphocytes through apoptosis in a reverse fashion. MATERIALS AND METHODS Samples. Lymph nodes were surgically removed from patients with reactive lymphoid hyperplasia. PBLs from healthy donors were separated by Ficoll-Hypaque density gradient (Sigma, St Louis, MO) and cultured in RPMI 1640 supplemented with10% fetal bovine serum (GIBCO, Gaithersburg, MD). To get B-cell-rich and T-cellrich fractions, B-cell-rich fractions were obtained using neuraminidase-pretreated sheep red blood cell (RBC) depleting T cells (<2%) and plate adherence depleting of monocytes (<2%) from PBLs, and T cells were purified from peripheral blood mononuclear cells with RBC-rosettes formation (>95%). Lymphoblasts were cultured in RPMI 1640 supplemented with 10% bovine serum and 0.05% pokeweed mitogen (PWM; GIBCO) for 72 hours. The activated B cells were obtained by the administration of 4 ng/mL interleukin-4 (IL4;Genzyme, Boston, MA) and 4 pg/mL anti-IgM antibody (DAKO, Copenhagen, Denmark) for 3 days or of PWM to the B-cell fraction. The activated T cells were obtained by the administration of IL-2 (Shionogi Phamacy, Tokyo, Japan) and 5 pg/mL anti-CD3 antibody (DAKO), administration of 1 pg/mL phytohemagglutinin (PHA) and 20 ng/mL phorbol myristate acetate (PMA) for 3 days, or administrationof PWM to the T-cell fraction. Flow cytofluorometry using propidium iodide staining confirmed the induction of proliferation in the activated B- and T-cell preparations. MoAb. The anti-Fas mouse MoAb, obtained from MBL (Nagoya, Japan), was established by Yonehara et al.’ Anti-bcl-2 protein MoAb, designated Bcl-2 124a. was obtained from DAKO. AntiCD3 and CD19 MoAbs conjugated with fluorescein isothiocyanate (FITC) were purchased from Becton Dickinson (Mountain View, CA). MOPC 21 and TEK 183 for IgGl and IgM class match control were obtained from Sigma. Immunofuorescence. Indirect immunofluorescence was performed on frozen tissue sections fixed with acetone and on cytosmears of PWM-treated or untreated PBLs. Samples were stained with Bcl-2 124a MoAb at a dilution of 1:40 and with anti-Fas MoAb at a concentration of 10 pg/mL for 60 minutes at room temperature. As a second antibody, FITC-conjugated goat antimouse IgG ( y chain-specific; Zymed, South San Francisco, CA) and biotin-conjugated goat antimouse IgM (p-chain-specific) were used at a 1:20 dilution. After washing, phycoerythrin (PE)-streptavidin (Vector Lab, Inc, Burlingame, CA) was further applied at a 1:lOO dilution to biotin-labeled specimens. Some samples were double-stained with anti-Fas MoAb (PE) and anti-CD3 or anti-CD19 MoAb (FITC). Blood, Vol 83,No 7 (April l), 1994:pp 1856-1861 From www.bloodjournal.org by guest on June 18, 2017. For personal use only. 1857 bcl-2 AND Fas IN LYMPHOBLASTS Fig 1. (A)Doubleimmunofluorescence of reactive lymph node hyperplasia using anti-Fasantigen MoAb (PE1and Bel-2 124a IFITC) is shown. Most GCCs and a few scattered interfollicular blastic cells reacted intensely with anti-Fas MoAb. The mantle zone and most mature interfollicular cells were very faintly stained or negative.Inversely, anti-bcl-2 MoAb reacted mainly with the mantle zone and interfollicular cells and not with GCCs. (B) Double immunofluorescence of PWM-treated PBL is shown. Blastic cells were intensely positive for Fas antigen (PE), and most of them were negative for bcl-2 protein (FITC). Nonblastic cells were positive for bcl-2 protein and faintly positive for Fas antigen. Aftera final wash,sectionswereobservedunderamicroscopic fluorometer (MPM, Zeiss, Germany). Flow cytomerry. One million PWM-stimulated and unstimulated PBLs were incubated with 4 pg of anti-Fas MoAb for 30 minutes at 4°C. were washed, and then were incubated with 20 pL of PEconjugated goat antimouse Ig (diluted1:80;Tago, Burlingame, CA) for 20 minutes. These specimens were immediately fixed with 2% paraformaldehyde in phosphate-buffered saline, applied to a FACScan, and analyzed with Consort30 (Becton Dickinson). DNA labeling assay using pow cyfomefry. Toevaluatethe or without mitoapoptosis inducedby anti-Fas MoAb on PBLs with gen treatment, we performed DNA labeling with propidium iodide (PI) and flow cytometric analysis. The method was essentially that described by Nicolettiet al." Inbrief,the 200g centrifugedcell pellet was gently resuspended in 1.2 mL hypotonic fluorochrome solution of PI 50 pg/mL in 0.1 mL sodium citrate plus0.1 % Triton X-100(Sigma). After 20 hours in the dark at 4"C, the samples were applied to FACScan. DNAfiagmenration assay. DNA fragmentation of PWM-stimulated or unstimulated samples was assessed following the method describd previo~sly.'~ In brief, low molecular weight DNA was extracted from the Supernatants of lysed cells with phenolkhloro- .. .. -. .. , . .. . . . ... . .. . -. ... . - - Fig 2. Flow cytometry of Pm-treated PBLs is shown. Blasticend nonblastic cells were examined by gating the forward scattering-aide scattering channel (bottoml. Large blastic cells (b) were intensely positive for anti-Fat MoAb as compared with nonblastic cells (a). TEPC 183 was the class-matched control (fine broken lines), and unstained samples are symbolizedby coarse broken lines. Both the X(fluorescenceintensity) and Y-axes (cell number) in the upper figure are linear. TheX- and Y-axes of the bottomfigure are forward and side scattering,respectively. From www.bloodjournal.org by guest on June 18, 2017. For personal use only. 1858 YOSHINO ET AL form and precipitated with ethanoVammonium acetate. After digestion with RNase A, 5 pg of each DNA fragment was loaded on a 2% agarose gel containing 0.01% ethidium bromide and waselectrophoresed. Bands were visualized by means of a UV transilluminator (Shoshin EM Cop, Okazaki, Japan). RESULTS Expression of Fas antigen and bcl-2 protein on germinal center cells. As shown in Fig lA, Fas antigen was strongly expressed on GCCs and on a few scattered interfollicular cells. Mantle zone mature lymphocytes and most interfollicular cells were faintly stained or mainly nonreactive with anti-Fas MoAb.In contrast to Fas antigen, bel-2protein was expressed on mantle zone lymphocytes andinmost interfollicular cells. Most GCCs were negative for bel-2 pro- tein. Double staining with anti-Fas MoAb and anti-CD3 or anti-CD19 MoAb showed that most of Fas-positive cells in germinal centers were B cells and that strongly Fas-positive interfollicular blastic cells were composed of both T and B cells (data not shown). Expression of Fas antigen on resting and blastic PBLs. As shown in Fig lB, Fas antigen was highly expressed on PWM-stimulated lymphoblasts. Most small nonblastic PBLs were faintly positive or negative for Fas antigen. Bcl-2 protein was expressed on nonblastic lymphocytes, and most PWM-stimulated lymphoblasts were negative for bcl-2 protein. PWM-untreated PBLs showed the same staining pattern as nonblastic cells in PWM-treated PBL cultures; they were faintly positive or negative for Fas antigen and more positive for bcl-2 protein. There was no difference in reactive pattern Fig 3. DNA fluorosmnca histogramsof PI-atained PBL cultures after 24 hours of incubation under various up.rim.ntal conditions isshown. (a) PBLs with control mouse IgM antibody, apoptotk ratio (AR), 2%; (b) PBLs with 4 pg/mL of anti-Fa. MoAb, AR, 8%; (c) PWM-tnated PBLs with controlMoAb, AR, 10%; Id) PWM-treated PBLs with 25 ng/mL of anti-Far MoAb, AR, 17%; (81 PWM-troated PBLs with 100 nglmL of antiFas MoAb, AR, 27%; (f) PWM-treated PBLs with 300 ng/mL of anti-Far MoAb, AR, 48%; (g) PWM-treated PBLs with 1 p g l m L of anti-Fas MoAb. AR, 47%; lh) PWM-treated PBLs with 4 pg/mL of a n t i - F r MoAb, AR, 57%; (i)IL-4 anti-lgM antibody-treatedPBLs with control antibody, AR, 9%; ljl IL-4 + anti-lgM antibody-treatedPBL. with 4 m / m L of anti-Fas MoAb, AR, 49%; (k)IL-2 + antl-CD3 antibody-treated PBL. with control antibody, AR, 3%; (I) IL-2 + anti-CD3 antibody-treated PBLs with 4 pg/mL of anti-Fas MoAb, AR, 38%; lm) PHA + PMA-treated PBLs with control antibody, AR, 23%; and In) PHA PMA-treated PBLs with 4 p g l m L of anti-Fas MoAb, AR, 56%. + + From www.bloodjournal.org by guest on June 18, 2017. For personal use only. bcl-2 AND Fas IN LYMPHOBLASTS 1859 Table 1. Anti-Fas MoAb-lnducd PBL Cultures Treated With Stimulants ~ B Cells Whole PBLs Untreated (%)* IgM control (%) Anti-Fas antibody (%) (4 pg/mL) T Cells Untreated IL-4 + Anti-lgM PWM Untreated IL-2 + Anti-CD3 9 8 <5 <5 13 11 14 12 <5 15 <5 <5 17 20 <5 <5 48 9 42 40 9 32 40 7 PWM PHA + PMA Untreated Apoptotic cells were evaluated with flow cytometry (see Materials and Methods). The number in each column is the average apoptotic percentage of samples from four individuals. between B and T lymphoblasts stimulated with PWM. The numbers of B lymphoblasts induced by E - 4 + anti-IgM antibody treatment and T lymphoblasts induced by IL-2 + anti-CD3 antibody treatment were smaller than those induced by PWM treatment, but the inverse expression of Fas antigen and bcl-2 protein was essentially the same (data not shown). Flow cytometry showed again that PWM-induced blasts definitely expressed more Fas antigen than did nonblastic cells (Fig 2). The cells between small-sized lymphocytes (designated “a” in Fig 2) and large-sized blastic cells (“b” in Fig 2) showed intermediate expression of Fas antigen. PWM-untreated PBL samples expressed the same level of Fas antigen as did nonblastic PBLs in PWM-treated samples. Induction of apoptosis by anti-Fas MoAb on PWM-treated PBLs. Anti-Fas MoAb (25 ng/mL to 4 pg/mL) was added to the PBL cultures that had been treated with PWM for 3 days, at which time about 40% to 70% of lymphocytes became blastic. Anti-Fas MoAb was also added to the B-cell cultures with IL-4 + anti-IgM treatment and to T-cell cultures with IL-2 + anti-CD3 antibody or PHA + PMA treatment. Three hours after culture with anti-Fas antibody, stimulator-induced blastic cells began to show pyknotic nuclei. We checked the apoptosis with flow cytometric analysis. As shown in Fig 3, anti-Fas MoAb induced apoptosis in PBL cultures treated with PWM (Fig 3c through h), in IL-4 + anti-IgM antibody-treated B cells (Fig 3i and j), in IL-2 + anti-CD3 antibody-treated T cells (Fig 3k and l), and in PHA + PMA-treated T cells (Fig 3m and n). Only a small amount of untreated PBLs underwent apoptosis (Fig 3a and b). PWM-treated T cells also showed apoptosis (data not shown). The data of apoptosis induced by anti-Fas MoAb were also listed in Table 1. As shown in Fig 4, the degree of apoptosis was dose-dependent at a range of 25 to 300 ng/ mL, and the ratio of apoptotic cells reached a plateau from 1 pg/mL to 4 pg/mL. There was an individual variation in the degree of blastic response to stimulators. We examined PBL cultures from five healthy donors, and the apoptotic ratio was 37% to 72% (average, 48%) at the concentration of 4 pglmL anti-Fas antibody. Most of the surviving cells were nonblastic, and only a minor population of lymphoblasts was distinct. Anti-Fas MoAb almost failed to induce apoptosis in PBLs without PWM. More than 90% of PWM-induced lymphoblasts were distinct at this time, unless incubated with anti-Fas MoAb. As shown in Table 1, B cells stimulated with IL-4 + anti-IgM antibody and T cells stimulated with IL-2 + anti-CD3 antibody or with PHA + PMA showed apoptosis at 42%, 32%, and 40%, respectively, on average with 4 pg/mL anti-Fas antibody, respectively. DNA-jragrnentation assay. PWM-stimulated lymphocytes showed DNA fragmentation when incubated with antiFas MoAb, whereas nontreated lymphocytes did not show fragmentation. Control samples treated with class-matched control sera also showed no DNA fragmentation (Fig 5). DISCUSSION T cells are differentiated and programmed within the thymus; most cortical immature thymocytes die by apoptosis.13 B cells proliferate mainly in the germinal centers of peripheral lymphoid organs. They respond to antigens and undergo somatic mutation of Ig variable region genes. Autoreactive B cells or those that failed to achieve appropriate avidity to the antigen undergo apoptosis accompanied by scavenging macrophage^.'^,'^ Most GCCs lack bcl-2 protein, which has been thought to be an antidote to apoptosis.lo3”Most PWMstimulated lymphoblasts from PBLs lack bcl-2 protein as well, despite high levels of bcl-2 transcripts.16 Therefore, with respect to bcl-2 regulation for apoptosis, PWM-induced lymphoblasts seem to be analogous to GCCs. Recently, MBller et all7 described that APO-Was antigen is expressed on GCCs (IgD- and CD10+) and is not detected on mantle zone surface (s)IgD+ lymphocytes. Miyawaki et all8 have described that Fas antigen is expressed exclusively on CD45RO+ memory or previously activated T cells and on sIgD- B cells in PBLs that increase in number according to age. Our results using lymph nodes partly support this notion; Fas antigen was expressed on sIgD- GCCs and not on sIgD+ mantle zone lymphocytes. Interfollicular mature lymphocytes were faintly positive or negative, and interfollicular scattered T blasts were intensely positive for Fas antigen. Nonstimulated PBLs were weakly positive for Fas antigen, but, after activation with PWM, IL-4 + anti-IgM antibody, IL-2 + anti-CD3 antibody, or PHA PMA, not only B cells but also T cells became intensely positive and underwent apoptosis in the presence of anti-Fas MoAb. This result is consistent with a previous report” which showed that Fas-resistant PBLs became sensitive after exposure to IL-2. Therefore, activation of lymphocytes seemedto be associated with upregulation of Fas antigen and the simultaneous downregulation of bcl-2 protein, and these findings seemed to be associated with most blastic cells undergoing apoptosis for clonal deletion and selection. Most blastic cells downregulated bcl-2 protein in the presence of PWM, but + From www.bloodjournal.org by guest on June 18, 2017. For personal use only. YOSHINO ET AL 1860 5 -a P c o. 0 n 0 0.0 1 .o 2.0 3.0 antl-ha antlbody and IgM control (uglml) some lymphoblasts were highly positive for bcl-2 protein and escaped apoptosis.I6 Fas antigen may functionally regulate programmed cell death, because anti-Fas MoAb induced apoptosis in lymphoblasts in a dose-dependent manner. The most distinctive cells among PWM-stimulated PBLs incubated with antiFas MoAb were small lymphocytes. These results contradict a previous report" which showed that the lymphocytes stimulated in vitro were not significantly changed by anti-Fas MoAb. We used adult PBLs for in vitro stimulation, which may explain the discrepancy with the previous study" that used neonatal PBLs. Interestingly, anti-Fas MoAb could not induce apoptosis in nontreated PBLs, although at least some of them were positive for Fas antigen. This may be related f' 4.0 Fig 4. The apoptotic effect of anti-Far MoAb on PWM-treated-untreated P B b is shown. PWMtreated or untreated PBLs were incubated with various concentrations of anti-Fas MoAb 10 t o 4 pg/mL) at 37°C for 24 hours. Apoptosis was evaluated by DNA-labeling assay using flow cytometry. A centrifuged cell pellet was resuspended in 1.2 mL hypotonic fluorochromesolution.'* After 20 hours at 4°C. the sample was applied t o a FACScan. Apoptosis of PBL cultures with or without stimulant was examined with samples from five healthy donors: (-1, PWM-treated PBLs; (---l, untreated PBLs; (01, PBL cultures with anti-Far MoAb; (01. PBL cultures with TEPC 183. Y-axis bar is thestandard deviation of the examined five samples. to the fact that more than 50% of PBLs were positive for bcl-2 protein." Mapara et al" have described that APO-I/ Fas-antigen-mediated apoptosis in chronic B-lymphocytic leukemia cells is correlated with downregulation of bcl-2 mRNA. The signalling mechanism in apoptosis by this exquisite and inverse regulation of Fas antigen and bcl-2 protein will be clarified by further examination. cDNA cloning for Fas/APO-I antigen showed that this apoptosis-associated molecule belongs to the TNFIUNGFR family.' Itoh et a17 have shown, using a transfection assay, that anti-Fas MoAb directly induces apoptosis by binding to its receptor. Fas maynot be the only apoptosis inducer, because TNF also induces tumor regression with apoptosis. BcI-2 protein may not bethe only apoptosis inhibitor either, S1 2 3 4 5 6 Fig 5. DNA fragmentation in PWM -stimulated unstimulated cells in the presence or absence of anti-Fas MoAb. Anti-Fas MoAb was added 3 days after PBLs were culturedwith or without 0.5% PWM. Twenty-four hours later, DNA was extracted from the supernatants of lysed calls with phanollchloroform andprecipitated with ethanol/ ammonium acetate. After digestion withRNase A, 5 p g of DNA fragments was loaded on a 2% agarose gel containing 0.01% ethidium bromide and resolved by electrophoresis. Lane l,untreated PBLs; lane 2, P B b w i t h TEPC183; lane 3, PBLs with antiFas MoAb; lane 4, PWM-treated PBLs without antibody; lane 5, PWM-treatedP8Ls with lEPC183; and lane 6, PWM-treated PBLs with anti-Fas MoAb. - 26451605676350- From www.bloodjournal.org by guest on June 18, 2017. For personal use only. bcl-2 AND Fas IN LYMPHOBLASTS because Hashimoto et a12* described the adenovirus oncogene Elb confers cellular resistance to cytolysis by anti-Fas MoAb. Our results, however, suggested that Fas-antigedbcl2-protein regulation plays an important role in the apoptotic events in GCCs and in PWM-stimulated PBLs. there Natural ligands to Fas antigen remain unclarified, but might be some natural ligands mimickingthe anti-Fas or Apo-l antibodies. Antigen-primed lymphocytes might express other apoptosis-inducing factors. It has been reported that human memoryT cells show enhancedlevels of various accessory molecules?3s24P%"-stimulated PBLsbegan to show blastic changes after 3 days. At that time, blastic cells did not show apoptosis but did show apoptosis after 7 days in the presence of PWM.I6 This finding suggests that some ligands for the Fas antigen or for other unknown apoptosisassociated receptors are presentin culture medium. The finding that GCCs lack bcl-2 protein and had upregulated expression of Fas antigen suggests that the inverse expression of bcl-2 and Fas antigen also plays an important role in vivo. In conclusion, the blastic changes of lymphoid cells induced by antigen stimulation or mitogens seem to be associated with upregulation of Fas antigen and with the inverse downregulation of bcl-2 protein, which may be related to the clonal deletion of unfavorable clones through apoptosis. REFERENCES 1 . Wylie AH, Kerr JFR, Cunie AR: Cell death: The significance of apoptosis. 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Mapara MY,BargouR,Zugck C.DGhnerH, Ustaoglu F, Jonker RR, Krammer PH, Darken B: APO-I mediated apoptosis or proliferation in human chronic B lymphocytic leukemia: Correlation with bcl-2 oncogene expression. Eur J Immunol 23:702, 1993 22. Hashimoto S , Ishii A, Yonehara S: The Elb oncogene of adenovirus confers cellular resistance to cytotoxicity of tumor necrosis factor and monoclonal anti-Fas antibody. Int Immunol 3:343, 1992 23. Beverley PCL: Is T-cell memory maintained by crossreactive stimulation? Immunol Today 11:203, 1990 24. Akbar AN, Salmon M, Janossy G: The synergy between naive and memory Tcells during activation. Immunol Today 12:184, 1991 From www.bloodjournal.org by guest on June 18, 2017. For personal use only. 1994 83: 1856-1861 Inverse expression of bcl-2 protein and Fas antigen in lymphoblasts in peripheral lymph nodes and activated peripheral blood T and B lymphocytes T Yoshino, E Kondo, L Cao, K Takahashi, K Hayashi, S Nomura and T Akagi Updated information and services can be found at: http://www.bloodjournal.org/content/83/7/1856.full.html Articles on similar topics can be found in the following Blood collections Information about reproducing this article in parts or in its entirety may be found online at: http://www.bloodjournal.org/site/misc/rights.xhtml#repub_requests Information about ordering reprints may be found online at: http://www.bloodjournal.org/site/misc/rights.xhtml#reprints Information about subscriptions and ASH membership may be found online at: http://www.bloodjournal.org/site/subscriptions/index.xhtml Blood (print ISSN 0006-4971, online ISSN 1528-0020), is published weekly by the American Society of Hematology, 2021 L St, NW, Suite 900, Washington DC 20036. 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