A New Histology-Based Prognostic Index for Aggressive T-Cell lymphoma: Preliminary Results of the "TCL Urayasu Classification"

Background: Aggressive mature T-cell lymphoma (TCL) is a disease that carries a poor prognosis. Methods: We analyzed the expression of 22 tumor cell functional proteins in 16 randomly selected patients with TCL. Immunohistochemistry was performed in paraffin-embedded tumor tissue sections to determine the protein expression statuses in tumor cells. Results: Glucose-regulated protein 94 (GRP94), a protein that serves as a pro-survival component under endoplasmic reticulum (ER) stress in the tumor microenvironment, was significantly associated with a shortened survival. Furthermore, significant differences were observed when GRP94 was combined with six other factors. The six factors were (1) programmed cell death-ligand 1 (PD-L1); (2) programmed cell death 1 (PD-1); (3) aldo-keto reductase family 1 member C3 (AKR1C3); (4) P53, a tumor suppressor; (5) glucose-regulated protein 78 (GRP78), an ER stress protein; and (6) thymidine phosphorylase (TP). Based on the combination of GRP94 and the six other factors expressed in the tumors, we propose a new prognostic classification system for TCL (TCL Urayasu classification). Group 1 (relatively good prognosis): GRP94-negative (n = 6; median OS, 88 months; p < 0.01); Group 2 (poor prognosis): GRP94-positive, plus expression of two of the six factors mentioned above (n = 5; median OS, 25 months; p > 0.05); and Group 3 (very poor prognosis): GRP94-positive, plus expression of at least three of the six factors mentioned above (n = 5; median OS, 10 months; p < 0.01). Conclusions: Thus, the TCL Urayasu prognostic classification may be a simple, useful, and innovative classification that also explains the mechanism of resistance to treatment for each functional protein. If validated in a larger number of patients, the TCL Urayasu classification will enable a targeted treatment using selected inhibitors acting on the abnormal protein found in each patient.

Possible New Histological Prognostic Index for Large B-Cell Lymphoma

We conducted a retrospective analysis of GRP94 immunohistochemical (IHC) staining, an ER stress protein, on large B-cell lymphoma (LBCL) cells, intracellular p53, and 15 factors involved in the metabolism of the CHOP regimen: AKR1C3 (HO metabolism), CYP3A4 (CHOP metabolism), and HO efflux pumps (MDR1 and MRP1). The study subjects were 42 patients with LBCL at our hospital. The IHC staining used antibodies against the 17 factors. The odds ratios by logistic regression analysis used a dichotomous variable of CR and non-CR/relapse were statistically significant for MDR1, MRP1, and AKR1C3. The overall survival (OS) after R-CHOP was compared by the log-rank test. The four groups showed that Very good (5-year OS, 100%) consisted of four patients who showed negative IHC staining for both GRP94 and CYP3A4. Very poor (1-year OS, 0%) consisted of three patients who showed positive results in IHC for both GRP94 and CYP3A4. The remaining 35 patients comprised two subgroups: Good (5-year OS 60-80%): 15 patients who showed negative staining for both MDR1 and AKR1C3 and Poor (5-year OS, 10-20%): 20 patients who showed positive staining for either MDR, AKR1C3, MRP1, or p53. The Histological Prognostic Index (HPI) (the four groups: Very poor, Poor, Good, and Very good) is a breakthrough method for stratifying patients based on the factors involved in the development of treatment resistance.

Role of TGF-beta1 and TNF-alpha1 produced by neoplastic cells in the pathogenesis of fibrosis in patients with hematologic neoplasms

We conducted this study with the objective of elucidating the mechanism of development of fibrosis in hematologic neoplasms and develop treatments for these patients. Among the suggested mechanisms of development of fibrosis is cases of hematologic neoplasms is the production of TGF-beta1 (transforming growth factor-beta-1) and TNF-alpha1 (tumor necrotizing factor-alpha-1) by the tumor cells, both of which are fibrosis-stimulating cytokines that act on fibroblasts to promote fibrosis. However, there are few reports based on human clinical pathology studies. We conducted an immunohistochemical study on paraffin-embedded formalin-fixed specimens obtained from 104 patients with various pathologic conditions (acute leukemia, malignant lymphoma, inflammation, cancer, etc.). The association of tissue fibrosis with positive immunohistochemistry for TGF- beta1 and/or TNF-alpha1, TGF-beta1 was found to be strongly associated with tissue fibrosis, and in cases with positive immunohistochemistry for TGF-beta1, the odds ratio for fibrosis was 12.8, which was significantly high. Combined positivity for TGF-beta1 and TNF-alpha1 was also associated with a significant odds ratio for fibrosis of 3.4, suggesting that TGF-beta1 expression is an important prerequisite. TGF-beta1 has been suggested as playing a relatively important role in tissue fibrosis. Future clinical application of these cytokines for both diagnosis and treatment is expected.

Use of Ibrutinib in 10 Patients with Treatment-Naïve or Relapsed/Refractory Chronic Lymphocytic Leukemia/Small Lymphocytic Lymphoma in Real-World Clinical Practice -A Report from a Single Medical Institution

In Japan, ibrutinib has been approved as both a front-line and later-line treatment for chronic leukemia/small lymphocytic lymphoma(CLL/SLL). However, little is known about the actual outcomes and adverse events(AEs)associated with the use of ibrutinib in Japanese patients.

OBJECTIVE

The outcomes and AEs of patients treated with ibrutinib in a real-world setting were investigated.

METHODS

A retrospective cohort study of all patients with CLL/SLL who were treated with ibrutinib at a single institution was conducted.

RESULT

In total, 10 patients, including 5 treatment-naïve patients(50%), were enrolled. The median follow-up period was 9.8 months(range, 0.2-21.6 months), and the estimated overall response rate (ORR: complete remission plus partial remission)was 60%. The median overall survival and progression-free survival outcomes were not reached. During the follow-up period, 4 patients(40%)had at least one AE and 1 patient(10%)had at least one grade≥3 AE. Ibrutinib was discontinued in 4 patients(40%)because of AEs in 2 patients(20%), the progression of CLL in 1 patient(10%), and financial reasons in 1 patient(10%). Richter's transformation did not occur in any of the cases.

CONCLUSION

The ORR was lower(60%)than that observed in clinical trials. The frequency and severity of AEs were both relatively low, although the discontinuation rate was high(40%). Patient education and medication adherence were considered important.

Low‒Risk Essential Thrombocythemia Who Presented with Recurrent Episodes of Cerebral Hemorrhage during Pregnancy and Developed Cerebral Infarction during Puerperium

A 42‒year‒old woman. At week 27 of pregnancy, she developed subcortical hemorrhage and underwent open cranial surgery for hematoma evacuation. The platelet(Plt)count was 297,000/μL. At week 34 of pregnancy, she developed subcortical hemorrhage again. The Plt count was 429,000/μL. At week 35 of pregnancy, the ventricular rupture and she underwent drainage and emergency cesarean section. The Plt count was 687,000/μL. Two days after delivery, hemorrhage was detected. The Plt count was 815,000/μL. Six days after delivery, she developed infarction. The Plt count was 915,000/μL. MRI revealed no evidence of aneurysm, arteriovenous malformations or tumor. Ten days after delivery, the Plt count was 1,173,000/μL. Bone marrow examination led to the diagnosis of essential thrombocythemia(ET). JAK2, CARL and MPL was negative. She was rated as"low‒risk"by IPSET‒thrombosis, and as"ultralow"risk by revised IPSET‒thrombosis. von Willebrand factor(VWF)activity was as high as 247%. The bleeding time and platelet aggregation activity were normal. There was no evidence of disseminated intravascular coagulation(DIC)or hypertensive disorders of pregnancy(HDP). She died of cerebral hemorrhage and infarction, 26 days after delivery.

A survey of nurses to assess transfusion practice at the bedside using an electronic identification system: Experience at a university hospital

OBJECTIVES

The objective of this study was to assess the performance and recognition of transfusion practice at the bedside by nurses in our hospital, where a barcode-based electronic identification system (EIS) has been used since 2002.

BACKGROUND

More than half of the steps in the transfusion chain are dependent on nurses' awareness and skills.

METHODS

Our transfusion policy at the bedside includes two-person checking of the patient and two-person signing of the label at the time of collecting blood samples for pre-transfusion testing and two-person blood administration, which generally involved a doctor-nurse pair but sometimes involved two nurses. Anonymous, paper-based questionnaires were sent in January 2018 to 1051 nurses who were working in Juntendo University Hospital, Tokyo, Japan. The questionnaire consisted of three parts: (a) background of respondents, (b) performance of collection of blood samples for pre-transfusion testing and (c) performance of pre-transfusion check procedures at the bedside using an EIS based on a total of 20 questions.

RESULTS

There was a good response rate of individual nurses (1006/1051, 96%). Most nurses (>90%) performed two-person checking of the patient and two-person signing of the label at the time of collecting blood samples. Most nurses (>90%) performed two-person blood administration involving a doctor-nurse pair and electronic pre-transfusion check using an EIS before blood administration.

CONCLUSIONS

The survey revealed that most nurses complied with our transfusion policy at the bedside, but some nurses did not. Further education/training and continuous support by the transfusion service may be needed for all nurses.

The Current Status of Screening for Essential Thrombocythemia and Polycythemia Vera in Clinical Practice-Report from a Single Institution

OBJECTIVE

We investigate the current status of screening for essential thrombocythemia(ET)and polycythemia vera(PV), at our hospital.

METHODS

According to the World Health Organization(WHO)diagnostic criteria.

PATIENTS

All patients who visited Juntendo University Urayasu Hospital between May 1984(when the hospital opened)and January 2019.

RESULT

More than 90% of patients with elevated platelet counts(PLT)(n=25,062)and more than 90% of patients with elevated hemoglobin( Hb)or hematocrit(Ht)levels(n=16,422)did not visit the department of hematology, suggesting that there could be a high percentage of patients with potentially latent ET and PV visiting the hospital. In addition, a large number of patients fulfilling the laboratory criteria for ET/PV visited various departments of the hospital other than the department of hematology.

CONCLUSION

Because ET/PV manifests with diverse symptoms, including non-specific symptoms and symptoms pertaining to other organ systems. Based on the findings, we consider that it is essential to disseminate information about the WHO diagnostic criteria/clinical symptoms and possibility of latent ET/PV to all departments of the hospital, and to establish cooperation between the department of hematology and other departments.

Threshold for optimal administration of plerixafor in autologous peripheral blood stem cell collections through CD34+ cell monitoring based on the experience from two Japanese university hospitals

Plerixafor was introduced to Japan in 2017 as a stem cell mobilization enhancement reagent, but the threshold for its use remains unclear. In this study, we assessed 57 patients treated with plerixafor (33 patients with multiple myeloma (MM) and 24 with malignant lymphoma (ML) and 152 patients without plerixafor administration. When CD34+ cell pre-counts were between 5.5 and 20 cells/μL in MM or 6 and 21 cells/μL in ML, the CD34+ cell count increased significantly, attaining the highest yield in response to plerixafor (achievement rate by one leukapheresis is 93.3% and 91.7% in MM and ML, at P < .001 and P = .012, respectively). In case the CD34+ cell pre-count was less than 5.5 cells/μL, an increase of at least 7 cells/μL from baseline by plerixafor was the necessary condition to achieve successful collection through a two-time leukapheresis. Monitoring CD34+ cell numbers might improve the collection efficiency and reduce the cost.

Methotrexate-associated Hodgkin Lymphoma in a Patient with Rheumatoid Arthritis Successfully Treated with Brentuximab Vedotin in Combination with Doxorubicin, Vinblastine, and Dacarbazine (BV+AVD)

A 53-year-old woman had been diagnosed with rheumatoid arthritis (RA) in X-6. She was started on methotrexate (MTX) in X-1. She developed a cough, and chest computed tomography showed abnormalities. In X, MTX was discontinued, but the cough persisted. A lung biopsy revealed a diagnosis of nodular sclerosis classic Hodgkin lymphoma (CHL-NS). She was considered to have "other iatrogenic immunodeficiency-associated lymphoproliferative disorders" (OIIA-LPD), MTX-associated Hodgkin lymphoma (MTX-HL). She received six courses of brentuximab vedotin (BV) in addition to AVD (BV+AVD). A complete metabolic response was obtained, and the RA went into remission. This is the fourth reported case of BV+AVD for MTX-HL.

Significant role of magnetic resonance imaging for the diagnosis and evaluation of cardiac amyloidosis in primary light chain amyloidosis

A 47-year-old male with macroglossia presented with dyspnea on effort and chest pain at rest. Cardiac MRI revealed diffuse global subendocardial late gadolinium enhancement below the left ventricular endocardium and a dark blood pool of intracardiac contrast medium. Tongue biopsy revealed amyloid deposition, which was limited in the myocardium. He was diagnosed with primary light chain amyloidosis. His condition was stage I according to the Mayo Clinic staging system. He underwent autologous peripheral blood stem cell transplantation. On Day 10, he developed chest pain and died suddenly on Day 11. Postmortem examination revealed amyloid deposition throughout the heart.

A Case of Primary Myelofibrosis in Which Ruxolitinib Therapy Ameliorated the Fibrosis, but Resulted in Fatty Marrow

A 63-year-old woman was referred to our department in 2015 because of anemia and thrombocytosis. MPL W515/K was positive, JAK-2V617F and CALR exon 9 were negative. Bone marrow(BM)biopsy led to a diagnosis of primary myelofibrosis (PMF)in the prefibrotic/early stage(Grade 1). BMbiopsy performed in 2016 showed overt fibrotic stage(Grade 2). She was classified according to the Dynamic International Prognostic Scoring System(DIPSS)as intermediate(Int)-Ⅱrisk. Ruxolitinib 10 mg daily was initiated. Ruxolitinib was suspended for hepatic dysfunction after the dose was increased to 15 mg. Subsequently, ruxolitinib was resumed at 10 mg. BM biopsy performed in 2017 showed progression of myelofibrosis(MF)to Grade 3. BM biopsy performed in 2018 showed improved to Grade 0-1, however, BM was fatty. Currently in 2019, she continues to be on ruxolitinib. Results of immunohistochemical staining of BM biopsy specimens for cytokines and CD34 suggested the role of cytokines in the pathogenesis of the PMF. It was speculated that ruxolitinib blocked the production of cytokines to ameliorate the MF and restore the hematopoietic function of the BM. Although the pathogenesis of the fatty marrow remained unclear, the possibility of involvement of ruxolitinib cannot be denied.

Impact of CD34+ pre-counting and plerixafor on autologous peripheral blood stem cell collection in Japanese university hospitals in eight years

OBJECTIVE

Over the past decade, there have been two major advancements in autologous peripheral blood stem cell (PBSC) collection, namely enumeration of CD 34+ cells for apheresis prediction and use of plerixafor to assist mobilization of PBSC. This study aimed to investigate changes in the efficacy of PBSC collection from two Japanese university hospitals over an eight-year period.

STUDY DESIGN AND METHODS

A series of 399 PBSC collection procedures from 239 patients with solid malignant tumors (ST, n = 42), malignant lymphoma (ML, n = 91), multiple myeloma (MM, n = 99), and others (amyloidosis and leukemia, n = 7) from two university hospitals from 2011 to 2018 were retrospectively analyzed. We also analyzed the effects of CD34+ pre-counting and plerixafor administration in improving CD34+ cell yield.

RESULTS

Using CD34+ pre-count as a reference, the frequency of apheresis was reduced and the yield of CD34+ cells increased in patients with ST. When administrating plerixafor, especially with a CD34+ pre-count <20/μL, the yield of CD34+ cells was significantly increased in patients with ML (p = 0.02) and MM (p = 0.03).

CONCLUSIONS

We verified that CD34+ cell counting and plerixafor administration contributed to effective PBSC collections in our hospitals for the eight-year study period. In patients with ST, CD34+ pre-count threshold for starting apheresis was ≥10/μL. CD34+ pre-count (<20/μL) was useful to select appropriate patients for plerixafor administration among the patients with ML and MM.

P1252Diagnostic performance of quantitative flow ratio from coronary angiography versus fractional flow reserve from computed tomography

Background

QFR and FFRCT are recently developed, less-invasive techniques for functional assessment of coronary artery disease.

Objectives

We compared the diagnostic performance between fractional flow reserve derived from computed tomography (FFRCT) and quantitative flow ratio (QFR) derived from coronary angiography, using FFR as the standard reference.

Methods

We measured FFRCT, QFR and FFR in 152 patients (233 vessels) with stable coronary artery disease.

Results

QFR was highly correlated with FFR (r=0.78, p<0.001), while FFRCT was moderately correlated with FFR (r=0.63, p<0.001). Both QFR and FFRCT showed good agreements with FFR, presenting small values of mean difference and root-mean-squared deviation (FFR -QFR: 0.02±0.09 and FFR -FFRCT: 0.03±0.11). The AUC of QFR was significantly greater than that of 3D-QCA-derived %DS (0.93 vs. 0.78; difference: 0.15; 95% CI: 0.09 to 0.20; p<0.001). The AUC of FFRCTwas significantly greater than that of CCTA-derived %DS (0.82 vs. 0.70; difference: 0.12; 95% CI: 0.05 to 0.19; p<0.001). The AUC of QFR was significantly greater than that of FFRCT (0.93 vs. 0.82; difference: 0.11; 95% CI: 0.05 to 0.16; p<0.001). The sensitivity, specificity, positive predictive value, and negative predictive valueof QFR ≤0.80 for predicting FFR ≤0.80 were 90%, 82%, 81%, and 90%, respectively. Those of FFRCT ≤0.80 for predicting FFR ≤0.80 were 82%, 70%, 70%, and 82%, respectively. The diagnostic accuracy of QFR ≤0.80 for predicting FFR ≤0.80 was 85% [95% confidence interval: 81% to 89%], while that of FFRCT≤0.80 for predicting FFR ≤0.80was 76% [95% confidence interval: 70% to 80%].

Figure 1. Comparison of FFR ≤0.80 predictors

Conclusions

Both QFR and FFRCTpossessed the ability to accurately evaluate the functional severity of coronary stenosis.

6108Efficacy of the PCSK9 inhibitor for lipid-rich coronary plaque reduction: a near-infrared spectroscopy analysis

Background

Recently, some studies have highlighted proprotein convertase subtilisin-kexin type 9 (PCSK9) inhibitors produce incremental low-density lipoprotein cholesterol (LDL-C) lowering effect. However, it is unknown whether the lipid composition of plaque changes is associated with serum LDL-C reduction due to PCSK9 inhibitors administration.

Purpose

The purpose of this study was to determine the effects of PCSK9 inhibitor (PCSK9i) on coronary plaque component in patients with a history of coronary artery disease (CAD) assessed by near-infrared spectroscopy intravascular ultrasound (NIRS-IVUS).

Methods

A total of 67 non-culprit coronary segments were identified in 34 patients. These lesions were analyzed utilizing NIRS-IVUS at baseline and follow-up coronary angiography (CAG). The subjects were divided into two groups according to lipid-lowering treatment; administration of PCSK9i group (PCSK9i: 19 segments, 9 patients) and traditional statin treatment group (Control: 48 segments, 25 patients). The change of lipid-rich plaque distribution between baseline and follow-up NIRS-IVUS was defined as the change of maximal lipid core burden index (LCBI) score for each of the 4-mm longitudinal segments (maxLCBI4mm).

Results

Mean duration from baseline to follow-up CAG was 239.4±52.4 days in the PCSK9i group and 341.0±84.1 days in the Control group (p<0.001). Despite the higher total cholesterol (TC) and low-density lipoprotein cholesterol (LDL-C) in the PCSK9i group at baseline (206.6±40.9 mg/dl vs. 168.5±37.1 mg/dl, 131.5±35.4 mg/dl vs. 100.0±29.5 mg/dl; respectively, p<0.001 for both), the PCSK9i group was significantly lower TC and LDL-C at the follow-up (111.5±23.5 mg/dl vs. 157.4±27.8 mg/dl, 40.8±15.7 mg/dl vs. 86.2±19.6 mg/dl; respectively, p<0.001 for both). Furthermore, the PCSK9i group induced greater regression of maxLCBI4mm than that of Control group (99.6±156.6 vs. 27.9±118.0, p=0.046) (Figure).

Figure 1

Conclusion

Compared with traditional statin therapy, PCSK9i treatment resulted in a greater decrease in lipid component in non-culprit coronary plaques. Therefore, PCSK9i may be useful option in preventing from adverse coronary events for the patients with CAD.

P974Efficacy of plaque debulking for bifurcated or ostial lesion by directional coronary atherectomy before 2nd generation drug eluting stent (PERFECT2)

Objectives

We sought to evaluate the efficacy of plaque debulking by directional coronary atherectomy (DCA) before 2nd generation drug-eluting stent (DES) implantation for bifurcated coronary lesions.

Background

Percutaneous coronary intervention (PCI) for bifurcated lesions still remains complex and challenging in terms of restenosis or stent thrombosis regardless of whether simple or complex stenting used.

Methods

Patients with bifurcated lesions were enrolled in this prospective multicenter registry. Pre-2nd generation DES plaque debulking with a novel DCA was conducted. All patients were scheduled to perform a follow up (9–12 months) angiography (coronary angiography or coronary computed tomography). The primary end point was the target vessel failure (TVF) at follow-up. Secondary end points were procedure-related events and major adverse cardiac events at 1 year.

Results

A total of 77 patients with bifurcated lesions were enrolled. PCI with DCA was performed successfully in all without any major procedure-related event and only 1 case needed complex stenting. TVF rate at 9–12 months follow up was 3.9% (3 of 77) and those were all associated with revascularization of the target vessel. Restenosis was only observed at ostial of main-branch in 3cases. No death, no coronary artery bypass grafting, and no myocardial infarction were reported in the patients within the first year.

Figure1

Conclusion

DCA before 2nd generation DES implantation can possibly avoid complex stenting and provide a good mid-term outcome in patients with bifurcated lesions.

Acknowledgement/Funding

None