Infliximab for managing steroid-refractory acute graft-versus-host disease

Infliximab has demonstrated activity in the treatment of steroid-refractory acute graft-versus-host disease (aGVHD). We aimed to confirm the effectiveness of infliximab as a salvage therapy for steroid-refractory aGVHD. In a series of 52 patients, 71% of whom had grade III-IV aGVHD, only 15% achieved complete remission (CR) with the use of infliximab alone as salvage therapy. CR of aGVHD differed according to overall aGVHD grade at salvage (grade II, 5/15; grade III, 2/17; grade IV, 1/20; P=.03). Median overall survival (OS) was only 1.7 months (95% confidence interval [CI]=0.99 to 2.3 months). CR of aGVHD was significantly associated with OS, with a hazard ratio of 8.4 for death in those without CR (95% CI=3.6 to 19.6; P < .0001). This series demonstrates the limited activity of infliximab in patients with high-grade aGVHD. Further work is needed to identify effective therapy for aGVHD.

Cytogenetic changes associated with myelodysplastic syndrome affecting bone marrow engraftment analysis

In vitro amplification of polymorphic genetic markers, especially short tandem repeats (STRs), has become standard laboratory practice in the monitoring of allogeneic bone marrow transplant patients. After initial analysis of donor and recipient samples at multiple loci before transplantation, one or more loci are used to follow engraftment status in subsequent specimens. We describe an unusual pattern of STRs in a transplanted patient with a prior history of refractory acute myelogenous leukemia. DNA chimerism studies showed a lack of engraftment at 1 and 2 months after transplantation. Atypical minor peaks occurred at each of three STR loci in the pre-transplant and 2-month post-transplant recipient samples. However, these peaks were of equal amplitude as the major corresponding allele in the 1-month post-transplant sample. A history of myelodysplasia with specific chromosomal deletions before the patient's acute myelogenous leukemia diagnosis appears to explain the spurious peaks. STR analysis of blood and archival paraffin-embedded tissues collected from the patient at various time points before transplantation reflected the evolution, progression, and response to therapy of the myelodysplasia. The case illustrates the need for comprehensive evaluation of pertinent clinical and laboratory data during engraftment monitoring to identify potential sources for error in interpretation of STR analysis.

Marginal zone B-cell lymphoma of the uterus: a case report and review of the literature

We report here a case of a 52-year-old female in whom immunohistological studies of the uterus established a diagnosis of extranodal marginal zone B-cell lymphoma. Malignant lymphoma arising from mucosa-associated lymphoid tissue (MALT) of uterus is extremely rare. Accurate histologic interpretation of uterine lymphoma is essential, as treatment options and prognosis vary based on the histological grade of such lymphomas. Patients with primary uterine lymphoma generally have intermediate or high-grade lymphoma and poorer prognosis.

Feasibility and correlates of arsenic trioxide combined with ascorbic acid-mediated depletion of intracellular glutathione for the treatment of relapsed/refractory multiple myeloma

Patients with multiple myeloma (MM) invariably relapse with chemotherapy-resistant disease, underscoring the need for new agents that bypass these resistance mechanisms. We have reported that ascorbic acid (AA) enhances the activity of arsenic trioxide (As(2)0(3)) against drug-resistant MM in vitro by depleting intracellular glutathione (GSH). These data led us to open a National Cancer Institute/Cancer Therapy Evaluation Program-sponsored Phase I/II trial of As(2)0(3) + AA for relapsed/refractory MM. We now present the completed Phase I component of this trial. The primary objective of the trial's Phase I component was to assess whether the addition of AA affected the well-described toxicity profile of As(2)0(3) alone. Correlative studies were undertaken of As(2)0(3) and AA pharmacokinetics, the ability of AA to deplete intracellular GSH in vivo, and the development of arsenic resistance. Six patients with stage IIIA relapsed/refractory myeloma were studied. We found that 0.25 mg/kg/day As(2)O(3) + 1,000 mg/day AA could be given for 25 days (over a 35-day period) without dose-limiting toxicity. One episode of grade 3 hematological toxicity (leukopenia) and no grade 3 nonhematological toxicities (in particular, cardiac) were observed. The coadministration of AA did not alter the pharmacokinetics of As(2)0(3), and elevated AA levels were associated with decreased intracellular GSH. Serial in vitro studies demonstrated continued sensitivity of patient myeloma cells to As(2)0(3) + AA. Two patients (both with thalidomide-refractory disease) had partial responses; four patients had stable disease. In conclusion, we have found that As(2)0(3) + AA has acceptable toxicity and that there is promising evidence of activity in refractory/relapsed myeloma.