Optimal patient selection for CPT-11 chemotherapy in colorectal cancer: Quantitative prediction of tumor response and overall survival using expression data of novel marker genes

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Background: Unlike the toxicity, none of the critical prediction markers of CPT-11 efficacy has been validated to date. With a hypothesis that expression analysis of a set of the key drug sensitivity genes could allow us to predict the therapeutic response, we identified potent marker genes for CPT-11 in in vitro, conducted this prospective study attempting to develop a prediction formula of efficacy using the expression data (2006 ASCO, 2006 ESMO), and demonstrated the latest prediction formula of the best tumor response (BTR), time to treatment failure (TTP), and the overall survival after CPT-11 chemotherapy (OS). Methods: Seven genes identified as possible marker genes for CPT-11 (SN-38)- AMD1, CTSC, EIF1AX, FLJ13089 , DDX54, PTPN2, and TBX3-, and 5 other possible marker genes (ABCG2, CYP3A4, MGMT, POR, and TOP2A) that had already been known as drug sensitivity determinants and selected by our in vitro screening process, were studied. CPT-11 was intravenously administered on Days 1, 8, and 15, every 4 weeks in chemo-naive patients with stage IV colorectal cancer after palliative operation. Tumor samples were collected at surgery and tumor response was evaluated by RECIST. Results: All of the 44 enrolled patients were assessable for BTR (% of initial tumor size), TTP (day), and OS (day) in the clinical study, and we successfully developed the best linear model for each, which converted the quantified expression data of the 7 selected genes into objective BTR, TTP, and OS. We used 20, 16, and 15 tumor specimens and constructed potent prediction formulae for BTR (r=0.9420), TTP (r=0.7103), and OS (r=0.8406), respectively. Utility-confirmation analyses using another 16, 10, 13 clinical samples appeared to show that the formulae could predict BTR (r=0.6491, p=0.007) and OS (r=0.7947, p=0.011). We also fixed the best linear models using 5 other known marker genes, but they had less advantage in prediction. Conclusions: Despite limited data, our developed formulae using the 7 novel genes would provide advantages in prediction of individual response to CPT-11. Based on the positive results of this study, we have initiated a large scale validation study of the formula.

[Table: see text]

Adjuvant radiotherapy to an initial bulky mass in diffuse large B-cell lymphoma: lack of survival benefit

The role of adjuvant radiotherapy to the site of the initial bulky mass in lymphoma remains to be determined. We retrospectively analyzed clinical data for 35 consecutive patients with diffuse large B-cell lymphoma who had an initial bulky mass were treated successfully by chemotherapy reaching complete remission or complete remission unconfirmed according to International Workshop Criteria. Median age was 57 years. Median follow-up period for surviving patients after completion of chemotherapy was 45 months. Twenty patients (group A) received adjuvant radiotherapy to the bulky mass, while 15 (group B) did not. Median dose of radiation in group A was 40 Gy (range, 30-60 Gy). In group A, four relapses occurred, all from other sites; group B included three relapses from bulky and one from other sites. Overall survival (P = 0.15) and recurrence-free survival (P = 0.48) did not differ significantly between groups. Although adjuvant radiotherapy to the initial bulky site is useful for controlling local disease, no survival benefit was seen.

[Usefulness of hematopoietic cell transplantation-specific comorbidity index after allogeneic hematopoietic stem cell transplantation]

We retrospectively investigated the hematopoietic cell transplantation-specific comorbidity index(HCT-CI)to predict non relapse mortality. Of 127 patients who underwent transplantation between January 2000 and December 2003 with conditioning consisting of total body irradiation, cyclophosphamide and thiotepa, HCT-CI scores were obtained for 83 patients. Median age was 42 years. The sources of stem cells included HLA-identical bone marrow or peripheral blood from sibling(30), HLA-matched bone marrow from unrelated donors(45), and HLA-mismatched bone marrow or peripheral blood from family donors(8). Hematological disease was divided into two groups, standard risk(47)and high risk(36). Standard risk indicates acute leukemia in first or second remission and chronic myelocytic leukemia in first chronic phase, while high risk indicates all other diagnoses. There were 45 patients with moderate or severe pulmonary comorbidities. 55 patients with HCT-CI scores of 2 or less had higher 2-year overall survival than 28 patients with HCT-CI scores of 3 or more(65% vs. 36%, p=0.0009). Although the non relapse mortality rate was not different, HCT-CI scores were a more useful indicator to predict survival in high risk patients than in standard risk patients. Prospective evaluation is warranted to clarify the usefulness of HCT-CI.

[Discrepant results of ABO type of red cells and serum in a patient with acute myelogenous leukemia]

A 42-year-old woman was admitted to our hospital with acute myelogenous leukemia. We conducted blood-type examination, and her serum showed strong agglutination with all B cells but questionable agglutination with A1 cells, which became stronger with incubation. We considered her blood type as O, but her previously assessed blood type was A. After receiving one cycle of induction therapy, she achieved complete remission and blood group A antigen was proven on her red blood cells. Anti-A1 in her serum disappeared after induction therapy. We should be aware that blood group antigens are not entirely independent of the environment and are occasionally modified by disease.

[Systemic neurolymphomatosis complicated in diffuse large B-cell lymphoma]

A 73-year-old woman was diagnosed with diffuse large B-cell lymphoma of the uterus (Stage IVB). After 3 courses of CHOP therapy, right abducens nerve paralysis appeared and was diagnosed as central nervous system infiltration with lymphoma cells. Although partial remission was obtained by chemotherapy with methotrexate, numbness and muscle weakness of all four limbs appeared asymmetrically and progressed subacutely. Nerve conduction velocity examination revealed mononeuritis multiplex, but we could not reach a final diagnosis. Steroid pulse therapy, chemotherapy including high-dose methotrexate, and radiation therapy were ineffective. On autopsy, histological examination of the peripheral nerves revealed systemic neurolymphomatosis.

Comparison of peripheral T-cell lymphomas and diffuse large B-cell lymphoma

BACKGROUND

Peripheral T-cell lymphomas (PTCLs) are a biologically heterogeneous subgroup of lymphomas with poor prognosis. In this study, the authors analyzed the clinical behaviors of PTCLs and diffuse large B-cell lymphoma (DLBCL).

METHODS

The authors compared the characteristics and outcomes of 59 patients with PTCLs, including 33 angioimmunoblastic T-cell lymphomas and 26 unspecified peripheral T-cell lymphomas, with the characteristics and outcomes of 193 patients with DLBCLs who were treated in the era before rituximab.

RESULTS

Based on the clinical characteristics, elevated lactate dehydrogenase (LDH), poor PS, advanced stage, higher International Prognostic Index score, and B symptoms were more common in patients with PTCLs, and bulky mass was more common in patients with DLBCL. The rates of complete response (CR) or an unconfirmed CR (CRu) were higher in patients with DLBCL (72%) than in patients with PTCLs (56%; P = .03). The 5-year overall survival (OS), progression-free survival (PFS), and disease-free survival (DFS) rates were 31%, 26%, and 47%, respectively, in patients with PTCLs and 59%, 55%, and 73%, respectively, in patients with DLBCL (P = .001, P < .001, and P = .003, respectively). Although multivariate analysis identified several risk factors that were significant in PTCLs, but not in DLBCLs, for the CR/CRu, OS, PFS, and DFS rates, the immunophenotype was not identified as a risk factor.

CONCLUSIONS

The poor response and survival of patients who had PTCLs, compared with patients who had DLBCL, was caused by numerous initial risk factors. T-cell phenotype itself did not appear to have a significant impact on either response or survival.

Secondary Central Nervous System Lymphoma

This review summarizes current knowledge of secondary central nervous system lymphoma (SCNSL) in adults. We define SCNSL as CNS involvement not obvious at the initiation of treatment for systemic lymphoma. Recently, polymerase chain reaction and flow cytometry assays of cerebrospinal fluid have become available for the correct diagnosis of SCNSL. We reviewed reports of patients treated without CNS prophylaxis to evaluate the incidence of SCNSL. Elevated serum lactate dehydrogenase levels, the involvement of more than one extranodal site, an advanced stage, a high age-adjusted International Prognostic Index score at presentation, and special anatomic sites of involvement such as the testis are important risk factors for SCNSL. Histologic evidence of aggressiveness is generally an indicator of risk for SCNSL. In addition to conventional treatment, stem cell transplantation, intrathecal administration of rituximab, and liposomal cytarabine have come into clinical use for the treatment of established SCNSL. Prevention of isolated CNS recurrence is thought to be the main target of CNS prophylaxis. The value of CNS prophylaxis according to histologic subtype, status of systemic lymphoma, and other risk factors is summarized. Although prophylaxis is fundamental for treating highly aggressive non-Hodgkin's lymphoma (NHL), it is beginning to be appreciated for the treatment of aggressive NHL. CNS involvement is almost always fatal; however, a CNS-active strategy could complement other approaches that have led to recent improvements in the prognosis for lymphoma.

Pharmacogenomic analysis for individual response to CPT-11 in colorectal cancer: Prediction formula of tumor response using novel marker genes and genotypes associated with the toxicity

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Background: Despite recent encouraging data, the clinical efficacy and toxicity of CPT-11 in most colorectal cancer patients remain unpredictable. We conducted this prospective study to develop a prediction formula of efficacy using expression data of genes newly identified in vitro and to evaluate the clinical significance of several genetic polymorphisms known as potent predictors of toxicity. Methods: CPT-11 was intravenously administered on Days 1, 8, and 15, every 4 weeks in chemo-naive patients with stage IV colorectal cancer after palliative operation. Tumor samples were collected at surgery and PK analysis was done on day 1 of cycle 1. Tumor response and toxicity were evaluated by RECIST and CTCAE, respectively. Results: Forty seven pts were enrolled. All pts were assessed for tumor response, toxicity, gene expression, genotype, and PK. Partial response was obtained in 11 cases, and common grade 3/4 toxicities were neutropenia (15%), leucopenia (5%), and diarrhea (4%). Despite no correlation of UGT1A1*28 (hetero=5, homo=1) alone with the toxicities, there were associations between UGT1A1*28 or *7 (hetero=1) with UGT1A1 -64G>C (hetero=3) and G3/4 leucopenia (p=0.036). UGT1A1 1091C>T (hetero=3) was found to be associated with leucopenia (p=0.0009), neutropenia (p=0.012), and diarrhea (p=0.036). UGT1A1 1091C>T, ABCC2 -24C>T and 3972C>T were correlated with SN-38 AUC. We identified 7 novel potent marker genes including AMD1, CTSC, and EIF1AX for CPT-11 efficacy in vitro, through 2 different microarray analyses and subsequent real-time RT-PCR. We then successfully developed the best linear model, which converted the quantified expression data into objective tumor response, using 18 data sets of gene expression and clinical response. Utility-confirmation analyses using other clinical samples appeared to show that the formula could accurately predict tumor response (r=0.712, p=0.042). Conclusions: Polygenetic strategies using several known polymorphisms for toxicity and a prediction formula using 7 novel genes for efficacy would be of predictive value for individual response to CPT-11.

No significant financial relationships to disclose.

Acceleration of wound healing by combined gene transfer of hepatocyte growth factor and prostacyclin synthase with Shima Jet

Although skin diseases are one of the target diseases for gene therapy, there has been no practical gene transfer method. First, we examined gene transfer efficiency of the spring-powered jet injector, Shima Jet, which was originally developed as a non-needle jet injector of insulin. Local gene expression was about 100 times higher when the luciferase plasmid was transferred by the Shima Jet than by a needle. Gene transfer of beta-galactosidase revealed gene expression in the epidermis. Based on these results, we then examined the potential of gene therapy using the Shima Jet for wound healing. An increase of cellular proliferation of the epidermis and the number of microvessels in the granulation tissue was observed after hepatocyte growth factor (HGF) gene transfer. An increase in blood flow around the wound was observed after prostacyclin synthase (PGIS) gene transfer. Moreover, promotion on wound healing was observed in HGF gene transferred group, and further promotion was observed in combined gene transferred group as assessed by measuring wound area. These results indicate that co-transfer of HGF and PGIS genes by the Shima Jet could be an effective strategy to wound healing.

Prognostic factors in diffuse large B-cell lymphoma treated by risk-adopted therapy

OBJECTIVE

The International Prognostic Index (IPI) was reported in 1993 and it is now widely used for predicting the outcome in patients with aggressive non-Hodgkin's lymphoma. It defines 5 risk factors and 4 distinct risk groups from retrospective data. In this study, we evaluated the outcome of risk-adopted therapy for diffuse large B-cell lymphoma (DLBCL), the most common aggressive lymphoma, and assessed the possible prognostic factors.

METHODS AND PATIENTS

We treated 177 consecutive patients newly diagnosed with DLBCL using therapies determined by putative risk factors. Therapies included CHOP followed by involved field irradiation; ACOMPB with the consolidation regimen MLY9; high-dose chemotherapy supported by autologous peripheral blood stem cell transplantation; or performance status (PS) oriented CHOP. Statistical analysis was performed to determine the comprehensive risk factors in DLBCL.

RESULTS

Overall, the complete response (CR), 3-year overall survival (OS), and 3-year relapse-free survival (RFS) rates for CR patients were 71%, 69%, and 75%, respectively. Male gender, high LDH, poor PS (> or = 2), more than one extranodal involvement site, and B symptoms were independent adverse prognostic factors for OS. High LDH and poor PS were independent, adverse prognostic factors for RFS.

CONCLUSION

In the 5 risk factors indicated by IPI, high LDH and poor PS remained for OS and RFS even after risk-adopted therapy.

[Evaluation of prophylactic use of lamivudine in HBV-positive patients with malignant lymphoma undergoing chemotherapy]

A prospective evaluation was carried out on the effect of lamivudine administration as a prophylactic measure to prevent exacerbation of hepatitis in HBV carrier or chronic hepatitis B patients with malignant lymphoma undergoing chemotherapy. Eighteen patients were registered between 1997 and 2002 from institutions of the Research Group for the Treatment of Malignant Lymphoma. The patients' median age was 53 years old (39-73), and consisted of 8 males and 10 females. HBe-seroconversion had already occurred in 13 and liver biopsy had been performed in 8. No adverse effects of lamivudine were noted and the serum HBV-DNA content did not increase during lamivudine administration. Planned treatment courses could be completed in all patients. In 2, however, the viral load increased and the HBe antibody (Ab) value declined after the cessation of lamivudine, which were reversed to the normal ranges following the resumption of lamivudine. As for the overall outcome, 14 of the patients survived, and there were 4 fatalities due to malignant lymphoma. Serum HBeAb status may be regarded as a useful laboratory marker for deciding the safe cessation of lamivudine. An additional case is described, who had recovered from past HBV infection, but eventually succumbed to fulminant hepatitis after the cessation of lamivudine covering prolonged courses of chemotherapy. This illustrates a need for inclusion of such cases for the prophylactic use of lamivudine.

[Clinical course of 8 patients with intravascular large B-cell lymphoma diagnosed while alive]

We retrospectively evaluated the diagnosis and clinical courses of 8 patients with intravascular large B-cell lymphoma (IVL) diagnosed while they were alive. The median age was 67 years old (range 54 to 82). Most complaints at diagnosis were fever or dyspnea. All patients were in clinical stage IV with B symptoms and 4 patients showed performance status 4. The diagnosis of IVL was confirmed by biopsy specimens from the bone marrow in 4, lung in 2, muscle, adrenal gland, and lymph node in 1 case, respectively. Initial bone marrow involvement was found in 6 patients. Chemotherapy was performed in 7 patients. Rituximab was added to chemotherapy in 5 patients. Though 5 patients are alive at the median follow up of 12.3 months, only 1 patient is in remission. Four of 5 patients treated with Rituximab relapsed. In suspicious cases, it is important to bear IVL in mind and examine bone marrow biopsies for an early diagnosis. In addition, it is suggested that Rituximab may play only a temporary role in the treatment of IVL.

[Trial of front-line intensive chemotherapy followed by peripheral blood stem cell transplantation in high-intermediate and high risk non-Hodgkin's lymphoma patients]

High-intermediate (HI)- and high (H)-risk non-Hodgkin lymphoma was treated with front-line intensive chemotherapy followed by autologous peripheral blood stem cell transplantation (auto-PBSCT). Twenty-eight cases were enrolled after obtaining informed consent, from November, 1998 to October, 2003. Initial treatment was 2 or 3 cycles of CHOP-V regimen, followed by three high-dose therapy, one each of cyclophosphamide, methotrexate and etoposide. The final high-dose therapy was a combination of ranimustine, ifosphamide and etoposide, which was followed by auto-PBSCT. Patients with a bulky mass received involved-field radiation therapy (IF-RT) after auto-PBSCT. Complete remission (CR) was achieved in 16 cases (57%) and partial remission (PR) in 9 cases (32%), after auto-PBSCT The final responses after IF-RT were CR in 20 cases (71%) and PR in 5 cases (18%). Overall survival of cases with 2 cycles of CHOP-V regimen was 56% after a median observation time of 30 months, compared with 82% in cases with 3 cycles (p = 0.0732). The results suggested that the reduction of tumor size with the initial CHOP-V treatment was most important. In all cases, progression-free survival was 64% and the overall survival was 74% after a median observation time of 30 months, which showed a good outcome compared with that of HI- and H-risk group defined by the age-adjusted international prognostic index reported by Shipp et al.

A possible association between the presence of interleukin-4–secreting cells and a reduction in the risk of acute graft-versus-host disease

OBJECTIVE

We monitored cytokine-secreting cells using an enzyme-linked immunospot (ELISPOT) assay in a prospective study to assess the cytokine network after transplantation.

PATIENTS AND METHODS

Peripheral blood mononuclear cells were collected from 23 patients who received allogeneic stem cell transplantation, from before the preconditioning regimen to 56 days after transplantation. The number of interleukin-4 (IL-4), interferon-gamma (IFN-gamma), and tumor necrosis factor-alpha (TNF-alpha)-secreting cells were measured by ELISPOT assay. For IL-4 and IFN-gamma, in vitro stimulation with phorbol 12-myristate 13-acetate and phytohemagglutinin was performed.

RESULTS

The frequency of IL-4-secreting cells was significantly higher in five patients receiving peripheral blood stem cell transplantation (PBSCT) than that in 18 patients who received bone marrow transplantation (BMT). Based on IFN-gamma and TNF-alpha release, there was a trend toward a decrease in the number of cytokine-secreting cells in PBSCT compared with BMT. Furthermore, patients who did not develop acute graft-vs-host disease (GVHD, n=5) showed a significantly higher number of IL-4-secreting cells compared with those who developed acute GVHD (n=18). Both IFN-gamma-secreting cells and TNF-alpha-secreting cells showed a trend to increase in number in patients with acute GVHD. In patients who received reduced-intensity stem cell transplantation (n=7) compared with conventional stem cell transplantation (n=16), there was a large number of cytokine-secreting cells detected by IL-4 and IFN-gamma release.

CONCLUSIONS

These results are consistent with the hypothesis that IL-4-producing cells inhibit the development of acute GVHD. In addition, the increased percentage of IL-4-secreting cells may be responsible for the unexpected low incidence of acute GVHD in PBSCT, despite the presence of large numbers of mature T cells in the donor infusion.

Atypical Burkitt Lymphoma Arising From Follicular Lymphoma

A 77-year-old man with disseminated lymphadenopathy was referred to our hospital. An inguinal lymph node biopsy specimen had the appearance of composite lymphoma consisting of follicular lymphoma and atypical Burkitt lymphoma. The bone marrow was involved, and chromosomal analysis of the marrow showed t(8;14) and t(14;18) in identical cells. The patient underwent systemic chemotherapy but died of lymphoma 4 months later. Polymerase chain reactions performed on cells obtained from follicular and diffuse components by laser capture microdissection showed the two components to be clonally identical. Moreover, fluorescence in situ hybridization performed on paraffin-embedded tissue sections demonstrated an immunoglobulin heavy chain (IGH)/BCL2 translocation signal in both follicular and diffuse components, but an IGH/c-MYC translocation signal in only the diffuse component. Accordingly, the atypical Burkitt lymphoma arose from the follicular lymphoma as a consequence of the additional IGH/c-MYC translocation, then involving the bone marrow.

[Esophageal cancer surgery; importance of surgical quality control]

In esophageal cancer, the rate of lymphatic metastasis is higher than any other gastrointestinal cancer. The morbidity and mortality rate of esophageal surgery is still high. In order to reduce high morbidity and mortality rate, esophageal cancer surgery is recommended to be performed at a high-volume hospital in Europe and United States. In Japan, "3-field lymph nodes dissection surgery" has been established for complete lymphatic clearance, and the overall survival has improved. This surgical procedure is now recognized as a standard surgery for advanced esophageal cancer by "Japan Esophageal Society". However, even in Japan, the morbidity and mortality rate of esophageal cancer surgery is higher than gastric or colonic cancer surgery. For rationale of esophageal cancer surgery, we have to continue to improve our surgical quality such as preserving bronchial artery or pulmonary branches of the vagal nerve.

Antisense oligonucleotides as a powerful molecular strategy for gene therapy in cardiovascular diseases

Antisense oligonucleotides (ODN) technology is one of the most promising therapeutic strategies to prevent the progress of diseases through inhibiting the specific gene expression. They are well established to serve as molecular tools for several biologic applications, from the study of single gene function up to complex target validations. From the theoretical simple action, sequence-specific inhibition of mRNA functions after complex formation and presumably enzymatic degradation of the target mRNA, they obviously carry a high therapeutic potential to treat human diseases. In addition to the potential for the treatment, antisense ODN may be applicable for investigations of the mechanism and stereochemistry of biochemical reactions, mapping of nucleic acid protein interactions, and diagnostic applications. However, the design of antisense ODN, is very difficult because many factors affecting their activity and stability must be considered. Especially, the modifications of ODN are very critical and many researchers are trying to establish ODN which have resistance to nucleolytic degradation, high affinity to complementary nucleic acid, high selectivity in binding with complementary nucleic acid, the ability to activate ribonuclease H that selectively degrades the RNA strand of ODN-RNA complex, cell permeability, and favorable pharmacokinetic and pharmacodynamic attributes. In this review we would like to introduce some modifications of ODN design and examples of our applications of antisense ODN in cardiovascular disease in animal models.

Effect of a static magnetic field on ion transport in a cellulose membrane

A cellulose membrane was exposed to the static magnetic field (SMF) in the presence of KCl solution and ion transport through the membrane was measured before and after the SMF exposure. SMF at 0.24 T significantly enhanced the rate of ion transport, especially after the first exposure (p<0.05), while the increased ion transport rate did not return to the initial basal level after exchange of the aqueous medium. These results suggest that an irreversible, temporal conformation change took place on the cellulose membrane or on the water bound to the cellulose surface. The accelerating effect of SMF on the ion transport seems to have occurred as a result of stabilized hydration layer on the cellulose surface.

Chromatin structure of yeast minichromosomes containing triplet repeat sequences associated with human hereditary neurological diseases

Expansion of triplet repeat sequences such as (CTG)n, (CGG)n, and (GAA)n causes human genetic diseases. Since DNA is packaged into arrays of nucleosomes in eukaryotic cells, chromatin may be involved in the mechanism of triplet repeat diseases. To elucidate this issue, we have examined effects of triplet repeat sequences on the chromatin organization in vivo using well defined yeast minichromosomes. We show here that (CGG)12 disrupts an array of positioned nucleosomes, whereas (CTG)12 promotes the nucleosome formation. Thus, triplet repeat sequences can affect the chromatin organization in vivo, which may contribute to the triplet repeat expansion or alterations in the expression of genes associated with triplet repeat diseases.

Involvement of central nervous system in prolymphocytoid transformation of chronic lymphocytic leukemia

We report a rare case of involvement of the central nervous system (CNS) by chronic lymphocytic leukemia (CLL). A 68-year-old man with prolymphocytic variant of B-CLL (CLL/PLL), develops CNS involvement with headache and vomiting. Computed tomography of the head showed no abnormalities. The cerebrospinal fluid (CSF) revealed numerous lymphocytoid cells of prolymphocytic appearance consistent with findings on the peripheral blood smear. Immunophenotypic analysis demonstrated that the leukemic B cells were positive for CD19, CD20, and HLA-DR, but CD5 was difficult to detect. The patient was treated with intrathecal methotrexate, cytarabine, and hydrocortisone and had improvement in symptoms and CSF findings. Although CNS involvement is an unusual manifestation in CLL, one should be aware of the possibility of this complication in cases presenting with neurological symptoms.

Clinical features and outcome in HCV-positive aggressive non-Hodgkin's lymphoma

The clinical features and outcome of 25 previously untreated aggressive non-Hodgidn's lymphoma (NHL) patients with hepatitis C virus (HCV) infection were evaluated retrospectively. The patients included 18 males and 7 females with a median age of 66 years. The median observation period for survivors was 32 months. Although there were no patients with hepatocellular carcinoma during the follow-up period, 7 patients had cirrhosis (LC) at the initiation of therapy for NHL. Seventeen patients (68%) had initial extranodal involvement including 2 cases with liver involvement. The 5-year overall survival (OS) rate in the whole group was 46%, and the 5-year relapse-free survival (RFS) rate of patients with complete response (CR) was 48%. Patients with non-cirrhosis (n = 18) showed better OS (P = 0.04) compared with patients with LC (n = 7) and 5-year OS rates were 55 and 21%, respectively. Fourteen patients died in the whole group; 4 of NHL and 2 of liver failure in the LC group and 8 of NHL in the non-cirrhotic group. Among the latter 8 patients, cumulative dose (CD) of doxorubicin (ADR) and cyclophosphamide (CPA) were significantly lower than those of survivors with non-cirrhosis. In conclusion, patients with HCV-positive aggressive NHL have a similar prognosis as HCV-negative aggressive NHL. In non-cirrhotic patients, attention should be paid to the CD of drugs required to cure the aggressive NHL.

Transfection of NFkappaB-decoy oligodeoxynucleotides using efficient ultrasound-mediated gene transfer into donor kidneys prolonged survival of rat renal allografts

Nuclear factor kappaB (NFkappaB) plays a pivotal role in the coordinated transactivation of a series of genes of cytokines and adhesion molecules that are highly involved in the onset of acute rejection in organ transplantation. We previously developed decoy cis-elements oligo deoxyribonucleic acid against NFkappaB (NFkappaB-decoy) that effectively inhibited the activation of major inflammatory mediators in vitro and in vivo. Accordingly, we hypothesized that transfection of NFkappaB-decoy into the donor kidney would prevent acute rejection and prolong graft survival, and thus provide effective therapy for renal acute rejection. To transfect NFkappaB-decoy, we employed a novel approach using ultrasound exposure with an echocardiographic contrast agent, Optison, and clearly demonstrated successful transfection of NFkappaB-decoy into renal tissue. The therapeutic effect of NFkappaB-decoy on renal allografts was then evaluated in a rat renal allograft model (Wistar-Lewis). In the control group, graft function significantly deteriorated with marked destruction of renal tissue, accompanied by increased production of major inflammatory mediators, and all animals died of renal failure by 9 days. In contrast, graft function (serum creatinine on day 2, NFkappaB-treated: 0.97+/-0.16 versus control: 1.84+/-0.23 mg/dl, P<0.01) and histological structure were well preserved with significantly decreased expression of NFkappaB-regulated cytokines and adhesion molecules, including IL-1, iNOS, MCP-1, TNF-alpha, and ICAM-1, in allografts transfected with NFkappaB-decoy. As a result, animal survival was significantly prolonged in this group as compared to controls (14.2+/-5.2 versus 7.1+/-1.2 days, P<0.01). Thus, we established a novel ultrasound-Optison-mediated gene transfection approach and demonstrated the significant prolongation of graft survival by the successful transfection of NFkappaB-decoy into the donor kidney in a rat renal allograft model.

Improvement of endothelial dysfunction by angiotensin II blockade accompanied by induction of vascular hepatocyte growth factor system in diabetic spontaneously hypertensive rats

Hepatocyte growth factor (HGF) is a unique growth factor with many protective functions. Previously, we demonstrated that HGF stimulated growth of endothelial cells without replication of vascular smooth muscle cells (VSMC) and that angiotensin (Ang) II significantly decreased local HGF production in VSMC. Moreover, we also reported that high glucose significantly decreased local vascular HGF production. Therefore, we examined effects of Ang II blockade on vascular HGF expression and endothelial injury in diabetic hypertensive rats. An angiotensin-converting enzyme inhibitor (quinapril) and an Ang II type 1 receptor antagonist (GA-0113) or vehicle was administrated to diabetic spontaneously hypertensive rats (SHR-DM), in whom diabetes was induced by streptozotocin. Endothelial function was evaluated by the vasodilator response to acetylcholine, and the expression of vascular HGF and its receptor, c-met, was examined by immunohistochemistry. Both quinapril and GA-0113 significantly improved the vasodilator response to acetylcholine ( P < 0.01), while vehicle did not as compared to untreated normotensive Wistar-Kyoto rats (WKY). We next examined the effects of Ang II blockade on vascular HGF expression in SHR-DM. Importantly, the vascular HGF level was markedly decreased in SHR-DM as compared to WKY, while Ang II blockade by quinapril or GA-0113 significantly increased positive staining for HGF in SHR-DM. Similarly, staining of its specific receptor, c-met, was less in the blood vessels of SHR-DM as compared to WKY. In contrast, Ang II blockade also significantly increased c-met production in SHR-DM. The present data demonstrated the improvement of endothelial dysfunction by Ang II blockade in SHR-SM, accompanied by an increase in vascular HGF and c-met.

Clinical significance of fragmented red cells after allogeneic bone marrow transplantation

To clarify the clinical significance of the presence of fragmented red cells (FRC) after allogeneic bone marrow transplantation (BMT), we measured the incidence and degree of FRC and their relationships to clinical features. The percentages of FRC (%FRC) were measured in 50 patients on weeks -2, 0, 2, 4, 6, 8, 10, and 12. The %FRC in pre-BMT patients (mean, 0.52%; range, 0.04%-1.56%) was higher than in healthy control subjects (mean, 0.08%; range, 0.02%-0.27%). The highest %FRC (> or = 1.3%) were seen in 2 pre-BMT and 17 post-BMT patients. Eight patients who developed thrombotic microangiopathy (TMA) showed %FRC values that were significantly higher than those in patients without TMA. However, the timing of elevated %FRC was delayed until several days after the onset of intravascular hemolysis and/or a drop in platelet count. Of the patients who did not experience TMA, 5 patients with infection and 4 patients with acute graft-versus-host disease (GVHD) also showed significant elevation of %FRC during the clinical course. Furthermore, multivariate analysis results demonstrated that TMA and infection had a statistically significant effect on the high value of %FRC. These findings indicate that the appearance of FRC is a common phenomenon in patients undergoing BMT and is not a predictive factor for the early diagnosis of TMA, although FRC is one of the main laboratory findings in TMA. Furthermore, an increased %FRC is seen in other post-BMT clinical settings, such as infection and acute GVHD.

[Lymphoblastic lymphoma presenting as a solitary subcutaneous mass]

A solitary cutaneous or subcutaneous mass in lymphoblastic lymphoma (LBL) is a rare manifestation. A 15-year-old girl presented with a subcutaneous LBL on her left back. There were no other lesions. Complete remission (CR) was achieved after 2 courses of ACOMP-B (doxorubicin, cyclophosphamide, vincristine, methotrexate, prednisolone, and bleomycin) therapy. Two courses of the chemotherapy and 4 sessions of prophylactic intrathecal methotrexate (15 mg/body) and hydrocortisone (25 mg/body) were added after CR. However, the patient relapsed with bone marrow involvement after 14 months remission. It is necessary to accumulate more experience with this kind of case to find the appropriate treatment strategy for solitary cutaneous or subcutaneous LBL.

Possible role of ILK-affixin complex in integrin-cytoskeleton linkage during platelet aggregation

Integrin-mediated adhesion induces the formation of focal adhesions that link the extracellular matrix and intracellular actin cytoskeletal networks. We previously showed that integrin-linked kinase (ILK), which can interact with beta1 and beta3 integrins, and its interacting protein, affixin, play an essential role in the initial assembly of focal adhesion structures and actin stress fibers. Although the relevant structures are also observed in integrin alphaIIbbeta3 in platelets, the precise underlying molecular mechanism remains unclarified. Here, we found that ILK stably forms a complex with ss-affixin in platelets. Thrombin stimulation induces their association with integrin beta3, which is followed by their incorporation into the Triton-insoluble membrane-cytoskeletal fraction. During the course of thrombin-induced platelet aggregation, ILK activity was enhanced within 90s to 2.1-fold of the basal level, independent of phosphatidylinositol 3-kinase. Taken together with the observation that the treatment with an anti-integrin beta3 antibody stimulates ILK activity without inducing platelet aggregation, these results suggest that the outside-in signaling induced by fibrinogen binding to integrin enhances ILK activity and results in the initial phase to reorganize the actin cytoskeleton.

Impaired endothelial dysfunction in diabetes mellitus rats was restored by oral administration of prostaglandin I2 analogue

We have previously reported that a decrease in hepatocyte growth factor (HGF), which has many protective functions against endothelial damage by high d-glucose, might be a trigger of endothelial injury. However, the regulation of vascular HGF in diabetes mellitus (DM) has not been clarified in vivo, although vascular disease is frequently observed in DM patients. In addition, our previous report revealed that a prostaglandin I(2) (PGI(2)) analogue prevented endothelial cell death through the induction of vascular HGF production in cultured human epithelial cells. Thus, in this study, we examined the effects of a PGI(2) analogue in the regulation of the local HGF system using DM rats. A PGI(2) analogue (beraprost sodium; 300 and 600 micro g/kg per day) or vehicle was administered to 16-week-old DM rats induced by administration of streptozotocin for 28 days. Endothelial function was evaluated by the vasodilator response to acetylcholine, and the expression of vascular HGF mRNA was measured by Northern blotting. Of importance, expression of HGF mRNA was significantly decreased in the blood vessels of DM rats as compared with non-DM (P<0.01). In addition, the in vitro vasodilator response of the abdominal aorta to acetylcholine was markedly impaired in DM rats. Importantly, the vasodilator response was restored by PGI(2) treatment in a dose-dependent manner (P<0.01), whereas N(omega)-nitro-l-arginine methyl ester inhibited the restoration of endothelial function. Of particular interest, vascular HGF mRNA and protein were significantly increased in the blood vessels of DM rats treated with PGI(2) as compared with vehicle. Similarly, an increase in HGF protein was also confirmed by immunohistochemical analysis. In addition, the specific HGF receptor, c-met, was also increased by PGI(2) treatment. Overall, this study demonstrated that treatment with a PGI(2) analogue restored endothelial dysfunction in DM rats, accompanied by the induction of vascular HGF and c-met expression. Increased local vascular HGF production by a PGI(2) analogue may prevent endothelial injury, potentially resulting in the improvement of endothelial dysfunction.

Histopathologic effects of neoadjuvant therapies for advanced squamous cell carcinoma of the esophagus: multivariate analysis of predictive factors and p53 overexpression

In 97 patients (60, chemotherapy; 22, chemoradiotherapy; 15, radiotherapy), histopathologic effects were evaluated microscopically, and histologic response rates were compared among three neoadjuvant treatment modalities. Predictive factors for neoadjuvant therapies were analyzed by logistic regression, including the results of p53 immunohistochemical staining. In the chemoradiotherapy group, the pathologic response rate was 86.4%, and was significantly higher than that for chemotherapy (P < 0.0001) or for radiotherapy (P = 0.0031). In patients with normal p53 protein expression, the histopathologic response rate to chemotherapy was 20.0%, a higher rate than that for patients with abnormal p53 overexpression. In the chemoradiotherapy or radiotherapy group, however, the response rates were almost the same, irrespective of p53 oncoprotein status. From multivariate analysis, the neoadjuvant treatment modality itself was identified as the most powerful predictive factor for the effect. Chemoradiotherapy had the most powerful effect on advanced esophageal cancer, and p53 status did not influence the clinical outcome in this group.

Resolution of psoriasis following allogeneic bone marrow transplantation for chronic myelogenous leukemia: case report and review of the literature

We describe a case of a 49-year-old man with chronic myelogenous leukemia (CML) whose coincidental psoriasis resolved following allogeneic bone marrow transplantation (BMT). The patient had suffered from psoriasis for 20 years and was treated with corticosteroid ointment. He was diagnosed as having CML in 1998, and his psoriasis deteriorated following interferon therapy. In March 1999, he received a BMT from an HLA-identical sister after undergoing a conditioning regimen involving busulfan, cytosine arabinoside, and cyclophosphamide. Prophylaxis of acute graft-versus-host disease was done using short-term methotrexate and cyclosporin A. His psoriasis improved immediately and disappeared completely on day 70 after BMT. For 2.5 years, his CML remains in remission and he is free of psoriasis without undergoing immunosuppressive therapy. This case suggests the potential benefits of the treatment of immune-mediated diseases with allogeneic BMT.

Prophylactic intrathecal methotrexate and hydrocortisone reduces central nervous system recurrence and improves survival in aggressive non-hodgkin lymphoma

BACKGROUND

Central nervous system (CNS) recurrence is almost invariably fatal in patients with aggressive non-Hodgkin lymphoma (NHL). Although some protocols are intended to prevent CNS disease, the value of CNS prophylaxis in patients with aggressive NHL remains to be determined.

METHODS

We retrospectively analyzed a cohort of 68 adults with NHL who had been treated uniformly with systemic chemotherapy and had attained complete remission (CR) of disease. Patients ranged in age from 15 to 77 years (median, 56 years). Median follow-up after CR was 40 months. After CR was attained, 29 patients (Group A) received CNS prophylaxis consisting of four doses of intrathecal methotrexate 10 mg/m(2) and hydrocortisone 15 mg/m(2) as soon as they could tolerate it. The other 39 patients (Group B) did not receive CNS prophylaxis.

RESULTS

Although bulky mass (45% vs. 21%, P = 0.03) was more frequent in Group A than in Group B, none of the patients in Group A experienced CNS recurrence (0%), whereas CNS recurrence occurred in six patients in Group B (15%). This difference was significant (P = 0.03). Multivariate logistic regression analysis for CNS recurrence identified no CNS prophylaxis (P = 0.01) and bone marrow involvement (P = 0.02) as independent predictors. Among patients without CNS disease, systemic recurrence occurred in 5 patients in Group A and in 11 patients in Group B (P = 0.12). The 5-year overall survival rate from CR was 80% in Group A and 58% in Group B (P = 0.05). The 5-year recurrence-free survival rate from CR was 85% in Group A and 51% in Group B (P = 0.01).

CONCLUSIONS

Prophylactic intrathecal methotrexate and hydrocortisone injection reduces the incidence of CNS recurrence following CR in patients with aggressive NHL and improves the chance of long-term survival.

[Clinical usefulness of ondansetron hydrochloride for nausea and vomiting during repeated courses of chemotherapy for malignant lymphoma--impact of prognosis announcement on anti-emetic effect and evaluation of patient perception of chemotherapy-associated adverse events]

We evaluated the efficacy and safety of ondansetron hydrochloride (OND) on nausea and vomiting during repeated courses of CHOP or ACOMP-B therapy in patients with malignant lymphoma. The impact of the prognosis announcement on the anti-emetic effect and chemotherapy-associated adverse events was also investigated. Forty-two subjects with malignant lymphoma who underwent CHOP or ACOMP-B therapy including cyclophosphamide 600 mg/m2 and adriamycin 40 mg/m2 were investigated for a maximum of 6 courses. For acute nausea and vomiting, ondansetron was injected intravenously before the start of chemotherapy on the first day of each course of chemotherapy. For delayed emesis, ondansetron was administered orally for 4 days from the following day. The efficacy on acute nausea and vomiting was found to be 95.0% (1st course), 95.0% (2nd course), 90.9% (3rd course), 88.2% (4th course), 92.3% (5th course) and 91.7% (6th course), respectively. A high efficacy of > or = 85% was also obtained for delayed nausea and vomiting on each day. Though the adverse event of elevated GPT value developed in one subject. It was mild and resolved. No difference in efficacy was seen with or without announcement of prognosis to patients. Following the investigation on antiemetic effect, patient perception of chemotherapy-induced adverse events was evaluated. The most common event was hair loss, followed by taste abnormality and numbness and hyposthesia of the tips of the fingers. The incidence of nausea and vomiting was the 4th and 5th most common, which are less frequent than in the report of Coates in 1983. In conclusion, ondansetron is considered clinically useful with stable anti-emetic effect on both acute and delayed nausea and vomiting over repeated courses of chemotherapy, without any significant safety problem.