Early ultrasonographic diagnosis and clinical follow-up of hepatic veno-occlusive disease after allogeneic bone marrow transplantation in a patient with acute lymphoblastic leukemia

Hepatic veno-occlusive disease (VOD) is a typical complication occurring soon after allogeneic hematopoietic stem cell transplantation (HST), characterized by jaundice, painful liver enlargement, and weight gain due to fluid retention. The study reported here concerns a patient with VOD after allogeneic HST. Hemodynamic evaluation using ultrasonography revealed reversed portal venous flow before elevation of serum bilirubin, in addition to gallbladder wall thickening, ascites, and hepatomegaly. Quantitative evaluation using abdominal ultrasonography showed improvement in the reversed portal venous flow before the peaking of the serum bilirubin level and coagulopathy. This analysis was useful for both early diagnosis and clinical follow-up of VOD.

Molecular characterization of a variant virus that caused de novo hepatitis B without elevation of hepatitis B surface antigen after chemotherapy with rituximab

Hepatitis B virus (HBV) reactivation in hepatitis B surface antigen (HBsAg)-negative patients following treatment with rituximab has been reported increasingly. The aim of this study was to investigate the molecular mechanisms underlying HBV reactivation in an HBsAg-negative patient. HBV was reactivated in a 75-year-old man following chemotherapy with rituximab, without elevation of HBsAg. The patient's full-length HBV genome was cloned and the entire sequence was determined. Transfection studies were performed in vitro using recombinant wild-type HBV (wild-type), the patient's HBV (patient), and two chimeric HBV constructs, in which the preS/S region of the patient and wild-type virus had been exchanged with one another. Secreted HBsAg and intra- and extra-cellular HBV DNA were measured. The number of amino acid substitutions in HBV from this patient was much higher than in previous reports of HBV mutants, such as occult HBV and vaccine escape HBV mutants. Levels of HBsAg and HBV DNA production in vitro were significantly lower in the patient compared to wild-type transfections. From analyses of the chimeric constructs, the altered preS/S region was responsible mainly for this impairment. These results show that highly mutated HBV can reactivate after chemotherapy with rituximab, despite an unusually large number of mutations, resulting in impaired viral replication in vitro. Severe immune suppression, probably caused by rituximab, may permit reactivation of highly mutated HBV. These findings have important clinical implications for the prevention and management of HBV reactivation and may explain partially the mechanism of recent, unusual cases of HBV reactivation.

Modified ELISPOT assay may predict T-cell hyporesponsiveness to non-inherited maternal antigens

Clinical reports have suggested the existence of immunological tolerance to noninherited maternal antigens (NIMA) in human leukocyte antigen (HLA) mismatched allogeneic stem cell transplantation (allo-SCT). We studied the T-cell reactivity using IFN-gamma enzyme-linked immunospot (ELISPOT) assay in three HLA fully matched allo-SCT cases and one healthy volunteer family case. In HLA fully matched allo-SCT cases, ELISPOT assay could detect the hyporesponsiveness of T cells from donors to the B cells from recipients. Moreover, ELISPOT assay showed that the T cells from an individual responded to B cell from his mother significantly weakly than those from an unrelated HLA-haploidentical individual. These observations suggest that our IFN-gamma ELISPOT assay-based method may predict the presence of immunological tolerance to NIMA.

Involvement of BH3-only proteins in hematologic malignancies

The interaction between anti-apoptotic and pro-apoptotic members of the Bcl-2 family proteins determines life or death for cancer cells. In this context, BH3-only proteins (such as Bim), members of the pro-apoptotic Bcl-2 family proteins, act as key initiators of apoptosis by activating Bax and Bak through liberating them from anti-apoptotic Bcl-2 members. This then leads to the disruption of mitochondrial outer membrane, and eventually promotes proteolytic cascades for cellular dismantling. We here review the growing evidence of how BH3-only proteins are involved in tumorigenesis and in apoptosis induced by anti-cancer agents in hematologic malignancies. A deeper understanding of the roles of BH3-only proteins in cell death regulation may yield crucial insights for the further development of more effective and rational cell killing strategies. Recent developments in the direct therapeutic manipulation of Bcl-2 proteins using BH3-mimicking agents, such as ABT-737 or GX15-070, for hematologic malignancies are also summarized.

Risk factors for infection in haematology patients treated with rituximab

OBJECTIVES

Although rituximab therapy is not considered to be closely associated with infection, there have been reports of serious infections in patients treated with rituximab. We performed a statistical retrospective analysis to clarify the risk factors for infection in patients receiving rituximab therapy.

METHODS

A retrospective study of data from clinical records was performed that targeted haematology patients treated at our university hospital between April 2003 and October 2006. We selected 63 patients with CD20-positive lymphoma whose peripheral blood immunoglobulin levels had been measured within 6 months before and after rituximab therapy. Logistic regression analysis was used to investigate the risk factors for serious infection in these patients.

RESULTS

The three risk factors identified were: 1) reduction in IgM after administration of rituximab [odds ratio (OR) = 1.032, confidence interval (CI) = 1.007-1.057; P = 0.009], 2) duration of rituximab therapy [OR = 0.962, CI = 0.932-0.994; P = 0.021] and 3) G-CSF administration [OR = 4.825, CI = 1.411-16.495; P = 0.012].

CONCLUSIONS

Rituximab therapy may be associated with infection, indicating the need for sequential monitoring of IgM levels and identification of the optimal interval between rituximab cycles.

A novel amplification target, ARHGAP5, promotes cell spreading and migration by negatively regulating RhoA in Huh-7 hepatocellular carcinoma cells

RhoA, a member of the Rho family of small GTPases, directs the organization of the actin cytoskeleton and is involved in regulating cell shape and movement. Its activity is negatively regulated by p190-B RhoGAP (GTPase-activating protein). We investigated DNA copy number aberrations in human hepatocellular carcinoma and esophageal squamous cell carcinoma cell lines using a high-density oligonucleotide microarray and found a novel amplification at chromosomal region 14q12. We identified ARHGAP5 (the gene encoding p190-B RhoGAP) as a probable target for the amplification at 14q12, and our results showed that p190-B RhoGAP promotes cells spreading and migration by negatively regulating RhoA activity in Huh-7 hepatocellular carcinoma cells.

Activation of B-Myb by E2F1 in hepatocellular carcinoma

AIM

Deregulation of E2F1 transcriptional activity is observed in a variety of cancers, including hepatocellular carcinoma (HCC). The aim of the present study is to identify transcriptional target genes of E2F1 in HCC.

METHODS

We determined expression levels for E2F1 and ten candidate genes thought to be targets of E2F1 in primary HCCs using a real-time quantitative reverse transcription-PCR assay. Following small interfering RNA (siRNA)-mediated knockdown of E2F1 in HCC cell lines, we quantified mRNA levels of the candidate E2F1 target genes.

RESULTS

E2F1 was significantly over-expressed in 41 primary HCCs as compared to non-tumorous liver tissues. Among the candidates, MYBL2, whose product is the transcriptional factor B-Myb, which is involved in controlling cell-cycle progression and apoptosis, was significantly over-expressed in primary HCCs. Additionally, expression levels of MYBL2 correlated with those of E2F1. Knockdown of E2F1 resulted in a decrease in expression of MYBL2. A copy-number gain for MYBL2 was observed in 36 of 66 primary HCCs, suggesting that MYBL2 expression is up-regulated by amplification in addition to being regulated by E2F1. Moreover, siRNA-mediated knockdown of MYBL2 led to reduced expression of CDC2 (which encodes CDC2), cyclin A2 (CCNA2), and topoisomerase II alpha (TOP2A), implicating these genes in the cell cycle and suggesting that they may be downstream targets of B-Myb.

CONCLUSION

MYBL2 is a probable transcriptional target of E2F1 in HCC and may therefore be a useful biomarker for diagnosis and an attractive target for molecular therapies useful to treat HCC.

Clostridium difficile-associated diarrhea with hematochezia is associated with ulcer formation

OBJECTIVE

Clostridium difficile-associated diarrhea (CDAD) is a well-known iatrogenic infection with typical endoscopic features including pseudomembranes and intervening normal mucosa. Clinically, diarrhea frequently occurs, but occurrence of hematochezia is rare. The objective of this study was to investigate the background and endoscopic features of CDAD patients with hematochezia.

MATERIAL AND METHODS

The endoscopic and clinical findings in 12 patients who showed evidence of C. difficile toxin A and who underwent colonoscopy between April 2002 and July 2007 were investigated retrospectively.

RESULTS

Eight patients were diagnosed as having CDAD and 4 patients had a diagnosis of ulcerative colitis. Six of the patients with CDAD presented with hematochezia, and 4 of them were diagnosed with hematological malignancies and received anticancer chemotherapy. Colonic ulcer was demonstrated in all CDAD patients with hematochezia, and bleeding from the ulcer was endoscopically confirmed in all of them.

CONCLUSIONS

CDAD accompanied by hematochezia is closely associated with ulcer formation. Ulcers are thought to occur during recovery from nadir after anticancer treatment, and white blood cells appear to be essential for their formation. Physicians should therefore pay close attention to the occurrence of colonic ulcer, especially in patients with CDAD during recovery from nadir.

Anti-myeloma effect of homoharringtonine with concomitant targeting of the myeloma-promoting molecules, Mcl-1, XIAP, and beta-catenin

Since a variety of cell intrinsic and extrinsic molecular abnormalities cooperatively promote tumor formation in multiple myeloma (MM), therapeutic approaches that concomitantly target more than one molecule are increasingly attractive. We herein demonstrate the anti-myeloma effect of a cephalotaxus alkaloid, homoharringtonine (HHT), an inhibitor of protein synthesis, through the induction of apoptosis. HHT significantly reduced Mcl-1, a crucial protein involved in myeloma cell survival, in all three myeloma cell lines examined, whereas certain BH3-only proteins, such as Bim, Bik, and Puma, remained unchanged following HHT treatment, and their expression levels depended on the cell type. HHT also reduced the levels of c-FLIP(L/S), activated caspase-8, and induced active truncated-Bid. Thus, HHT-induced apoptosis appears to be mediated via both intrinsic and extrinsic apoptosis pathways, and the resultant imbalance between BH3-only proteins and Mcl-1 may be pivotal for apoptosis by HHT. In addition, HHT treatment resulted in reduced levels of beta-catenin and XIAP proteins, which also contribute to disease progression and resistance to chemotherapy in MM. In combination, HHT enhanced the effects of melphalan, bortezomib, and ABT-737. These results suggest that HHT could constitute an attractive option for MM treatment though its ability to simultaneously target multiple tumor-promoting molecules.

Optimized dosage and frequency of cefozopran for patients with febrile neutropenia based on population pharmacokinetic and pharmacodynamic analysis

OBJECTIVES

To establish a cefozopran (a fourth-generation cephem) population pharmacokinetic model using patient data and use it to explore alternative dosage regimens that could optimize the currently used dosing regimen to achieve higher likelihood of pharmacodynamic exposure against pathogenic bacteria.

METHODS

We conducted a prospective clinical trial of cefozopran for haematological patients with febrile neutropenia (FN). Twenty-two patients (30 episodes) were selected to receive intravenous cefozopran every 8 h on a daily basis. We gathered concentration data and performed the NONMEM program. The Monte Carlo simulation was performed to assess the pharmacodynamic exposure based on the population pharmacokinetics and MIC.

RESULTS

The NONMEM program demonstrated that a two-compartment model provided a best fit for the data, that is, CL of 4.62 (L/h), V1 of 10.3 (L), Q of 4.47 (L/h), and V2 of 4.48 (L). On the basis of the Japanese national surveillance findings for Pseudomonas aeruginosa, methicillin-sensitive Staphylococcus aureus, coagulase-negative Staphylococcus, viridans group streptococci, Escherichia coli and Klebsiella pneumoniae, Monte Carlo simulation data showed that probability of target attainment(T>MIC = 70%) is 67% to 97% for dosing every 8 h, and 48% to 88% for dosing every 12 h. For the patients in whom the efficacy of cefozopran could be evaluated, 17 of 22 patients (77.2%) survived the episode of FN without requiring further antibacterial treatment.

CONCLUSIONS

Our study proved that Monte Carlo simulation based on population pharmacokinetics can determine optimized dosage and method. The optimal regimen for this cephem was found to be three times daily.

Pharmacokinetic-pharmacodynamic target attainment analysis of cefozopran in Japanese adult patients

This study aimed to perform a pharmacokinetic-pharmacodynamic (PK-PD) target attainment analysis to create a dosing strategy for cefozopran in Japanese adult patients. A total of 145 plasma concentration samples from 32 adult patients were used for a population pharmacokinetic modeling and Monte Carlo simulation to assess the probability of attaining the PK-PD target (70% of the time above the minimum inhibitory concentration for the bacterium). The final population pharmacokinetic model was based on a two-compartment model, and creatinine clearance (Cl(cr)) and body weight (BW) were the most significant covariates: Cl(l/h) = 0.0263 x Cl(cr) + 1.49, V (c)(l) = 0.185 x BW(0.931), Q(l/h) = 4.55, V (p)(l) = 5.86, where Cl is the clearance, V (c) is the volume of distribution of the central compartment, Q is the intercompartmental clearance, and V (p) is the volume of distribution of the peripheral compartment. The Monte Carlo simulation demonstrated that 1 g q 12 h achieved a PK-PD target attainment probability of > or =85% against Escherichia coli, Klebsiella pneumoniae, and Streptococcus pneumoniae isolates. However, against Haemophilus influenzae and Pseudomonas aeruginosa isolates, 1 g q 8 h and (2 g, 1 g, 1 g) q 8 h were required to achieve a high probability, which value varied with the Cl(cr) and BW of the patient. These results provide a PK-PD-based strategy for tailoring cefozopran regimens in Japanese adult patients.

Fully automated and super-rapid system for the detection of JAK2V617F mutation

JAK2V617F is a common mutation in chronic myeloproliferative diseases (CMPDs). We have developed a system utilizing JAK2V617F-specific guanine quenching probe (QP-system) to detect JAK2V617F. With QP-system, results can be obtained from 100 microl of blood within 90 min. We compared QP-system with direct sequencing using 42 CMPD patients' specimens. JAK2V617F was detected in 25 specimens by QP-system, while direct sequencing failed to detect JAK2V617F in 7 of those 25. The presence of JAK2V617F mutation in these 7 specimens was confirmed by allele-specific PCR. These findings indicate that QP-system is more sensitive and useful than direct sequencing for diagnoses of CMPDs.

CREB3L4, INTS3, and SNAPAP are targets for the 1q21 amplicon frequently detected in hepatocellular carcinoma

High-density single nucleotide polymorphism (SNP) array analysis revealed novel amplification at 1q21 in cell lines derived from hepatocellular carcinomas (HCCs). Fluorescence in situ hybridization and real-time quantitative polymerase chain reaction studies verified amplification at 1q21. An increase in copy number at the region was detected in 32 of the 36 primary HCC tumors (89%). To identify the targets for amplification, we examined 19 HCC cell lines for expression levels of all 26 genes located within the 700-kb amplified region. Five genes were overexpressed in cell lines with amplification at 1q21. Among these, CREB3L4 (cAMP responsive element binding protein 3-like 4), INTS3 (integrator complex subunit 3), and SNAPAP (SNAP-associated protein) were significantly overexpressed in tumors from 18 HCC patients, compared with counterpart nontumorous tissues. The findings suggest that CREB3L4, INTS3, and SNAPAP are probable targets for the amplification mechanism and may therefore be involved, together or separately, in the development or progression of HCCs.

Diagnosis of acute myeloid leukemia according to the WHO classification in the Japan Adult Leukemia Study Group AML-97 protocol

We reviewed and categorized 638 of 809 patients who were registered in the Japan Adult Leukemia Study Group acute myeloid leukemia (AML)-97 protocol using morphological means. Patients with the M3 subtype were excluded from the study group. According to the WHO classification, 171 patients (26.8%) had AML with recurrent genetic abnormalities, 133 (20.8%) had AML with multilineage dysplasia (MLD), 331 (51.9%) had AML not otherwise categorized, and 3 (0.5%) had acute leukemia of ambiguous lineage. The platelet count was higher and the rate of myeloperoxidase (MPO)-positive blasts was lower in AML with MLD than in the other WHO categories. The outcome was significantly better in patients with high (≥50%) than with low (<50%) ratios of MPO-positive blasts (P < 0.01). The 5-year survival rates for patients with favorable, intermediate, and adverse karyotypes were 63.4, 39.1, and 0.0%, respectively, and 35.5% for those with 11q23 abnormalities (P < 0.0001). Overall survival (OS) did not significantly differ between nine patients with t(9;11) and 23 with other 11q23 abnormalities (P = 0.22). Our results confirmed that the cytogenetic profile, MLD phenotype, and MPO-positivity of blasts are associated with survival in patients with AML, and showed that each category had the characteristics of the WHO classification such as incidence, clinical features, and OS.

JAK2V617F-positive essential thrombocythemia and multiple myeloma with IGH/CCND1 gene translocation coexist, but originate from separate clones

Overlapping of essential thrombocythemia (ET) and multiple myeloma (MM) has been extremely rare. Our report concerns a case with concomitant ET and MM, where JAK2V617F was present in non-myeloma peripheral blood leukocytes and bone marrow (BM) hematopoietic cells, but not in BM-derived CD138-positive myeloma cells. In contrast, double-color fluorescence in situ hybridization analysis showed that BM-derived CD138-positive myeloma cells possessed the gene translocation between the immunoglobulin heavy chain gene and the cyclin D1 gene, which was not involved in non-myeloma hematopoietic cells. This is the first case with concomitant ET and MM in which the 2 hematologic neoplasms were shown to have originated from separate malignant clones at hierarchically different differentiation levels resulting from independent acquisition of different molecular aberrations. Among the 10 reported cases, including ours, ET preceded MM in 8 cases, but MM never preceded ET. We suggest that MM clones may have greater proliferative potency compared with ET clones, and that the treatment modification from ET to MM did not seem to exacerbate ET in most reported cases, perhaps because of the suppression of the ET clone by both the cytotoxic effect of anti-myeloma therapy and the clonal repression by MM progression.

Immunoglobulin light chain gene translocations in non-Hodgkin's lymphoma as assessed by fluorescence in situ hybridisation

In non-Hodgkin's lymphoma (NHL), the majority of translocations involve the immunoglobulin heavy chain gene (IGH) locus, while a few involve the immunoglobulin light chain gene (IGL) locus, consisting of the kappa light chain gene (IGkappa) and the lambda light chain gene (IGlambda). Although many reports have dealt with the translocation and/or amplification of IGH in NHL, only a few have identified IGL translocations. To identify cytogenetic abnormalities and the partner chromosomes of IGL translocations in NHL, we performed dual-colour fluorescence in situ hybridisation (DC-FISH) and spectral karyotyping (SKY) in seven NHL cell lines and 40 patients with NHL. We detected IGL translocations in two cell lines and nine patients: four patients with diffuse large B-cell lymphoma, three with follicular lymphoma, one with extranodal marginal zone B-cell lymphoma of mucosa-associated lymphoid tissue and one with mantle cell lymphoma. Five distinct partners of IGlambda translocation were identified by SKY analysis: 3q27 in three patients, and 1p13, 6p25, 17p11.2 and 17q21 in one patient each. Three cases featured double translocations of IGH and IGL. These findings warrant the identification of novel genes 1p13, 6p25, 17p11.2 and 17q21.

Protein-losing enteropathy in a case of nodal follicular lymphoma without a gastrointestinal mucosal lesion

Protein-losing enteropathy (PLE) is characterized by gastrointestinal loss of serum protein. It is usually caused by hypersecretion from a tumor, ulcer, or long standing lymphangiectasia. However, we report a 47-year-old man of peritoneal nodal follicular lymphoma who developed PLE with none of them. Oozing of whitish fluid from duodenal bulbar mucosa was endoscopically seen, resulting in continuous loss of protein. Chemotherapy was effective and PLE was rapidly diminished. Nodal lymphoma lesion was considered to disturb lymphatic flow and to regurgitate it to duodenal mucosa. To our knowledge, this is the second report of a lymphoma patient presenting PLE without a gastrointestinal mucosal lesion.

Population pharmacokinetics of levofloxacin as prophylaxis for febrile neutropenia

BACKGROUND

Levofloxacin (LVFX) is widely used against a broad spectrum of bacteria. To prevent the emerging of resistance resulting from its abuse, an optimal method and dosage are needed. In the field of hematological malignancies, LVFX is one of the choices for prophylaxis for febrile neutropenia (FN). There is no consensus about the optimal dosage and method among hematologists. Aims To determine the population pharmacological parameters based on the population pharmacokinetics of LVFX. We considered the optimal dosage and method of LVFX based on various simulations depicted by personal computer.

METHODS

We performed population pharmacokinetic analysis for seven patients receiving LVFX as prophylaxis (200 mg, b.i.d.) for FN with blood sampling. One patient received 100 mg t.i.d. All patients were treated at Kyoto Prefectural University of Medicine.

RESULTS

Clearance (CL) is 5.8 L/hr, distribution volume (Vd) is 58.5 L, area under the blood concentration-time curve (AUC(0-24)) is 69.0 microg x hr/mL, t1/2 is 6.9 hr, Cmax is 3.4 microg/mL at administration of 200 mg b.i.d. Cmax (peak) of 500 mg, and q.d. is simulated as 8.54 microg/mL.

CONCLUSION

For LVFX 500 mg q.d. is predicted to be the most effective dosage and method. Because the predicted Cmax value is similar to that of western countries, the frequency of adverse effects is thought to be same as in western countries. 500 mg, q.d., may also be an optimal dosage and method for Japanese.

Real-time therapeutic drug monitoring of cefozopran in plasma using high-performance liquid chromatography with ultraviolet detection

A simple, rapid, and precise HPLC method using ultrafiltration to remove plasma protein was developed to determine cefozopran concentrations in human plasma for real-time therapeutic drug monitoring. Plasma was separated by centrifugation at 4 degrees C from blood collected in heparinized vacuum tubes. Cefozopran and an internal standard were detected by ultraviolet absorbances at 235 nm with no interfering plasma peak. The calibration curve of cefozopran in human plasma was linear from 0.2 to 200 microg/ml. The limit of detection was 0.05 microg/ml. The assay was applied to febrile neutropenia patients in a clinical setting.

[Cytogenetic and molecular basis of multiple myeloma]

Multiple myeloma(MM) originating from plasma cells is characterized by complex chromosomal aberrations. The most prominent chromosomal abnormalities of MM are aneuploidy and translocations affecting the immunoglobulin heavy chain locus on chromosome 14q32. Additionally, a variety of genetic aberrations such as ras mutations have been found in MM. Because these chromosomal and genetic abnormalities are closely associated with clinical behavior including prognosis, cytogenetic findings have a great impact on planning treatment strategy. Furthermore, studies of signal transductions and mechanisms of oncogenesis in association with these abnormalities will provide targets to develop novel therapeutic agents. Here we summarize the chromosomal and genetic abnormalities of MM and their clinical implications.

ABT-737 is a useful component of combinatory chemotherapies for chronic myeloid leukaemias with diverse drug-resistance mechanisms

The effect of ABT-737, a BH3-mimicking inhibitor for anti-apoptotic Bcl-2 and Bcl-X(L), but not Mcl-1, against Bcr-Abl-positive (Bcr-Abl(+)) leukaemic cells was examined. ABT-737 potently induced apoptosis in Bcr-Abl(+) chronic myeloid leukaemia (CML) cell lines and primary CML samples in vitro and prolonged the survival of mice xenografted with BV173 cells, a CML cell line. Higher expression of anti-apoptotic Bcl-2 proteins reduced cell killing by ABT-737 in each cell line, but there was no correlation between the sensitivities to ABT-737 and the specific expression patterns of Bcl-2 family proteins among cell lines. Thus, the cell killing effect of ABT-737 must be determined not only by the expression patterns of Bcl-2 family proteins but also by other mechanisms, such as high expression of Bcr-Abl, or a drug-efflux pump, in CML cells. ABT-737 augmented the cell killing effect of imatinib in Bcr-Abl(+) cells with diverse drug-resistance mechanisms unless leukaemic cells harboured imatinib-insensitive Abl kinase domain mutations, such as T315I. The combination of homoharringtonine that reduces Mcl-1 enhanced the killing by ABT-737 strongly in Bcr-Abl(+) cells even with T315I mutation. These results suggest that ABT-737 is a useful component of chemotherapies for CML with diverse drug-resistance mechanisms.

[Combination therapy with rituximab and cladribine for patients with follicular lymphoma]

Treatment strategies for follicular lymphoma have not been established. We report the outcome after combination therapy with rituximab and cladribine (RC) for 8 patients with follicular lymphoma treated between January 2005 and December 2006 in our hospitals. Median patient age was 57 (range 42 approximately 73) years. There were 4 males and 4 females. Only 1 patient had refractory disease, while the others had untreated disease. On the follicular lymphoma international prognostic index, 4 patients were in the low-risk group, 3 in the intermediate-risk group and 1 in the high-risk group. The median follow-up period was 36 (range 22 approximately 90) weeks. The RC protocol consisted of intravenous rituximab at a dose of 375 mg/m (2) on day 1 and cladribine at a dose of 0.1 mg /kg per day for 2-hours on day 1 through 5. The median number of RC courses was 5 (range 3 approximately 8). The median interval between the 2 courses was 7 (range 3 approximately 26) weeks. The overall response rate was 87.5%. Grade 3 neutropenia was observed in 50% patients, although G-CSF was not needed. There was no apparent thrombocytopenia or anemia. Herpes zoster was observed after treatment in 1 patient. RC is considered highly effective and well tolerated.

Clinicopathological analysis of a case with mesenteric solitary Castleman's disease: diagnostic value of radiological findings

We report a case with rare solitary mesenteric Castleman's disease (CD). A 45-year-old woman complaining of nausea was presented. A round-shaped, smooth margin, and hypoechoic mass was seen on screening abdominal ultrasonography. Computed tomography showed a markedly enhanced tumor anterior to the left iliopsoas muscle. Selective jejunal arteriography revealed an extreme hypervascularity without vascular invasion. These results retrospectively seem to differ from those of malignant lymphoma or sarcoma. The tumor was surgically resected, and hyaline-vascular type CD was pathologically diagnosed. We postulate that these radiological findings might suggest hyaline-vascular type CD as one of the differential diagnoses in similar cases, although more clinical data should be evaluated.

[Prophylactic effect of tropisetron hydrochloride against nausea and vomiting in patients receiving chemotherapy for hematological malignancies]

To establish the effectiveness of oral 5-HT(3) antagonist, oral 5 mg tropisetron was introduced in the 21 cases with hematological malignancies for the prevention of chemotherapy-induced nausea and vomiting. Nausea and vomiting did not develop in 81% of patients receiving the tropisetron in this study. The results suggested that oral tropisetron is effective for the control of acute, and to a lesser extent, delayed, nausea and vomiting. The drug enhanced patients' quality of life and reduced the clinical cost. In conclusion, tropisetron is effective for the prevention of chemotherapy-induced nausea and vomiting in treatment for hematological malignancies. It is suitable as first-line therapy for outpatients.

Effectiveness and limitation of gamma knife radiosurgery for relapsed central nervous system lymphoma: a retrospective analysis in one institution

We describe 6 patients with relapsed central nervous system lymphoma (CNSL) treated with Gamma Knife radiosurgery (GKR). The histologic diagnosis in all 6 patients was diffuse large B-cell lymphoma without human immunodeficiency virus infection. Two patients had intracranial relapse of primary CNSL, and the remaining 4 had CNS relapse of systemic lymphoma. All patients were treated with GKR without severe adverse effects, and all but 1 patient received subsequent chemotherapy shortly after GKR. Four patients showed a complete response, and the remaining 2 patients had a partial response or stable disease. Although the neurologic symptoms disappeared or improved markedly in all patients, all of the diseases recurred or progressed 3 to 13 months after the first GKR. A second GKR was eventually performed in 4 patients. The median overall survival and progression-free survival times after the first GKR were 17 and 11 months, respectively. In our experience, GKR seems to be a useful procedure for the treatment of relapsed CNSL, because it facilitates excellent local control in a short-term treatment period without severe complications, although the efficacy period is not long enough.

Detection of NOTCH1 mutations in adult T-cell leukemia/lymphoma and peripheral T-cell lymphoma

We analyzed NOTCH1 gene mutation in 53 adults with mature T-cell leukemia/lymphoma: 21 patients with adult T-cell leukemia (ATL), 25 with T-cell non-Hodgkin's lymphoma (T-NHL), and 7 with T-cell prolymphocytic leukemia. We detected a nonsense mutation, C7249T (resulting in Q2417X, where X is a termination codon) in the PEST domain of NOTCH1 in an ATL patient and detected a 3-bp deletion (positions 7234-7236) that resulted in deletion of a proline codon at codon 2412 in the PEST domain of NOTCH1 in a patient with a T-NHL, peripheral T-cell lymphoma-unspecified (PTCL-u). We also analyzed the expression of NOTCH1 target genes (HES1, CCND1, and MYC), all of which were expressed in the sample of the PTCL-u patient with the NOTCH1 mutation, but found only MYC to be expressed in the sample from the ATL patient. These findings suggest that nonsense mutation in the PEST domain in the ATL case was associated with NOTCH1 signaling through a pathway different from that for T-cell acute lymphoblastic leukemia (T-ALL). Although NOTCH1 mutation occurs infrequently in mature T-cell leukemia/lymphoma, NOTCH1 may be involved in leukemogenesis associated with various forms of T-cell leukemia/lymphoma rather than only with T-ALL.

Dasatinib phase I/II study of patients with chronic myeloid leukemia (CML) resistant or intolerant to imatinib: Results of the CA180031 study in Japan

17515

Background: Dasatinib is a potent, orally active, multi-targeted kinase inhibitor of BCR-ABL and SRC family kinases. Studies outside Japan have shown dasatinib to be highly effective in overcoming resistance and intolerance to imatinib, inducing durable cytogenetic (CyR) and hematologic responses (HR) in this population. The maximum tolerated dose was not reached in the Phase-I trial outside Japan and a 70-mg BID dose was determined to provide the optimal benefit-risk profile. Methods: This Phase-I/-II study was designed to assess the safety and efficacy of dasatinib in Japanese patients with imatinib-resistant or -intolerant CML or Ph+ALL. In the 4-week Phase-I portion in patients with chronic-phase (CP) CML, three dose levels were evaluated: 50 mg, 70 mg, and 90 mg BID. The Phase-II portion is currently evaluating the CyR of dasatinib in patients with CP-CML at 24 weeks, and the HR rate in accelerated- (AP) or blast-phase (BP) CML and Ph+ ALL at 12 weeks. Results: As of December 2006, 17 eligible patients have been treated in Phase I. Six patients (4F, 2M; median age 43 y [range 27–56]) were treated with 50 mg BID and 1 dose-limiting toxicity (DLT) was observed (Grade 4 thrombocytopenia). Two patients experienced transient Grade 3 ALT elevations but as treatment was uninterrupted, these were not considered DLTs. Six patients (6M; median age 42 y [range 27–55]) were treated with 70 mg BID and again 1 DLT was observed (Grade 4 thrombocytopenia). No DLT has been observed among 4 patients (3M, 1F; median age 41 y [range 27–64]) at the 90-mg BID dose. Major CyRs have been achieved in all three cohorts in the Phase-I segment of the trial. Thirty six patients were enrolled and treated in the Phase-II part of the trial (12 CP-CML, 7 AP- CML, 4 BP-CML, and 13 Ph+ALL). Efficacy and safety data as well as the baseline BCR-ABL mutation data are currently being assessed and will be presented. Conclusions: Dasatinib can be safely administered at doses of up to 90 mg BID to Japanese patients with imatinib-resistant or -intolerant CP-CML.

No significant financial relationships to disclose.

Apoptosis-based dual molecular targeting by INNO-406, a second-generation Bcr-Abl inhibitor, and ABT-737, an inhibitor of antiapoptotic Bcl-2 proteins, against Bcr-Abl-positive leukemia

Bcr-Abl is the cause of Philadelphia-positive (Ph(+)) leukemias and also constitutes their principal therapeutic target, as exemplified by dramatic effects of imatinib mesylate. However, mono-targeting of Bcr-Abl does not always achieve complete leukemia eradication, and additional strategies those enable complete elimination of leukemic cells are desired to develop. Here we demonstrate that INNO-406, a much more active Bcr-Abl tyrosine kinase inhibitor than imatinib, augments the activities of several proapoptotic Bcl-2 homology (BH)3-only proteins (Bim, Bad, Bmf and Bik) and induces apoptosis in Ph(+) leukemia cells via Bcl-2 family-regulated intrinsic apoptosis pathway. ABT-737, an inhibitor of antiapoptotic Bcl-2 and Bcl-X(L), greatly enhanced the apoptosis by INNO-406, even in INNO-406-less sensitive cells with Bcr-Abl point mutations except T315I mutation. In contrast, co-treatment with INNO-406 and other pharmacologic inducers of those BH3-only proteins, such as 17-allylaminogeldanamycin, an heat shock protein-90 inhibitor, or PS-341, a proteasome inhibitor, did not further increase the BH3-only protein levels or sensitize leukemic cells to INNO-406-induced apoptosis, suggesting a limit to how much expression levels of BH3-only proteins can be increased by anticancer agents. Thus, double-barrelled molecular targeting for Bcr-Abl-driven oncogenic signaling and the cell protection by antiapoptotic Bcl-2 family proteins may be the rational therapeutic approach for eradicating Ph(+) leukemic cells.

Establishment and characterization of the new splenic marginal zone lymphoma-derived cell line UCH1 carrying a complex rearrangement involving t(8;14) and chromosome 3

A new cell line, designated UCH1, was established from a patient with splenic marginal zone lymphoma (SMZL). UCH1 cells feature a mature B-cell phenotype, characterized by surface IgM +, kappa+, CD5-, CD10-, CD19+ and CD20+. The BCL2 and BCL6 genes retained their germ-line configurations and overexpression of cyclin D1 was not detected. UCH1 cells carry numerical and structural aberrations in chromosome 3, but these were too complex to be analyzed with the conventional G-banding method. Spectral karyotyping (SKY) and fluorescence in situ hybridization analysis clearly demonstrated the presence of a balanced translocation between chromosomes 8 and 14 [t(8;14)(q24;q32)] in the complex aberrations involving chromosome 3. The results of Southern blot analysis supported this finding by showing rearrangement of the c-myc gene in UCH1 cells. SKY analysis also identified a translocation involving chromosome band 18q21, to which BCL2 and MALT1 genes were assigned, suggesting their implication in the development or progression of SMZL.

γδT cells kill myeloma cells by sensing mevalonate metabolites and ICAM-1 molecules on cell surface

We evaluated the mechanism of recognition of myeloma cells by gammadeltaT cells. The expanded gammadeltaT cells killed RPMI8226 and U266 myeloma cells in a gammadeltaT-cell dose-dependent manner. Pretreatment of myeloma cells with zoledronic acid or mevastatin showed that gammadeltaT cells kill myeloma cells by recognizing the mevalonate metabolites. The expression level of intercellular cell adhesion molecule-1 (ICAM-1) on myeloma cells correlates with the cytotoxicity by gammadeltaT cells. Pretreatment of RPMI8226 and U266 with an anti-ICAM-1 monoclonal antibody inhibited their cytolysis. Moreover, AMO-1 myeloma cells transfected with of human ICAM-1 cDNA were susceptible to gammadeltaT cells compared to parental AMO-1 cells. In conclusion, gammadeltaT cells recognize the mevalonate metabolites and ICAM-1 on myeloma cells.

Successful induction of clinically competent dendritic cells from granulocyte colony-stimulating factor-mobilized monocytes for cancer vaccine therapy

Recent studies have suggested that dendritic cell (DC)-based immunotherapy is one promising approach for the treatment of cancer. We previously studied the clinical toxicity, feasibility, and efficacy of cancer vaccine therapy with peptide-pulsed DCs. In that study, we used granulocyte colony-stimulating factor (G-CSF)-mobilized peripheral blood monocytes as a cell source of DCs. However, previous investigations have suggested that G-CSF-mobilized peripheral blood monocytes produce reduced levels of proinflammatory cytokines such as interleukin (IL)-12 and tumor necrosis factor (TNF)-alpha. These T helper (Th)-1-type cytokines are thought to promote antitumor immune response. In this study, we assessed the functional abilities of DCs generated from G-CSF-mobilized monocytes obtained from 13 patients with CEA-positive advanced solid cancers. Peripheral blood mononuclear cells were obtained from leukapheresis products collected before and after systemic administration of G-CSF (subcutaneous administration of high-dose [5-10 microg/kg] human recombinant G-CSF for five consecutive days). In vitro cytokine production profiles after stimulation with lipopolysaccharide (LPS) were compared between monocytes with and without G-CSF mobilization. DCs generated from monocytes were also examined with respect to cytokine production and the capacity to induce peptide-specific T cell responses. Administration of G-CSF was found to efficiently mobilize peripheral blood monocytes. Although G-CSF-mobilized monocytes (G/Mo) less effectively produced Th-1-type cytokines than control monocytes (C/Mo), DCs generated from G/Mo restored the same level of IL-12 production as that seen in DCs generated from C/Mo. T cell induction assay using recall antigen peptide and phenotypic analyses also demonstrated that DCs generated from G/Mo retained characteristics identical to those generated from C/Mo. Our results suggest that G-CSF mobilization can be used to collect monocytes as a cell source for the generation of DCs for cancer immunotherapy. DCs generated in this fashion were pulsed with HLA-A24-restricted CEA epitope peptide and administered to patients safely; immunological responses were induced in some patients.

Hyperbaric oxygen in addition to antibiotic therapy is effective for bisphosphonate-induced osteonecrosis of the jaw in a patient with multiple myeloma

A 60-year-old man with multiple myeloma (MM) (IgG-kappa, stage IIIA) had been treated with minodronate at 6 mg orally as a phase 1 clinical trial for myeloma bone disease for 13 months (total dose, 4032 mg). Then he received incadronate at 10mg intravenously every 1 to 4 weeks (total dose, 350 mg). In July 2005, he complained of mild right mandibular pain, and bone scintigram showed a hot spot at the right side of the mandible. Panoramic radiograph showed osteonecrosis of the jaw (ONJ) and axial and 3-dimensional computed tomography confirmed ONJ. Oral examination showed massive gingival swelling of the right side of the mandible without exposed necrotic bone. He was given clarithromycin in addition to levofloxacin, followed by hyperbaric oxygen (HBO) therapy, which resulted in the complete disappearance of the pain. This is a first reported case of ONJ induced by incadronate. The present case suggests that early detection of ONJ by regular dental check-ups is important in the management of patients with MM who have received bisphosphonate therapy, and HBO in combination with antibiotic therapy is effective in the early stage of ONJ.

Expression and role of MHC class I-related chain in myeloma cells

BACKGROUND

The molecular mechanism of natural killer (NK) cell cytotoxicity to myeloma cells remains unclear. We investigated whether MHC class I-related chain (MIC), a ligand of NKG2D that is an activating NK cell receptor, is involved in the cytotoxicity of NK cells toward myeloma cells, and examined the effects of various drugs on the cytotoxicity.

METHODS

Two human myeloma cell lines and fresh myeloma cells from 10 patients were used. MIC expression was examined by flow cytometry and reverse transcription (RT)-PCR. NK cell cytotoxicity was examined using a 51Cr-release assay. The effects of various drugs, including thalidomide, all-trans retinoic acid, dexamethasone, IFN-alpha and incadronate, on the MIC expression and NK cell cytotoxicity were examined.

RESULTS

MIC was highly expressed on the human myeloma cell lines U266 and RPMI-8226 and in myeloma cells of one of 10 patients examined. MIC expression on these cells was not changed by various drugs except IFN-alpha, by which MIC expression was down-regulated. Although MIC and HLA class I molecules were similarly expressed at high levels on both cell lines, U266 was sensitive to NK cells whereas RPMI-8226 was not. Furthermore, cytolysis by NK cells was not inhibited by the addition of anti-MIC Ab or decreased expression of MIC caused by IFN-alpha.

DISCUSSION

MIC plays a role in the cytolysis by NK cells in multiple myeloma.

Simultaneous complication of multiple myeloma with Sjögren syndrome

We report a 72-year-old female case of IgG-kappa type multiple myeloma (MM) simultaneously complicated with Sjögren syndrome (SS). She also presented marked hyperamylasemia of salivary-type isozyme. Although she had received sequential chemotherapy completed with high-dose therapy with autologous hematopoietic stem cell transplantation, she died of relapse fifteen months after the initial diagnosis. Various autoantibodies indicated that her sicca symptoms were due to true SS and not caused by MM cell infiltration to exocrine glands. MM cells appeared to produce amylase that fluctuated correspondingly to the disease status of MM. To our knowledge, this is the first English report of simultaneous complication of SS and MM referring to hyperamylasemia. Accumulation of this rare clinical manifestation is important to elucidate the pathogenesis of MM under condition of immunological disorder caused by SS.

Comparison of human herpes virus 8 related primary effusion lymphoma with human herpes virus 8 unrelated primary effusion lymphoma-like lymphoma on the basis of HIV: report of 2 cases and review of 212 cases in the literature

BACKGROUND

Primary lymphomatous effusion is a rare lymphoma that arises in the body cavity and has a peculiar proliferative form, lacking a tumor. This primary lymphomatous effusion includes human herpes virus 8 (HHV8)-related primary effusion lymphoma (PEL) and HHV8-unrelated PEL-like lymphoma. We attempted to clarify the nature of the primary lymphomatous effusion.

METHODS

Using 'PEL' and 'body cavity-based lymphoma' (BCBL) as key words, reports written in English were collected from PubMed. Primary lymphomatous effusion was defined as BCBL with primary effusion and without tumor at onset. Adding our 2 PEL-like lymphoma cases, each case was studied as to the patients' and lymphomas' characteristics, therapy and survival time. Moreover, each item was compared among four groups according to the presence of HHV8 and HIV.

RESULTS

In 214 cases investigated, there was no difference in proliferation, but an apparent difference in age, gender, phenotype, effectiveness and prognosis among the four groups.

CONCLUSIONS

Both PEL and PEL-like lymphoma are thought to be characterized by a peculiar proliferation, regardless of the presence of HHV8. Dividing PEL or PEL-like lymphoma into two subgroups on the basis of HIV presentation might also be appropriate.

Role of SPA-1 in Phenotypes of Chronic Myelogenous Leukemia Induced by BCR-ABL–Expressing Hematopoietic Progenitors in a Mouse Model

SPA-1 is a negative regulator of Rap1 signal in hematopoietic cells, and SPA-1-deficient mice develop myeloproliferative disorders (MPD) of long latency. In the present study, we showed that the MPDs in SPA-1(-/-) mice were associated with the increased hematopoietic stem cells expressing LFA-1 in bone marrow and their premature mobilization to spleen with extensive extramedullary hematopoiesis, resembling human chronic myelogenous leukemia (CML). We further showed that human BCR-ABL oncogene caused a partial down-regulation of endogenous SPA-1 gene expression in mouse hematopoietic progenitor cells (HPC) and immature hematopoietic cell lines. Although both BCR-ABL-transduced wild-type (wt) and SPA-1(-/-) HPC rapidly developed CML-like MPD when transferred to severe combined immunodeficient mice, the latter recipients showed significantly increased proportions of BCR-ABL(+) Lin(-) c-Kit(+) cells compared with the former ones. Serial transfer experiments revealed that spleen cells of secondary recipients of BCR-ABL(+) wt HPC failed to transfer MPD to tertiary recipients due to a progressive reduction of BCR-ABL(+) Lin(-) c-Kit(+) cells. In contrast, SPA-1(-/-) BCR-ABL(+) Lin(-) c-Kit(+) cells were sustained at high level in secondary recipients, and their spleen cells could transfer MPD to tertiary recipients, a part of which rapidly developed blast crisis. Present results suggest that endogenous SPA-1 plays a significant role in regulating expansion and/or survival of BCR-ABL(+) leukemic progenitors albeit partial repression by BCR-ABL and that Rap1 signal may represent a new molecular target for controlling leukemic progenitors in CML.