An unusual regressive germinal center, the 'FDC-only lymphoid follicle,' in lymph nodes of organ transplant recipients

Follicular lesions include germinal center (GC) hyperplasia, regressive transformation of GCs, and follicle lysis. The present histologic, electron microscopic, and immunohistochemical study of six autopsy cases after organ transplantation accompanied by the administration of immunosuppressive drugs revealed a peculiar regression of lymph node GCs in two cases, which has not been noted previously. The histologic findings of the regressive GCs were classified into three patterns. In pattern A, the GCs had few or no lymphocytes and were surrounded by a poorly developed mantle zone-like structure. Apoptotic cell death of GC lymphocytes was found in a few GCs, but most GCs lacked tingible body macrophages. In pattern B, the GC lymphocytes and tingible body macrophages were absent, showing crowded follicular dendritic cells (FDCs) in a corpuscular shape. In pattern C, the lymphocytic mantle was absent. The GCs were smaller than those in the other patterns, and the shape was irregular because of disintegration of FDCs. The immunostaining for FDC markers revealed dispersed growth of FDCs. On electron microscopy, the lesions were composed of a dense mass of elliptical and oval cells without prominent cytoplasmic processes, a labyrinthlike structure, and emperipolesis of lymphocytes. The distinct desmosomelike adhesive junctions, specific electron microscopic features of FDCs, were evident. We propose to call these follicular lesions "FDC-only lymphoid follicles." It is speculated that this follicle may be evoked after preceding follicular hyperplasia with a complicated mechanism including increased apoptosis of GC lymphocytes and decreased lymphocyte migration to lymph node GCs caused by immunosuppressive drugs.

Initial daily interferon administration can gain more eradication of HCV-RNA in patients with chronic hepatitis C, especially with serum intermediate viral load

BACKGROUND/AIMS

We studied the effect of initial daily administration of interferon for the treatment of chronic hepatitis C, especially in patients with intermediate viral load.

METHODOLOGY

Consecutive patients who met the inclusion criteria were randomly enrolled into two groups in this study. All patients analyzed could be treated with interferon-alpha for 6 months. Patients in group A were administered 6 million units of interferon-alpha subcutaneously daily initially for 2 weeks and then thrice weekly. Patients in group B were treated with the same dose of interferon-alpha thrice weekly from the first administration. We decided the criteria of complete remission as the absence of serum HCV-RNA at both points of the end of interferon treatment and 6 months later.

RESULTS

Due to the relationship between the efficacy and serum viral load, we decided the criteria of the intermediate load as the quantitative value of serum HCV-RNA to be not lower than 10(5.0) and not higher than 10(6.5) copies/ml. Seventy-six and 78 patients, whose genotype and quantitative value of serum HCV-RNA could be measured before treatment, were analyzed in group A and B, respectively. The rate of complete remission in group A (40.8%) was higher than that in group B (25.6%), significantly (p = 0.046). In the intermediate viral load group, the rate of complete remission in group A (52.3%) was significantly higher than that in group B (29.3%) (p = 0.045). In the patients with genotype 1 b virus, the rate of complete remission had a tendency to be higher in group A (33.3%) than in group B (17.4%) (not significant). In the patients with genotype 2, the rate of complete remission was higher in group A (77.8%) than in group B (41.2%) (significant, p = 0.041).

CONCLUSIONS

These results suggest that the initial daily interferon administration is necessary to gain a higher rate of serum HCV-RNA eradication in patients with intermediate viral load in chronic hepatitis C.

[The benefit of head rotation on pharyngoesophageal dysphagia from three cases of paraganglioma in the parapharyngeal space]

The benefit of head rotation to the affected side is indicated during swallowing in patients complaining of dysphagia with unilateral pharyngeal palsy and/or laryngeal palsy. We experienced three cases of severe dysphagia after operations for giant paragangliomas (two vagal paraganglioma and one carotid body tumor) in the parapharyngeal space. During operation, the transmandibular transpterygoid approaches were applied to ensure better surgical views, and tracheostomy was performed to keep the airway open after operation. In each case, dysphagia during the pharyngeal stage of swallowing was significantly improved with rehabilitation using of this head rotation. We believe that rather than forbid oral intake, using an active bolus with head rotation is important for cases where dysphagia in the pharyngeal stage of swallowing is present with unilateral pharyngeal and/or laryngeal palsy. Repetitive swallowing exercises are important to reacquire the complicated movement of swallowing. Additionally, an active bolus flowing into the pyriform sinus on the healthy side will prevent a relaxation disorder of the cricopharyngeal muscle on that side. Furthermore, compensatory movement of the arytenoid on the healthy side improves dysphagia. We emphasize the usefulness of head rotation during swallowing rehabilitation for dysphagia with unilateral pharyngeal and/or laryngeal palsy in spite of its simplicity.

Gene targeting reveals a critical role for neurturin in the development and maintenance of enteric, sensory, and parasympathetic neurons

Neurturin (NTN) is a neuronal survival factor that activates the Ret tyrosine kinase in the presence of a GPI-linked coreceptor (either GFR alpha1 or GFR alpha2). Neurturin-deficient (NTN-/-) mice generated by homologous recombination are viable and fertile but have defects in the enteric nervous system, including reduced myenteric plexus innervation density and reduced gastrointestinal motility. Parasympathetic innervation of the lacrimal and submandibular salivary gland is dramatically reduced in NTN-/- mice, indicating that Neurturin is a neurotrophic factor for parasympathetic neurons. GFR alpha2-expressing cells in the trigeminal and dorsal root ganglia are also depleted in NTN-/- mice. The loss of GFR alpha2-expressing neurons, in conjunction with earlier studies, provides strong support for GFR alpha2/Ret receptor complexes as the critical mediators of NTN function in vivo.

Effect of nonweight bearing on tibial bone density measured by QCT in patients with hip surgery

Tibial bone mineral density (BMD) was measured in 11 patients who had undergone hip joint surgery, including 10 women (22-61 years old; mean +/- SD = 42.6+/-10.3) and 1 man (61 years old). Four patients received total hip replacement (THR), while the others underwent rotational acetabular osteotomy (RAO). In one case, the start of rehabilitation was delayed until 4 months after the surgery because of infection at the surgical site. Nine patients underwent hip surgery for osteoarthritis and 2 patients for avascular necrosis. These 2 patients had a history of medication with corticosteroid. BMD of the tibia on the surgically treated side was measured by a peripheral quantitative CT (pQCT) system, which provided three different BMD values of trabecular BMD in the distal portion, total BMD in the distal portion, and total BMD in the diaphysis. The measurements were obtained preoperatively, and at several time points postoperatively, at 2, 4, 6, and 8 weeks and 3, 4, 5, 8, 12, 18, and 24 months after surgery. Brief periods of nonweightbearing lead to significant bone loss, and 1-1.5 years was required to recover to the baseline BMD. Accelerated bone loss was seen in patients in the perimenopausal state, with prolonged bed rest, and in patients receiving corticosteroid. Both trabecular and cortical components were influenced by nonweightbearing and restoration of weightbearing. The decrease in the cortical region occurs after the decrease in the trabecular and endosteal regions.

Expression of MRP and cMOAT in childhood neuroblastomas and malignant liver tumors and its relevance to clinical behavior

Advanced neuroblastoma and malignant liver tumor are representative childhood cancers for which combined chemotherapy including cisplatin and doxorubicin is routinely performed. The prognosis of patients with tumors which develop multiple drug resistance (MDR) is unfavorable. To elucidate the role of multidrug resistance-associated protein (MRP) and canalicular multispecific organic anion transporter (cMOAT) in the clinical behavior of the tumors, we examined 42 neuroblastomas and 10 malignant liver tumors for the expressions of MRP and cMOAT by quantitative RNA-polymerase chain reaction (PCR). The amplification and expression of N-myc oncogene in the neuroblastomas were also investigated. We found a close association between MRP and N-myc expression in each neuroblastoma sample but no significant relationship between MRP expression and the patients' outcome. The forced expression of N-myc failed to enhance the expression of MRP in N-myc transfected neuroblastoma cell lines. cMOAT was rarely expressed in the neuroblastomas, but was frequently expressed in the malignant liver tumors. The expression of MRP and cMOAT in the childhood liver tumors was more common and higher, especially in advanced cases with a poor outcome, than that observed in normal liver or in 9 hepatocellular carcinomas from adult patients. The enhanced expression of these genes might be characteristic of childhood malignant liver tumors and related to their clinical chemoresistance.

Artemin, a novel member of the GDNF ligand family, supports peripheral and central neurons and signals through the GFRalpha3-RET receptor complex

The glial cell line-derived neurotrophic factor (GDNF) ligands (GDNF, Neurturin [NTN], and Persephin [PSP]) signal through a multicomponent receptor system composed of a high-affinity binding component (GFRalpha1-GFRalpha4) and a common signaling component (RET). Here, we report the identification of Artemin, a novel member of the GDNF family, and demonstrate that it is the ligand for the former orphan receptor GFRalpha3-RET. Artemin is a survival factor for sensory and sympathetic neurons in culture, and its expression pattern suggests that it also influences these neurons in vivo. Artemin can also activate the GFRalpha1-RET complex and supports the survival of dopaminergic midbrain neurons in culture, indicating that like GDNF (GFRalpha1-RET) and NTN (GFRalpha2-RET), Artemin has a preferred receptor (GFRalpha3-RET) but that alternative receptor interactions also occur.

The effect of calcium-related factors on the predominance of IFN-gamma or interleukin-4 in cultured mononuclear cells

Certain factors have been studied that might influence whether interferon-gamma (IFN-gamma) or interleukin-4 (IL-4) will predominate in cultures of peripheral blood mononuclear cells (PBMC). ELISA was used to measure cytokine protein, and PCR was used to quantitate mRNA. It was found that induction with plant lectins produced greater yields of IFN-gamma than induction with ionophores, but ionophores alone produced at least equal yields of IL-4 as did lectins. Phorbol myristate acetate (PMA) greatly enhanced IFN yields in the presence of ionophores but had no significant influence on IL-4 production. Calcium-independent cytokine induction using anti-CD28 and PMA resulted in production of both cytokines, whereas depletion of extracellular calcium and magnesium adversely influenced the yield of both IL-4 and IFN-gamma. Finally, calmidazolium, an inhibitor of calmodulin, had an enhancing effect on IFN-gamma yields when phytohemagglutinin (PHA) was the inducer and an adverse effect when A23187 was the inducer. In contrast, calmidazolium reduced IL-4 yields with both PHA and A23187 induction.

In vivo karyotypic evolution with altered biological characteristics in a case of neuroblastoma

Molecular and biological analyses of a neuroblastoma case in which the original tumor contained a nodular region are described. No significant difference was observed between the nodular and the surrounding tumor tissue with respect to histopathologic examination, N-myc amplification, and trkA expression. However, flow cytometric analysis demonstrated that the nodular region consisted of a hypertetraploid clone, whereas the surrounding tissue mostly contained a hyperdiploid clone. Chromosome analysis showed that each clone had a similar chromosome acquisition pattern, suggesting that the hypertetraploid cells of the nodular region arose from the hyperdiploid cells of the surrounding tissue. Moreover, primary culture findings of the tumor cells showed that the responses to nerve growth factor or retinoic acid were different between the two. Collectively, this case suggests the possibility that neuroblastoma acquires novel biological characteristics through karyotypic evolution in vivo.

GFR alpha1-deficient mice have deficits in the enteric nervous system and kidneys

Glial cell line-derived neurotrophic factor (GDNF) signals through a receptor complex composed of the Ret tyrosine kinase and a glycosylphosphatidylinositol- (GPI-) anchored cell surface coreceptor, either GDNF family receptor alpha1 (GFR alpha1) or GFR alpha2. To investigate the usage of these coreceptors for GDNF signaling in vivo, gene targeting was used to produce mice lacking the GFR alpha1 coreceptor. GFR alpha1-deficient mice demonstrate absence of enteric neurons and agenesis of the kidney, characteristics that are reminiscent of both GDNF- and Ret-deficient mice. Midbrain dopaminergic and motor neurons in GFR alpha1 null mice were normal. Minimal or no neuronal losses were observed in a number of peripheral ganglia examined, including the superior cervical and nodose, which are severely affected in both Ret- and GDNF-deficient mice. These results suggest that while stringent physiologic pairing exists between GFR alpha1 and GDNF in renal and enteric nervous system development, significant cross-talk between GDNF and other GFR alpha coreceptors must occur in other neuronal populations.

Antitumor vaccine effect of irradiated murine neuroblastoma cells producing interleukin-2 or granulocyte macrophage-colony stimulating factor

We have examined vaccination effects of cytokine-producing murine neuroblastoma cells (C1300). C1300 cells retrovirally transduced with interleukin-2 (IL-2) or granulocyte macrophage-colony stimulation factor (GM-CSF) gene were established. Their in vitro proliferation rates and the class I expression of major histocompatibility complex were not different from those of wild-type cells. Five-Gy irradiation of the respective cytokine producers slightly reduced the in vitro cell growth but treatment with 15 Gy significantly impaired the proliferation. In contrast, the secretion of both cytokines from the respective transduced cells was retained compared with the cell growth. We immunized syngeneic mice with irradiated wild-type cells as a control or cytokine-producing cells and challenged the mice with unirradiated wild-type cells. The control mice developed tumors of the challenged wild-type cells, on the contrary, the mice which had received irradiated IL-2 or GM-CSF producers did not. Thus, IL-2- or GM-CSF-expressing syngeneic tumor cells can be potentially used as a tumor vaccine by inducing protective immunity against low immunogenic neuroblastomas in the inoculated hosts.

Prolactin modulates the disease activity of systemic lupus erythematosus accompanied by prolactinoma

We present a 31-year-old female patient with systemic lupus erythematosus (SLE) which was accompanied by prolactinoma. Her SLE flared when the plasma levels of prolactin (PRL) increased, and subsided when these levels decreased following the administration of bromocriptine, irrespective of the glucocorticoid dosage. For the 29 plasma samples obtained during the clinical course, PRL levels were significantly correlated to the serum anti-DNA antibody titers (r = 0.55, p < 0.05) and inversely to the serum complement activity (r = -0.33, p < 0.05). This result suggests that PRL may play a role in the pathogenesis of SLE in some patients.

Decreased Th1-like and increased Th2-like cells in systemic lupus erythematosus

The proportion of the lymphocytes which produce the cytokines corresponding to murine T helper- (Th1) or Th2 cells was studied using flow cytometry in systemic lupus erythematosus (SLE). When the peripheral mononuclear cells were stimulated with phorbol myristate acetate and ionomycin in the presence of monensin, which blocks the secretion of cytokines, the positive rates for the cytoplasmic IL-2 and IFN-gamma were lower and those for the cytoplasmic IL-4 and IL-10 were higher in SLE than in normal subjects. When the cells were cultured with monensin alone, the positive rates for these 4 cytokines were slightly increased in SLE. These data suggest that the mononuclear cells are already activated in vivo and a deviation of the proportion of the Th cells to the Th2-like ones might be associated with the polyclonal B cell activation seen in SLE.

Neuronal src and trk a protooncogene expression in neuroblastomas and patient prognosis

Neuroblastomas present a wide variety of clinical and biological behaviors, which are reflected by the heterogeneous expressions of protooncogenes related to the neuronal differentiation and amplification of the N-myc gene. High expression of trk A and Ha-ras in neuroblastomas has been shown to be associated with an excellent patient outcome. We have previously reported that neuron-specific src mRNA was increased in chemically differentiated neuroblastoma cell lines and in clinically observed neuroblastomas without N-myc amplification. In the present study, to clarify both the value of neuronal c-srcN2 expression as a prognostic indicator and the significance of the coexpression of these protooncogenes, we examined the expression of 3 alternatively spliced src, trk A and Ha-ras in neuroblastoma tissues from 60 patients by competitive RNA-polymerase chain reaction (PCR). The results indicate that protooncogene expression in neuroblastomas correlated with a favorable outcome for c-srcN2 and trk A. N-myc gene was amplified exclusively in tumors with low levels of trk A. Low expression of c-srcN2 and trk A might thus characterize different aggressive phenotypes due to different signal transduction pathways of neural differentiation in neuroblastoma. The combined analyses for c-srcN2 and trk A expression by RNA-PCR should provide information about the biological phenotype of a neuroblastoma within a short period of time after obtaining tumor material.

Topographic distribution of Helicobacter pylori in the resected stomach

OBJECTIVES

The aim of this study was to elucidate the prevalence of Helicobacter pylori and its distribution in order to clarify the frequency of H. pylori infection and the most appropriate site of endoscopic biopsy for studies of H. pylori infection associated with different gastric diseases.

DESIGNS AND METHODS

Swiss role mucosal strips from 275 resected stomachs, which included the greater curvature, anterior wall and lesser curvature of the antrum, incisura and corpus, were stained with haematoxylin-eosin and H. pylori antibody.

RESULTS

The prevalence of H. pylori infection was 97% in duodenal ulcers, 98% in gastric ulcers, 98% in intestinal-type carcinomas and 99% in diffuse-type carcinomas. H. pylori was present at a rate of 100% in any site in cases of duodenal ulcer, but was diffusely distributed in the antrum and patchily distributed in the corpus. The detection rate of H. pylori was 50-100% in gastric ulcers, 30-100% in intestinal-type adenocarcinomas and 63-100% in diffuse-type adenocarcinomas depending on the site of the stomach examined.

CONCLUSIONS

The prevalence of H. pylori infection was very high in peptic ulcers of the duodenum and stomach and gastric carcinomas of Japanese patients. Biopsy specimens for evaluation of H. pylori infection should be taken routinely from both the greater curvature of the antrum and corpus. Immunohistochemical staining should be used to assay for H. pylori when few organisms are present or eradication therapy has been used.

[Thymidylate synthase expression in patients with hypopharyngeal carcinoma]

We analyzed the relationship between clinical response to neo-adjuvant chemotherapy including 5-fluorouracil (5-FU) in patients with hypopharyngeal carcinoma (HPC) and thymidylate synthase (TS) expression in their tumors. TS expression was evaluated with immunohistochemical staining techniques on biopsy specimens from HPC patients. TS immunostaining was divided into four levels (TS0-TS3) according to its level and pattern. The relationship between prognosis, tumor size, nodal status, differentiation of tumor cells and TS expression were also investigated. There was a statistically significant association between the level of TS expression and tumor size (p < 0.01). In terms of the effectiveness of chemotherapy, tumor differentiation, nodal status and prognosis, a statistical difference was not found in TS expression. These results suggest that the level of TS expression may show the degree of tumor proliferation, but may not necessarily be useful to obtain a response to chemotherapy including other drugs, e.g., cisplatin and other derivatives of platinum.

Impaired tumorigenicity of IL-4-producing murine neuroblastoma cells in immunodeficient nude mice

We have examined antitumor effect of murine neuroblastoma cells (C1300) retrovirally transduced with interleukin-4 (IL-4) gene in syngeneic A/J and nude mice. Although in vitro proliferation of IL-4-secreting C1300 cells (C1300/IL-4) was not different from that of wild-type cells, the in vivo tumor growth of C1300/IL-4 cells subcutaneously inoculated into immunocompetent A/J mice was retarded compared with that of wild-type cells and consequently, the survival of the A/J mice which received C1300/IL-4 cells was prolonged. In immunodeficient nude mice we observed accelerated growth rate of wild-type tumors in comparison with the tumors developed in A/J mice. In contrast, the tumor growth of C1300/IL-4 cells in nude mice was significantly suppressed and the growth was much slower than that of C1300/IL-4 cells inoculated in A/J mice. Thus, the secretion of IL-4 from tumor cells produced antitumor effect more efficiently in mature T cell-defective hosts than in immunocompetent mice. Our results suggest a possible clinical application of IL-4 expression in tumor cells via genetic manipulations especially in immunocompromised cancer patients.

Effects of SA6541, a leukotriene A4 hydrolase inhibitor, and indomethacin on carrageenan-induced murine dermatitis

We investigated the effects of S-(4-dimethylaminobenzyl)-N-[(2S)-3-mercapto-2-methylpropionyl]-L- cysteine (SA6541), a potent leukotriene A4 hydrolase inhibitor. on early phase of carrageenan-induced dermatitis model. Carrageenan injection induced edema and neutrophil influx in the mouse ear. SA6541 inhibited edema formation and neutrophil influx. SA6541 also inhibited leukotriene B4 production but not prostaglandin E2 production in the mouse ear. On the other hand, indomethacin inhibited edema formation but not neutrophil influx. Indomethacin also inhibited prostaglandin E2 production but not leukotriene B4 production. Combination therapy with SA6541 and indomethacin strongly inhibited edema formation in comparison with treatment with either agent alone. These results suggest that leukotriene B4 may be important in the pathogenesis of dermatitis.

Adenocarcinoma arising in the retrorectal space: report of a case

We herein present an extremely rare case of adenocarcinoma of unknown origin arising in the retrorectal space. The imaging and endoscopic findings misled us to preoperatively diagnose a "submucosal tumor." This histological findings were highly suggestive of adenocarcinoma, and its unexpected early and aggressive recurrence required thorough investigation on the true cell type and its origin. Both radiochemotherapy findings and conclusive findings of immunohistochemical staining finally revealed this tumor to be an ordinary adenocarcinoma. It was impossible to identify its origin histologically, because this case was so advanced that it had already replaced the entire entity with adenocarcinoma without leaving any clues as to its former nature. We thus assumed this tumor to be an adenocarcinoma of unknown origin arising in the retrorectal space.

Decreased levels of IGF binding protein-3 in serum from children with Perthes' disease

The concentrations of insulin-like growth factor (IGF)-I and IGF-binding protein (IGFBP)-3 in serum obtained from 27 children with Perthes' disease and 10 age-matched control subjects were measured by radioimmunoassay (RIA). IGFBPs were also analyzed by a Western ligand blotting (WLB) method. The bone age was determined in 18 patients from hand-wrist radiographs. Serum levels of IGFBP-3 but not IGF-I were significantly lower than those in normal controls. WLB showed a decrease in the intensity of the IGFBP-3 band in 19 of the 27 patients. The bone age was delayed, 2 years or more compared with the chronological age in 7 of 18 patients, and all of them, except 1, showed decreased levels of IGFBP-3 on WLB. We conclude that there may be disturbances in availability of IGFs in some patients with Perthes' disease.

Topological study of Vibrio alginolyticus NhaB Na+/H+ antiporter using gene fusions in Escherichia coli cells

NhaB, an Na+/H+ antiporter, of Vibrio alginolyticus is a 528-amino-acid protein. Hydropathy profile-based computer analysis predicted that the NhaB might contain up to 13 membrane-spanning domains. To examine this hypothesis, we applied the phoA fusion method to the cloned nhaB gene. Eighteen plasmid-borne nhaB-phoA fusion genes were constructed in Escherichia coli cells and the alkaline phosphatase activity and expression level of the fusion proteins analyzed. These results and the results obtained with additional constructs indicated that V. alginolyticus NhaB has a unique topology consisting of nine transmembrane segments with the N-terminus in the cytoplasm and the C-terminus in the periplasm.

Expansion of the oral end of free revascularised jejunum with a jejunal patch flap rotated like a folding fan

We have devised a new expansion process for the reconstruction of the cervical oesophagus with free revascularised jejunum in cases of hypopharyngeal cancer. The jejunal island flap is divided into three subislands and the major island of the caudal end is split partially at its oral end. The middle island is split, trimmed triangularly, and inserted into opened major island to expand the diameter of the oral end of the conduit for the cervical oesophagus and to make it funnel-shaped. The smallest island on the oral side is used as a circulation monitor for the transferred jejunum. Because the jejunal island patch is rotated around the root of mesentery like a folding fan and joined to the major island, there is neither shortening of the pedicle nor distortion. This method allows expansion of the oral end by up to 180% to facilitate end to end anastomosis in proximal pharyngeal defects.

Impaired tumorigenicity and decreased liver metastasis of murine neuroblastoma cells engineered to secrete interleukin-2 or granulocyte macrophage colony-stimulating factor

We have examined the antitumor effect of murine neuroblastoma cells (C1300) engineered to produce cytokines. Retrovirally transduced cells with human interleukin-2 (IL-2) or murine GM-CSF gene, but not murine IL-4 gene, abolished their tumorigenicity in syngeneic mice, although their in vitro growth rate and expression of class I antigens of the major histocompatibility complex were unchanged. Inoculation of wild-type cells into the mice, which had rejected IL-2 or GM-CSF producers, did not develop tumors, indicating that protective immunity was induced. In an experimental hematogenous metastasis model, we found that the numbers of metastatic foci in the liver caused by intravenous administration of IL-2 or GM-CSF producers were significantly reduced compared with those by the injection of wild-type or vector virus-transduced cells. No significant differences in their adhesiveness to extracellular matrices and ability to differentiate were observed among parent and transduced cells. Thus, these results indicate that IL-2 or GM-CSF secretion, in the vicinity of neuroblastoma cells, produced antitumor effect and reduced metastatic ability.

[Combination chemotherapy (CVP) in a patient with refractory idiopathic thrombocytopenic purpura (ITP)]

A 54-year-old woman, who had been given a diagnosis of idiopathic thrombocytopenic purpura (ITP) refractory to steroid therapy, was admitted to our hospital because of severe bleeding tendency. Splenectomy, high dose vitamin-C and interferon-alpha were not effective, although high-dose gamma-globulin had some effect. Since high-dose glucocorticoid was effective temporarily, we decided to perform chemotherapy. Seven courses of CVP chemotherapies (CVP; CPM 500 mg, VCR 2 mg, PSL 50 mg) prevented severe bleeding and did not have serious toxicity. Chemotherapy can be indicated for refractory ITP reactive to immunosuppressive therapy such as high-dose glucocorticoid.