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Yamamoto M, Sato M, Onishi Y, Sasahara Y, Sano H, Masuko M, Nakamae H, Matsuoka K, Ara T, Washio K, Onizuka M, Watanabe K, Takahashi Y, Hirakawa T, Nishio M, Sakashita C, Kobayashi T, Sawada A, Ichinohe T, Fukuda T, Hashii Y, Atsuta Y, Arai A. Registry data analysis of hematopoietic stem cell transplantation on systemic chronic active Epstein-Barr virus infection patients in Japan. Am J Hematol 2022; 97:780-790. [PMID: 35312194 DOI: 10.1002/ajh.26544] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2021] [Revised: 03/15/2022] [Accepted: 03/17/2022] [Indexed: 12/27/2022]
Abstract
The effects of allogeneic hematopoietic stem cell transplantation (allo-HSCT) on systemic chronic active Epstein-Barr virus infection (sCAEBV) are yet to be analyzed in a large number of patients. Using the Japanese registry database, Transplant Registry Unification Management Program, we investigated the outcomes of 102 sCAEBV patients who underwent allo-HSCT. The median age at HSCT was 21 years, and the three-year overall survival (3-year OS) rate was 72.5%. Of the 90 patients whose viral load after allo-HSCT was evaluated, 56 (62.2%) achieved a virological complete response, defined by the complete resolution of disease activity with a significant decrease in EBV-DNA in peripheral blood. The multivariate Cox proportional hazard model indicated that advanced age, in adolescents and young adults (AYA) (age, 15-39) and adults (age, ≥40 years) was a risk factor of poor OS. The hazard ratios (HRs) of the AYA and adult groups were 10.87 (95% confidence interval [CI]: 1.98-59.56, p = .006) and 15.93 (95% CI: 2.45-103.8, p = .004), respectively. Disease activity (HR 5.74), elevated soluble IL-2 receptor (sIL-2R) (≥ median, 691 U/mL) at HSCT (HR 6.93), and conditioning without radiotherapy (HR 3.53) were also independently associated with poor survival. Notably, 79% of radiotherapy doses were less than 6 Gy. Regardless of the presence of hemophagocytic lymphohistiocytosis, the group with a high sIL-2R level (≥2000 U/mL) showed a poorer prognosis. Although allo-HSCT is the only curative therapy for sCAEBV, treatment strategies need to be improved for high-risk patients, especially those with high levels of sIL-2R.
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Affiliation(s)
- Masahide Yamamoto
- Department of Hematology Tokyo Medical and Dental University (TMDU) Tokyo Japan
| | - Maho Sato
- Department of Hematology/Oncology Osaka Women's and Children's Hospital Izumi Japan
| | - Yasushi Onishi
- Department of Hematology Tohoku University Hospital Sendai Japan
| | - Yoji Sasahara
- Department of Pediatrics Tohoku University Hospital Sendai Japan
| | - Hideki Sano
- Department of Pediatric Oncology Fukushima Medical University Hospital Fukushima Japan
| | - Masayoshi Masuko
- Division of Stem Cell Transplantation Niigata University Medical and Dental Hospital Niigata Japan
| | | | - Ken‐ichi Matsuoka
- Department of Hematology and Oncology Okayama University Hospital Okayama Japan
| | - Takahide Ara
- Department of Hematology Hokkaido University Hospital Sapporo Japan
| | - Kana Washio
- Department of Pediatrics Okayama University Hospital Okayama Japan
| | - Makoto Onizuka
- Department of Hematology/Oncology Tokai University School of Medicine Isehara Japan
| | - Kenichiro Watanabe
- Department of Hematology and Oncology Shizuoka Children's Hospital Shizuoka Japan
| | - Yoshiyuki Takahashi
- Department of Pediatrics Nagoya University Graduate School of Medicine Nagoya Japan
| | - Tsuneaki Hirakawa
- Division of Hematology and Oncology, Department of Internal Medicine St. Marianna University School of Medicine Kawasaki Japan
| | - Miwako Nishio
- Department of Laboratory Molecular Genetics of Hematology, Graduate School of Medical and Dental Sciences Tokyo Medical and Dental University (TMDU) Tokyo Japan
| | - Chizuko Sakashita
- Department of Hematology Tokyo Medical and Dental University (TMDU) Tokyo Japan
| | - Tohru Kobayashi
- Clinical Research Center, National Center for Child Health and Development Tokyo Japan
| | - Akihisa Sawada
- Department of Hematology/Oncology Osaka Women's and Children's Hospital Izumi Japan
| | - Tatsuo Ichinohe
- Department of Hematology and Oncology Research Institute for Radiation Biology and Medicine, Hiroshima University Higashihiroshima Japan
| | - Takahiro Fukuda
- Hematopoietic Stem Cell Transplantation Division National Cancer Center Hospital Tokyo Japan
| | - Yoshiko Hashii
- Cancer Immunotherapy/Pediatrics Osaka University Graduate School of Medicine Osaka Japan
| | - Yoshiko Atsuta
- Japanese Data Center for Hematopoietic Cell Transplantation Nagoya Japan
- Department of Registry Science for Transplant and Cellular Therapy Aichi Medical University School of Medicine Nagakute Japan
| | - Ayako Arai
- Division of Hematology and Oncology, Department of Internal Medicine St. Marianna University School of Medicine Kawasaki Japan
- Department of Hematological Therapeutics, Graduate School of Medical and Dental Sciences Tokyo Medical and Dental University (TMDU) Tokyo Japan
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2
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Saito R, Tanaka M, Ito H, Kuramoto N, Fujii T, Saito S, Kaneko Y, Nakano K, Saito K, Takada H, Sugimoto N, Sasaki S, Harigai M, Suzuki Y. Overall survival and post-spontaneous regression relapse-free survival of patients with lymphoproliferative disorders associated with rheumatoid arthritis: a multi-center retrospective cohort study. Mod Rheumatol 2021; 32:50-58. [PMID: 33336615 DOI: 10.1080/14397595.2020.1866837] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2020] [Accepted: 11/22/2020] [Indexed: 10/22/2022]
Abstract
OBJECTIVES To clarify factors affecting 5-year survival rates and relapse rates after spontaneous regression (SR) of lymphoproliferative disorders (LPDs) in patients with rheumatoid arthritis (RA). METHODS This retrospective longitudinal study comprised 232 patients with RA diagnosed with LPDs between January 2000 and March 2017 at eight hospitals in Japan. The Kaplan-Meier method was used to analyze survival and the Cox proportional hazard model was applied to identify predictive factors. RESULTS Among all patients, 1-, 2- and 5-year overall survival rates were 89.5%, 86.1%, and 78.2%, respectively. Multivariable analysis revealed four 5-year survival risk factors assessed at diagnosis: age above 70 years (p = .002), deep lymphadenopathy and/or more than one extranodal lesion (p = .008), Eastern Cooperative Oncology Group/Zubrod performance status of 2-4 (p = .004), and classic Hodgkin lymphoma (CHL) histology (p = .047). Among 143 patients who achieved SR, 2- and 5-year relapse rates were 14.2% and 24.9%, respectively. CHL histology (p = .003) and serum soluble interleukin-2 receptor levels exceeding 2000 IU/L (p = .014) were associated with post-SR relapse-free survival. Blood lymphocyte counts were significantly lower at relapse than at 3-6 months prior (p < .001). CONCLUSION Assessment of the above risk factors and routine inspection of blood lymphocyte counts could aid in the care management of LPDs in RA.
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Affiliation(s)
- Rintaro Saito
- Department of Rheumatology and Clinical Immunology, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Masao Tanaka
- Department of Advanced Medicine for Rheumatic Diseases, Graduate School of Medicine, Kyoto University, Kyoto, Japan.,Working Group on the Rheumatoid Arthritis-associated Lymphoproliferative Disorders of the Japan College of Rheumatology, Tokyo, Japan
| | - Hiromu Ito
- Department of Advanced Medicine for Rheumatic Diseases, Graduate School of Medicine, Kyoto University, Kyoto, Japan.,Department of Orthopaedic Surgery, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Nobuo Kuramoto
- Department of Rheumatology and Clinical Immunology, Wakayama Medical University, Wakayama, Japan
| | - Takao Fujii
- Working Group on the Rheumatoid Arthritis-associated Lymphoproliferative Disorders of the Japan College of Rheumatology, Tokyo, Japan.,Department of Rheumatology and Clinical Immunology, Wakayama Medical University, Wakayama, Japan
| | - Shuntaro Saito
- Division of Rheumatology, Department of Internal Medicine, Keio University School of Medicine, Tokyo, Japan
| | - Yuko Kaneko
- Working Group on the Rheumatoid Arthritis-associated Lymphoproliferative Disorders of the Japan College of Rheumatology, Tokyo, Japan.,Division of Rheumatology, Department of Internal Medicine, Keio University School of Medicine, Tokyo, Japan
| | - Kazuhisa Nakano
- Working Group on the Rheumatoid Arthritis-associated Lymphoproliferative Disorders of the Japan College of Rheumatology, Tokyo, Japan.,The First Department of Internal Medicine, School of Medicine, University of Occupational and Environmental Health, Kitakyushu, Japan
| | - Kazuyoshi Saito
- Working Group on the Rheumatoid Arthritis-associated Lymphoproliferative Disorders of the Japan College of Rheumatology, Tokyo, Japan.,The First Department of Internal Medicine, School of Medicine, University of Occupational and Environmental Health, Kitakyushu, Japan.,Tobata General Hospital, Kitakyushu, Japan
| | - Hideto Takada
- Department of Rheumatology, Tokyo Women's Medical University School of Medicine, Tokyo, Japan
| | - Naoki Sugimoto
- Department of Rheumatology, Tokyo Women's Medical University School of Medicine, Tokyo, Japan
| | - Sho Sasaki
- Division of Rheumatology, Tokai University Hachioji Hospital, Tokyo, Japan
| | - Masayoshi Harigai
- Working Group on the Rheumatoid Arthritis-associated Lymphoproliferative Disorders of the Japan College of Rheumatology, Tokyo, Japan.,Department of Rheumatology, Tokyo Women's Medical University School of Medicine, Tokyo, Japan
| | - Yasuo Suzuki
- Working Group on the Rheumatoid Arthritis-associated Lymphoproliferative Disorders of the Japan College of Rheumatology, Tokyo, Japan.,Division of Rheumatology, Tokai University Hachioji Hospital, Tokyo, Japan
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Umino K, Fujiwara SI, Ikeda T, Kawaguchi SI, Toda Y, Ito S, Ochi SI, Nagayama T, Mashima K, Minakata D, Nakano H, Yamasaki R, Morita K, Kawasaki Y, Yamamoto C, Ashizawa M, Hatano K, Sato K, Oh I, Ohmine K, Muroi K, Kanda Y. Predictive value of soluble interlukin-2 receptor level at diagnosis on the outcome for patients with classical Hodgkin lymphoma treated with ABVD with or without radiotherapy. Ann Hematol 2019; 98:2121-2129. [PMID: 31240469 DOI: 10.1007/s00277-019-03738-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2018] [Accepted: 06/12/2019] [Indexed: 01/20/2023]
Abstract
We retrospectively analyzed 70 patients with classical Hodgkin lymphoma (cHL) who were treated with doxorubicin, bleomycin, vinblastine, and dacarbazine (ABVD) with or without radiotherapy to assess the influence of the soluble interleukin-2 receptor (sIL-2R) level at diagnosis on the clinical outcome. Receiver operating characteristic analyses determined that the optimal cutoff value of the sIL-2R level for progression-free survival (PFS) was 2490 U/mL. Using this cutoff value, patients were classified into low (n = 46) and high (n = 24) sIL-2R groups. The patients in the high sIL-2R group exhibited a significantly inferior PFS (44.1% vs. 90.4% at 5 years, P < 0.001) and overall survival (OS) (67.6% vs. 94.7% at 5 years, P = 0.001) compared with those in the low sIL-2R group. Multivariate analysis showed that a high sIL-2R level was an independent prognostic factor for PFS after adjusting for stage, white blood cell, hemoglobin, and B symptoms, and also OS after adjusting for age and stage (hazard ratio (HR) 6.49, P < 0.001 and HR 5.98, P = 0.009, respectively). In patients with advanced-stage cHL, a high sIL-2R level predicted 5-year PFS even after adjustment for international prognostic score > 4 (HR 6.00, P = 0.007). These results demonstrate that the sIL-2R level can be a useful prognostic factor in patients with cHL treated with ABVD with or without radiotherapy.
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Affiliation(s)
- Kento Umino
- Division of Hematology, Department of Medicine, Jichi Medical University, 3311-1 Yakushiji, Shimotsuke, Tochigi, 329-0498, Japan
| | - Shin-Ichiro Fujiwara
- Division of Hematology, Department of Medicine, Jichi Medical University, 3311-1 Yakushiji, Shimotsuke, Tochigi, 329-0498, Japan
| | - Takashi Ikeda
- Division of Hematology, Department of Medicine, Jichi Medical University, 3311-1 Yakushiji, Shimotsuke, Tochigi, 329-0498, Japan
| | - Shin-Ichiro Kawaguchi
- Division of Hematology, Department of Medicine, Jichi Medical University, 3311-1 Yakushiji, Shimotsuke, Tochigi, 329-0498, Japan
| | - Yumiko Toda
- Division of Hematology, Department of Medicine, Jichi Medical University, 3311-1 Yakushiji, Shimotsuke, Tochigi, 329-0498, Japan
| | - Shoko Ito
- Division of Hematology, Department of Medicine, Jichi Medical University, 3311-1 Yakushiji, Shimotsuke, Tochigi, 329-0498, Japan
| | - Shin-Ichi Ochi
- Division of Hematology, Department of Medicine, Jichi Medical University, 3311-1 Yakushiji, Shimotsuke, Tochigi, 329-0498, Japan
| | - Takashi Nagayama
- Division of Hematology, Department of Medicine, Jichi Medical University, 3311-1 Yakushiji, Shimotsuke, Tochigi, 329-0498, Japan
| | - Kiyomi Mashima
- Division of Hematology, Department of Medicine, Jichi Medical University, 3311-1 Yakushiji, Shimotsuke, Tochigi, 329-0498, Japan
| | - Daisuke Minakata
- Division of Hematology, Department of Medicine, Jichi Medical University, 3311-1 Yakushiji, Shimotsuke, Tochigi, 329-0498, Japan
| | - Hirofumi Nakano
- Division of Hematology, Department of Medicine, Jichi Medical University, 3311-1 Yakushiji, Shimotsuke, Tochigi, 329-0498, Japan
| | - Ryoko Yamasaki
- Division of Hematology, Department of Medicine, Jichi Medical University, 3311-1 Yakushiji, Shimotsuke, Tochigi, 329-0498, Japan
| | - Kaoru Morita
- Division of Hematology, Department of Medicine, Jichi Medical University, 3311-1 Yakushiji, Shimotsuke, Tochigi, 329-0498, Japan
| | - Yasufumi Kawasaki
- Division of Hematology, Department of Medicine, Jichi Medical University, 3311-1 Yakushiji, Shimotsuke, Tochigi, 329-0498, Japan
| | - Chihiro Yamamoto
- Division of Hematology, Department of Medicine, Jichi Medical University, 3311-1 Yakushiji, Shimotsuke, Tochigi, 329-0498, Japan
| | - Masahiro Ashizawa
- Division of Hematology, Department of Medicine, Jichi Medical University, 3311-1 Yakushiji, Shimotsuke, Tochigi, 329-0498, Japan
| | - Kaoru Hatano
- Division of Hematology, Department of Medicine, Jichi Medical University, 3311-1 Yakushiji, Shimotsuke, Tochigi, 329-0498, Japan
| | - Kazuya Sato
- Division of Hematology, Department of Medicine, Jichi Medical University, 3311-1 Yakushiji, Shimotsuke, Tochigi, 329-0498, Japan
| | - Iekuni Oh
- Division of Hematology, Department of Medicine, Jichi Medical University, 3311-1 Yakushiji, Shimotsuke, Tochigi, 329-0498, Japan
| | - Ken Ohmine
- Division of Hematology, Department of Medicine, Jichi Medical University, 3311-1 Yakushiji, Shimotsuke, Tochigi, 329-0498, Japan
| | - Kazuo Muroi
- Division of Hematology, Department of Medicine, Jichi Medical University, 3311-1 Yakushiji, Shimotsuke, Tochigi, 329-0498, Japan
| | - Yoshinobu Kanda
- Division of Hematology, Department of Medicine, Jichi Medical University, 3311-1 Yakushiji, Shimotsuke, Tochigi, 329-0498, Japan.
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4
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Umino K, Fujiwara SI, Minakata D, Yamamoto C, Meguro A, Matsuyama T, Sato K, Ohmine K, Izumi T, Muroi K, Kanda Y. Prognostic impact of serum soluble interleukin-2 receptor level at diagnosis in elderly patients with diffuse large B-cell lymphoma treated with R-CHOP. Leuk Lymphoma 2018; 60:734-741. [PMID: 30188236 DOI: 10.1080/10428194.2018.1504939] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
Diffuse large B-cell lymphoma (DLBCL) is a clinically heterogeneous disease. To evaluate the clinical relevance of the serum soluble interleukin-2 receptor (sIL-2R) level, we retrospectively analyzed 178 patients aged ≥60 years who were newly diagnosed with DLBCL. We determined the cutoff value of the sIL-2R level to be 1280 U/mL using the area under the receiver operating characteristic curve. The high sIL-2R group exhibited significantly inferior 5-year progression-free survival (PFS) (36.2% vs. 86.1%, p < .001) and 5-year overall survival (OS) (49.7% s. 83.8%, p < .001) than the low sIL-2R group. Multivariate analysis revealed that a high sIL-2R level was a significant prognostic factor for PFS and OS (hazard ratio [HR]: 5.65, p < .001 and HR: 2.99, p = .001, respectively). This study showed that measurement of the sIL-2R level at diagnosis is clinically beneficial for identifying elderly patients with DLBCL who have a poor prognosis.
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Affiliation(s)
- Kento Umino
- a Division of Hematology, Department of Medicine , Jichi Medical University , Tochigi , Japan
| | - Shin-Ichiro Fujiwara
- a Division of Hematology, Department of Medicine , Jichi Medical University , Tochigi , Japan
| | - Daisuke Minakata
- a Division of Hematology, Department of Medicine , Jichi Medical University , Tochigi , Japan
| | - Chihiro Yamamoto
- a Division of Hematology, Department of Medicine , Jichi Medical University , Tochigi , Japan
| | - Akiko Meguro
- b Department of Hematology , Tochigi Cancer Center , Tochigi , Japan
| | | | - Kazuya Sato
- a Division of Hematology, Department of Medicine , Jichi Medical University , Tochigi , Japan
| | - Ken Ohmine
- a Division of Hematology, Department of Medicine , Jichi Medical University , Tochigi , Japan
| | - Tohru Izumi
- b Department of Hematology , Tochigi Cancer Center , Tochigi , Japan
| | - Kazuo Muroi
- a Division of Hematology, Department of Medicine , Jichi Medical University , Tochigi , Japan
| | - Yoshinobu Kanda
- a Division of Hematology, Department of Medicine , Jichi Medical University , Tochigi , Japan
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Phillips AA. Hematopoeitic stem cell transplantation for adult T cell leukemia-lymphoma: Who is the best candidate? Leuk Lymphoma 2016; 58:1-3. [PMID: 27786571 DOI: 10.1080/10428194.2016.1246730] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Affiliation(s)
- Adrienne Alise Phillips
- a Division of Hematology and Oncology, Department of Medicine , Weill Cornell Medical College , New York , NY , USA
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Umino K, Fujiwara SI, Ito S, Mashima K, Minakata D, Nakano H, Yamasaki R, Kawasaki Y, Sugimoto M, Ashizawa M, Hatano K, Okazuka K, Sato K, Oh I, Ohmine K, Suzuki T, Muroi K, Kanda Y. Serum soluble interleukin-2 receptor level at diagnosis predicts transformation in patients with follicular lymphoma. Leuk Lymphoma 2016; 58:316-323. [DOI: 10.1080/10428194.2016.1190975] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
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7
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Gupta M, Stenson M, O'Byrne M, Maurer MJ, Habermann T, Cerhan JR, Weiner GW, Witzig TE. Comprehensive serum cytokine analysis identifies IL-1RA and soluble IL-2Rα as predictors of event-free survival in T-cell lymphoma. Ann Oncol 2015; 27:165-72. [PMID: 26487586 DOI: 10.1093/annonc/mdv486] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2015] [Accepted: 09/30/2015] [Indexed: 12/27/2022] Open
Abstract
BACKGROUND T-cell malignancies are heterogeneous in their clinical presentation and pathology, and have a poor prognosis. New biomarkers are needed to predict prognosis and to provide insights into signal pathways used by these cells. The goal of this study was to evaluate pretreatment serum cytokines in patients with newly diagnosed T-cell neoplasms and correlate with clinical outcome. PATIENTS AND METHODS We evaluated 30 cytokines in pretreatment serum from 68 untreated patients and 14 normal controls. Significantly elevated cytokines were correlated with patterns of abnormalities, event-free survival (EFS) and overall survival (OS). RESULTS Our data demonstrated significantly elevated levels (versus controls) of seven cytokines-epidermal growth factor (EGF), IL-6, IL-12, interferon gamma-induced protein (IP)-10, soluble interleukin (sIL)-2Rα, monokine induced by gamma interferon (MIG), and IL-1RA-in all T-cell neoplasms (P < 0.05). In the angioimmunoblastic subset, all seven cytokines except IP-10 and in the peripheral T-cell lymphoma (TCL)-not otherwise specified subset, only IP-10, sIL-2Rα, MIG, and IL-8 were statistically elevated compared with control. Of these, elevated cytokines all but EGF were predictive of an inferior EFS; IL-1RA, sIL-2Rα, and MIG predicted an inferior OS. In a multivariate analysis, sIL-2Rα [hazard ratio (HR) = 3.95; 95% confidence interval (CI) 1.61-8.38] and IL-1RA (HR = 3.28; 95% CI 1.47-7.29) levels remained independent predictors of inferior EFS. TCL cell lines secreted high levels of sIL-2Rα and expressed the IL-2Rα surface receptor. CONCLUSIONS This report describes the cytokines relevant to prognosis in patients with untreated TCL and provides the rationale to include serum IL-1RA and sIL-2Rα as biomarkers in future trials. Inhibition of these cytokines may also be of therapeutic benefit.
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Affiliation(s)
- M Gupta
- Division of Hematology, Department of Internal Medicine, Mayo Clinic, Rochester
| | - M Stenson
- Division of Hematology, Department of Internal Medicine, Mayo Clinic, Rochester
| | - M O'Byrne
- Department of Health Sciences Research, Mayo Clinic, Rochester, USA
| | - M J Maurer
- Department of Health Sciences Research, Mayo Clinic, Rochester, USA
| | - T Habermann
- Division of Hematology, Department of Internal Medicine, Mayo Clinic, Rochester
| | - J R Cerhan
- Department of Health Sciences Research, Mayo Clinic, Rochester, USA
| | - G W Weiner
- Department of Internal Medicine, University of Iowa College of Medicine, Iowa City, USA
| | - T E Witzig
- Division of Hematology, Department of Internal Medicine, Mayo Clinic, Rochester
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