Post-transplantation consolidation and maintenance therapy with lenalidomide for Japanese patients with multiple myeloma

BACKGROUND

Post-autologous stem cell transplantation (ASCT) consolidation and maintenance therapies in multiple myeloma (MM) have recently been the central focus of studies. However, there have been no reports of Japanese patients with MM treated with post-ASCT consolidation/maintenance therapies.

PATIENTS AND METHODS

We retrospectively evaluated eight Japanese patients with newly-diagnosed symptomatic MM who received ASCT after high-dose melphalan, and three to four courses of bortezomib-plus-dexamethasone and two courses of lenalidomide-plus-dexamethasone followed by maintenance lenalidomide for 6-24 months.

RESULTS

Four patients achieved complete response (CR) after ASCT, and five patients (63%) achieved stringent CR after the consolidation and maintenance therapy; two out of these five were in molecular CR. At the median follow-up of 38 months, all patients were alive and only one patient had disease progression following post-ASCT therapy.

CONCLUSION

Post-ASCT consolidation and maintenance therapy using lenalidomide may be effective in the treatment of Japanese patients with MM.

Detection of minimal residual disease in patients with multiple myeloma using clonotype-specific PCR primers designed from DNA extracted from archival bone marrow slides

Polymerase chain reaction (PCR)-negative molecular complete remission (mCR) can be induced by stem cell transplantation in some patients with multiple myeloma (MM) and is associated with long-term progression-free survival (PFS). The detection of molecular minimal residual disease (MRD), however, requires fresh or frozen materials for designing clone-specific primers, which are not always readily available. In this study, we used DNA extracted from archival bone marrow (BM) slides for PCR to detect MRD in 50 patients with MM who received various induction therapies and autologous peripheral blood stem cell transplantation (ASCT). Clonotype-specific immunoglobulin (Ig) H PCR primers were prepared for 32 of 50 cases (64%) using BM slides, and for 9 of 14 cases (64%) using fresh BM cells. DNA in peripheral blood stem cell autografts of the 22 patients who achieved at least a partial response after ASCT was subjected to PCR to amplify clonotype-specific rearranged IgH gene sequences. The median PFS of the eight patients with MRD-positive autografts was 18 months, whereas that of 14 patients with MRD-negative autografts was not reached at a median follow-up of 27 months (p = 0.012). Post-ASCT PFS of the four patients who achieved mCR was 100% at a median follow-up of 47 months. These results indicate that archival BM slides can serve as a source of DNA for preparing clonotype-specific primers for MRD monitoring in patients with MM whose cryopreserved myeloma cells are not available for DNA preparation. Our results also suggest that patients with MM who received MRD-negative autografts and achieved mCR have a long PFS.

[Concurrent chemo-radiotherapy for localized refractory non-Hodgkin's lymphoma--report of two cases]

Localized refractory diffuse large B-cell lymphomas (DLBCL) were treated with concurrent chemo-radiotherapy. Case 1 had right cervical lymphadenopathy. Lymphoma enlarged even after the fourth courses of chemotherapy consisting of cyclophosphamide, doxorubicin, vincristine, and prednisolone (CHOP). The second case had a pharyngeal tumor and bilateral cervical lymphadenopathy. A lymphoma enlarged after eighth courses of CHOP. Both cases were treated with concurrent chemo-radiotherapy. Chemotherapy consisted of mitoxantrone, methotrexate, ifosfamide,and prednisolone (MMIP). The dose of radiation to the involved sites was 40 Gy. The first case received chemotherapy three days after radiotherapy was started. The second case was treated with chemotherapy, and radiotherapy was begun one day after. Both cases show mucositis and leukopenia. One case received two courses of chemotherapy after chemo-radiotherapy, and the other received no additional chemotherapy. Both cases achieved complete remission after the combined therapy, however, lymphoma in one case recurred three months after the therapy. It is possible that this concurrent chemo-radiotherapy is effective for localized DLBCL which did not disappear after standard chemotherapy.

Congenital arachnoid cyst mimicking meningocele

The subject of this report is a rare case of a 5-year-old girl who developed an arachnoid cyst with a bony and dural defect in the parietal convexity. She had no history of head trauma or infection. Surgical exploration revealed the bulging lesion to consist of cerebrospinal fluid-containing spongy subcutaneous tissue and to extend into the bony and dural defect. The arachnoid cyst cavity was found beneath the subcutaneous lesion and was not connected to the adjacent subarachnoid space. Histologically, the subcutaneous tissue contained a complex of sinusoidal channels formed by an abundance of migrating arachnoidal cells, thus mimicking meningocele.

[Usefulness of the interlocking detachable coil for the repeatedly ruptured dissecting aneurysm of the vertebral artery in the acute stage]

A 44-year-old male with a repeatedly ruptured dissecting aneurysm of the vertebral artery (VA) manifesting with subarachnoid hemorrhage was successfully treated with endovascular surgery using an interlocking detachable coil (IDC). He had a dissecting aneurysm in the left VA distal to the left posterior inferior cerebellar artery (PICA). Because the dissecting aneurysm ruptured repeatedly and his clinical condition was moribund, direct surgery was not indicated. The dissecting aneurysm was embolized with an IDC and additional platinum coils. Among patients with a ruptured VA dissecting aneurysm, proximal occlusion is generally indicated. But the direct embolization of a dissecting aneurysm can be applied in cases in which the aneurysm is ruptured repeatedly in the acute stage. IDC is a useful and safe material for endovascular surgery of a ruptured VA dissecting aneurysm.

[Studies on cerebrospinal fluid penetration of cefpirome in adult with meningitis]

A patient with intracerebral hematoma suffered from postoperative bacterial meningitis. Staphylococcus aureus was found from CSF. The organism was multiple drug resistant and refractory to antibiotics including piperacillin (PIPC), cephalexin (CEX), cefotaxime (CTX), ceftazidime (CAZ) and latamoxef (LMOX). It was susceptible to cefpirome (CPR). Treatment with CPR resulted in clinical improvement associated with clearing of the organism from CSF. Serum level of CPR was high enough and CPR penetration into the CSF was satisfactory. The results suggest that CPR is an extremely effective antibiotic for meningitis caused by CPR-susceptible bacteria. Evaluation of the CPR penetration into the CSF of adult meningitis was rarely reported. The result we obtained was important in the treatment for the adult meningitis.

[Parasagittal meningioma growing in the superior sagittal sinus presenting intracranial hypertension: a case report]

Parasagittal meningiomas often invade the superior sagittal sinus (SSS), but rarely grow inside the SSS as a primary tumor. The authors report a case of parasagittal meningioma growing mainly inside the SSS and presenting papilledema. The SSS is invisible behind the tumor end on the right carotid angiogram but still patent on the left carotid angiogram. The superficial cortical vein on the opposite side works as a collateral pathway. The tumor may have originated from the right wall of the SSS, grew inside the sinus and covered the entrances of the right ascending cerebral veins. V-P shunt was performed after removal of the mass outside the sinus for resolving headache and visual symptoms.

[A case report of a 6-year-old boy with intracranial yolk sac tumor treated by VAB-6 regimen]

Several clinical trials have demonstrated that cisplatin-based chemotherapy for primary intracranial germ-cell tumors is effective as a neoadjuvant chemotherapy. In this report, we describe a 6-year-old boy, Down syndrome and Hirschsprung's disease with intracranial pure yolk sac tumor treated by combined chemotherapy with cisplatin, vinblastine, bleomycin and cyclophosphamide (modified VAB-6 regimen). He had been admitted to our hospital because of intractable vomiting, and left facial nerve palsy since 1 month before. An MRI revealed an enlarged mass, 4cm in diameter, in the left cerebello-pontine angle with uniformal enhancement by Gd-DTPA, and bilateral ventricular dilatation. He was found to have increased serum alpha-fetoprotein level (AFP 11, 786ng/ml), but not human chorionic gonadotropin beta-subunit. After a partial resection of the tumor, diagnosed as pure yolk sac tumor, and ventriculo-peritoneal shunt, three courses of combined chemotherapy with cisplatin, bleomycin, vinblastine and cyclophosphamide (modified VAB-6 therapy) were carried out. The serum AFP level returned to normal, and the tumor mass entirely disappeared (a complete response) on MRI after the second course of chemotherapy. However, cisplatin-induced vomiting and mild neutropenia and renal tubular injury developed after the third course of chemotherapy. Irrespective of administration of recombinant human G-CSF and broad spectrum antibiotics, he suffered from pneumonia and died of septic shock and multiple organ failure. Autopsy showed microscopic residual tumors. The combination chemotherapy with cisplatin, bleomycin, vinblastine and cyclophosphamide is effective for initial treatment of childhood intracranial yolk sac tumor. It is necessary, however, to reevaluate the cisplatin dosage and treatment schedule in order to reduce such side effects as bone marrow suppression and renal damage.

[Ceftazidime in the treatment of meningitis caused by multiresistant Serratia marcescens]

A patient of subarachnoid hemorrhage was treated with spinal CSF drainage. Serratia marcescens meningitis occurred because of the spinal CSF drainage. The organism was multiresistant and refractory to antibiotics including piperacillin, imipenem, gentamicin and cephaloridine. It was sensitive to ceftazidime (CAZ). Treatment with CAZ resulted in clinical improvement associated with rapid clearing of the organism from CSF. CAZ serum level was high enough and CAZ penetration into the CSF was satisfactory. According to the evaluation of CAZ concentrations in serum and CSF, two regimens of treatment were recommended. One is an administration of CAZ 1 g x 4 times/day. Another is a combination with CAZ administration 2 g x 2 times/day and followed by 1 g x 4 times/day. The results suggest that CAZ is an extremely effective antibiotic for meningitis caused by CAZ-susceptible bacteria.

[Interhemispheric cyst of an adult associated with partial agenesis of the corpus callosum]

The authors report an adult patient with an asymptomatic interhemispheric cyst demonstrated by computerized tomography (CT), magnetic resonance imaging (MRI) scan and angiography. Partial agenesis of the corpus callosum is associated.

[Hyponatremia due to excess natriuresis]

Nine cases with hyponatremia were precisely examined during the past 2 years. Seven of them showed normal plasma volume, serum aldosterone and pituitary function, although ADH was detected. Therefore, those seven cases were diagnosed without dilutional hyponatremia due to SIADH (a syndrome of inappropriate secretion of antidiuretic hormone). The mechanism of hyponatremia of such a type has not been yet explained definitely, but it may be referring to excess natriuresis. Only each one case of hyponatremia due to hypopituitarism and dilutional hyponatremia due to SIADH was verified in this series. SIADH showing high plasma volume value was thought to be rare. Differential diagnosis between SIADH and hyponatremia due to excess natriuresis is essential and simple. Non-invasive plasma volume measurement using RISA is significantly useful for it. For the hyponatremia due to excess natriuresis, water restriction is not necessary, but digestive supply of NaCl is needed.

[Traumatic arteriovenous fistula with feeders of the scalp, dura mater and pia mater: case report]

A very rare case of 41-year-old male with symptomatic dural arteriovenous fistula which was detected after 22 years from receiving head injury is reported. This AVF had arterial blood supply of scalp, dural and pial origins. In the literature, only two similar cases have so far been reported. The draining veins were the superior sagittal sinus and the vein of Trolard, and a large vascular sac was seen in the pial vein.

The change of plasma volume, central venous pressure and water balance of patients treated by haemodynamic therapy for vasospasm

The plasma volume, central venous pressure and water balance of 24 patients were measured around the 1st and 2nd week after early operations for ruptured aneurysms. All of the patients had been successfully treated by induced hypertension therapy for delayed vasospasm. Plasma volume was measured by the RI method using RISA. The average plasma volume of 16 patients was 58.3 +/- 6.2 ml/kg. This group had 200 ml of 25% albumin every day. It was 48.2 +/- 6.2 ml/kg for 8 patients without albumin administration. The average CVP was 11.3 +/- 2.2 cm on the albumin group. It was 5.3 +/- 1.5 cm on the non-albumin group. The value of plasma volume and CVP was statistically higher in the albumin group than in the non-albumin group. Water balance was positive in about half of the albumin group. It was negative in the non-albumin group. Three patients of the albumin group had pulmonary oedemas and one patient of the non-albumin group had congestive heart failure.

[A large AVM extensively involving the parietal region and posterior fossa]

A 47-year-old male was concerned with a large AVM involved extensively in the parietal region and the posterior fossa. Radiological examinations showed multiple radiolucencies in the parietal and occipital bone and torturous vascular nets (nidus) in those bones on the angiograms. Nidus was found also in the dura mater in the posterior fossa. Therefore, this case seemed to be an extremely rare case of calvarial AVM in the parietal region with the mixed calvarial dural AVM in the posterior fossa. His symptoms were bruit, transient hemiparesis and Gerstmann's syndrome in addition to the symptoms due to raised intracranial pressure. Favorable results of therapies could be attained by extensive exfoliation of dura mater from the cranial bone and incision of proximal dura mater in the sinus.

[Change of plasma volume on patients treated by induced hypertension therapy for vasospasm]

Plasma volume, central venous pressure and water balance of 24 patients were measured about 1st and 2nd week after early operation for the ruptured aneurysms. All of the patients had been treated by induced hypertension therapy for delayed vasospasm successfully. Plasma volume was measured by RI method using RISA. The average of plasma volume of 16 patients was 58.3 +/- 6.0 ml/kg. This group had 200 ml of 25% albumin every day. It was 48.2 +/- 6.2 ml/kg on 8 patients without albumin. The average of CVP was 11.3 +/- 2.2 cm on the albumin group. It was 5.3 +/- 1.5 cm on the other group. The value of plasma volume and CVP was higher statistically on the albumin group than the other group. Water balance was positive on about half of the albumin group. It was negative on the other group. Three patients of the albumin group had pulmonary edema.

THE CONCLUSION

The state of patient's hydration is not hypovolemic, as far as the induced hypertension therapy is possible, even though patient's CVP is low and water blance is negative. Albumin lets the plasma volume increase easily. Therefore, the risk of pulmonary edema may rise when only unreliable CVP is used for the monitoring of plasma volume. Plasma volume measurement is indispensable to the monitoring of fluid management for vasospasm and plasma volume should be aimed at 55-60 ml/kg.

[Intraventricular and intracerebral hemorrhage as complication of hemodynamic therapy for vasospasm after subarachnoid hemorrhage--analysis of 2 cases]

Intraventricular and intracerebral hemorrhage were observed in two patients (36-year-old male and 45-year-old female) whose ischemic deficits from vasospasm after subarachnoid hemorrhage due to ruptured aneurysm were treated or prevented with hemodynamic therapy. Both patients had a long history of arterial hypertension and showed high values of urinary catecholamine after subarachnoid hemorrhage. The cause of hemorrhage seemed to be the induced hypertension and the volume expansion in one case and the uncontrolled hypertension and the volume expansion in the other case. Although two patients were treated with the volume expansion therapy continuously after hemorrhage, neurological status deteriorated due to infarction caused by vasospasm. We discussed the limit and risk of hemodynamic therapy for patients who had a long history of arterial hypertension and increased catecholamine release after subarachnoid hemorrhage.

[Traumatic hemorrhage in the basal ganglia in the child. Five cases]

Traumatic hemorrhages in the basal ganglia were seen in five children. The CT findings and the characteristics of these injuries were discussed. All of children were injured in car accidents. They ranged in age from 3 to 13 years. The patients comprised 3 boys and 2 girls. On admission, case 1 was conscious and case 2 was in a stupor. Case 1 and 2 were mild cases in which spotty hematomas were seen in the ganglionic region. They recovered fully. Case 3-5 were severe cases in which massive hematomas were seen in the ganglionic region. On admission, their consciousness ranged from stupor to coma. We performed operations on two of them but their recoveries were unsatisfactory. Their results were as follows. One had residual hemiparesis and dysarthria, one experienced tetraparesis and dysarthria and the last went from coma to a vegetative state. Concerning the directions of the impacts, 4 were hit in the frontal region or face and the last one received blows on the occipital region. Skull fractures were seen in two cases. Mandibula and clavicula fractures were seen in the other two cases. Only one child had no fractures. We conclude that pediatric traumatic hemorrhages in the basal ganglia are induced by severe impact on the frontal or occipital regions. The size of hematomas in this injury is spotty or massive. The massive type has a poor prognosis. On the other hand, the spotty type's prognosis is good. We speculate that impact to the head causes a shear strain in the ganglionic region. At that time, vessels in the area are injured.

[A case of huge diploic epidermoid of the temporal bone with intratumoral hemorrhage]

A case of huge diploic epidermoid which occurred in the right temporal bone and occupied almost all of the middle fossa and a part of the posterior fossa. CT of the tumor showed a low density lesion with multiform isodensity spots and a rim enhancement by CECT. Histologically, multiple old blood clots were recognized in this tumor contents. A review of the literature was made as regards CT findings of diploic epidermoid.

Association of persistent hypoglossal artery, multiple intracranial aneurysms, and polycystic disease

A case of multiple intracranial aneurysms associated with a persistent hypoglossal artery and polycystic disease of the liver and kidneys is reported. The persistent hypoglossal artery was seen on the right side, and the left vertebral artery was hypoplastic. There were three aneurysms, each of which was located on bifurcations of right and left middle cerebral artery, and basilar artery. They were successfully treated by direct approach.

[Aspiration of hypertensive intracerebral hematoma by stereotactic technique (author's transl)]

Stereotactic aspiration of hypertensive intracerebral hematoma was performed in 10 patients. The patients selected for this operation had localized putaminal, thalamic hematoma and thalamic hemorrhages with ventricular penetration. The aspiration technique employed here could not remove the total hematoma, but did evacuate between half and two thirds of the volume estimated by CT scan. The target point determination was made by CT scan. In 6 patients with localized hematomas, the operation was carried out between 18 and 60 days after the hemorrhage. Three patients operated on between 18 and 26 days after the hemorrhage recovered markedly from hemiparesis and aphasia, while the remaining 3 patients operated on between 40 and 60 days showed no improvement in spite of the hematoma evacuation. In 4 patients with thalamic hemorrhage with ventricular penetration, continuous ventricular drainage was made as a first choice. About 2 weeks after starting the drainage, the remaining hematoma located in the thalamus was evacuated by the stereotactic technique. Marked improvement in consciousness and from aphasia were observed while there was a slight reduction in hemiparesis and sensory disturbance after surgery. Stereotactic method is only slightly traumatic, hence the technique described here may be indicated in patients with deep-seated hematomas, especially in the thalamus.

Intracranial pressure in patients with diffuse cerebral arterial spasm following ruptured intracranial aneurysms

Intracranial pressure (ICP) was recorded continuously in 12 pre-operative patients with angiographic evidence of diffuse cerebral arterial spasm due to a ruptured intracranial aneurysm. Recordings were made for 1 to 7 days, starting within 13 days after the haemorrhage. 1. An increased ICP was observed in the first week after subarachnoid haemorrhage (SAH) in 4 of the patients without any signs of angiographic arterial spasm. 2. This initial increase was regularly followed by a depression of ICP in between 7--12 days after SAH. In 11 out of 12 patients such a depression was concomitant with the beginning of arterial spasm. During the period of depressed ICP pattern, 6 patients showed little or no neurological deterioration, whereas 5 patients showed impaired consciousness or neurological deficits. 3. A secondary rise of ICP thereafter always followed due to ischaemic brain swelling or infarction, and was usually associated with a serious neurological deterioration. 4. Continuous ventricular drainage was performed to control the secondary increased ICP in 7 patients who survived, 4 of them with good clinical improvement and 3 with severe neurological deficits. 5. In the stage of depressed ICP, the administration of isoproterenol and steroids is recommended in order to try to alleviate the secondary rise of ICP.

[Aneurysmal bone cyst of the frontal bone (author's transl)]

A six year-old boy. He complained of a swelling of the left forehead since October of 1971, the region of his upper eyelid has then been gradually swollen. He was admitted to our institute on the 24th of February, 1973, without the past history of head trauma. We found that the swollen region had a diameter of about 4 centimeters covered from the left upper eyelid to the forehead with a slight tenderness on pressure. We had no neurological findings. According to the results of skull X rays, the superior margin of left orbit and zygomatic process of frontal bone were swollen and like honey combs. An irregular, long and narrow osteolytic legion was found, which was about 4 centimeters long and 5 centimeters wide. According to the results of the left selective external carotid angiography, after injection of 60% Urografin, for more than 2.5- 10 seconds, at the left frontal bone an abnormal shadow (patchy contrast filling) was noted, which was about 4 centimeters long and 5 centimeters wide. After the direct injection of Urografid into the lesion, the cyst of one centimeter long and 3 centimeters wide was observed at the zygomatic process of the frontal bone. Operation was performed to excise the outer plate of the swollen bone and to curette the lesion after the ligature of the left external carotid artery. Histological examination showed many blood lakes and some multinuclear giant cells in the specimens and we diagnosed it was an aneurysmall bone cyst. This case is the first one of aneurysmall bone cyst confirmed by the selective external carotid angiography and the direct puncture of lesion.