Targeting complete response with upfront bortezomib consolidation versus observation after the achievement of complete response following autologous transplantation for multiple myeloma (TUBA study)

Complete response (CR) after treatment for multiple myeloma is associated with superior progression-free survival (PFS). Multiple myeloma patients were prospectively recruited for induction treatment with bortezomib and dexamethasone (BD) followed by autologous hematopoietic cell transplantation (auto-HCT) between 2010 and 2012. If patients did not achieve CR after auto-HCT, BD consolidation therapy was added to target CR. After the BD induction phase (n = 46), greater than or equal to CR was achieved in 4 patients (8%). After auto-HCT (n = 34), greater than or equal to CR was achieved in 9 patients (20%) and very good partial response (VGPR) was achieved in 11 (24%). Of the 24 patients who received auto-HCT and whose response was less than CR, 21 received BD consolidation therapy for a median of 4 courses. Finally, the maximum response with or without BD consolidation was greater than or equal to CR in 19 (41%), VGPR in 7 (15%), and PR in 6 (13%). Through BD consolidation, CR was achieved in 8 of 11 patients with post-HCT VGPR and in 2 of 12 patients with post-HCT PR. In total, 4 year PFS and overall survival were 43 and 80%, respectively. After adjusting for clinical factors, there was no difference in PFS between CR patients after auto-HCT and BD consolidation, while patients with less than or equal to VGPR after consolidation had a significantly lower PFS. Patients with post-HCT CR showed good PFS, and targeting CR through BD consolidation could improve the CR rate. It would be worthwhile to prospectively compare the efficacy of consolidation only for patients who failed to achieve CR to a universal consolidation strategy.

48 CARBOXYLATED ε-POLY-L-LYSINE (COOH-PLL) IMPROVES DEVELOPMENTAL ABILITY AND REDUCES MITOCHONDRIAL DAMAGE OF VITRIFIED PORCINE EMBRYOS AT THE PRONUCLEAR STAGE

Although cryopreservation of pronuclear-stage embryos has increasing importance in the production of genetically modified animals via microinjection, it is well known that cryopreserved porcine embryos show low developmental ability. Cryopreservation causes damage to organelles such as mitochondria that are involved in metabolism and play important roles in embryonic development. To reduce the damage in embryo cryopreservation, we focused on carboxylated ε-poly-l-lysine (COOH-PLL), which has been recently developed as a new cryoprotective agent. Carboxylated ε-poly-l-lysine has antifreeze protein properties, such as inhibition of ice recrystallization (Matsumura and Hyon 2009). In this study, we examined the effect of COOH-PLL on development and mitochondrial damage of vitrified porcine embryos at the pronuclear stage. Porcine follicular oocytes were matured (in vitro) and then fertilized (IVF) in vitro. At 10 h after IVF, the presumptive embryos were centrifuged to visualise the pronuclei. Embryos with 2 or 3 pronuclei (PN embryos) were used for vitrification. The PN embryos were exposed to equilibration solution for 10 min and then exposed to vitrification solution for 1 min before being plunged into LN on Cryotop®. Vitrification solution was phosphate buffered saline supplemented with 30% (vol/vol) ethylene glycol + 0.5 M sucrose + 20% (vol/vol) fetal calf serum + 0 or 20% (wt/vol) COOH-PLL (P0 or P20). Development to the blastocyst stage of the vitrified PN embryos was observed after in vitro culture for 158 h. Nonvitrified embryos were used as a control (fresh). Fresh and vitrified with P0 or P20 PN embryos were stained with MitoTracker® Red CMXRos. The embryos stained with MitoTracker® Red CMXRos were investigated by using a laser-scanning confocal microscope. Mitochondrial fluorescent intensity of embryos was evaluated by measuring the mean numbers of pixels in the fluorescent area (mean/area) using the NIH ImageJ software. The blastocyst rate of embryos vitrified with P20 (19.4%) was significantly (P < 0.05) higher than that of P0 (1.3%), and there were no significant differences in blastocyst rates between P20 and fresh group (28.4%; P > 0.05). The mitochondrial fluorescent intensity of embryos vitrified with P20 (2.8 mean/area) was significantly higher than that of P0 (1.5 mean/area), but the intensity of embryos vitrified with P20 was significantly lower than that of fresh (4.2 mean/area; P < 0.05). Our results suggest that supplementation of COOH-PLL with vitrification solution improved development and also reduced mitochondrial damage of vitrified porcine embryos at the pronuclear stage. Further studies are required to clarify the effect of COOH-PLL on various kinds of damage caused by cryopreservation such as other organelles, including endoplasmic reticulum damage, cytoskeleton damage, or DNA fragmentation of vitrified or warmed embryos in pigs.

Measurement of Proteasome Activity in Peripheral Blood Mononuclear Cells as an Indicator of Susceptibility to Bortezomib-Induced Severe Neurological Adverse Events in Patients with Multiple Myeloma

AIMS

To explore the biomarker for predicting the occurrence of adverse events in myeloma patients treated by intravenous bortezomib, we measured proteasome activity in peripheral blood mononuclear cells.

METHODS

Samples were obtained from 34 bortezomib-naïve patients. Proteasome activity was measured at pre- and postchemotherapy phase by using a synthetic substrate.

RESULTS

Bortezomib injection resulted in a dramatic decrease in proteasome activity, reaching 32.4 ± 18.79% (mean ± SD) of the pretreatment level at 1 h, but it generally recovered at the end of the first course. In total, 6 patients manifested with severe bortezomib-induced peripheral neuropathy (sBIPN) in the second-third course. There was a nonsignificant trend for these patients to have lower levels of the relative proteasome activity at the end of the first course than those without sBIPN (median: 74.03 vs. 103.2%, p = 0.052). Moreover, in all of them, proteasome activity did not recover to the pretreatment level, whereas no patients with complete recovery manifested with sBIPN. Analysis with Fisher's exact test demonstrated that incomplete recovery of proteasome activity is a significant risk factor for sBIPN (p = 0.014).

CONCLUSION

Patients with incomplete recovery of proteasome activity are at high risk for developing sBIPN, and the susceptible patients can be indicated by monitoring proteasome activity.

An autopsy case of chronic active Epstein-Barr virus infection (CAEBV): distribution of central nervous system (CNS) lesions

A 27-year-old Japanese man developed recurrent respiratory and central nervous system (CNS) symptoms, and hemophagocytic syndromes with a clinical course of 6 years. CT demonstrated multiple nodular lesions in the bilateral lungs, and MRI revealed multiple abnormal intensity areas in the brain and spinal cord. Cerebrospinal fluid (CSF) examination disclosed mild pleocytosis and the presence of Epstein-Barr virus (EBV)-DNA detected by polymerase chain reaction (PCR). The patient died of a hemorrhagic shock associated with a hemophagocytic syndrome. A postmortem study revealed massive hemorrhage in the abdominal cavity and iliopsoas muscles, as well as diffuse infiltration of lymphocytes and/or macrophages into the lungs, liver, kidneys, spleen, cardiac muscle, bone marrow, and CNS. The severe involvement was demonstrated in the CNS, especially in the spinal cord and brainstem. The CD3 positive cells of the brainstem were EBV-encoded RNA 1 positive. This is the first autopsy case of chronic active EBV infection (CAEBV) in which severe and extensive CNS involvement was demonstrated.

[Comparison of antimicrobial use density (AUD) of carbapenem antibacterial agents and investigation of the drug susceptibility of Pseudomonas aeruginosa in 3 hospitals in southern Ibaraki Prefecture, Japan]

The optimal use of anti-Pseudomonas agents is an important issue in the prevention of a tolerance against Pseudomonas aeruginosa. We evaluated the effect of antimicrobial use density (AUD) of carbapenem on drug susceptibility. The AUD of the four carbapenems, imipenem (IPM/CS), panipenem (PAPM/BP), meropenem (MEPM), and biapenem (BIPM), was examined at three hospitals in Ibaraki Prefecture, between April and September 2004. The AUD was calculated using the Defined Daily Doses (DDD) methodology developed by the WHO. A drug susceptibility test was conducted on the 306 Pseudomonas aeruginosa strains randomly collected from clinical specimens at the three hospitals between September and December 2004. In accordance with the standards set by the Clinical and Laboratory Standards Institute (CLSI), minimal inhibitory concentration (MIC) was measured using the broth microdilution method. The results showed that the AUD of carbapenem at the three hospitals tended to be higher than that in other research results in Japan. At one of the three hospitals, the AUD of the PAPM was remarkably high compared to the other carbapenems. Furthermore, P. aeruginosa strains collected at this hospital showed a low susceptibility to carbapenem, and many highly tolerant strains were also observed in this hospital. In order to maintain the susceptibility of Pseudomonas aeruginosa to carbapenem, the overall extent of carbapenem use must be optimal. The use of antimicrobial drugs should be controlled properly at each hospital, in order to prevent excessive use of PAPM/BP from being used over a long period of time.

Clinicopathological features and prognostic factors of Japanese patients with “peripheral T-cell lymphoma, unspecified” diagnosed according to the WHO classification

Clinicopathological features of 36 patients, male: 58.3%; median: 68 years, with "peripheral T-cell lymphoma, unspecified" diagnosed by the WHO criteria were reviewed. Majority (69.4%) had stage IV disease with frequent involvements into bone marrow, spleen, liver, and skin. According to the IPI, 72.2% were categorized as high or high-intermediate risk group. CR and PR were achieved in 12 and 10 out of 31 patients treated by CHOP-based chemotherapy, respectively. One- and two-year overall survivals were 60.6 and 25.0%, respectively. Performance status, serum LDH, and B symptom were significant prognostic factors. Survival of CD4-/CD8+ cases, corresponding to cytotoxic T-cell lymphoma, was significantly worse than that of CD4+/CD8-.

Clinicopathological analyses of 5 Japanese patients with CD56+ primary cutaneous lymphomas

We analyzed the clinicopathological features of 5 Japanese patients with CD56+ primary cutaneous lymphomas (3 men and 2 women aged 25 to 73 years). Except for 1 patient in whom bone marrow involvement was simultaneously observed, all patients presented with cutaneous lesions. Based on their Epstein-Barr virus (EBV) status, we categorized these patients into 2 groups, namely EBV-encoded small RNA-1 (EBER-1) (3 patients) and EBER-1- (2 patients). Generalized lymphadenopathy and bone marrow involvement were observed only in EBER-1 patients. Morphologically, angiocentric proliferation was more prominent in EBER-1+ patients and was accompanied by panniculitis-like changes. The lymphomas in EBER-1- patients featured monomorphic proliferation of lymphoblastic cells with no cytoplasmic granules. Phenotypically, CD3-, cytoplasmic CD3 epsilon+, and CD56+ were common findings in both types. The EBER-1- type showed an additional distinguishing feature, CD7+, CD4+, CD8-, HLA-DR+, and terminal deoxynucleotidyl transferase-positive (TdT+) phenotype. The lymphoma was primarily resistant in the EBER-1+ type, and the patients died within 6 months of admission. In contrast, the lymphoma in the EBER-1- patients was originally chemosensitive. Collectively, we consider there to be at least 2 types of CD56+ primary cutaneous lymphomas, corresponding to nasal-type natural killer (NK)/T-cell lymphomas (EBER-1+) and blastic NK-cell lymphomas (EBER-1-).

Interstitial pneumonitis related to granulocyte colony-stimulating factor administration following chemotherapy for elderly patients with non-Hodgkin's lymphoma

We treated three cases of interstitial pneumonitis (IP) in 26 elderly (> or = 65 years old) patients with non-Hodgkin's lymphoma (NHL) who received the same chemotherapeutic protocol including granulocyte colony-stimulating factor (G-CSF) administration. Fortunately, all three patients recovered from IP spontaneously by discontinuation of G-CSF alone or with administration of corticosteroid. Because the duration and extent of neutrophilia induced by G-CSF administration was not different between the cases complicated by IP and those without IP, underlying pulmonary damage is suggested to be more involved than neutrophil count in the development of IP.

Disseminated nontuberculous mycobacteriosis caused by mycobacterium kansasii in a patient with myelodysplastic syndrome

A 38-year-old man with pancytopenia due to myelodysplastic syndrome exhibited persistent pyrexia and mediastinal lymphadenopathy. A biopsy specimen of the lymph nodes showed diffuse infiltration of epitheloid cells, including acid-fast bacilli identified as Mycobacterium kansasii. Cultures from gastric lavage and stool yielded M. kansasii, and granulomas were found in the bone marrow. A diagnosis of disseminated nontuberculous mycobacteriosis (DNTM) was established. The patient's condition improved after treatment with isoniazid, rifampicin, ethambutol and granulocyte colony-stimulating factor. Although DNTM due to M. kansasii is rare in Japan, it should be recognized as a possible cause of opportunistic infections.

Effects of anti-platelet glycoprotein Ib and/or IIb/IIIa autoantibodies on the size of megakaryocytes in patients with immune thrombocytopenia

To determine whether anti-platelet autoantibodies react with megakaryocytes, as well as with platelets, in immune thrombocytopenia (ITP), 38 ITP patients were studied. They were classified into four groups; anti-platelet glycoprotein Ib-positive (group A, n = 5), anti-platelet glycoprotein II/b/IIIa-positive (group B, n = 2), positive to both antibodies (group C, n = 3), and negative to both antibodies (group D, n = 28). The number and size of megakaryocytes in each group were compared. The number of megakaryocytes in groups A, B, C, and D was 12.8 +/- 8.9, 75.2, 29.1, and 17.0 +/- 21.7/mm2, respectively. The mean cytoplasmic area of megakaryocytes in groups A, B, C, and D was 1001 +/- 26.3, 1621, 1109, and 1311 +/- 235.6/micrograms2, respectively. This finding indicated that, in the presence of anti-platelet glycoprotein Ib, megakaryocytes were not increased in number and were small in size, whereas, in the presence of anti-platelet glycoprotein IIb/IIIa, megakaryocytes were increased in number and in cytoplasmic area. Our study suggested that anti-platelet glycoprotein Ib may impair platelet production by megakaryocytes in ITP.

Megakaryopoiesis in patients with cyclic thrombocytopenia

Megakaryopoiesis was examined in 10 patients (eight females and two males) with cyclic thrombocytopenia (CT) to investigate the underlying pathogenesis. Numbers of CFU-Meg and megakaryocytes and the mean cytoplasmic area (mean area) of megakaryocytes at the peak, nadir, ascent mid phase, and descent mid phase of the platelet cycle were determined. The patients were classified as female cases group I (cases 1-4; previously diagnosed as ITP and CT occurred during remission), female cases group II (cases 5-8; persistent CT from initial diagnosis), and male CT (cases 9 and 10). In three of the four female cases in group I, numbers of CFU-Meg and megakaryocytes were normal or increased persistently during the platelet cycle, whereas the mean area fluctuated in synchrony with the platelet cycle, suggesting failure of cyclic production rather than platelet destruction. In the female cases in group II and one female case in group I, numbers of CFU-Meg and megakaryocytes were also normal or increased at four phases of the cycle, but the mean area did not fluctuate, remaining large during the cycle, suggesting cyclic destruction or platelet clearance. In contrast, in the male patients values for numbers of CFU-Meg, megakaryocytes and mean cytoplasmic area fluctuated during the platelet cycle, indicating that cyclic changes in megakaryopoiesis generated the platelet cycle. These findings indicate that the measurement of cytoplasmic area is useful for distinguishing cyclic platelet production from cyclic destruction or clearance in CT.

[Minimally differentiated hypoplastic leukemia]

Sixty-seven years-old female, who was an atomic bomb survivor in Hiroshima, was pointed out as having leukopenia and anemia in 1991. She was referred to Tsukuba University Hospital in June 1992. Her peripheral blood count showed pancytopenia- 2,600/microliters WBC, 10.5 g/dl hemoglobin, and 80,000/microliters platelets- at that time. BM biopsy revealed hypoplastic marrow and increased peroxidase-negative blasts (32.8%). Surface marker analysis of the blasts showed a feature of CD2+ CD33+ CD34+ CD13+ CD3-. Electronmicroscopically, myeloperoxidase was positive. She was diagnosed as having hypoplastic leukemia of which the blasts had a feature of AML-M0 by FAB-group. After 6 months' silent period, her pancytopenia became profound. We successfully reduced the blasts by BAM therapy. However, she died of bacterial pneumonia during the myelosuppressive state. This is a case of minimally differentiated hypoplastic AML.

[von Recklinghausen's disease complicated by macroglobulinemia, malignant schwannoma and pheochromocytoma]

We reported a case of von Recklinghausen's disease complicated by macroglobulinemia, malignant Schwannoma and pheochromocytoma. A 43-year-old male patient who was diagnosed as von Recklinghausen's disease developed abdominal masses at 5 years after the adrenalectomy for pheochromocytoma. Computed tomography showed multiple heterogeneous tumors in abdominal cavity. Histological examination of resected tumor was compatible with malignant Schwannoma. At the same time, peripheral blood and bone marrow smears showed a large number of plasmacytoid lymphocytes. Immunoelectrophoresis revealed M-protein of IgM, kappa type. He was also diagnosed of coexistence with macroglobulinemia. The chemotherapeutic protocols used were not effective against both malignant Schwannoma and macroglobulinemia. The present case is a rare case of von Recklinghausen's disease associated with triple neoplasms.

[A study of hypoplastic myelodysplastic syndrome]

To distinguish hypoplastic myelodysplastic syndrome (MDS) from aplastic anemia (AA), morphological abnormalities of bone marrow hematopoietic cells in 8 patients with MDS and 39 patients with AA were studied. All the patients with MDS and AA showed prolonged plasma iron disappearance time, (PIDT1/2) > 120 min. Five hundred erythroid and myeloid cells, as well as 20 megakaryocytes were counted. Dysplastic changes were defined if morphological changes were present in more than 1.0% cells with only one lineage, or in more than 0.6% cells with more than two lineages. Twenty six of 39 patients with AA showed morphological abnormalities. In MDS cases, morphological abnormalities were prominent in trilineage cells in some cases, in bilineage (erythroid and megakaryocytic or myeloid and megakaryocytic cells), in others, or solely in myeloid cells or in megakaryocytic cells in other cases. Morphological abnormalities seen solely in erythroid cells, especially those with segmented nuclei were considered to be less significant for the diagnosis of MDS. The findings were considered to be useful to distinguish hypoplastic MDS from AA.

[Human parvovirus B19-induced aplastic crisis in an elderly man with intestinal hemorrhage]

An elderly man with an intestinal hemorrhage from bowel diverticulosis developed human parvovirus B19-induced aplastic crisis. A 71-year-old man noticed occasional tarry stools and at the same time showed fever, arthralgia and severe anemia. Blood counts revealed Hgb 5.3g/dl, reticulocytes 0%, and WBC 1,900/microliters. Bone marrow examination showed hypocellular marrow with rare erythroid precursors (4.8%). A few giant proerythroblasts were found in the bone marrow smears. A diagnosis of parvovirus B19 infection was made because of detection of B19-specific IgM and IgG antibodies. Parvovirus B19 infection should be carefully checked for in patients with hemorrhage as well as those with hemolysis.