Morphological and physiological changes in Artemisia selengensis under drought and after rehydration recovery

Changes in global climate and precipitation patterns have exacerbated the existing uneven distribution of water, causing many plants to face the alternate situation of drought and water flooding. We studied the growth and physiological response of the wetland plant Artemisia selengensis to drought and rehydration. In this study, Artemisia selengensis seedlings were subjected to 32.89% (SD), 47.36 % (MD), 60.97% (MID), and 87.18 % (CK) field water holding capacity for 70 days, followed by 14 days of rehydration. The results showed that drought inhibited the increase of plant height, basal diameter, and biomass accumulation under SD and MD, but the root shoot ratio (R/S) increased. Drought stress also decreased the content of total chlorophyll (Chl), chlorophyll a (Chl-a), chlorophyll b (Chl-b), and carotenoid (Car). Soluble sugar (SS) and proline (Pro) were accumulated rapidly under drought, and the relative water content (RWC) of leaves was kept at a high level of 80%. After rehydration, the plant height, basal diameter, biomass, and R/S ratio could not be recovered under SD and MD, but these indicators were completely recovered under MID. The RWC, Chl, Chl-a, Chl-b, Car, and osmotic substances were partially or completely recovered. In conclusion, Artemisia selengensis not only can improve drought resistance by increasing the R/S ratio and osmotic substances but also adopt the compensatory mechanism during rehydration. It is predictable that A. selengensis may benefit from possible future aridification of wetlands and expand population distribution.

MicroRNA-543 inhibits the proliferation, migration, invasion, and epithelial-mesenchymal transition of triple-negative breast cancer cells via down-regulation of ACTL6A gene

PURPOSE

To investigate the effect of microRNA-543 (miR-543) on the proliferation, migration, invasion, and epithelial-mesenchymal transition (EMT) of triple-negative breast cancer (TNBC) cells, and the associated mechanism.

METHODS

Human breast cancer cells (MDA-MB-231, HCC1937, and MCF-7, ZR-75-1) and normal human breast epithelial cell line (MCF10A) were transfected with miR-543 mimics or inhibitor using lipofectamine 2000. Quantitative reverse transcription polymerase chain reaction (qRT-PCR) and Western blotting were used to determine the mRNA and protein expression levels of miR-543, actin-like protein 6A (ACTL6A), vimentin, Snail, and E-cadherin in breast cancer cells/tissue. Cell counting kit-8 (CCK-8), wound-healing, and Transwell assays were used to measure the effect of miR-543 on TNBC cell proliferation, invasion, and migration. Overall survival was determined using data from Gene Expression Omnibus (GEO) and Cancer Genome Atlas (TCGA) databases. Bioinformatics analysis and luciferase reporter gene assay were used to determine the regulatory effect of miR-543 on ACTL6A.

RESULTS

The level of expression of miR-543 was significantly lower in breast cancer cells/tissue than in normal human breast epithelial cell/tissue (p < 0.05). MicroRNA-543 expression level was significantly reduced in TNBC cells/tissue, relative to the other breast cancer cells/normal breast tissue (p < 0.05). MicroRNA-543 significantly suppressed tumor growth and the proliferation, migration, invasion, and epithelial-mesenchymal transition (EMT) of TNBC cells, in mouse xenograft model (p < 0.05).

CONCLUSIONS

miR-543 influences the biological behavior of TNBC cells by directly targeting ACTL6A gene. miR-543 could serve as a novel diagnostic and therapeutic target for TNBC.

Mechanism of Bushen Jianpi decoction in preventing and treating osteoporosis caused by aromatase inhibitors in breast cancer treatment

PURPOSE

Research on the mechanism of Bushen Jianpi decoction (BJD) for preventing and treating osteoporosis caused by aromatase inhibitors (AI) during treatment for breast cancer resection.

METHODS

An ovariectomized mouse model was established using random division into 6 groups: a sham ovariectomized group, a blank control group, a control group, an alendronate group, a BJD group, and a drug combination group. Mice breast cancer cell lines (4T1) were cultured and seeded into the armpits of 6 groups of BALB/c mice. The mouse breast cancer postoperative model was built when resecting the tumor after 3 weeks following seeding tumor. After 1 weeks, the 6 groups of mice were given different drugs. Then the following analyses were made: estradiol (E2) levels and alkaline phosphatase (ALP) levels in the serum; detection of in vitro bone density and calcium and bone phosphorus content; tumor pathology and immunohistochemistry detection.

RESULTS

The results suggested that BJD decreased levels of ALP in ovariectomized mice, and there was a trend for improved bone loss. BJD strengthened the trend of alendronate to improve bone loss, improved bone density, bone calcium and phosphorous, and reduced ALP. BJD had a certain role on the promotion of the expression of estrogen receptors (ERs) in the relapse of the tumor tissue.

CONCLUSIONS

Combined therapy with BJD and alendronate can act synergistically against osteoporosis, which was possibly related to a reduced bone conversion rate through inhibiting bone resorption. BJD may block the MAPK signal pathway in breast cancer cells, increasing the expression of ERs and making cancer cells sensitive to endocrine treatment.

Expressions of ECE-CYC2 clade genes relating to abortion of both dorsal and ventral stamens in Opithandra (Gesneriaceae)

BACKGROUND

ECE-CYC2 clade genes known in patterning floral dorsoventral asymmetry (zygomorphy) in Antirrhinum majus are conserved in the dorsal identity function including arresting the dorsal stamen. However, it remains uncertain whether the same mechanism underlies abortion of the ventral stamens, an important morphological trait related to evolution and diversification of zygomorphy in Lamiales sensu lato, a major clade of predominantly zygomorphically flowered angiosperms. Opithandra (Gesneriaceae) is of particular interests in addressing this question as it is in the base of Lamiales s.l., an early representative of this type zygomorphy.

RESULTS

We investigated the expression patterns of four ECE-CYC2 clade genes and two putative target cyclinD3 genes in Opithandra using RNA in situ hybridization and RT-PCR. OpdCYC gene expressions were correlated with abortion of both dorsal and ventral stamens in Opithandra, strengthened by the negatively correlated expression of their putative target OpdcyclinD3 genes. The complement of OpdcyclinD3 to OpdCYC expressions further indicated that OpdCYC expressions were related to the dorsal and ventral stamen abortion through negative effects on OpdcyclinD3 genes.

CONCLUSION

These results suggest that ECE-CYC2 clade TCP genes are not only functionally conserved in the dorsal stamen repression, but also involved in arresting ventral stamens, a genetic mechanism underlying the establishment of zygomorphy with abortion of both the dorsal and ventral stamens evolved in angiosperms, especially within Lamiales s.l.

Liver graft-versus-host disease after donor lymphocyte infusion for relapses of hematologic malignancies post allogeneic hematopoietic stem cell transplantation

Graft-versus-host disease (GVHD) is the commonest complication after donor lymphocyte infusion (DLI). In 19 patients undergoing DLI for relapses of hematologic malignancies post hematopoietic stem cell transplantation (HSCT), 11 developed GVHD, of whom nine had isolated liver involvement, and two had liver and skin involvement. The clinical diagnosis of liver GVHD was hepatitic in six patients (55%) and classical in five patients (45%). Patients with GVHD post-DLI showed a different clinical pattern when compared to a cohort of 106 cases of GVHD post-HSCT, in having significantly more isolated liver involvement (9/11 vs 17/106, P<0.001), and less skin (2/11 vs 80/106, P<0.001) and gut (0/11 vs 28/106, P<0.001) involvement. However, liver GVHD post-DLI and post-HSCT had comparable patient characteristics, underlying diseases, clinical subtypes (classical and hepatitic) and response to treatment.

Quantification of polyoma BK viruria in hemorrhagic cystitis complicating bone marrow transplantation

Polyoma BK virus (BKV) is frequently identified in the urine of bone marrow transplantation (BMT) patients with hemorrhagic cystitis (HC). However, viruria is common even in asymptomatic patients, making a direct causative role of BKV difficult to establish. This study prospectively quantified BK viruria and viremia in 50 BMT patients to define the quantitative relationship of BKV reactivation with HC. Adenovirus (ADV) was similarly quantified as a control. More than 800 patient samples were quantified for BKV VP1 gene with a real-time quantitative polymerase chain reaction. Twenty patients (40%) developed HC, 6 with gross hematuria (HC grade 2 or higher) and 14 with microscopic hematuria (HC grade 1). When compared with asymptomatic patients, patients with HC had significantly higher peak BK viruria (6 x 10(12) versus 5.7 x 10(7) genome copies/d, P <.001) and larger total amounts of BKV excreted during BMT (4.9 x 10(13) versus 7.7 x 10(8) genome copies, P <.001). There was no detectable increase in BK viremia. Binary logistic regression analysis showed that BK viruria was the only risk factor, with HC not related to age, conditioning regimen, type of BMT, and graft-versus-host disease. Furthermore, the levels of ADV viruria in patients with or without HC were similar and comparable with those of BK viruria in patients without HC, suggesting that the significant increase in BK viruria in HC patients was not due to background viral reactivation or damage to the urothelium. BK viruria was quantitatively related to the occurrence of HC after BMT.

Successful mismatched sibling cord blood transplant in Hb Bart's disease

A 20-month-old girl with Hb Bart's disease, who had survived neonatal complications, underwent HLA-DR antigen mismatched sibling cord blood transplantation successfully. Immune thrombocytopenia, which occurred around 2.5 months after transplant, responded to intravenous gamma-globulin. The fetal hemoglobin level rose to a peak of 52.3% on day +69 post transplant and declined gradually during the following year. Ten percent of hemoglobin Bart's was detected 2 months after transplant and this reflects the alpha-thalassemia trait of the donor.

Expression of HLA class I, beta(2)-microglobulin, TAP1 and IL-10 in Epstein-Barr virus-associated nasal NK/T-cell lymphoma: Implications for tumor immune escape mechanism

Several mechanisms of immune escape might be in operation in Epstein-Barr virus (EBV)-associated nasal NK/T-cell lymphoma. We have previously shown the downregulation of the immunogenic EBV nuclear antigens by alternative promoter usage and the preferential selection of the deletion genotype of latent membrane protein 1 in nasal lymphoma. To understand further the strategies used for immune escape by this tumor, we examined by immunohistochemistry HLA class I expression in 15 cases using frozen sections, along with beta(2)-microglobulin and transporter associated with antigen processing 1 (TAP1) expression in 39 cases using paraffin sections. All nasal NK/T-cell lymphomas showed positive staining for HLA class I, beta(2)-microglobulin and TAP1 on most tumor cells, except for two cases (5%) in which most of the tumor cells lacked beta(2)-microglobulin staining. We next immunostained for interleukin-10 on frozen sections in 13 cases, all of which showed strong expression by most tumor cells. Transcription of human interleukin-10 but not EBV BCRF1 (viral interleukin-10) was identified by reverse transcriptase-polymerase chain reaction in these nasal NK/T-cell lymphomas. Overall, our data suggest that global downregulation of HLA class I or TAP1 rarely accounts for the ability of nasal NK/T-cell lymphoma to evade immunosurveillance and that other immune escape mechanisms may be operating in nasal NK/T-cell lymphoma, such as production of interleukin-10 to suppress the local immune response.

BCL10 somatic mutations rarely occur in gastric lymphoma: detection of high frequency of polymorphisms in BCL10 coding region

The BCL10 gene, recently isolated due to its involvement in the t(1;14)(p22;q32) of mucosa-associated lymphoid tissue B cell non-Hodgkin lymphoma (MALToma), was shown to have frequent somatic mutations and short deletions within the coding region in MALToma and a variety of other lymphomas and solid tumors. These observations have been recently questioned. In this study, we examined BCL10 gene mutations by direct sequencing of the entire coding region of the BCL10 gene, amplified from paired normal and tumor genomic DNAs, as well as tumor cDNAs, in 23 cases of primary gastric B cell non-Hodgkin lymphomas, comprising of 6 cases of MALToma and 17 cases of diffuse large cell (DLC) lymphoma. Heterozygosity due to three types of known polymorphisms in codon 5 (17.3%), codon 8 (21.7%), and codon 213 (8.6%) were observed in both normal germline DNA and tumor DNAs and tumor cDNAs in individual cases. In one case (4.3%) G/C heterozygosity in codon 8 in normal germline DNA was reduced to homozygosity (LOH) in tumor DNA and cDNA. Mutations inactivating BCL10 gene product function were not found in any of these cases. Moreover, post-transcriptional alterations were not indicated by abnormalities in BCL10 mRNA sequence in tumor cDNAs in these gastric lymphoma cases. Our results show that somatic mutations in the BCL10 gene rarely occur in gastric lymphoma and indicate that this gene is unlikely to be of pathogenetic significance in the majority of gastric lymphomas.

Identification and characterization of BCL6 translocation partner genes in primary gastric high-grade B-cell lymphoma: heat shock protein 89 alpha is a novel fusion partner gene of BCL6

Primary gastric high-grade B-cell lymphoma (HGBL) is a special type of non-Hodgkin's lymphoma. So far, the genetic features of this tumor have not been well characterized. Recently, a high incidence of BCL6 rearrangements has been detected in HGBL. However, no previous cytogenetic studies have found translocations involving the BCL6 locus (3q27) in HGBL, and the genetic basis underlying the BCL6 rearrangements in this tumor remains unclear. We therefore characterized the partner genes of BCL6 in five primary gastric HGBLs with a rearranged BCL6 gene by analyzing BCL6 transcripts using the 5' RACE (rapid amplification of cDNA end) strategy. BCL6 translocation partner genes were identified at the 5' end of the chimeric transcripts in all five cases, including the immunoglobulin heavy-chain (IGH) gene in three cases and the immunoglobulin lambda-light-chain gene and the heat shock protein 89 alpha (HSP89A) gene in the other two cases. The chimeric transcripts in all cases contained the intact BCL6 exon 2, but lacked exon 1, which was replaced by sequences from the partner genes, suggesting that BCL6 expression was under the control of regulatory sequences of the partner genes. These results, for the first time, indicate that immunoglobulin genes, especially IGH, are the most common BCL6 translocation partner genes in primary gastric HGBL and that HSP89A is a novel partner of BCL6. Because immunoglobulin genes are also the most frequent partners of BCL6 in nodal diffuse large B-cell lymphoma (DLBCL), these data suggest that primary gastric HGBL shares a common genetic basis with nodal DLBCL. Genes Chromosomes Cancer 27:69-75, 2000.

Differential cytokine expression in EBV positive peripheral T cell lymphomas

AIM

To investigate whether specific cytokines are secreted locally at the tumour site in Epstein-Barr virus (EBV) positive peripheral T cell lymphoma (PTCL).

METHODS

An RNase protection assay system was used to study the differential expression of 21 cytokines in parallel in eight cases of EBV positive non-nasal PTCL, and compared with 11 EBV negative non-nasal PTCLs and three EBV positive nasal natural killer (NK) cell lymphomas.

RESULTS

Among the eight EBV positive cases, interferon gamma (IFN-gamma), lymphotoxin beta (LT beta), interleukin 10 (IL-10), tumour necrosis factor alpha (TNF-alpha), transforming growth factor beta 1 (TGF-beta 1), and IL-1 receptor a (IL-Ra) were frequently detectable. IL-15, IL-6, IL-4, IL-1 beta, TNF-beta, and IL-9 were sporadically detectable. Of the frequently detectable cytokines, IFN-gamma and LT beta were commonly detected in the EBV negative cases. For cases with > 50% EBV encoded small non-polyadenylated RNA (EBER) positive cells, IL-10, TNF-alpha, and TGF-beta 1 were detected in three of three cases, and IL-1Ra in two of three cases. For cases with < 20% EBER positive cells, IL-10 was detected in three of five cases, TNF-alpha in two of four cases, but TGF-beta 1 and IL-1Ra were not detected. Interestingly, IL-6 was detected in two of three cases with > 50% EBER positive cells, but only in one of five cases with < 20% EBER positive cells. For comparison, in NK cell lymphomas, IL-10, TNF-alpha, IL-1Ra, and IL-6 were all detectable, but TGF-beta 1 was not detected at all. Immunohistochemical staining revealed IL-10 in many cells; in contrast, EBV latent membrane protein 1 (LMP1) was only found to be positive in isolated cells.

CONCLUSIONS

Certain cytokines, such as IL-10 and TNF-alpha, might be expressed preferentially in EBV positive peripheral T cell lymphomas. It is likely that such a cytokine environment enhances EBV infection and contributes towards tumorigenesis.

Preferential type 1-1 cytokine gene expressions in peripheral T-cell lymphomas

In this study, we have investigated whether a pattern of cytokine gene expression can be found in non-Hodgkin's peripheral T-cell lymphoma (PTCL). By using RNase protection assays and RT-PCR, we have systematically studied IL1alpha, IL1beta, IL1-Ra, IL2, IL4, IL5, IL6, IL9, IL10, IL12p35, IL12p40, IL13, IL14, IL15, IFNgamma, IFNbeta, TNFalpha, TNFbeta, LTbeta, and TGFbeta1, TGFbeta2 and TGFbeta3. Twenty-two cases of PTCL inclusive of three nasal NK-cell lymphomas were selected for the study; three cases of reactive lymphoproliferation were included for comparison. Results show that IFNgamma gene expression (key Type 1 cytokine) was frequently detected [18/22 (82 per cent)]. In contrast, IL4 (key Type 2 cytokine) was only detected in 4/22 (18 per cent) of cases (weaker than IFNgamma in three cases). This distinction was also found at the protein level by immunohistochemistry. In addition, TNFbeta and TNFalpha (strongly expressed by Type 1 cells) were almost complimentarily detected [4/19 (21 per cent)] and 12/19 (63 per cent), respectively). In contrast, neither IL5 nor IL13 (strongly expressed by Type 2 cells) were detected at all. However, 14/22 cases expressed IL10, another Type 2 cytokine, which suggests that the autoregulatory feedback loop is stimulated. Compared to the tumour types, the cytokine profiles in the reactive lymphoproliferative types also resembled a Type 1-like pattern but was less striking. The overall result suggested a preferential expression of certain cytokines, and these cytokines may play an important role in pathophysiologic progression in these T-cell disorders.

Epstein-Barr virus infection and its gene expression in gastric lymphoma of mucosa-associated lymphoid tissue

The role of Epstein-Barr virus (EBV) in the pathogenesis of gastric lymphoma of mucosa-associated lymphoid tissue (MALT) has not been well understood. The aim of the study was to investigate EBV infection and its gene expression in this tumor in order to understand its role in the pathogenesis. EBV infection was screened by in situ hybridization for EBV-encoded non-polyadenylated RNA (EBER ISH) in 79 cases of gastric MALT lymphoma of nonimmunocompromised patients. The expression of EBV proteins [LMP1 (latent membrane protein 1), EBNA2 (EBV nuclear antigen 2), ZEBRA (switch protein encoded by BZLF1 gene)] was studied by immunohistochemistry in EBER-positive cases. EBV was detected with EBER ISH in 15 (19%) of the 79 cases. EBV was found in virtually all tumor cells in 2 cases of high-grade MALT lymphoma (2.5%) (EBV-associated), and was found only in occasional large or small lymphoid cells in 13 cases (16.5%). False positive EBER signal was detected in the mucinous glandular epithelial cells of gastric antrum with FITC-labeled oligonucleotide probe but not with digoxigenin or 35S-labeled riboprobes. Type II latency (EBER+LMP1+ EBNA2-) was detected in both EBV-associated cases. Type III latency (EBER+LMP1+EBNA2+) was also identified in one EBV-associated case besides latency II. Double labeling showed coexpression of LMP1 and EBNA2 in a small number of tumor cells, indicating the presence of type III latency in single cell level. In cases with only occasional EBER-positive large or small lymphoid cells, LMP1 and EBNA2 were not detected. ZEBRA was negative in all the cases. These findings suggest that EBV may contribute to the pathogenesis of a small proportion of high-grade MALT lymphoma, where virtually all tumor cells harbored EBV and the oncogenic viral protein LMP1 was expressed. Moreover, latency III of EBV infection may exist in nonimmunocompromised patient.

Risk factors for pulmonary tuberculosis in bone marrow transplant recipients

Little is known about the profile of infection with Mycobacterium tuberculosis in bone marrow transplant (BMT) recipients. Of five BMT series with a total of more than 5,000 patients, only 10 cases of M. tuberculosis infection were described, with an overall incidence of 0.19%. We have conducted a prospective evaluation of 183 consecutive BMT recipients, and 10 patients were found to develop pulmonary tuberculosis post-BMT, yielding an incidence of 5.5%. We described the clinical features of these 10 patients, and analyzed the risk factors for development of tuberculosis using age- and sex-matched case control subjects who did not develop the disease. The median age of the 10 patients who developed tuberculosis was 29 yr (range, 17 to 40 yr). The median time for onset of symptoms was 150 d (range, 23 to 550 d), mainly presenting with fever and cough, with infiltrates on chest radiograph. Respiratory tract specimens, mostly sputum, yielded positive smears for acid-fast bacilli in three and positive M. tuberculosis culture in eight, whereas lung tissue histology was the first diagnostic test in two patients. Treatment with standard antituberculosis drugs for a longer duration was highly effective, with no excessive side effects. Risk factors identified for development of tuberculosis included allogeneic BMT (p < 0.05, relative risk [RR] = 23.7), total body irradiation (p < 0. 05, RR = 4.9), and chronic graft-versus-host disease (GVHD) (p < 0. 05, RR = 3.6). It is postulated that chronic GVHD predisposed to development of tuberculosis mainly via disruption of host reconstitution of immune defenses against M. tuberculosis.

Sibling HLA-matched cord blood transplant for beta-thalassemia: report of two cases, expression of fetal hemoglobin, and review of the literature

PURPOSE

A program of cord blood stem cell (CBSC) transplants for patients with beta-thalassemia major was initiated in conjunction with the prenatal diagnostic service in 1994. Two patients who received HLA-matched related CBSC transplants with posttransplant fetal hemoglobin (HbF) expression are described and the literature is reviewed.

PATIENTS AND METHODS

After screening 12 pregnancies, matched sibling CBSC transplants were performed for 2 girls with beta-thalassemia major when they were 3.8 and 2.2 years old, respectively. Their HbF was assayed serially.

RESULTS

The nucleated cell counts/kg were 11.4 x 10(7) and 6.2 x 10(7), which engrafted on days 19 and 24, respectively. The children are now transfusion-independent at 3 years and 1.2 years posttransplant. Their HbF levels showed a rapid rise posttransplant and reached peak levels of 37.2% and 42.2% on day 83 and day 88, respectively. The HbF levels declined to 1.0% and 3.8% on day 581 and day 305, respectively. Nine other sibling CBSC transplants for thalassemias have been reported with an engraftment rate of approximately 50%. Graft rejection was related to insufficient CBSC number in one.

CONCLUSIONS

HbF levels in patients with beta-thalassemia major after CBSC transplants could be influenced by many factors, including reactivation of HbF synthesis, intrinsic rate of Hb switching of CBSC, and mixed chimerism.

Clinicopathological features of megaloblastic anaemia in Hong Kong: a study of 84 Chinese patients

Megaloblastic anaemia is uncommon in Hong Kong. Eighty-four consecutive Chinese patients with megaloblastic anaemia were studied. There were 48 males and 36 females, with a median age at presentation of 67 years. Vitamin B12 deficiency was found in all cases, with none of the patients showing folate deficiency. The frequency of pernicious anaemia in our patients was higher than in other south-east Asian series but comparable with western ones. When compared with patients in the West, our cases showed the following main differences: virtual absence of folate deficiency, even in alcoholics; absence of associated gastric malignancies; and a high frequency of tuberculosis.

Clonorchiasis in bone marrow transplant recipients

Among 380 bone marrow transplant (BMT) recipients, five cases (1.3%) of clonorchiasis were observed from 1991 to 1996. Clonorchis sinensis infection was evident in the results of stool examinations performed for screening purposes 7 days before bone marrow transplantation. Salmonella species were isolated concomitantly from the stools of two of the five patients. None of the patients had symptoms due to clonorchiasis. Ultrasonography did not show dilated hepatobiliary ducts, stones, or periportal fibrosis. Fatty liver changes were detected in one patient. All five patients received praziquantel (25 mg/kg po t.i.d. for 1 day) before bone marrow transplantation. Only two patients who underwent allogeneic transplantation had mild venoocclusive disease of the liver with transient hyperbilirubinemia and mildly elevated liver enzyme levels, whereas hyperbilirubinemia or elevated serum alanine aminotransferase levels, related to conditioning toxicity, occurred in two other patients. After treatment with praziquantel, stool examination for all five patients were negative for C. sinensis ova. In addition, Salmonella species were not detected after ciprofloxacin prophylaxis. All five patients survived for > 300 days. Given the availability of effective therapy and in the absence of excessive complications, clonorchiasis is not a contraindication to bone marrow transplantation.

Acute myeloid leukemia after azathioprine treatment for autoimmune diseases: association with -7/7q-

Azathioprine is used as an immunosuppressant in a variety of clinical situations, and its prolonged use is associated with an increased risk of solid malignancies. Three patients (one with rheumatoid arthritis and two with systemic lupus erythematosus) treated with azathioprine for 3 to 7 years developed acute myeloid leukemia (AML). The total cumulative doses of azathioprine varied from 89-260 g. An antecedent prolonged pancytopenic phase suggestive of myelodysplasia developed in all the cases. Morphological analysis showed AML with trilineage myelodysplastic features in residual marrow cells in all the cases. Karyotypic analysis showed deletion of the long arm of chromosome 7 (7q-) in one case and monosomy 7 (-7) in two cases. These were chromosomal aberrations typically associated with mutagen- or therapy-related AML. Fluorescence in situ hybridization with a chromosome-7-specific DNA probe was used to investigate the distribution of the monosomy 7 clone in two cases. Monosomy 7 was demonstrated in both the leukemic blasts and the residual myeloid cells of various stages of differentiation. This finding indicated that the leukemia had evolved from a mutated clone that was capable of terminal differentiation, which was consistent with the biological characteristics of the myelodysplastic syndromes. These cases represented therapy-related AML, as evidenced by clincopathological features, karyotypic aberrations of 7q-/-7, and demonstration of leukemic evolution from an underlying clonal myeloid disorder. The data support the hypothesis that azathioprine might be directly mutagenic.

Frequent detection of Epstein-Barr virus-infected B cells in peripheral T-cell lymphomas

Although Epstein-Barr virus (EBV) positivity has been described in peripheral T-cell lymphomas (PTCLs) in Chinese patients, the cellular lineage of EBV-harbouring cells is unknown. Forty-four cases of PTCL were therefore studied by in situ hybridization (ISH) for EBV-encoded small non-polyadenylated RNA 1 and 2 (EBER), and the lineage of the EBER+ cells was determined by double labelling. The findings were further correlated with the clonality of EBV and the genotype of these EBER+ tumours. The results for the detection of EBV by ISH show that 23 of the 44 cases were EBER+. In 5/23 of the EBER+ cases, EBER was found in around 50 per cent of atypical cells and in 18/23 cases, EBER was found in a subpopulation of atypical cells. Among the EBER+ cases, all 15 tested showed clonal T-cell receptor gene rearrangement by Southern blot hybridization. Double labelling was successfully done in 11 EBER+ cases, and by comparison, EBER+/CD20+ B cells outnumbered the EBER+/CD3+ T cells in all these cases. EBV clonality analysis revealed that EBV was monoclonal in six EBER+ cases and biclonal in three cases. With the predominance of EBV+ B cells over EBV+ neoplastic T cells being observed in most of these cases, it is possible that the EBV-infected clonal population may be of B-cell lineage. This was supported in some cases where a faint clonal band was seen over a background smear in the gene rearrangement study of immunoglobulin heavy chain gene by polymerase chain reaction (PCR), indicating a minor B-cell clone. It is concluded that in EBV+ PTCL, EBV is preferentially localized in B cells rather than neoplastic T cells. The neoplastic T cells may support the clonal proliferation of a subpopulation of EBV+ B cells in PTCLs.

Clinical significance of alimentary tract microbes in bone marrow transplant recipients

A prospective study on the microbes isolated from the alimentary tract in 120 bone marrow transplant (BMT) recipients (1991-1993) was undertaken to define the spectrum of organisms isolated under antimicrobial prophylaxis, their temporal sequence of emergence, and the associated morbidity and mortality. Clostridium difficile (n = 20), isolated in the pre-engraftment and early post-engraftment periods (day 2-45 post-BMT), was the most common microbe recovered from stool of patients with diarrhea. In contrast to previous reports, no significant difference in mortality was observed between patients with and without C. difficile isolated in stool. Two patients had neutropenic ileocecitis with concomitant bacteremia due to Escherichia coli and Klebsiella pneumoniae. One patient was found to have astrovirus gastroenteritis (day 7), and Giardia lamblia was recovered from the stool of another (day -7). Heavy growth of Staphylococcus aureus from direct smear-positive specimens was found from the upper airway of two patients with severe mucositis and complete dysphagia (day 12 and 23). Salmonella spp. of groups B and E were found in the stool of five asymptomatic patients at the time of conditioning. No specific organisms was recovered from the endoscopic brushing of two patients with lower end esophagitis, three patients with upper gastrointestinal bleeding, and three patients with perirectal cellulitis. During the post-engraftment period, five patients had documented cytomegalovirus gastroenterocolitis (days 34-97), one had Mycobacterium chelonae colitis (day 70), and another had nodular gastritis due to Acremonium falciforme (day 270). Overall, only 28% of patients with alimentary tract symptoms/syndrome had specific pathogens isolated from clinical specimens. Differentiation of the causation of alimentary tract symptoms was often difficult because noninfectious complications such as conditioning toxicity, graft-versus-host disease, and its treatment often caused alimentary tract symptoms in addition to predisposed BMT patient to infection. The reluctance of obtaining tissue biopsy for ascertaining the importance of those potential alimentary tract pathogens often dictate the use of empirical treatment.

Treatment of adenovirus-associated haemorrhagic cystitis with ganciclovir

We report a 47-year-old bone marrow transplant recipient with haemorrhagic cystitis caused by adenovirus successfully treated with ganciclovir. This is the first report on the use of ganciclovir for the successful treatment of adenoviral infection. Shell vial culture may be more sensitive than conventional culture in the detection of adenovirus in such patients.

Human herpesvirus-6 and human herpesvirus-7 infections in bone marrow transplant recipients

Human cytomegalovirus (HCMV), human herpesvirus-6 (HHV-6), and human herpesvirus-7 (HHV-7) DNA in peripheral blood leukocytes (PBL) of 61 bone marrow transplant recipients was monitored weekly during the first 12 weeks post-transplantation by a nested polymerase chain reaction (PCR). Thirty-seven (61%), 17 (28%), and 32 (53%) of patients had one or more PBL specimens positive for HCMV, HHV-6 or HHV-7 DNA, respectively. HHV-7 DNA in PBL during the early post-transplant period was associated with a longer time to neutrophil engraftment (mean 28.8 days vs 19.8 days; P = 0.01). In two patients who failed to engraft, HHV-6 DNA and HHV-7 DNA was detected in plasma and PBL, respectively, early in their post-transplant period. Patients with HCMV disease were more likely to have concurrent HHV-7 DNA in PBL prior to onset of disease than were patients with asymptomatic HCMV infection, suggesting that HHV-7 may be a cofactor in the progression from HCMV infection to HCMV disease. In the 17 patients (179 specimens) in whom viral DNA in plasma was studied (in addition to PBL), a positive result was found only in 3. In each, viral DNA in plasma appeared to correlate with clinically significant disease. HHV-7 DNA in plasma was associated with encephalitis in an allograft recipient.

Stage-specific manifestation of mold infections in bone marrow transplant recipients: risk factors and clinical significance of positive concentrated smears

Potassium hydroxide-concentrated smears, prepared from sedimented remains of clinical specimens, were used to distinguish between mold infection and exogenous contamination in fungal culture-positive specimens. This method was applied in the study of 3,857 clinical specimens from 230 bone marrow transplant recipients who were followed up prospectively for infectious complications. Concentrated smears of only 86 (from 21 infected patients) of 149 fungal culture-positive specimens were positive for hyphae; 82 of the strains were Aspergillus species. Concentrated smears of the remaining 63 fungal culture-positive specimens were negative; the strains identified by culture were considered as exogenous contaminants (87% of which were Penicillium species). A stage-specific manifestation of mold infection was observed: 67% of mold infections occurred during acute graft-vs.-host disease (GVHD) a median of 47 days after transplantation, whereas 9% of mold infections occurred as rapidly fatal invasive disease before engraftment. Overall, of the 21 patients with mold infection, 17 (81%) had invasive mold disease, and four (19%) had mold colonization of airways secondary to chronic GVHD after day 100. The significant risk factors for mold infection were total-body irradiation and grade 2-4 acute GVHD. Because of our high mortality rate (82%), the consideration of antimold prophylaxis for such patients may be warranted.

Clearance of hepatitis B surface antigen after bone marrow transplantation: role of adoptive immunity transfer

Adoptive immunity transfer has been reported to be effective in clearing chronic hepatitis B virus (HBV) infection. Two hundred twenty-six patients who received allogeneic bone marrow transplantation (BMT) between May 1990 and September 1995 were screened for hepatitis B markers. Twenty-one patients were hepatitis B surface antigen (HBsAg) positive before BMT. The median follow-up period was 20 months (range, 2-59 months). Two of these patients had sustained clearance of HBV infection after transplantation. Both patients were hepatitis B e antigen (HBeAg)-negative, hepatitis B e antibody (anti-HBe)-positive, and serum HBV DNA-negative (by dot-blot hybridization) before BMT. Both had a flare in the serum alanine transaminase (ALT) level around the time of HBsAg clearance. Sustained clearance of HBsAg was observed in 2 of the 5 patients who received hepatitis B surface antibody (anti-HBs)-positive marrow but in none of the 16 patients who received anti-HBs-negative marrow (P < .05). One additional patient who received anti-HBs-positive marrow had transient HBsAg seroconversion. Among the 18 patients who remained persistently HBsAg-positive after BMT, 3 had HBeAg seroconversion and 3 had reversion to HBeAg positivity. In this study, we found a significant association between clearance of HBV infection and anti-HBs-positive bone marrow donors. Adoptive immunity transfer is effective in clearing HBV from patients with chronic HBV infection.

Natural killer cell lymphoma/leukemia: pathology and treatment

Malignancies arising from cells of putative natural killer (NK) cell origin have increasingly been recognized as distinct clinicopathological entities. These malignancies are marked by tumour cells with NK cell characteristics, including the immunophenotype of CD2+, surface CD3-, cytoplasmic CD3 epsilon+, CD7 +/-, and CD56+, and the genotype of germline T cell receptor gene. A consistent association with monoclonal Epstein-Barr virus infection in the tumour cell has been observed. These tumours are now regarded as putative NK cell lymphoma/leukemia. Pathologically, tumour cells show variable cytological appearances, with frequent angiocentricity and angioinvasion, associated with zonal necrosis. Clinically, most cases occur in the nasal area and upper aerodigestive tract. However, occurrence in non-nasal sites such as the skin, gastrointestinal tract and testis is also observed. A particularly aggressive form of NK lymphoma/leukemia presents fulminantly as disseminated disease sometimes with a leukemic phase. All types of NK lymphoma/leukemia have an extremely poor prognosis with a median survival of less than a year. New modalities of treatment, including the use of high dose chemotherapy and stem cell rescue may be needed to improve treatment outcome.

Hematological features and treatment outcome in acute myeloid leukemia with t(8;21)

We analyzed the hematological features and treatment outcome in 18 patients with t(8;21) acute myeloid leukemia (AML) diagnosed in Queen Mary Hospital, Hong Kong. They comprised 15 cases of M2, two cases of M4 and one case of M1 according to FAB criteria. Auer rods (17 cases) and dysgranulopoietic features (15 cases) were very frequently observed. Two cases showed marrow eosinophilia while blast cells in one patient demonstrated erythrophagocytic activity. Chromosome changes in addition to t(8;21) were seen in 14 patients, the most common of which was loss of a sex chromosome (10 cases). Of the 14 patients treated with intensive chemotherapy, 13 (93 per cent) entered complete remission with a median event-free survival (EFS) and overall survival (OS) of 11 and 24 months respectively. The probability of EFS and OS at 3 years were 33 +/- 14.3 per cent and 55.1 +/- 15.6 per cent respectively with a median duration of follow-up of 22 months. When compared with AML having no t(8;21) treated similarly in the same period, we could not demonstrate a better clinical outcome for t(8;21) AML.

Detection of CMV DNA in bone marrow transplant recipients: plasma versus leucocyte polymerase chain reaction

AIMS

To compare the nested polymerase chain reaction (PCR) assay for the detection of cytomegalovirus (CMV) DNA in peripheral blood leucocytes and plasma obtained from heparinised blood; to determine the efficiency of various DNA extraction methods to minimise inhibition of plasma PCR and their effect on the sensitivity of plasma PCR; to determine the inhibitory effect of heparin, dextran, and EDTA on the CMV PCR assay.

METHODS

217 heparinised blood specimens from 58 bone marrow transplant patients were processed and the sensitivities and specificities of the PCR assays using peripheral blood leucocytes and plasma (with simple, Instagene, and Geneclean extraction methods) were compared to those of conventional CMV culture. In a separate experiment, dilutions of heparin, dextran, and EDTA were included in PCR assays.

RESULTS

The detection of CMV DNA using peripheral blood leucocytes for PCR assay was significantly more sensitive (100%) than when using plasma (60%). Instagene and Geneclean extraction removed inherent inhibition but did not improve the sensitivity of the plasma PCR reaction. Heparin had an inhibitory effect on PCR.

CONCLUSIONS

PCR assay using peripheral blood leucocytes is better than plasma for guiding the prescription of ganciclovir to bone marrow transplant patients. Heparin is inhibitory to the plasma PCR reaction.

Essential thrombocythemia with BCR/ABL rearrangement

Essential thrombocythemia (ET) was diagnosed clinically in three patients Karyotypic analysis and reverse transcription polymerase chain reaction for the bcr-abl chimeric transcript showed that two were Philadelphia chromosome (Ph) positive, bcr-abl positive, whereas the third was Ph negative, bcr-abl positive. The first patient received an allogeneic bone marrow transplantation but relapsed as localized blastic transformation, thus behaving similarly to chronic myeloid leukemia (CML). However, the other patients showed clinical courses more in keeping with ET. Essential thrombocythemia with BCR rearrangements may resemble CML but there are clinical differences. These may be due to genetic changes in addition to the BCR rearrangement.

Pure red cell aplasia: clinical features and treatment results in 16 cases

Pure red cell aplasia (PRCA) is a rare hematological disease characterized by selective marrow erythroid aplasia. We report the clinical features and treatment results of 16 Chinese patients with PRCA. Nine (56%) cases were not associated with any underlying disorders and were considered idiopathic, while seven patients (44%) had associated diseases, three involving the thymus, two with T large granular lymphocyte leukemia (T-LGLL), and one each with Stevens-Johnson syndrome and acute hepatitis A. Conventional-dose corticosteroid therapy resulted in complete remission in three of 13 patients. Cyclosporin A was used in six patients. There were three complete and one partial remissions. High-dose methylprednisolone was ineffective in four patients who failed conventional-dose corticosteroids but achieved complete remission in one patient with thymoma who did not respond to thymectomy. Antithymocyte globulin was used in four patients, resulting in partial remission in only one patient with concomitant T-LGLL. Intravenous gamma globulin and danazol were ineffective in three patients. Thymectomy was performed in two patients, with one patient remitting. This is the largest series of PRCA reported in an oriental population. Our results indicate that treatment of PRCA may still be problematic and better therapeutic strategy will have to be defined.

Essential thrombocythemia: a retrospective analysis of 39 cases

Thirty-nine Chinese patients presenting as essential thrombocythemia (ET) were analyzed retrospectively. The median age at presentation was 69 years and the M:F ratio was 1.35:1. At diagnosis, 33 cases (84%) were asymptomatic and the diagnosis was made incidentally, while 3 cases (8%) presented with small vessel, and 2 cases (5%) with large vessel, thrombosis. One patient (3%) presented with minor bleeding. The platelet count ranged from 0.9-34 x 10(12)/l. Of 12 karyotypes done, 2 cases were abnormal, both showing the Philadelphia (Ph) chromosome. First-line therapy was radiophosphorus (32P) in 3 cases, melphalan in 20 cases, and hydroxyurea in 12 cases; 4 cases did not receive specific therapy. During the follow-up (mean = 4 years), no thrombotic or bleeding episodes were observed. One patient with the Ph chromosome underwent blastic transformation. These results indicate that bleeding and thrombosis occur significantly less in Chinese patients than in Western patients. The Ph chromosome appears to be a bad prognostic indicator. Because of the very low incidence of complications and good prognosis, the authors believe that cytoreductive therapy is best achieved by the use of hydroxyurea instead of alkylating agents or radiophorphours, as the latter agents are potentially leukemogenic.

Incidence of graft-versus-host disease in Hong Kong Chinese and its influence on survival after bone marrow transplantation from HLA-identical siblings

Graft-versus-host disease (GVHD) is an important complication of allogeneic bone marrow transplantation (BMT). To assess its influence on transplant outcome, we studied 90 Chinese patients with hematologic disorders with BMT from HLA-identical siblings. GVHD prophylaxis consisted of a combination of methotrexate (MTX) and cyclosporine A (CsA). The incidence of grade II-IV acute GVHD was 29% (95% CI 19-38%). The incidence of limited and extensive chronic GVHD was 30% (95% CI 20-40%). For patients transplanted for early hematologic malignancy (n = 40), those with GVHD (acute and/or chronic) had lower relapse rate (17% (95% CI 0-36%) vs. 54% (95% CI 26-82%), P = 0.043). They had higher transplant-related mortality (12% (95% CI 0-28%) vs. 6% (95% CI 0-18%), P = 0.715) and event-free survival (EFS) (73% (95% CI 53-93%) vs. 43% (95% CI 17-69%), P = 0.104) that had not reached statistical significance. For patients transplanted for advanced hematologic malignancy (n = 37), those with GVHD also had lower relapse rate (5% (95% CI 0-15%) vs. 72% (95% CI 50-94%), P = 0.002) and higher transplant-related mortality (50% (95% CI 27-73%) vs. 8% (95% CI 0-24%), P = 0.006) than those without any GVHD. They had higher EFS (47% (95% CI 24-70%) vs. 26% (95% CI 5-47%), P = 0.609) that had not reached statistical significance. Therefore, the incidence of acute and chronic GVHD in Chinese was similar to that of their Caucasian counterparts using MTX and CsA for GVHD prophylaxis.(ABSTRACT TRUNCATED AT 250 WORDS)

Large granular lymphocyte leukemia. A study of nine cases in a Chinese population

Large granular lymphocyte (LGL) leukemia is a neoplastic disorder of lymphocytes that is characterized by the presence of prominent cytoplasmic granules, and involves the proliferation of at least two distinct cell types, T cells and natural killer (NK) cells. The authors report the clinical and pathologic features of 9 Chinese patients with LGL leukemia, who represented 14% of 64 cases of chronic lymphoproliferative disorders diagnosed at their centers in 3 years. Three different groups could be defined on immunophenotypic and clinical grounds. The first group of 4 cases were CD2+CD3+CD4-CD8+. With the exception of a pediatric case, these cases ran an indolent course that was similar to the T-cell LGL leukemia most common in Western patients. However, thrombocytopenia and pure red cell aplasia were more common in the patients in this study, which was similar to the experience in Japanese patients. The second group of two cases were CD2+CD3+CD4+CD8-, and appeared to have worse outcomes than the first group. The third group of 3 cases were CD2+CD3-CD4-CD8-CD56+. Although phenotypically similar to the NK-cell LGL leukemia reported in Western patients, these cases were clinically more aggressive than their Western counterparts. This study is the first to report comprehensively the different types of LGL leukemias in Chinese patients, and provides useful information on the similarities and similarities and differences of these disorders as compared to those cases in the West.

The spectrum of chronic lymphoproliferative disorders in Chinese people. An analysis of 64 cases

BACKGROUND

Chronic lymphoproliferative disorders are considered rare in Oriental patients and are thought to constitute only 2% of all leukemias in these patients, compared to 20-30% in Western patients. We conducted a retrospective analysis of Chinese patients with chronic lymphoproliferative disorders to define the frequency and spectrum of these disorders.

METHODS

A consecutive series of Chinese patients with leukemia and lymphoproliferative disorders seen at two regional hospitals in Hong Kong were analyzed retrospectively. The diagnosis of chronic lymphoproliferative disorders was based on morphologic and immunologic criteria proposed by the French-American-British Cooperative Study Group.

RESULTS

Sixty-four Chinese patients with chronic lymphoproliferative disorders were identified, and these patients constituted 19% of a total of 342 cases of leukemia diagnosed in 3 years. Chronic lymphocytic leukemia was the most common form, occurring at a frequency of 12.5% of all leukemias. The clinicopathologic features of these patients were similar to those of Western patients, except that Chinese patients tended to present with more advanced (Rai's Stages III and IV; Binet's Stage C) and bulky (splenomegaly > 9 cm) disease, and expressed lambda light chain about six times more frequently. Other chronic lymphoproliferative disorders identified in this study included prolymphocytic leukemia, mantle zone lymphoma, hairy cell leukemia, splenic lymphoma with villous lymphocytes, large granular lymphocyte leukemia, and Sezary syndrome. The authors did not identify any case of human T-cell lymphotropic virus-I-related lymphoproliferative disorders within the study period.

CONCLUSION

In addition to providing the frequencies of various chronic lymphoproliferative disorders in southern Chinese people, this study also showed that these disorders no longer should be considered rare in this population. Inherent biologic differences between lymphoproliferative disorders in Chinese and Western patients also may exist.

Epstein-Barr virus (EBV)-related lymphoproliferative disorder with subsequent EBV-negative T-cell lymphoma

A 58-year-old Chinese man presented initially with generalized lymphadenopathy, and lymph-node biopsy showed disturbed architecture with preponderance of large B-blasts mixed with numerous CD8+ T lymphocytes, consistent with an acute Epstein-Barr virus (EBV) infection. Immunohistological and gene rearrangement studies confirmed the absence of clonal T or B cells. Polyclonal EBV with lytic infection was detected by Southern blot hybridization (SoBH). Expression of EBV proteins (EBNA2, LMP and ZEBRA) was detected in a proportion of cells by immunostaining. EBV-lytic proteins EA-D, VCA, MA were also detected in rare scattered cells. Double immunostaining showed that the LMP-positive cells were of B and of T phenotype: 73% CD19+, 26% CD2+, 23% CD3+, 8% CD4+, 17% CD8+. After biopsy, there was spontaneous regression of lymph-node enlargement, but lymphadenopathy recurred 8 months later, and the second lymph-node biopsy showed T-cell lymphoma, confirmed by detection of clonally rearranged T-cell-receptor beta-chain gene. However, EBV genome could not be detected in the second biopsy by SoBH, in situ hybridization for EBV-encoded EBER RNA, and immunostaining for EBNA2, LMP and ZEBRA was also negative. This case is of special interest because an EBV-negative T-cell lymphoma developed shortly after an acute episode of EBV-related lymphoproliferation, even though many EBV-positive T cells were detected during the acute episode. EBV was apparently not a direct cause of the lymphoma, but the close temporal association of the 2 lesions supports the hypothesis that EBV can act as a co-factor in lymphomagenesis.

Trisomy 12 in chronic lymphocytic leukemia. An interphase cytogenetic study by fluorescence in situ hybridization

B-cell chronic lymphocytic leukemia (CLL) is a rare disorder in the Chinese population. We evaluated the use of fluorescence in situ hybridization (FISH) with a chromosome 12-specific probe in the detection of trisomy 12 in interphase cell of 19 Chinese CLL patients. FISH successfully detected trisomy 12 in two cases, one of which had normal conventional cytogenetic findings, giving an incidence of 10%. The low incidence of trisomy 12 in our CLL patients may also reflect a biologic difference of this rare disorder in our population, compared to that of the West.

Pulmonary toxicity in patients with non-Hodgkin's lymphoma treated with bleomycin-containing combination chemotherapy

Subclinical and clinical bleomycin-induced pulmonary toxicity (BIP) were investigated retrospectively in 109 patients with non-Hodgkin's lymphoma treated by combination chemotherapy containing bleomycin. A decrease in carbon monoxide diffusing capacity (DLCO) was found in 12.8% of patients. The cumulative risk of abnormal DLCO increased with the increasing total cumulative dose of bleomycin. No significant difference in the rate of BIP was observed between patients receiving bleomycin/Adriamycin/cyclophosphamide/vincristine/prednisone (BACOP; bleomycin given at 10 mg/m2 for 4 weeks) and bleomycin/Adriamycin/cyclophosphamide/vincristine/dexamethasone/methotre xate/ folinic acid (m-BACOD; bleomycin given at 4 mg/m2 for 3 weeks, methotrexate given at 200 mg/m2. Monitoring for subclinical BIP should be considered in patients with non-Hodgkin's lymphoma even if only a low dose of bleomycin was given in the presence of other chemotherapeutic agents.

T-lymphoblastic lymphoma arising in the small intestine

The authors report the clinical, pathological and immunological features of a case of T-lymphoblastic lymphoma presenting with protein-losing enteropathy. There was extensive multifocal involvement of the duodenum, jejunum and ileum. The mediastinum was not enlarged; the peripheral blood picture and bilateral bone marrow trephine biopsies were unremarkable. The tumor cells were positive for terminal deoxynucleotide transferase, CD3, CD2, CD7 and CD10; they were negative for CD1, CD5, CD4, CD8 and HLA-DR. The immunophenotype was that of an immature thymic T-cell. Monocytic and B-cell markers were negative. Despite initial dose reduction in chemotherapy, the patient still developed massive intestinal hemorrhage and succumbed 2 wks after treatment. Postmortem examination confirmed absence of thymic involvement. The overall picture strongly suggests a primary intestinal origin of this T-lymphoblastic lymphoma which contradicts the conventional wisdom that T-lymphoblastic lymphoma arises in the thymus from primitive cortical lymphocytes before rapidly disseminating.

Reactivation of hepatitis B virus replication in patients receiving cytotoxic therapy. Report of a prospective study

One hundred Chinese patients who received induction cytotoxic therapy for malignant lymphoma were prospectively studied to determine the incidence, morbidity, mortality, and predisposing factors for reactivation of hepatitis B virus replication during cytotoxic therapy. In 18 (67%) hepatitis B surface antigen-positive and 10 (14%) hepatitis B surface antigen-negative patients, hepatitis developed during cytotoxic therapy (P less than 0.0001). Hepatitis could be attributed to exacerbation or reactivation of chronic hepatitis B in 13 (72%) hepatitis B surface antigen-positive patients but in only 2 (20%) hepatitis B surface antigen-negative patients (P less than 0.0001). Sudden increase or reactivation of hepatitis B virus replication gave rise to icteric hepatitis, nonfatal hepatic failure, and death in 22.3%, 3.7%, and 3.7% of patients who were positive for hepatitis B surface antigen; in 2%, 2%, and 0% of those positive for hepatitis B antibodies; and in none of those who were seronegative. Among the hepatitis B surface antigen-positive patients, male sex was the only factor that was associated with an increased risk of reactivation of hepatitis B virus replication. We recommend that hepatitis B surface antigen-positive patients with malignancies receiving cytotoxic therapy be closely monitored.

Hepatitis B infection in patients with lymphomas

This paper reviewed the clinical characteristics and treatment outcome of 484 lymphoma patients with known hepatitis B status. Comparisons were made between the hepatitis B surface antigen positive and negative patients. Also, the effect of treatment for lymphomas, including cytotoxic chemotherapy, in the hepatitis B antigen positive patients were analysed. The hepatitis B status was determined in 484 Chinese lymphoma patients at the time of initial diagnosis. Hepatic complications occurring during therapy for lymphomas were analysed. Although our lymphoma patients had a similar prevalence of hepatitis B markers of 42 per cent, they had a strikingly higher positive rate of 22 per cent for hepatitis B surface antigen and a relatively lower positive rate of 20 per cent for antibody, as compared to the respective figures of 9.5 per cent and 33 per cent in the control population. The hepatitis B surface antigen positive patients were younger than the negative patients but their treatment outcomes were similar despite the higher incidence of hepatic complications (21 per cent) in the hepatitis B surface antigen positive patients during therapy for lymphomas. None of the clinical parameters analysed appeared to be useful in predicting the development of these complications which included fatal liver failure (5.7 per cent), icteric hepatitis (5.7 per cent) and anicteric hepatitis (9.5 per cent). The high prevalence of hepatitis B surface antigen in our lymphoma patients may be related to the immunosuppressive effect of lymphomas. There is no definite evidence to suggest that hepatitis B infection has an aetiological or promoting role in the pathogenesis of lymphomas. Hepatitis B infection has contributed to the high incidence of hepatic complications during therapy for lymphomas and possible ways of prevention need to be investigated.

Management of advanced stage intermediate grade non-Hodgkin's lymphomas

The treatment result of 271 cases of advanced stage intermediate grade lymphoma were reviewed. Ninety-four patients received CHOP chemotherapy, 45 BACOP and 17 m-BACOD. The clinical characteristics of the three groups of patients were comparable. Patients receiving CHOP had a complete response (CR) rate of 60 per cent, the disease-free survival of CR patients was 31 per cent at 5 years. The overall survival following CHOP chemotherapy was 38 per cent at 5 years. The use of the BACOP or m-BACOD regime did not appear to improve significantly the prognosis of these patients. Clinical staging, B symptoms, age and serum lactate dehydrogenase level were the most important independent prognostic factors.

Cerebral thrombosis in beta-thalassemia/hemoglobin E disease

We describe two Chinese patients with beta-thalassemia/hemoglobin E disease who developed cerebral infarction due to occlusion or stenosis of their extracranial carotid arteries. The roles of platelet abnormalities and other factors in this condition are discussed.

Long-term follow-up of patients receiving salvage chemotherapy for intermediate and high grade non-Hodgkin's lymphomas

This is an analysis of the long-term follow-up data of 99 patients receiving HOAP-Bleo, IMVP-16 and PAC as salvage chemotherapy for refractory or relapsed intermediate or high grade non-Hodgkin's lymphomas. Most of the patients received HOAP-Bleo or PAC following failure of initial chemotherapy and IMVP-16 was used mainly for HOAP-Bleo failures. The longest follow-up time of the surviving patients was 108 months. Twenty-two and 29 per cent of the patients survived beyond 2 years following HOAP-Bleo and PAC respectively. The treatment outcome following IMVP-16 was worst with a 2-year survival of only 5 per cent, as it was used mainly following HOAP-Bleo failures. Although the prognosis of these refractory or relapsed cases are poor, salvage treatment is still worthwhile as a small proportion of these patients may have long-lasting remissions and occasional patients may be cured. Newer approaches such as autologous bone marrow transplantation should be compared with current salvage chemotherapy regimens.

Ofloxacin versus co-trimoxazole for prevention of infection in neutropenic patients following cytotoxic chemotherapy

The efficacy of ofloxacin in preventing infection in neutropenic patients following cytotoxic chemotherapy was evaluated and was compared with that of co-trimoxazole. A total of 102 patients with hematological malignancies were randomly selected to receive either co-trimoxazole or ofloxacin. All patients were monitored for compliance, occurrence of infection, and drug-related side effects. A surveillance culture of a rectal swab was performed regularly. A total of 25 of the 52 patients (48%) who received co-trimoxazole and 11 of the 50 patients (22%) who received ofloxacin developed fever during the study period (P less than 0.025). Gram-negative bacteremia occurred in nine patients in the co-trimoxazole group (17%) but in only one patient (2%) in the ofloxacin group (P less than 0.05). No patient in either group had documented gram-positive bacterial or Pneumocystis carinii infection. Poor performance status was the only identifiable factor associated with an increased incidence of bacteremia. The surveillance study showed that significantly fewer bacterial strains were resistant to ofloxacin than to co-trimoxazole and that acquisition of resistance to co-trimoxazole was more commonly observed than was acquisition of resistance to ofloxacin. Significantly more patients had skin rashes following co-trimoxazole than ofloxacin treatment (P less than 0.05). Ofloxacin was superior to co-trimoxazole in preventing infection in this population of neutropenic patients.