[The 504th case: Multiple lymph node enlargement, renal insufficiency, blindness, and white matter lesions of the brain]

A 65-year-old male patient was admitted for recurrent lymph node enlargement for 5 years and elevated creatinine for 6 months. This patient was diagnosed with angioimmunoblastic T-cell lymphoma 5 years ago and underwent multiple lines of anti-tumor therapy, including cytotoxic chemotherapy; epigenetic modifying drugs such as chidamide and azacitidine; the immunomodulator lenalidomide; and targeted therapy such as rituximab, a CD20-targeting antibody, and brentuximab vedotin, which targets CD30. Although the tumor was considered stable, multiple virus activation (including BK virus, JC virus, and cytomegalovirus) accompanied by the corresponding organ damage (polyomavirus nephropathy, cytomegalovirus retinitis, and progressive multifocal leukoencephalopathy) occurred during anti-tumor treatment. Anti-tumor therapy was suspended and ganciclovir was used. The serum viral load decreased and organ functions were stabilized. The purpose of this report was to raise clinicians' awareness of opportunistic virus reactivation during anti-tumor treatment.

[Efficacy of different regimens and prognostic factors in patients with first relapsed multiple myeloma treated after front-line bortezomib, cyclophosphamide, and dexamethasone]

Objective: To analyze the efficacy of second-line regimens and prognostic factors in patients with first-relapsed multiple myeloma (MM) treated with bortezomib, cyclophosphamide, and dexamethasone (BCD). Methods: A retrospective cohort study. Clinical data were collected in first-relapsed MM patients after BCD treatment from three tertiary hospitals in north China from July 2009 to October 2022. Patients were classified according to the second-line regimen into the immunotherapy group, single novel agent group [either proteasome inhibitor (PI) or immunomodulatory drug (IMiD)], combination treatment group (both PI+IMiD), and traditional treatment group. Responses to second-line regimens and survival data were analyzed. The Kaplan-Meier method was used for survival analysis and the Cox proportional risk model was used for univariate and multivariate analyses. Results: A total of 217 patients were enrolled including 8.8% (19/217) in the immunotherapy group, 48.4% (105/217) in the PI/IMiD group, 29.9% (65/217) in the PI+IMiD group, and 12.9% (28/217) in the traditional treatment group. The median age was 62 years (range 31-83 years) and 56.2% (122/217) were males. The overall response rates (ORRs) in the four groups were 94.7% (18/19) vs. 56.2% (59/105) vs. 73.8% (48/65) vs. 32.1% (9/28) (χ2=24.55; P<0.001), respectively. The progression-free survival (PFS) of the second-line regimens (2ndPFS) was 17.7 vs. 9.0 vs. 9.2 vs. 4.6 months (χ2=22.74; P<0.001), respectively, among which patients in the PI/IMiD and PI+IMiD groups had comparable 2ndPFS (χ2=1.76; P=0.923). Patients with high-risk cytogenetic abnormalities (HRCAs) achieved the longest 2ndPFS of 22.0 months in the immunotherapy group (χ2=15.03; P=0.002). Multivariate analysis suggested that immunotherapy (HR=0.11, 95%CI 0.05-0.27), achievement of efficacy of partial response or better (HR=0.47, 95%CI 0.34-0.66), and non-aggressive relapse (HR=0.25, 95%CI 0.17-0.37) were independent prognostic factors of 2ndPFS. Conclusion: In this real-world study, immunotherapy was associated with a more favorable efficacy and PFS for first-relapsed MM patients after BCD treatment, with similar outcomes in patients with HRCAs.

[Clinical and molecular characteristics and prognosis of classical hairy cell leukemia and hairy cell leukemia variant]

Objective: To evaluate the clinical characteristics, treatment response, and outcomes in patients with classical hairy cell leukemia (cHCL) and HCL variant (HCL-V). Methods: This is a retrospective case series study. Between January 2011 and December 2021, clinical data of 30 patients newly with diagnosed HCL at Peking Union Medical College Hospital were analyzed. The main outcome measures include clinical characteristics, treatment efficacy and survival. The Kaplan-Meier method was used for survival analysis. Results: Twenty-one cases of cHCL and 9 cases of HCL-v were included. The median age at diagnosis was 55.5 (range, 30-86) years, with the ratio of male to female 2.75∶1. The main clinical manifestations included fatigue in 11 cases (36.7%), abdominal distension in 7 cases (23.3%), and infection in 4 cases, while 8 cases were asymptomatic. Splenomegaly was reported in 24 cases (80.0%), including 7 (23.3%) with megalosplenia. The white blood cell count, lymphocyte count, and the proportion of peripheral hairy cells in HCL-v group were significantly higher than those in cHCL group, whereas the development of anemia, thrombocytopenia, and monocytopenia in cHCL group was more remarkable than that in HCL-v group (all P<0.05). The BRAF-V600E gene mutation was detected only in cHCL patients (11/14 vs. 0/9, P<0.001). In terms of immunophenotype, the expression of CD25, CD103, CD123 and CD200 in cHCL group (20/20, 20/20, 4/7, 7/17) were all stronger than those in HCL-v group (3/9, 7/9, 0/4, 2/8). Twenty-two patients were treated, of which 13 cases (12 cases of cHCL and 1 case of HCL-v) with cladribine, and 9 cases (4 cHCL and 5 HCL-v) with interferon. Complete remission rate and overall response rate were comparable between cladribine and interferon treatment groups (both P<0.05). The median follow-up time was 31 (range, 1-125) months, and the median overall survival (OS) of the entire group was 125 months. The 5-year OS rate in HCL-v patients represented a trend of inferior (50.0% vs. 95.0%, P=0.207). Conclusions: The clinical features of HCL are unspecific, which includes fatigue, splenomegaly and recurrent infection. The clinical features, immunophenotype, treatment response and prognosis of HCL-v are different from those of cHCL. BRAF-V600E gene mutation is suggested as a key marker for differential diagnosis. Cladribine is recommended as front-line regimen of cHCL patients with satisfactory efficacy and prognosis. Conversely, response and clinical outcome in HCL-v patients still need to be improved.

[Clinical characteristics and progression risk factors for patients with monoclonal gammopathy of undetermined significance]

Objective: To analyze the clinical presentation and progression risk factors of patients with monoclonal gammopathy of undetermined significance (MGUS) in China. Methods: We retrospectively assessed the clinical features and disease progression of 1 037 patients with monoclonal gammopathy of undetermined significance between January 2004 and January 2022 at Peking Union Medical College Hospital. Results: A total of 1 037 patients were recruited in the study, including 636 males (63.6%) , with a median age of 58 (18-94) years. The median concentration of serum monoclonal protein was 2.7 (0-29.4) g/L. The monoclonal immunoglobulin type was IgG in 380 patients (59.7%) , IgA in 143 patients (22.5%) , IgM in 103 patients (16.2%) , IgD in 4 patients (0.6%) , and light chain in 6 patients (0.9%) . 171 patients (31.9%) had an abnormal serum-free light chain ratio (sFLCr) . According to the Mayo Clinic model for risk of progression, the proportion of patients in the low-risk, medium-low-risk, medium-high risk, and high-risk groups were 254 (59.5%) , 126 (29.5%) , 43 (10.1%) , and 4 (0.9%) , respectively. With a median follow-up of 47 (1-204) months, 34 of 795 patients (4.3%) had disease progression, and 22 (2.8%) died. The overall progression rate was 1.06 (0.99-1.13) /100 person-years. Patients with non-IgM MGUS have a markedly higher disease progression rate per 100 person-years than IgM-MGUS (2.87/100 person-years vs 0.99/100 person-years, P=0.002) . The disease progression rate per 100 person-years in non-IgM-MGUS patients of Mayo classification low-risk, medium-low risk and medium-high risk groups were 0.32 (0.25-0.39) /100 person-years, 1.82 (1.55-2.09) /100 person-years, and2.71 (1.93-3.49) /100 person-years, which had statistically difference (P=0.005) . Conclusion: In comparison to non-IgM-MGUS, IgM-MGUS has a greater risk of disease progression. The Mayo Clinic progression risk model applies to non-IgM-MGUS patients in China.

[The influencing factors of renal response in newly diagnosed multiple myeloma patients with renal impairment]

Objective: To investigate the causative factors of renal function in newly diagnosed multiple myeloma (MM) patients with renal inadequacy. Methods: 181 MM patients with renal impairment from August 2007 to October 2021 at Peking Union Medical College Hospital were recruited, whose baseline chronic kidney disease (CKD) stage was 3-5. Statistical analysis was performed based on laboratory tests, treatment regimens, hematological responses, and survival among various renal function efficacy groups. A logistic regression model was employed in multivariate analysis. Results: A total of 181 patients were recruited, and 277 patients with CKD stages 1-2 were chosen as controls. The majority choose the BCD and VRD regimens. The progression-free survival (PFS) (14.0 months vs 24.8 months, P<0.001) and overall survival (OS) (49.2 months vs 79.7 months, P<0.001) of patients with renal impairment was considerably shorter. Hypercalcemia (P=0.013, OR=5.654) , 1q21 amplification (P=0.018, OR=2.876) , and hematological response over a partial response (P=0.001, OR=4.999) were independent predictive factors for renal function response. After treatment, those with improvement in renal function had a longer PFS than those without (15.6 months vs 10.2 months, P=0.074) , but there was no disparity in OS (56.5 months vs 47.3 months, P=0.665) . Conclusion: Hypercalcemia, 1q21 amplification, and hematologic response were independent predictors of the response of renal function in NDMM patients with renal impairment. MM patients with CKD 3-5 at baseline still have worse survival. Improvement in renal function after treatment is attributed to the improvement in PFS.

[Prognostic value of translocation t(11;14) in primary light-chain amyloidosis treated with bortezomib-based regimen]

Objective: To investigate the prognostic value of translocation t(11;14) in newly-diagnosed primary light-chain (AL) amyloidosis patients treated with bortezomib-based regimen. Method: Clinical information of newly-diagnosed AL amyloidosis patients in Peking Union Medical College Hospital who had baseline t(11;14) data and accepted bortezomib-combined therapies from September, 2015 to September, 2021 was collected. The relationships between t(11;14) status and baseline characteristics, hematological response, organ response and prognosis were analyzed. Results: A total of 152 patients were included, aged (59.5±9.1) years and 93 cases were male (61.2%). Forty-six patients carried t(11;14) (30.3%). There was no statistical difference in the proportion of organ involved, distribution of Mayo 2004 and 2012 stages and laboratory indexes between patients with and without t(11;14) (all P>0.05). For hematological response, the difference in the rates of ≥very good partial response (VGPR) between those with t(11;14) and without after the first cycle [28.2%(11/39) vs 37.4%(34/91), P>0.05] was not statistically significant. After 3 cycles, the difference in the rates of ≥VGPR between two groups was not statistically significant [35.9%(14/39) vs 51.1%(46/90), P>0.05]. The difference in the ratio of the best hematological response reaching ≥VGPR between two groups during the first-line treatment was not statistically significant [52.2%(24/46) vs 64.2%(68/106), P>0.05]. But patients with t(11;14) had lower cardiac response rate at 3 months [15.2%(5/33) vs 34.6%(28/81), P=0.038] and 6 months [19.4%(6/31) vs 50.6%(42/83),P=0.003] than those without, but the difference in cardiac response rates at 12 months was not statistically significant [41.7%(10/24) vs 53.5%(38/71),P>0.05]. For survival, the differences in overall survival (not reached vs 50.1 months, P>0.05) and hematological event-free survival (36.2 months vs 39.9 months, P>0.05) between patients carrying t(11;14) and those without were not statistically significant. Conclusion: Patients with t(11;14) had lower cardiac response rate than those without, but their hematological response and survival are not significantly different from those free from t(11;14).

[The 492nd case: recurrent thrombosis, thrombocytopenia]

A 43-year-old female patient was admitted with recurrent thrombosis for more than 2 years and thrombocytopenia for more than 1 year. Both arterial and venous thromboses developed especially at rare sites even during anticoagulation therapy such as cerebral venous sinus thrombosis. Antinuclear antibody, anti-ENA antibody and antiphospholipid antibody were all negative. Platelet count elevated to normal after high dose glucocorticoid and intravenous immunoglobulin (IVIG). Immune thrombocytopenia was suspected. When 4 grade thrombocytopenia recurred, intravenous heparin, rituximab 600 mg, IVIG and eltrombopag were administrated. After 3 weeks, thrombocytopenia did not improve, and new thrombosis developed instead. Screening of thrombophilia related genes revealed PROS1 gene heterozygous mutation and MTHFR TT genotype. Low amount of serum IgG κ monoclonal protein was detected. Heparin-induced thrombocytopenia was differentiated and excluded. Finally, serum negative antiphospholipid syndrome was considered the most likely diagnosis. Dexamethasone 20 mg/day × 4 days combined with sirolimus 2 mg/day was prescribed. The patient was discharged with low molecular weight heparin. At one month, her headache was greatly relieved. The platelet count raised to 20-30×10⁹/L, and no new thrombosis or bleeding was reported.

[MYC and BCL-2 protein co-expression and prognosis of patients with diffuse large B-cell lymphoma: a propensity score matching analysis]

目的

探究MYC/BCL-2蛋白双表达对弥漫大B细胞淋巴瘤（DLBCL）患者预后的影响，观察纳入DA-EPOCH-R（利妥昔单抗+依托泊苷+泼尼松+长春新碱+环磷酰胺+表阿霉素）、中枢神经系统预防治疗、移植等治疗因素后，双表达是否仍是DLBCL的独立预后不良因素。

方法

回顾性收集2015−2018年在北京协和医院血液科治疗且具有可用病理结果的223例初治DLBCL患者，75例MYC/BCL-2高表达的患者归为双表达组，从148例非双表达的患者中，应用倾向性评分（PSM），根据年龄、国际预后指数（IPI）评分、治疗选择等因素进行1∶1匹配，筛选出75例作为对照组，比较两组患者总生存（OS）及无进展生存（PFS）等方面的差异。

结果

PSM后双表达组和非双表达组的3年OS率分别为（69.8±5.5）％及（77.0±4.9）％（P＝0.225），3年PFS率分别为（60.7±5.8）％及（65.3±5.5）％（P＝0.390），差异均无统计学意义。R-CHOP方案（利妥昔单抗+环磷酰胺+阿霉素+长春新碱+泼尼松）治疗的亚组分析显示，双表达和非双表达患者的3年OS率分别为（61.3±7.5）％及（77.2±5.6）％（P＝0.027），3年PFS率分别为（52.1±7.5）％及（70.6 ± 6.0）％（P＝0.040），差异均具有统计学意义。多因素Cox回归分析显示年龄、Ann Arbor分期、细胞起源（COO）分型、是否进行中枢神经系统预防、是否进行移植是DLBCL患者预后的独立影响因素（P值均<0.05），而MYC/BCL-2蛋白双表达不是预后的影响因素。

结论

MYC/BCL-2蛋白双表达在R-CHOP方案治疗下与不良预后显著相关，但在DA-EPOCH-R、移植等治疗方案下，双表达对DLBCL的不良预后影响在一定程度上得到消除。

Retro Baeyer–Villiger reaction: thermal conversion of the [60]fullerene-fused lactones to ketones

The conversion of the [60]fullerene-fused lactones to ketones with triflic anhydride as an unusual reductant under aerobic conditions has been achieved in excellent yields. The present thermal retro Baeyer–Villiger reaction...

Unexpected Diels-Alder reaction of [60]fullerene with electron-deficient ferrocenes as cyclopentadiene surrogates

The unexpected Diels-Alder reaction of [60]fullerene (C₆₀) with ferrocenes bearing electron-withdrawing groups as cyclopentadiene surrogates has been developed to selectively afford single isomers of [2 + 4] cycloadducts of C₆₀. Mechanistic studies indicate that cyclopentadienes are in situ generated from electron-deficient ferrocenes in the presence of an oxidant and an acid, followed by [2 + 4] cycloadditions with dienophiles. A Michael addition reaction using a Grignard reagent has been utilized to transform the Diels-Alder adducts of C₆₀ into more stable fullerene derivatives.

Magnetic solid-phase extraction based on sulfur-functionalized magnetic metal-organic frameworks for the determination of methylmercury and inorganic mercury in water and fish samples

A novel magnetic metal-organic frameworks (Fe₃O₄@UiO-66-SH) was successfully prepared by coating Fe₃O₄ nanospheres with sulfur-functionalized UiO-66. The Fe₃O₄@UiO-66-SH possesses both the magnetic properties of Fe₃O₄ and the diverse properties of metal-organic framework (MOF) in one material, which has the superiority of high surface area, easy-operation and strong adsorb ability with mercury, is used for the magnetic solid-phase extraction of methylmercury (MeHg⁺) and inorganic mercury (Hg²⁺) in water and fish samples. The analyzes were conducted by high performance liquid chromatography-inductively coupled plasma mass spectrometry (HPLC-ICP-MS). The different pretreatment conditions influencing the extraction recoveries of Hg²⁺ and MeHg⁺, including adsorbent amount, pH, extraction time, elution solvent, elution volume, desorption time, co-existing ions and dissolved organic materials were investigated. Under the optimized conditions, the limits of detection (LODs) of Hg²⁺ and MeHg⁺ for water samples were 1.4 and 2.6 ng L^-1, and the limits of quantification (LOQs) of Hg²⁺ and MeHg⁺ for water samples were 4.7 and 8.7 ng L^-1. The enrichment factors (EFs) were 45.7 and 47.6 fold for Hg²⁺ and MeHg⁺, respectively. The accuracy of the proposed method was demonstrated by analyzing the certified reference material of fish tissue (GBW10029) and by determining the analyte content in spiked water and fish samples. The determined values were in good agreement with the certified values and the recoveries for the spiked samples were in the range of 84.5-96.8%.

[Clinical characteristics and outcome of patients with type Ⅱ cryoglobulinemia]

目的

探讨Ⅱ型冷球蛋白血症患者的临床特征及预后。

方法

回顾性分析2015年5月至2020年1月北京协和医院确诊的61例Ⅱ型冷球蛋白血症患者的临床资料。

结果

61例患者中，男性26例（42.6％），中位诊断年龄为53（28～79）岁。继发病因包括丙型肝炎病毒（HCV）感染（21.3％）、乙型肝炎病毒（HBV）感染（21.3％）、自身免疫性疾病（14.8％）和血液系统肿瘤（11.5％）。31.1％患者为特发性。常见首诊症状包括皮肤紫癜、蛋白尿、血尿、肾功能不全、发热及关节痛。实验室检查显示，中位冷球蛋白水平为215.9（22.0～17 075.8）g/L，54例（88.5％）为IgM单克隆。类风湿因子（RF）升高患者占93.2％，C3下降患者占57.6％，C4下降患者占61.0％。共49例（80.3％）患者接受治疗，总体临床缓解率为75.5％，预计3年总生存率为89.3％。

结论

Ⅱ型冷球蛋白血症是一种多系统受累的全身性疾病，病因以肝炎病毒感染多见。早期诊断和干预对于改善预后有重要意义。

[Clinical presentation and prognosis in patients with light-chain amyloidosis with an ultra-high level of serum free light-chain]

Objective: To investigate the clinical features and outcomes of patients with light-chain (AL) amyloidosis with an ultra-high level of serum free light-chain (FLC) . Methods: Five hundred and ninety-five patients with AL amyloidosis were retrospectively reviewed between January 2009 and January 2020 at Peking Union Medical College Hospital. We analyzed the clinical features and prognosis of patients with ultra-high FLC levels [difference between involved and uninvolved light chains (dFLC) >500 mg/L; n=124] and those without ultra-high FLC levels (dFLC≤500 mg/L; n=471) . Results: Patients with ultra-high FLC presented with more frequent cardiac involvement (82.3% vs 70.1%, P=0.007) , and a higher percentage of patients with 2004 Mayo Ⅲ stage (41.8% vs 33.8%, P=0.029) , but less frequent renal involvement than patients without an ultra-high FLC (59.7% vs 71.8%, P=0.009) . Patients with an ultra-high FLC achieved a lower proportion of hematologic (72.4% vs 82.3%, P=0.048) and cardiac response (37.3% vs 54.7%, P=0.016) and had shorter overall survival (13.0 months vs not reached, P<0.001) and a higher early death rate within 3 months (28.2% vs 11.3%, P<0.001) than those without an ultra-high FLC. Ultra-high FLC independently predicted worse prognosis in patients with AL amyloidosis (HR=2.279, 95%CI 1.685-3.083, P<0.001) . Conclusions: Patients with an initially ultra-high FLC represented a subgroup with more common cardiac involvement, more advanced cardiac stages, and extremely poor prognosis.

A copper-promoted synthesis of epoxy-bridged [60]fullerene-fused lactones and further derivatization

A facile copper-promoted decarboxylative annulation of [60]fullerene (C60) with two identical α-oxocarboxylic acids via an unprecedented cascade addition pathway has been exploited to synthesize the unique epoxy-bridged C60-fused lactones for the first time. Further transformations into the rare epoxy-bridged C60-fused hemiacetals and bicyclic-fused 1,2,3,4-adducts as well as application in a perovskite solar cell device of the obtained products have also been demonstrated. The structures of the epoxy-bridged C60-fused lactones and derived reductive products have been unequivocally established by single-crystal X-ray crystallography. Plausible reaction mechanisms leading to the observed products are proposed.

[Clinical characteristics and prognostic analysis of advanced-stage extranodal NK/T cell lymphoma]

Objective: This study aimed to explore the clinical characteristics, survival rate, and prognostic factors of advanced-stage extranodal nasal type NK/T cell lymphoma (ENKTL) patients. Methods: The clinical data of 51 advanced-stage ENKTL patients in Peking Union Medical College Hospital from January 2012 to September 2019 were retrospectively analyzed. The clinical characteristics, treatment responses, survival rate, and prognostic factors were elucidated. The differences between nasal and non-nasal type and the significance of EBV-DNA in treatment response assessment and prognosis analysis were also evaluated. Results: The male-to-female ratio in the whole group was 2.9∶1 with a median age of 42 years old (range, 14-67 years) . The median follow-up time was 30 months (range, 1-78 months) . The one- and three-year progression-free survival (PFS) rates for the whole cohort were 34.1% and 24.6%, respectively, and the one- and three-year overall survival (OS) rates were 39.9% and 26.6%, respectively. The ratio of nasal to non-nasal type was 1.6∶1. The proportion of hemophagocytic lymphohistiocytosis (HLH) was significantly higher in non-nasal-type patients than nasal-type (P=0.039) , and the complete response (CR) rate of first-line chemotherapy is significantly lower in non-nasal type patients (P=0.008) . The median OS for nasal and non-nasal types were nine months and four months, respectively. The three-year PFS rates of nasal and non-nasal type patients were 36.0% and 10.0% (P=0.029) , respectively, and the three-year OS rates were 37.9% and 11.4% (P=0.050) , respectively. The correlation between the Epstein-Barr virus DNA (EBV-DNA) and treatment response were satisfactory. Survival curve between baseline EBV-DNA-negative and EBV-DNA-positive patients showed no significant difference. The three-year OS rates of EBV-DNA-negative and EBV-DNA-positive patients after one cycle of treatment were 77.9% and 8.1% (P=0.002) , respectively. In a multivariate analysis, EBV-DNA-positive following one cycle of treatment was an independent adverse prognostic factor for OS. Conclusions: The efficacy of pegaspargase-based chemotherapy and long-term survival of advanced-stage ENKTL patients were still poor. Clinical characteristics, treatment response, and long-term survival of non-nasal-type patients were worse than that of nasal-type patients. In a multivariate analysis, EBV-DNA-positive after one cycle of treatment was an independent adverse prognostic factor for OS. It can be used for early prediction of treatment response and prognosis.

[A pediatric-inspired regimen for adolescents and young adults with Philadelphia chromosome-negative acute lymphoblastic leukemia: results from a single center]

目的

探索应用类似儿童方案治疗Ph染色体阴性青少年及年轻成人急性淋巴细胞白血病（ALL）患者的疗效和安全性。

方法

回顾性分析2012年1月至2018年11月在北京协和医院确诊并且应用统一的类似儿童ALL方案治疗的71例15～39岁Ph染色体阴性ALL/淋巴母细胞淋巴瘤(LBL)初治患者的临床资料和生存数据。

结果

71例患者中，男性46例（64.8%）；中位年龄为20（15～38）岁。B-ALL/LBL占69.0%（49/71）。高危ALL占ALL总数的35.5%。诱导治疗的完全缓解率为93.0%。中位随访时间为44个月。2年累积复发率为34.6%（95% CI 27.0%～42.2%）。5年无病生存（DFS）率和总生存（OS）率分别为56.3%和64.3%。完成4个疗程化疗后一线行异基因造血干细胞移植组与化疗组患者的5年OS率差异无统计学意义（P>0.05）。非高危ALL患者的预计5年DFS率和OS率分别为63.1%和73.7%，明显高于高危ALL患者的32.0%和44.4%（P值均<0.001）。不良事件主要为血流感染、真菌感染、股骨头坏死，发生率与既往报道相当。

结论

类似儿童ALL方案是一种对Ph染色体阴性青少年及年轻成人ALL/LBL患者较为安全和有效的治疗方案。

Magnetic C60 nanospheres based solid-phase extraction coupled with isotope dilution gas chromatography-mass spectrometry method for the determination of sixteen polycyclic aromatic hydrocarbons in Chinese herbal medicines

C₆₀-based magnetic nanospheres were synthesized by coating Fe₃O₄ nanospheres with silica, then modifying with 3-aminopropyltriethoxysilane as a linker and a C₆₀ fullerene stationary phase. The morphologies, magnetic properties, infrared absorption and carbon content of magnetic nanospheres were studied by TEM, VSM, FTIR and carbon and sulfur analyzer. The magnetic nanospheres were employed for the magnetic solid-phase extraction (MSPE) of 16 polycyclic aromatic hydrocarbons (PAHs) in nine Chinese herbal medicines. The analyses were conducted by isotope dilution gas chromatography-mass spectrometry. The main parameters influencing the extraction, including extraction solvent, adsorbent amount, and extraction time were optimized. Method validation showed that the limit of detection (LOD) was 0.02-0.11 µg/kg, and the limit of quantification (LOQ) was 0.07-0.36 µg/kg. The spiked recoveries rates for 16 PAHs in white peony root were 84.7-107.2%. The relative standard deviation (RSD) was 1.7-8.4%. The established method was further used for the determination 16 PAHs in nine Chinese herbal medicines. Total content of 16 PAHs varied from 73.6 µg/kg (fructus lycii) to 2172.6 µg/kg (astragalus root). The results indicate that the pollution of PAHs in Chinese herbal medicines is serious. The established method can effective detect PAHs contamination in Chinese herbal medicines.

[Oral melphalan plus high-dose dexamethasone as first-line therapy for patients with primary light chain amyloidosis]

目的

探讨口服美法仑联合大剂量地塞米松（MDex）方案一线治疗原发性轻链型淀粉样变（pAL）的疗效。

方法

收集2009年1月至2017年7月接受MDex方案治疗的76例初治pAL患者临床资料，对其疗效及生存进行回顾性分析。

结果

①76例患者中，男47例，女29例，中位年龄为56（20~74）岁。66例患者可进行梅奥2004分期（1、2、3期者分别为21、32、13例），65例（85.53%）患者存在≥2个器官受累。中位疗程数为5（1~21）个。②在可评价疗效的60例患者中，总体血液学缓解率为48.33%（29/60），完全缓解率和非常好的部分缓解率均为20.00%（12/60），获得最佳血液学缓解的中位时间为5（1~15）个月；总体器官缓解率为36.67%（22/60）。③生存患者的中位随访时间为23（1~113）个月，中位无进展生存（PFS）及总生存（OS）时间及分别为34、43个月。治疗3个月后仍存活患者的中位PFS和OS时间分别为46、65个月。④梅奥2004分期3期和1~2期患者的中位OS时间分别为5、65个月，差异有统计学意义（P=0.001）。

结论

MDex方案是pAL早期患者一种有效的治疗手段，但不适用于心脏受累的晚期患者。

[Clinical characteristics of intravascular large B cell lymphoma: a single-center retrospective study]

目的

提高对血管内大B细胞淋巴瘤（IVLBCL）的认识。

方法

回顾性分析北京协和医院自2010年1月至2016年6月收治的12例IVLBCL患者的临床资料。

结果

①12例患者中，男6例，女6例，中位年龄为58.5（32~76）岁。临床表现：发热最为常见（10/12），其次为呼吸系统症状（咳嗽、呼吸困难、胸腔积液等，6/12）、噬血细胞综合征（6/12）、神经系统症状（1/12）；所有患者均有LDH升高（367~1 700 U/L）、铁蛋白升高（805~1 527 µg/L）、结外器官受累（肺6例，骨髓3例，脑2例，软脑膜、肾上腺、副鼻窦、胆囊、甲状腺各1例）。②组织病理特征：光镜下可见分布于小血管内的单个或小簇状淋巴瘤细胞，毛细血管或血窦结构得以保留，免疫组化显示CD20、CD79a等B淋巴细胞标志阳性。③疗效及预后：11例患者接受CHOP或R-CHOP方案化疗，其总反应率为90.1%，完全缓解率为66.7%。患者平均随访20（1~40）个月，中位生存期及中位无进展生存期尚未达到。单因素Cox回归分析未能发现年龄、分期、IPI等临床参数与预后相关。

结论

IVLBCL临床罕见，出现肺部受累比例高，肺活检有较高阳性率；R-CHOP方案目前仍是最主要的治疗方案。

[Clinical features and prognosis of 17 patients with primary cold agglutinin disease]

目的

探讨17例原发性冷凝集素病（CAD）患者的临床特征、治疗及转归。

方法

回顾性分析2007年4月至2016年10月北京协和医院确诊的17例原发性CAD患者的临床资料、治疗和转归，并检测了其中4例患者MYD88^L265P突变情况。

结果

17例患者中，男女比为1.1∶1，中位年龄67（51～86）岁。7例伴有惰性淋巴瘤，包括3例华氏巨球蛋白血症/淋巴浆细胞淋巴瘤（WM/LPL），2例小淋巴细胞淋巴瘤/慢性淋巴细胞白血病（SLL/CLL）和2例脾边缘区淋巴瘤（SMZL）。患者中位HGB为67（35～127）g/L，15例存在贫血。11例患者的冷凝集素（CA）滴度≥1∶64，中位CA滴度为1∶1 024。4例行MYD88^L265P突变检测的患者中1例MYD88^L265P阳性。12例患者接受了药物治疗：7例使用糖皮质激素为基础的化疗，1例有效；5例使用利妥昔单抗为基础的免疫化疗的治疗，3例有效。1例患者失访，其余16例患者中位随访14（0.5～96）个月，中位总体生存时间尚未达到。

结论

CAD的临床表现多样，CA检测是诊断CAD的关键。CAD糖皮质激素治疗效果不佳，推荐利妥昔单抗治疗。

[Posaconazole as primary prevention of fungal infection in intensive immunosuppressive therapy for severe aplastic anemia]

目的

评价在初治重型/极重型再生障碍性贫血（SAA/VSAA）患者抗胸腺/淋巴细胞免疫球蛋白（ATG/ALG）联合环孢素A的强化免疫抑制治疗（IST）中，采用泊沙康唑初级预防真菌感染的疗效及安全性。

方法

回顾性分析北京协和医院2013年4月至2017年5月接受强化IST及抗真菌初级预防的58例SAA患者资料，根据抗真菌预防药物分为泊沙康唑预防组和对照组（伊曲康唑或氟康唑预防），对比两组患者疾病特征、侵袭性真菌病（IFD）预防效果及药物不良反应。

结果

58例初治SAA/VSAA患者中，泊沙康唑预防组20例，对照组38例（伊曲康唑预防23例，氟康唑预防15例）。两组患者基线特征（性别、年龄、疾病严重程度、病因、起病到治疗间隔时间、ATG/ALG种类）差异均无统计学意义（P值均>0.1）。泊沙康唑预防组和对照组IFD发生率分别为0和15.8%（P=0.084），对照组6例IFD中确诊、拟诊、未确定各2例；5例为肺部感染，1例为血流感染。在VSAA中，8例泊沙康唑预防组患者无一例发生IFD，15例对照组患者5例发生IFD。泊沙康唑预防组未见明显不良反应。

结论

在SAA/VSAA的强化IST中，本回顾性分析结果提示采用泊沙康唑初级预防真菌感染有效、安全，对于VSAA患者效果明显。

[Clinical characteristics of 6 patients with blastic plasmacytoid dendritic cell neoplasm]

目的

探讨母细胞性浆细胞样树突细胞肿瘤（BPDCN）的临床特征、治疗和预后。

方法

回顾性分析2008年1月至2016年5月北京协和医院确诊的6例BPDCN患者的临床资料。

结果

6例患者起病时均有皮肤受累，常见表现包括骨髓受累（5例）、淋巴结肿大（4例）、脾大（4例）和肝大（3例）。皮肤外的结外器官受累包括乳腺、上颌窦、椎体和中枢神经系统各1例。肿瘤细胞特征性的免疫表型CD4、CD56、CD123均为阳性。治疗均采用急性淋巴细胞白血病样方案，4例达到完全缓解。中位随访9.5（7~37）个月，中位无进展生存期7个月，中位总生存期9个月。死亡3例，均在诊断后1年内死于原发病复发或进展。

结论

BPDCN侵袭性强，常以皮肤受累为首发症状，骨髓受累、淋巴结和肝脾大较为常见；特征性免疫标志包括CD4、CD56和CD123；目前缺乏有效、标准的治疗方案，预后不良。

A retro Baeyer-Villiger reaction: electrochemical reduction of [60]fullerene-fused lactones to [60]fullerene-fused ketones

An unprecedented retro Baeyer–Villiger reaction has been achieved by the electrochemical reduction of [60]fullerene-fused lactones in the presence of acetic acid at room temperature, affording [60]fullerene-fused ketones in excellent yields within a short time.

A highly efficient electrochemical reduction of [60]fullerene-fused lactones to [60]fullerene-fused ketones, a formal process of retro Baeyer–Villiger reaction, has been achieved for the first time. The electrochemically generated dianionic [60]fullerene-fused lactones can be transformed into [60]fullerene-fused ketones in the presence of acetic acid in 85–91% yields. Control experiments have been performed to elucidate the reaction mechanism. The products have been characterized with spectroscopic data and single-crystal X-ray analysis. Moreover, the electrochemical properties have also been investigated.

[The diagnostic and prognostic values of serum free light chain in patients with primary light chain amyloidosis]

目的

研究血清游离轻链（sFLC）检测在原发性轻链型淀粉样变（pAL）中的诊断和预后价值。

方法

回顾性分析2009年1月至2015年6月确诊且有完整sFLC数据的126例pAL患者的临床资料，探讨sFLC的诊断价值，并采用Cox回归法分析sFLC差值（dFLC）的预后价值。

结果

126例患者中男女比例为1.57∶1，中位年龄为57 (37~81）岁，λ轻链型者80例（63.5%），肾脏受累者87例（69.0%），心脏受累者79例（62.7%）。126例患者的中位dFLC为99 (1~4 263）mg/L。血清蛋白电泳、血清免疫固定电泳、尿免疫固定电泳和sFLC比值异常法检测单克隆免疫球蛋白（M蛋白）的阳性检出率分别为34.9%（44/126）、63.5%（80/126）、77.0%（97/126）和81.0%（102/126）。联合上述四种方法可将M蛋白的检出率提高至98.4%（124/126）。中位随诊16个月后，37例患者死亡，所有患者的中位生存时间尚未达到。多因素分析发现dFLC ≥130 mg/L是影响pAL患者预后的独立危险因素（HR=3.272, 95% CI 1.384~7.739，P=0.007）。

结论

sFLC检测可显著提高pAL患者M蛋白的检出率；高水平dFLC是影响患者预后的独立危险因素。

[Efficacy and safety of JAK inhibitor ruxolitinib in Chinese patients with myelofibrosis: results of a 1-year follow-up of A2202]

目的

评价芦可替尼在中国骨髓纤维化患者中的疗效和安全性。

方法

63例中国骨髓纤维化患者纳入研究，男32例，女31例，中位年龄55(25~79)岁。芦可替尼起始剂量：基线PLT(100~200)×10⁹/L者(25例)30 mg/d，基线PLT>200×10⁹/L者(38例)40 mg/d。使用MRI/CT、欧洲癌症研究与治疗组织生活质量调查问卷核心30(EORTC QLQ-C30)和骨髓纤维化症状评估表(MFSAF)v2.0对患者进行脾脏体积、生活质量和症状评估。

结果

截至12个月随访结束，47例(74.6%)患者仍在继续治疗，25例(39.7%)患者脾脏体积较基线缩小超过35%，首次达到脾脏体积缩小≥35％的中位时间为12.71(95%CI 12.14~35.00)周。治疗期间，85.7%(54/63)的患者有不同程度的脾脏缩小，中位最佳脾脏体积缩小百分比为35.5%，48周时中位脾脏缩小体积为34.7%。治疗48周时53.1 %(26/49)的患者MFSAF症状评分降低超过50%，生活质量得到改善。最常见的血液学不良事件包括贫血和血小板计数降低，但极少造成停药。非血液学不良事件以1/2级为主。

结论

芦可替尼使中国骨髓纤维化患者的脾脏体积获得持续缩小、症状改善，不良反应可耐受。

[Analysis of clinical characteristics and outcome of patients with very high risk primary immunoglobulin light-chain amyloidosis]

目的

探讨极高危原发性轻链型淀粉样变（pAL）患者的临床特征及其预后。

方法

回顾性分析2009年1月至2016年2月在北京协和医院确诊的205例pAL患者的临床资料，将梅奥2004分期Ⅲb期或梅奥2012分期4期的患者定义为极高危患者。

结果

34例（16.6%）为极高危pAL患者，中位年龄57（20~84）岁，男性22例（64.7%）。所有患者均有心脏受累，15例（44.1%）患者的受累脏器≥ 3个。27例（81.8%）患者的心功能分级为3~4级，中位血清肌钙蛋白I为0.25（0.08~1.23）µg/L，中位血清N末端B型利钠肽前体为11 733（1 892~103 277）ng/L，中位血清游离轻链差值为403.0（18.1~1 911.6）mg/L，8例（24.2%）患者的骨髓浆细胞比例≥0.100。16例（47.1%）患者采用硼替佐米为主的化疗方案，总体血液学缓解率为58.3%。中位随诊27（1~40）个月，14例（41.2%）患者在诊断后3个月内死亡，中位生存时间仅为4个月。3、6、12和24个月的预期生存率分别为51.3%、44.0%、35.2%和29.6%。一线化疗后获得血液学缓解、未获得血液学缓解以及姑息治疗的患者1年预计存活率分别为90.9%、11.1%及0（P<0.001）。

结论

极高危pAL患者的预后极差，早期病死率高，获得血液学缓解的pAL患者有着明显更好的预后。

[Efficacy and safety analysis of the combination of cladribine, cytarabine, granulocyte colonystimulating factor (CLAG) regime in patients with refractory or relapsed acute myeloid leukemia]

目的

分析CLAG方案（克拉屈滨＋阿糖胞苷+ G-CSF）对难治复发急性髓系白血病（AML）的疗效及安全性。

方法

回顾性分析2014年4月1日至2015年12月9日采用1个疗程CLAG方案治疗的33例难治复发AML患者的临床资料。

结果

33例难治复发AML患者中，男16例，女17例，中位年龄49(14~68）岁。按照WHO分类（第4版）诊断：伴有重现性遗传学异常AML 7例（21.2%），伴有多系病态造血AML 5例（15.2%），治疗相关AML 2例（6.1%），其他类型19例（57.5%）。NCCN危险分层低危、中危、高危组分别为6、18、9例，其中FLT3-ITD基因突变5例。复发16例，难治17例，既往化疗疗程中位数为2(1~36）个。经CLAG方案1个疗程化疗后，26例（78.8%）获得完全缓解（CR），难治组CR率低于复发组[64.7%（11/17）对93.8%（15/16），P=0.041]。5例FLT3-ITD基因突变患者均获CR。所有患者均出现4级白细胞减少和血小板减少和不同部位感染，3例因感染而早期死亡。5例患者CR后接受异基因造血干细胞移植。中位随访142(9~525) d，复发10例，死亡13例，中位无事件生存期为230(9~525）d，中位总生存期为419(9~525) d。获CR患者（26例）中位总生存期长于未缓解患者（7例）[447(165~525) d对52(9~162) d，P <0.001]。

结论

CLAG方案对难治复发AML疗效肯定，复发患者CR率高于难治患者。控制感染是治疗成功的关键。

[Analysis of the safety and efficacy of 60 mg·m-2·d-1daunorubicin combined with standard dose of cytarabine as induction therapy in acute myeloid leukemia patients under 65 years old]

Objective: To evaluate the long- term safety and efficacy of high- dose daunorubicin(DNR)(60 mg·m-2·d-1)combined with standard dose of cytarabine(DA)as induction therapy in patients under 65 years old with newly diagnosed acute myeloid leukemia(AML). Methods: The complete remission(CR)rate, disease free survival(DFS), overall survival(OS)and side effects of therapy were retrospectively assayed in 116 patients with newly diagnosed AML who were younger than 65 years old and received daunorubicin(60 mg · m-2·d-1)combined with cytarabine(Ara- C 200 mg ·m-2·d-1)as induction therapy at Peking Union Medical College Hospital during July 2012 to February 2016. Results: Of 116 patients, 78 cases(67.2%)achieved CR after first course of induction treatment, 94(81.0%)achieved CR after two courses of induction, and early death occurred in only 3 patients(2.6%)during the first course of induction treatment. Only 1 patient had asymptomatic decreased ejection fraction after 6 months of induction treatment. Eighty nine patients received 1 to 4 courses of consolidation. With a median follow-up of 24(1-46)months, the median DFS was 25 months and median OS was not achieved yet. Cox regression multifactor analysis showed genetics risk groups was the only risk factor for DFS(HR=0.258, 95% CI 0.100- 0.664, P=0.005), while genetics risk groups(HR=0.309, 95% CI 0.126- 0.756, P=0.010)and whether patients received more than one cycle of high dose of Ara-C as consolidation therapy(HR= 0.370, 95% CI 0.179- 0.765, P=0.007)were independent factors associated with OS. Conclusions: In young adults with AML, intensifying induction therapy with a high daily dose of daunorubicin(60 mg/m2)could improve the rate of complete remission without obvious side effects.

Computed tomography-guided aspiration versus key-hole craniotomy for spontaneous putaminal haemorrhage: a prospective comparison of minimally invasive procedures

OBJECTIVES

To compare the effectiveness of two minimally invasive procedures, namely computed tomography-guided aspiration and the key-hole approach, in the neurosurgical management for spontaneous putaminal haemorrhage, and to explore the indications for the two approaches.

DESIGN

A multicentre, single-blinded controlled trial.

SETTING

Hospitals taking part in this trial and the sources for patients were from China. Among others, the hospitals involved in the interventions included: the Beijing Tiantan Hospital (of the Capital University of Medical Sciences), the General Hospital of People's Liberation Army, the Peking Union Hospital, and the Shanghai Huashan Hospital (of the Fudan University medical school).

PATIENTS

From September 2001 to November 2003, data were available for analysis from a total of 841 patients with spontaneous putaminal haemorrhage from 135 hospitals all over China (except Tibet, Hong Kong, Taiwan, and Macao). All follow-up data were for at least 3 months.

MAIN OUTCOME MEASURES

Mortality, Glasgow Coma Scale score, postoperative complications, Kanofsky Performance Scale score, and Barthel Index.

RESULTS

There were 563 patients who underwent computed tomography-guided aspiration, and 165 were treated by the key-hole approach. Respective mortality rates 1 month after the operation were 17.9% and 18.3%; at 3 months they were 19.4% and 19.4%. In those undergoing computed tomography-guided aspiration, mortality rates at 3 months after the operation were 28.2% in patients with Glasgow Coma Scale scores of 8 or below, as opposed to 8.2% in those with higher scores. This amounted to a 3.4-fold difference. In those treated by the key-hole approach, the corresponding rates were 30.2% and 7.6%, which amounted to a 4-fold difference. The corresponding mortality at 3 months in patients with complications was 3.9 times as great as in those without complications. In those with haematoma volumes of 70 mL or greater, it was 2.7 times as much as in those in whom the volumes below 30 mL. The postoperative complication rate of computed tomography-guided aspiration (23.7%) did not differ significantly from that in those having the key-hole approach (25.7%) [P=0.420].

CONCLUSIONS

Computed tomography-guided aspiration is not superior to the key-hole approach for treating spontaneous putaminal haemorrhage in terms of favourable outcomes, mortality, and morbidity. However, it could be the first-choice approach for those with bleeds of 50 mL or less, while the key-hole approach may be more suitable for those with larger haematomas.

[Effects of microinjection of sodium glutamate and glycine into ventrolateral nucleus of tractus solitarius on the discharges of phrenic nerve in rabbits]

The effects of microinjection of sodium glutamate and glycine into ventrolateral nucleus of tractus solitarius (VLNTS) on the discharges of phrenic nerve were observed on 40 anaesthetized, vagotomized, paralyzed and artificially ventilated rabbits. The results were as follows: Phrenic nerve discharges were increased, inspiratory duration prolonged, expiratory duration shortened and respiratory frequency not changed by microinjection of sodium glutamate into VLNTS. While by microinjection of glycine, phrenic nerve discharges were decreased, even abolished, inspiratory duration shortened, expiratory duration irregularly prolonged and respiratory frequency decreased. The above results show that VLNTS exert important effects on the genesis of respiratory rhythm.

[Effect of microinjection of sodium giutamate and glycine into ventrolateral nucleus of tractus solitarius on the evoked potentials of arcuatus nucleus in rabbits]

Experiments were performed on 66 anaesthetized, vagotomized, paralyzed and artificially ventilated rabbits. The effects of microinjection sodium glutamate and glycine into ventrolateral nucleus of tractus solitarius (VLNTS) on hypothalamic arcuatus nucleus evoked potentials were observed. The main results obtained were as follows: (1) Phrenic nerve discharges were increased and the amplitude of P2 and N2 waves of arcuatus nucleus evoked potentials were decreased by microinjection of sodium glutamate into VLNTS. Phrenic nerve discharges were decreased and the amplitude of P2 and N2 waves of arcuatus nucleus evoked potentials were increased by microinjection of glycine into VLNTS. (2) After intravenous injection of naloxone, the phrenic nerve discharges could still be excited by microinjection of sodium glutamate as before, but the effects on the amplitude of P2 and N2 waves of arcuatus nucleus evoked potentials, unlike that of sodium glutamate, were reversed. The results suggest that the excitatory action of respiratory neurons in the VILTS may affect on the sensory function of arcuatus nucleus. The mechanism involved was discussed.

[Intracranial chordoma and its surgical treatment]

Twenty-one patients with intracranial chordomas were classified into sellar region, middle fossa, posterior fossa and nasopharynx patterns according to their location. Twenty patients were operated on via various approaches: retromastoid, extreme lateral suboccipital, anterior basal, sphenoidal, oral, subtemporal, etc. The tumors were removed totally in 5 patients, subtotal or largely partial in 11, and partial in 3. Biopsy was performed only in one patient. No death occurred. The classification, diagnosis and treatment were discussed as well as the surgical approaches and techniques.

[Diagnosis and treatment of congenital atlantoaxial dislocation]

23 patients, aged from 10 to 52 years (24 years on the average), with congenital dislocation of atlanto-axial joint were treated. Symptoms were chiefly functional disturbance of motion; diagnosis was based on malformation of cranio-vertebral junction shown on radiograms; and operation of transoral decompression or/and posterior decompression and fusion was performed on each patient. Such operation did benefited 19 patients, a rate of 82.6%, evaluated in 0.2 to 8.7 years (1.9 years on the average) after operation. Skull traction tried on several patients failed to reduce the dislocation because of dense fibrous tissues in the joint space, hindering reduction. Posterior decompression alone was seldom effective and even dangerous. For this condition, transoral decompression and anterior or posterior fusion is a good choice of treatment. Mechanism of developing symptoms, key points of making diagnosis and surgical procedures were described in detail.