Lenalidomide, bortezomib and dexamethasone followed by tandem- autologous stem cell transplantation is an effective treatment modality for multi-hit multiple myeloma

In order to investigate the efficacy of lenalidomide, bortezomib and dexamethasone (VRD) induction chemotherapy regimen combined with tandem autologous stem cell transplantation (ASCT) in treating multi-hit multiple myeloma (MM), we analyzed 252 cases of newly diagnosed MM treated with the bortezomib-containing induction chemotherapy from June 2016 to June 2019. According to the fluorescence in situ hybridization (FISH) results on diagnosis, the patients were divided into multi-hit MM group (47 cases), single-hit MM group (81 cases), and standard-risk group (124 cases). Our analysis showed that R-ISS stageⅢ in transplantation group and R-ISS stageⅢ, multi-hit and VGPR or above was not achieved at the fourth cycle of chemotherapy in non-transplantation group were independent factors for poor prognosis by univariate and multivariate analyses. Moreover, the overall response rate (ORR) of VRD induction chemotherapy group was significantly higher than that of the non-VRD group in the single-hit and multi-hit groups (P = 0.021, P = 0.032); In terms of ASCT, tandem-ASCT can significantly improve the 2-year PFS (77.8 ± 3.9 %) and OS (83.3 ± 5.6 %) of multi-hit MM (P = 0.024, P = 0.037), while single-ASCT only has a limited effect on PFS (61.5 ± 3.0 %) and OS (71.9 ± 4.5 %) (P = 0.115, P = 0.155).

High expression of COMMD7 is an adverse prognostic factor in acute myeloid leukemia

Acute myeloid leukemia (AML) is a frequent malignancy in adults worldwide; identifying preferable biomarkers has become one of the current challenges. Given that COMMD7 has been reported associated with tumor progression in various human solid cancers but rarely reported in AML, herein, RNA sequencing data from TCGA and GTEx were obtained for analysis of COMMD7 expression and differentially expressed gene (DEG). Furthermore, functional enrichment analysis of COMMD7-related DEGs was performed by GO/KEGG, GSEA, immune cell infiltration analysis, and protein-protein interaction (PPI) network. In addition, the clinical significance of COMMD7 in AML was figured out by Kaplan-Meier Cox regression and prognostic nomogram model. R package was used to analyze incorporated studies. As a result, COMMD7 was highly expressed in various malignancies, including AML, compared with normal samples. Moreover, high expression of COMMD7 was associated with poor prognosis in 151 AML samples, as well as subgroups with age >60, NPM1 mutation-positive, FLT3 mutation-negative, and DNMT3A mutation-negative, et al. (P < 0.05). High COMMD7 was an independent prognostic factor in Cox regression analysis; Age and cytogenetics risk were included in the nomogram prognostic model. Furthermore, a total of 529 DEGs were identified between the high- and the low- expression group, of which 92 genes were up-regulated and 437 genes were down-regulated. Collectively, high expression of COMMD7 is a potential biomarker for adverse outcomes in AML. The DEGs and pathways recognized in the study provide a preliminary grasp of the underlying molecular mechanisms of AML carcinogenesis and progression.

Identifying a novel 5-gene signature predicting clinical outcomes in acute myeloid leukemia

BACKGROUND

Acute myeloid leukemia (AML) is the most common type of acute leukemia and biologically heterogeneous diseases with poor prognosis. Thus, we aimed to identify prognostic markers to effectively predict the prognosis of AML patients and eventually guide treatment.

METHODS

Prognosis-associated genes were determined by Kaplan-Meier and multivariate analyses using the expression and clinical data of 173 AML patients from The Cancer Genome Atlas database and validated in an independent Oregon Health and Science University dataset. A prognostic risk score was computed based on a linear combination of 5-gene expression levels using the regression coefficients derived from the multivariate logistic regression model. The classification of AML was established by unsupervised hierarchical clustering of CALCRL, DOCK1, PLA2G4A, FCHO2 and LRCH4 expression levels.

RESULTS

High FCHO2 and LRCH4 expression was related to decreased mortality. While high CALCRL, DOCK1, PLA2G4A expression was associated with increased mortality. The risk score was predictive of increased mortality rate in AML patients. Hierarchical clustering analysis of the five genes discovered three clusters of AML patients. The cluster1 AML patients were associated with lower cytogenetics risk than cluster2 or 3 patients, and better prognosis than cluster3 patients (P values < 0.05 for all cases, fisher exact test or log-rank test).

CONCLUSION

The gene panel comprising CALCRL, DOCK1, PLA2G4A, FCHO2 and LRCH4 as well as the risk score may offer novel prognostic biomarkers and classification of AML patients to significantly improve outcome prediction.

Comprehensive characterization of driver genes in diffuse large B cell lymphoma

Diffuse large B cell lymphoma (DLBCL) is the most common hematological malignancy and is one of the most frequent non-Hodgkin lymphomas. Large-scale genomic studies have defined genetic drivers of DLBCL and their association with functional and clinical outcomes. However, the lymphomagenesis of DLBCL is yet to be fully understood. In the present study, four computational tools OncodriveFM, OncodriveCLUST, integrated Cancer Genome Score and Driver Genes and Pathways were used to detect driver genes and driver pathways involved in DLBCL. The aforementioned tools were also used to perform an integrative investigation of driver genes, including co-expression network, protein-protein interaction, copy number variation and survival analyses. The present study identified 208 driver genes and 31 driver pathways in DLBCL. IGLL5, MLL2, BTG2, B2M, PIM1, CARD11 were the top five frequently mutated genes in DLBCL. NOTCH3, LAMC1, COL4A1, PDGFRB and KDR were the 5 hub genes in the blue module that were associated with patient age. TP53, MYC, EGFR, PTEN, IL6, STAT3, MAPK8, TNF and CDH1 were at the core of the protein-protein interaction network. PRDM1, CDKN2A, CDKN2B, TNFAIP3, RSPO3 were the top five frequently deleted driver genes in DLBCL, while ACTB, BTG2, PLET1, CARD11, DIXDC1 were the top five frequently amplified driver genes in DLBCL. High EIF3B, MLH1, PPP1CA and RECQL4 expression was associated with decreased overall survival rate of patients with DLBCL. High XPO1 and LYN expression were associated with increased overall survival rate of patients with DLBCL. The present study improves the understanding of the biological processes and pathways involved in lymphomagenesis. The driver genes, EIF3B, MLH1, PPP1CA, RECQL4, XPO1 and LYN, pave the way for developing prognostic biomarkers and new therapeutic strategies for DLBCL.

L-Tetrahydropalmatine Induces Apoptosis in EU-4 Leukemia Cells by Down-Regulating X-Linked Inhibitor of Apoptosis Protein and Increases the Sensitivity Towards Doxorubicin

BACKGROUND

L-Tetrahydropalmatine (L-THP) is a tetra-hydro protoberberine isoquinoline alkaloid. The phyto-compounds bearing isoquinoline alkaloids have been reported to show a potential effect against a number of human cancers cell lines including leukemia. We hypothesized that L-THP, being an isoquinoline alkaloid, could be a potential molecule against acute lymphoblastic leukemia (ALL), in this study, we evaluate L-THP against p53 deficient leukemia EU-4 cell lines in vitro.

METHODS

For the study, p53 null leukemia EU-4 cells were used and treated with LTHP. The extent of apoptosis and viability of cells were determined. Expression of apoptosis related proteins such as XIAP and MDM2 was done by western blot and PCR studies. The expression of MDM2 and XIAP was knocked down by small interfering RNA (siRNA).

RESULTS

Outcomes of the study suggested that L-THP caused p53-indipendent apoptosis mediated by XIAP in EU-4 cells. The treatment of L-THP caused a decrease in the levels of XIAP protein with increasing dose and time. L-THP caused down-regulation of XIAP protein via inhibiting the expression of MDM2 and involving proteasomedependent pathway. Also, the outcomes of experiments suggested increased sensitivity of leukemia cells towards doxorubicin due to the inhibition of XIAP by L-THP or by siRNA.

CONCLUSION

Findings of the study confirm that L-THP resulted in p53 independent apoptosis via down-regulating XIAP protein by inhibiting MDM2 associated with proteasome-dependent pathway and increased sensitivity of EU-4 cells against doxorubicin. L-THP caused activation of caspase and resulted in apoptosis, L-THP may be a novel molecule for inducing apoptosis specifically in p53 null leukemia EU-4 cells.

[DNA methylation-mediated epigenetic silencing of miR-720 contributes to leukemogenesis in acute myeloid leukemia]

OBJECTIVE

To investigate the expression level and regulation mechanism of miR-720 as well as the association of miR-720 expression with leukemia biological characteristics.

METHODS

Expression and promoter methylation of miR-720 were determined by quantitive PCR and pyrosequencing in 38 patients with AML and 20 normal controls. Lentivirous-mediated miR-702 overexpression was constructed in AML cell line kasumi-1. The cell proliferation, apoptosis, cycle, colony formation, migration and P53-mediated apoptosis pathway were determined.

RESULTS

AML patients showed significantly lower miR-720 expression compared with normal controls (0.69±0.09 vs 3.00±0.46, P<0.01); The methylation level of miR-720 promoter region in AML patients were significantly higher than normal controls [(75.56±2.35)% vs (47.65±2.78)%, P<0.01]. miR-720 overexpression in kasumi-1 cells induced significantly increased cell apoptosis (P=0.017), elevated apoptosis sensitivity to etoposide (P=0.004), and reduced cell proliferation (P<0.01). miR-720 overexpression also induced reduced colony formation (P=0.005), cell cycle arrest in G(1)/G(0) phase and decreased migration ability in kasumi-1 cells. In addition, overexpression of miR-720 significantly induced increased cell apoptosis-related proteins including P53 and Bax, and activation of NF-κB signal transduction pathway. After kasumi-1 cells were treated with 1uM decitabine for 48 hours, miR-720 promoter methylation reduced significantly, and miR-720 expression significantly increased.

CONCLUSION

The expression of miR-720 in AML patients reduced significantly, and DNA methylation-mediated epigenetic silencing of miR-720 contributed to maintain the malignant characteristics of AML.

Long term curative effects of sequential therapy with all-trans retinoic acid, arsenious oxide and chemotherapy on patients with acute promyelocytic leukemia

BACKGROUND

Both all-trans retinoic acid (ATRA) and arsenic trioxide (As(2)O(3)) have proven to be very effective in obtaining high clinical complete remission (CR) rates in acute promyelocytic leukemia (APL).

METHODS

In this study, 73 newly diagnosed APL subjects were treated with an ATRA and As(2)O(3) combination treatment in remission induction and post remission therapy. Tumor burden was examined with PCR of the PML-RAR fusion transcripts, and side effects were evaluated by means of clinical examination.

RESULTS

The results showed that ATRA/As(2)O(3) combination therapy yielded a CR rate of 94.5% (69/73) with a shorter time to enter CR (median: 27 days; range: 21-43 days). Four cases failed to enter CR; three of these died of cerebral hemorrhage and disseminated intravascular coagulation (DIC) within 72 hours of starting induction therapy, one older patient died of severe pulmonary infection. The early death rate was 5.5% (4/73). All 69 cases that obtained CR remained in good clinical remission after a follow-up of 35-74 months (median: 52 months).The drug toxicity profile with the use of As(2)O(3) showed mainly hepatotoxicity. Liver dysfunction was slight in most cases. There were no severe side effects in long term follow-up.

CONCLUSION

We conclude that APL patients may benefit from the use of the combination of ATRA and As(2)O(3) in either remission induction or consolidation/maintenance.

[Effect of colforsin daropate hydrochloride after cardiopulmonary bypass]

We evaluated the effects of colforsin daropate hydrochloride (CDH) after cardiopulmonary bypass (CPB) in comparison with milrinone. CDH or milrinone were given during and after CPB combined with cathecholamines so as to maintain mean arterial pressure (mABP > 60 mmHg) and cardiac index (CI > 3.0 l.min-1.m-2). Hemodynamics measurement was done immediately after CPB (A 1), one hour after CPB (A 2) and after the chest closure (A 3). In CDH group, mABP was significantly higher compared with milrinone group. Also, CDH group showed a significant reduction in the cases of combined use of dobutamine (at A 2, A 3) and norepinephrine (at A 1, A 2) compared with milrinone group. In conclusion, colforsin daropate hydrochloride exerts more inotropic effect and could reduce the necessity of combined use of cathecholamine compared with milrinone.

[Differences in hemodynamic effects of amrinone, milrinone and olprinon after cardiopulmonary bypass in valvular cardiac surgery]

The differences in hemodynamic effects of amrinone, milrinone and olprinone were evaluated in 46 patients for valvular cardiac surgery after cardiopulmonary bypass (CPB). Patients were randomly allocated to three groups; group A with amrinone infusion (17 patients); group M with milrinone infusion (15 patients); and group O with olprinone infusion (14 patients). Each drug was administrated as a single dose into the venous reservoir of the CPB circuit 15 min prior to the end of emergence from CPB, followed by continuous infusion. Hemodynamic parameters were measured at the time of preCPB (C0), just after the end of CPB (C1), one hour after the termination of CPB (C2) and after the chest closure (C3). Catecholamines were used in order of dopamine, norepinephrine and dobutamine. These doses were modulated to maintain the cardiac index > 3.0 l.min-1.m-2 by each anesthesiologist. Hemodynamic parameters (at C0, C1, C2 and C3) and the doses of cathecholamine (at C1, C2 and C3) were compared among the 3 drugs. The systolic blood pressure in group M was significantly higher than that of group A and group O after chest closure. In group M and A, the systolic blood pressure showed a significant increase after CPB. On the other hand, the systolic blood pressure showed no significant change in group O after CPB. Three drugs showed no significant difference in the dosages of catecholamines used.

[Optimal dose of indocyanine-green injected from the peripheral vein in cardiac output measurement by pulse dye-densitometry]

Cardiac output is measured by pulse dye-densitometry using indocyanine-green (ICG). This cardiac output is estimated by correlating with the cardiac output measured by pulmonary artery catheter using thermodilution method. Twenty-four patients scheduled for elective cardiovascular surgeries under general anesthesia were studied. The pulse dye-densitometry monitoring system used was DDG-2001 (Nihon Kohden, Japan). In group A (13 patients: 19 times), ICG was administered from the peripheral vein as bolus doses of 5, 10 or 20 mg (5 mg.ml-1 water solution). In group B (11 patients: 12 times), ICG was administered from the peripheral vein as bolus doses of 20, 10 or 5 mg (5 mg.ml-1 water solution). The correlation (Pearson's correlation coefficient) and precision (the method proposed by Bland and Altman) compared with cardiac output measured by pulmonary artery catheter were examined. Better correlation and precision were recognized after 20 mg ICG injection than 5 or 10 mg ICG injection. In conclusion, the measurement of cardiac output by pulse dye-densitometry with peripheral vein ICG injection was useful using a bolus dose of ICG 20 mg.

[Ventricular fibrillation during mild hypothermic therapy in a patient undergoing neurosurgery]

A 35 year old male for mild hypothermic therapy for neurosurgery, developed ventricular fibrillation. Total resection of cerebral arteriovenous malformation was performed under mild hypothermic therapy, with the target core temperature of 33 degrees C. Intraoperatively cooling rate was low and a reduction of peripheral temperature associated with metabolic acidosis was noted. After the conclusion of the operation and during transferring the patient to an intensive care unit, multiple ventricular premature beats were noted. Thereafter, ventricular tachycardia developed proceeding ventricular fibrillation. We suggest that careful management of thermal and cardiovascular systems is required to prevent adverse events during mild hypothermic therapy.

Clinical and biological features of t1 ductal adenocarcinoma of the pancreas

BACKGROUND/AIMS

The impact of tumor size on tumor development and long-term prognosis is still controversial for patients with ductal adenocarcinoma of the pancreas. We investigated the clinicopathological and biological features of ductal adenocarcinoma limited to the pancreas without direct histological extrapancreatic invasion (t1 tumor).

METHODOLOGY

The clinical records of 86 patients who underwent surgery for ductal adenocarcinoma of the pancreas were reviewed to determine clinical features, histopathological findings, operative management and outcomes. Immunohistochemical staining of the p53 tumor suppressor gene (p53) was performed for the resected specimens.

RESULTS

Only 10 (12%) of the 86 resected ductal adenocarcinomas of the pancreas were t1 tumors. Six of the 10 patients with t1 tumors survived for more than 5 years. The rates of nodal metastasis (10%) and neural plexus invasion (0%) in t1 tumors were significantly lower than those in non-t1 tumors, although the rates of blood-borne metastasis (30%) and p53 expression (50%) in t1 tumors were the same as those in non-t1 tumors.

CONCLUSIONS

Curative resection contributes to a satisfactory long-term prognosis of patients with t1 tumor of the pancreas as a result of the low rates of both nodal metastasis and neural plexus invasion associated with this procedure. In patients with t1 tumor of the pancreas, a satisfactory long-term prognosis can be assured as a result of the low rates of both nodal metastasis and neural plexus invasion associated with curative resection.

[Effects of amrinone on oxygen demand-supply relationship after cardiopulmonary bypass in patient undergoing coronary bypass surgery]

We evaluated the effects of amrinone on oxygen demand-supply relationship after cardiopulmonary bypass (CPB) in patient undergoing coronary bypass surgery comparing with the patients not receiving amrinone. In amrinone treated patients bolus dose of amrinone 1.5 mg.kg-1 was administrated into the reservoir of CPB and followed by continuous infusion at a rate of 5 micrograms.kg-1.min-1. Hemodynamics and blood gas (arterial and mixed venous) measurements were carried out immediately after CPB, 1 hour after CPB and after the chest closure. After the chest closure, cardiac index and oxygen supply in amrinone treated group were significantly higher and systemic vascular resistance was significantly lower than in non-treated group. Left ventricular stroke work index, rate pressure product and oxygen consumption showed no significant difference between the two groups. These data indicate that the amrinone treated patients preserved better oxygen demand-supply relationship after CPB compared with the non-treated patients undergoing coronary bypass surgery.

[Anesthetic management for a patient with pheochromocytoma using magnesium sulfate and epidural block]

A 54-year-old woman with pheochromocytoma was anesthetized using magnesium sulfate infusion. Anesthesia was induced with thiopental and fentanyl, and maintained with 0.5% sevoflurane in nitrous oxide/oxygen and 60 mg.hr-1 of epidurally infused lidocaine. Muscle relaxation was achieved with intermittent administration of vecuronium under neuromuscular monitoring. Magnesium 2 g was infused prior to the tracheal intubation and followed by continuous infusion of 2 g.hr-1. These anesthetic techniques made hemodynamic state stable, and no additional vasoactive agents were needed. However, the infusion rate of magnesium was reduced to a half because of PQ interval prolongation. Magnesium is believed to be useful for anesthetic management for patients with pheochromocytoma, but the proper dose and the way of administration should be further investigated for their safe clinical use.

[Effects of nitroglycerin, prostaglandin E1, trimetaphan and nicardipine on systemic vascular resistance, pulmonary vascular resistance and pulmonary-systemic vascular resistance ratio in dogs]

Effects of the experimentally induced hypotension with 4 vasodilators; nitroglycerin (TNG), prostaglandin E1 (PGE1), trimetaphan (TMP) and nicardipine (NCP) on systemic vascular resistance (SVR), pulmonary vascular resistance (PVR) and pulmonary-systemic vascular resistance ratio (PVR/SVR ratio) were studied in dogs. The SVR values were significantly reduced by TNG, PGE1 and NCP, and not affected by TMP. The PVR values were significantly reduced by TNG and PGE1, and not affected by TMP and NCP. The PVR/SVR ratio values were significantly reduced by TNG, and significantly increased by NCP, and not affected by PGE1 and TMP. We concluded that TNG reduced PVR and SVR but it affected PVR more; PGE1 reduced PVR and SVR equivalently; TMP did not affect PVR and SVR remarkably; NCP reduced SVR but did not affect PVR.

[Evaluation of selective lumbar radiculography and radicular block]

We analyzed 56 patients who received selective lumbar radiculography and radicular block (88 procedures in total). The underlying conditions were spinal diseases in 43 cases, cancer pain in 6 cases, post-herpetic neuralgia (PHN) in 5 cases and reflex sympathetic dystrophy (RSD) in 2 cases. In the spinal disease group, 24 cases showed complete pain relief and 12 cases showed partial pain relief after the therapy, with a success rate of 83.7%. In the cancer pain group, 3 cases showed complete pain relief and one showed partial pain relief (success rate: 66.7%). In the PHN group, 1 case showed complete pain relief and 2 showed partial pain relief (success rate: 60%). In the RSD group, all cases showed pain relief. When examined 3 months after this treatment, the effect had persisted in 15 cases from the spinal disease group, in 1 case from the cancer pain group, in 2 cases from the PHN group and in 2 cases from the RSD group. Selective lumbar radiculography and radicular block are useful in identifying a nerve root responsible for abnormalities. In addition, this procedure is expected to exert a long-lasting therapeutic effect in cases indicated for the procedure.

[Effects of different positions for epidural block on skin-epidural space distance]

Epidural block was performed in the same intervertebral space by both approaches with either flank position or prone position under fluoroscopy. The distances from with both positions the skin to the epidural space (SED) were compared. The prone position approach under fluoroscopy resulted in a significantly greater SED in both T2/3 puncture and L4/5 puncture groups. This was assumed to be due to the fact that the prone position approach does not always allow minimum distance. It was also thought to be due to the fact that in this position, compared with the flank position, a pillow is inserted under the thoracic (or abdominal) region, and the skin in the dorsal region is looser and the subcutaneous tissue is thicker. The lumbar vertebrae form the lordosis, and it does not disappear when the pillow is placed under the abdominal region. This causes the SED to be greater.

[Removal of a bronchial foreign body in a child using the laryngeal mask]

The laryngeal mask (LM) was employed for the removal of a bronchial foreign body (screw) in a 2-year-old boy weighing 16 kg since the 6.0 mm external diameter fiberoptic bronchoscope (FBS) for extraction forceps could not be used under tracheal intubation. Anesthesia was induced with sevoflurane in 100% oxygen. After injection of fentanyl 25 micrograms and vecuronium 2 mg, a gastric tube and a size 2 LM were inserted. Throughout the extraction procedure by the FBS in the left main bronchus, the boy had one lung ventilated manually. The airway pressure was kept under 15 cmH2O to avoid gas leakage around the cuff and gastric inflation. Oxygen saturation of 100% with pulse oximetry and PETCO2 of 35 to 45 mmHg with capnometry were maintained. The foreign body was extracted by biopsy forceps. A Fogarty catheter was not effective because the balloon tip was broken by the screw. The LM does not prevent regurgitation and does not provide adequate ventilation under increased airway pressure, but it facilitates the use of a larger size FBS equipped with a variety of extraction forceps. Therefore, it seems to be a useful device for the removal of bronchial foreign bodies in children.

[Effects of controlled hypotension induced by prostaglandin E1 on the cerebral blood flow]

The effect of controlled hypotension induced by prostaglandin E1 (PGE1) on the cerebral blood flow (CBF) was studied in 14 patients undergoing neurosurgery. CBF was measured by thermal diffusion using a flow probe with a Peltier stack. PGE1 was injected i.v. continuously, at a dose of 0.05, 0.1 and 0.2 micrograms.kg-1.min-1. CBF tended to increase dose-dependently but not significantly by PGE1 administration. Cerebral vascular resistance was reduced significantly by every dose of PGE1 administered. Therefore, the results indicate that the cerebral vascular beds are dilated directly by PGE1. In conclusion, this study suggests that PGE1 can be used safely to control hypotension without reducing CBF during neurosurgery.