Phase 2 clinical study evaluating the efficacy and safety of disitamab vedotin with or without pembrolizumab in patients with HER2-expressing urothelial carcinoma (RC48G001)

TPS594

Background: Urothelial carcinoma (UC) is the 10th most diagnosed cancer worldwide, and nearly 50% of patients cannot tolerate the current first-line (1L) standard of care. There is a need to improve outcomes in 1L and later lines of therapy. HER2 is overexpressed in UC and may be associated with poor outcomes. Despite this, no HER2-directed therapies are currently approved for UC. Disitamab vedotin (DV; RC48-ADC) is an investigational antibody-drug conjugate comprising a novel HER2-directed monoclonal antibody, disitamab, conjugated to monomethyl auristatin E (MMAE) via a protease-cleavable mc-vc linker. DV elicits antitumor activity through multimodal mechanisms of action including MMAE-mediated direct cytotoxicity, bystander effect, and immunogenic cell death. Methods: RC48G001 (NCT04879329) is a phase 2, multi-cohort, open-label, multicenter trial to evaluate DV in patients with HER2-expressing locally advanced/metastatic UC (LA/mUC). Patients are enrolled in 3 cohorts based on prior treatment and tumor HER2 expression by immunohistochemistry (IHC) and gene amplification (via in situ hybridization [ISH]), assessed centrally. Cohorts A and B are enrolling patients who have received prior systemic therapy (1 or 2 lines, including platinum-containing chemotherapy) and whose tumors are HER2-positive (IHC 3+, or 2+ and ISH-positive) or HER2-low (IHC 2+ and ISH-negative, or IHC 1+), respectively. Cohort C is enrolling 1L treatment-naive patients in the LA/mUC setting, whose tumors have HER2-positive or HER2-low expression. Cohorts A and B will evaluate DV as monotherapy (intravenous [IV] administration, once every 2 weeks [Q2W]). Cohort C will evaluate DV (IV, Q2W) +/– pembrolizumab (IV, Day 1 of each 6-week cycle). Patients in all cohorts must have measurable disease per Response Evaluation Criteria in Solid Tumors (RECIST) v1.1 and an Eastern Cooperative Oncology Group Performance Status of 0–1 in Cohorts A and B, and 0–2 in Cohort C. The primary endpoint is confirmed objective response rate (cORR) per blinded independent central review (BICR). Secondary endpoints include cORR by investigator assessment, overall survival, duration of response, progression-free survival, disease control rate per RECIST v1.1 by BICR and investigator, safety, and pharmacokinetic parameters. Enrollment for all cohorts is ongoing in North America and Europe, and planned in Latin America, Asia-Pacific, and Israel. Clinical trial information: NCT04879329 .

SKYSCRAPER-07: A phase III, randomized, double-blind, placebo-controlled study of atezolizumab with or without tiragolumab in patients with unresectable ESCC who have not progressed following definitive concurrent chemoradiotherapy

TPS374

Background: The current standard of care for patients (pts) diagnosed with unresectable, locally advanced esophageal squamous-cell carcinoma (ESCC) is definitive platinum-based concurrent chemoradiotherapy (dCRT). However, ESCC has poor prognosis, with more than half of tumors reoccurring after dCRT (Smyth et al. Nat Rev Dis Primers 2017), highlighting the need for additional therapy options in this setting. Cancer immunotherapies have demonstrated activity in ESCC, and targeted inhibition of the PD-L1/PD-1 pathway may be further amplified using novel anti-TIGIT agents such as tiragolumab. In preclinical mouse models, concomitant blockade of PD-L1/PD-1 and TIGIT pathways demonstrated prolonged survival over the respective single-agents. In the phase II CITYSCAPE study (NCT03563716), tiragolumab plus atezolizumab (anti-PD-L1) resulted in a clinically meaningful improvement in PFS and higher ORR vs atezolizumab alone (31.3 vs 16.2%) in first-line pts with PD-L1+ (TPS ≥1%) metastatic NSCLC. SKYSCRAPER-07 (NCT04543617) will determine if tiragolumab plus atezolizumab combination therapy provides superior clinical benefit to atezolizumab monotherapy or placebo in pts with unresectable ESCC whose cancers have not progressed following dCRT. We hypothesize that combination therapy will prolong PFS and OS compared with placebo in this setting. Methods: Eligible pts (≥18 years) must have unresectable ESCC, without progressive disease (PD) after platinum-based dCRT (according to regional oncology guidelines for ESCC); ECOG PS 0–1; no prior treatment with any immune checkpoint inhibitor. Approximately 750 pts will be randomized 1:1:1 to either Arm A (tiragolumab 600mg + atezolizumab 1200mg IV Q3W), Arm B (atezolizumab 1200mg + placebo IV Q3W) or Arm C (double placebo IV Q3W). Treatment will continue for up to 17 cycles of 21 days, or until unacceptable toxicity or investigator-assessed radiographic PD (per RECIST v1.1). Stratification factors include geographic region (Asia vs rest of world), PD-L1 expression and staging prior to dCRT (II vs III vs IV). Co-primary efficacy endpoints are investigator-assessed PFS and OS; key secondary endpoints include independent review facility-assessed PFS and DoR. Safety, pharmacokinetic, biomarker and immunogenicity analyses will be performed. Recruitment is ongoing. Clinical trial information: NCT04543617.

Bioconversion studies in cultured cells of Corydalis species

Structural analysis of the metabolites of dopamine and salsolinol in cultured cells of Corydalis species was carried out using the combination of LC-MS and LC-NMR techniques. Metabolic pathways were clarified without the need to isolate the individual metabolites.

Cassipoureamide-A and -B: new sulfur-containing amides from stem wood of Cassipourea guianensis

New sulfur-containing amides, cassipoureamide-A (1) and -B (2), have been isolated from the stem wood of Cassipourea guianensis, and their structures were determined to be cis-N-(2-hydroxyethyl)-4-hydroxy-1,2-dithiolane-3-carboxamide and cis-N-(2-hydroxyethyl)-5-hydroxy-1,2,3-trithiane-4-carboxamide, respectively, by MS and NMR studies.

Alternating combination chemotherapy COP (cyclophosphamide, vincristine, prednisone) and MP (melphalan, prednisone) in multiple myeloma: a multicenter phase II study (JCOG8906). Lymphoma Study Group of the Japan Clinical Oncology Group

BACKGROUND

The main form of cytotoxic treatment for multiple myeloma (MM) is conventional dose chemotherapy at present.

METHOD

Between November 1989 and December 1991, a multicenter phase II study of alternating conventional dose combination chemotherapy (CCT) with COP (cyclophosphamide, vincristine, prednisone) and MP (melphalan and prednisone) to evaluate its clinical usefulness for overt MM patients was conducted by the Lymphoma Study Group of the Japan Clinical Oncology Group (JCOG).

RESULTS

Eighty-one previously untreated patients were enrolled in the study. For 69 eligible patients, the response rate was 50.7% [95% confidence interval (CI) 38.4-63.0%]. The median survival time was 38.5 (95% CI 32.0-44.4) months. The survival rate at 3 and 5 years was 50.7 and 27.3%, respectively. Grade 4 toxicity by the criteria of the World Health Organization consisted of anemia in eight patients, leucocytopenia in three, cardiac in one and hepatic in two, but there was no treatment-related death.

CONCLUSION

The COP-MP regimen for overt MM is thought to be one of the effective CCTs according to the results of the present phase II study.

Minor Flavanones from Erythrina abyssinica

Four new prenylated flavanones, abyssinone-V 4'-methyl ether (1) and abyssinoflavanones IV (2), V (3), and VI (4), have been isolated as minor flavanones from the African medicinal plant, Erythrina abyssinica, together with a known flavanone, sigmoidin D. The structure elucidation of compounds 1-4 by spectroscopic studies is described.

Cardiotonic activity of the rhizome of Polygonatum sibiricum in rats

The cardiotonic effect of the rhizome of Polygonatum sibiricum was investigated in the left atria of rats. The methanol extract of the rhizome of Polygonatum sibiricum (OM) (1-7 mg/ml) concentration-dependently increased the developed tension of the left atrium. It also strongly inhibited cAMP phosphodiesterase. The increase cAMP level correlated the increase in left atrial contraction. On the other hand, OM did not inhibit Na+, K+-ATPase. The cardiotonic effect of OM was strongly inhibited by reserpine, a sympatholytic agent. Furthermore, OM-treated left atria inhibited the tension produced by propranolol, a beta adrenocepter antagonist. These findings suggested that the cardiotonic effect is due to stimulating beta adrenoceptors through activation of sympathetic nerves.

Hypoglycemic activity of some triterpenoid glycosides

Four triterpenoid glycosides isolated from the rhizomes of Polygala senega var. latifolia, senegins II-IV (1-3) and desmethoxysenegin II (4), were tested for hypoglycemic activity in normal and KK-Ay mice. Compounds 1 and 2 reduced the blood glucose of normal mice 4 h after intraperitoneal administration and also significantly lowered the glucose level of KK-Ay mice under similar conditions. Compounds 3 and 4, as well as senegose A (5), an oligosaccharide ester, were inactive when tested against normal mice.

Hypoglycemic effect of the rhizomes of Polygala senega in normal and diabetic mice and its main component, the triterpenoid glycoside senegin-II

The hypoglycemic effect of the rhizomes of Polygala senega L. var. latifolia Torrey et Gray (Polygalaceae) was investigated in normal and KK-Ay mice, one of the model animals of non-insulin dependent diabetes mellitus (NIDDM). The n-butanol extract of senega rhizomes (SN) (5 mg/kg) reduced the blood glucose of normal mice from 191 +/- 3 to 120 +/- 3 mg/dl 4 hours after intraperitoneal administration (P < 0.001), and also showed a significant decrease in the glucose level of KK-Ay mice from 469 +/- 38 to 244 +/- 14 mg/dl under similar conditions (P < 0.001). But streptozotocin-induced diabetic mice did not experience a change in the blood glucose after administration of SN. We propose that the hypoglycemic effect of SN occurs without altering the insulin concentration. Moreover, SN needs the presence of insulin in order to act. In addition, one of the active components of the hypoglycemic effect was identified as a triterpenoid glycoside, senegin-II.

Intraperitoneal administration of Senegae Radix extract and its main component, senegin-II, affects lipid metabolism in normal and hyperlipidemic mice

The hypolipidemic effect of Senegae Radix, i.e. "Senega," was investigated in normal and hyperlipidemic mice. The n-butanol fraction of the methanol extract of Senegae Radix (SN) (5 mg/kg) significantly reduced the blood triglyceride level of normal mice 7 h after intraperitoneal administration (p < 0.05) and also significantly reduced the blood triglyceride level of cholesterol-fed mice under similar conditions (p < 0.05). SN (5 mg/kg) also reduced the blood triglyceride and cholesterol levels after repeated administration to cholesterol-fed mice. SN also decreased the blood triglyceride level in Triton-induced hyperlipidemia. It is suggested that this fraction contains one or more hypolipidemic components including the main triterpenoid glycoside, senegin-II, which significantly reduces the levels of blood triglycerides in normal mice.

Hypoglycemic activity and structure-activity relationship of iridoidal glycosides

Four iridoidal glycosides, deacetylasperulosidic acid methyl ester (DE), scandoside methyl ester (SC), geniposide (GE) and gardenoside (GA) isolated from Gardenia jasminoides Ellis grandiflora Makino leaves, were tested hypoglycemic activity in mice. DE lowered the blood glucose level in normal mice. However, SC, GE and GA did not affect the blood glucose level in normal mice, indicating that the absolute configuration of 6 position hydroxy based (OH) should be essential for the biological activity.

Effect of senegin-II on blood glucose in normal and NIDDM mice

The hypoglycemic effect of senegin-II, the main component of Polygala senega (Polygalaceae), was examined in normal and KK-Ay mice, one of the model animals of non-insulin-dependent diabetes mellitus (NIDDM). Senegin-II (2.5 mg/kg) reduced the level of blood glucose in normal mice from 220 +/- 8 to 131 +/- 5 mg/dl 4 hours after intraperitoneal administration (P < 0.001), and also significantly lowered the blood glucose of KK-Ay mice from 434 +/- 9 to 142 +/- 6 mg/dl under similar conditions (P < 0.001).

Anti-Human T-lymphotropic virus type-I antibodies in atomic-bomb survivors

Adult T-cell leukemia (ATL), induced by human T- lymphotropic virus type-I (HTLV-I), is endemic in Nagasaki, Japan. To investigate the effects of atomic-bomb radiation on development of this specific type of leukemia, 6182 individuals in the Radiation Effects Research Foundation (RERF) Adult Health Study sample in Hiroshima and Nagasaki were examined for positive rate of HTLV-I antibody. Several lymphocyte parameters were also studied for 70 antibody- positive subjects in Nagasaki. The HTLV-I antibody-positive rate was higher in Nagasaki (6.36%) than in Hiroshima (0.79%) and significantly increased with increasing age, but no association was observed with radiation dose. Whether relationship existed between antibody titer levels and radiation dose among antibody-positive subjects was not The frequency of abnormal lymphocytes tended to be higher in antibody-positive subjects than in antibody-negative subjects, and higher in females than in males regardless of radiation dose. The lymphocyte count was lower in antibody-positive subjects than in antibody-negative subjects and lower in female than in male subjects. No evidence was found to suggest that atomic-bomb radiation plays an important role in HTLV-I infection.

Monoclonal gammopathy in atomic bomb survivors

An analysis of monoclonal gammopathy in relation to radiation exposure was conducted on atomic bomb survivors examined between October 1979 and September 1981 and between June 1985 and May 1987. There was no overall increase in the relative risk of monoclonal gammopathy and only a suggestive increase in benign monoclonal gammopathy in the second survey which did not achieve statistical significance (P = 0.17). Thirty-one cases were detected among 8796 individuals studied in the first survey, whereas 68 cases were found among 7350 people in the second survey. Among the 31 cases found in the first survey, 9 individuals (29%) died before the second survey: 4 of cancer, 4 of vascular disease, and 1 of infection. Among the 8 individuals with benign monoclonal gammopathy examined in both surveys, 4 developed suppression of residual immunoglobulin(s), suggesting the progression of monoclonal gammopathy. The overall relative risks of monoclonal gammopathy in atomic bomb survivors in the two surveys were not significantly increased with increasing radiation dose. Only benign monoclonal gammopathy in 1985-1987 showed a suggestive increase with radiation exposure. The relative risk of benign monoclonal gammopathy in 1985-1987 was 2.64 in the group exposed to 0.01-0.49 Gy and 2.14 in the > or = 0.50-Gy group (95% confidence intervals = 0.90-8.82 and 0.69-7.31, respectively).

Treatment of disseminated intravascular coagulation and its prodromal stage with gabaxate mesilate (FOY): a multi-center trial

One hundred and ninety-one patients with disseminated intravascular coagulation syndrome (DIC) or its prodromal stage (preDIC) were treated with only gabaxate mesilate (FOY) (group G) or a combination of gabaxate and unfractionated heparin (group GH), and the efficacy of gabaxate was evaluated in a multicenter study. Following the treatment, the mean DIC score, which was evaluated on the basis of clinical symptoms and hemostatic parameters, decreased significantly to 5.58 +/- 3.48 from 6.75 +/- 3.14 in group G (p < 0.001) and to 6.34 +/- 3.33 from 7.31 +/- 3.00 in group GH (p < 0.05). In patients with overt DIC, the mean score decreased to 6.71 +/- 3.54 from 8.42 +/- 2.84 (p < 0.001). In DIC, the rate of overall efficacy was 46.2% in group G and 35.1% in group GH. In preDIC, it was 41.5% in group G and 27.3% in group GH. No side effects, including severe bleeding, were found in this study. The results indicate that gabaxate mesilate is clinically effective for patients with DIC and preDIC.

A case of beta-thalassemia with a C----T substitution at position 654 of the second intervening sequence of the beta-globin gene

A 26-year-old Chinese-Malaysian female patient with beta-thalassemia is presented. The main hematological values found in this patient were as follows: 1) normocytic hypochromic anemia (RBC 444 x 10(4)/microliters, Hb 11.8 g/dl) with marked anisopoikilocytosis, 2) erythroid hyperplasia, and 3) increased HbF (HbA 41.4%, HbA2 2.9%, HbF 48.9%). DNA obtained from peripheral leukocytes was analyzed using dot blot hybridization of the polymerase chain reaction (PCR)-amplified DNA with allele-specific oligonucleotide probes. A C----T substitution at position 654 of the second intervening sequence (IVS-2) was detected in her beta-globin clone.

[No rearrangement of the breakpoint cluster region in two juvenile chronic myeloid leukemia]

We performed cytogenetic studies and breakpoint cluster region (bcr) rearrangement analysis in two cases of juvenile chronic myeloid leukemia (JCML) which is special type of chronic myeloid leukemia (CML). Case 1 (8-month-old male) and case 2 (3-month-old female) showed clinical and hematologic manifestations similar to CML. Each of case 1 and 2 had normal karyotype and no bcr rearrangement. These findings suggest that JCML is a different heterogeneous disorder from that of adult CML.

A T-cell neoplasia showing clinicopathologic features of malignant histiocytosis with novel chromosomal abnormalities and N-ras mutation

Malignant histiocytosis (MH) is a distinct disease entity defined clinically and morphologically. However, the neoplastic origin of MH is not well established. The authors report a 26-year-old woman who showed the typical clinicopathologic features of so-called MH. Cytogenetic and molecular genetic examinations were performed in addition to the morphologic and immunologic approach. The expression of CD2 and T-cell receptor gene rearrangements indicated the T-cell origin of this case. CD30, which is positive for anaplastic large cell lymphoma (Ki-1 lymphoma), was not expressed. The cytogenetic study revealed a clonal chromosome abnormality involving 3q25, 6p21, 11p15, and 11q21. An N-ras point mutation within codon 12 (GGT----GCT) was also detected. These finding indicate that MH defined clinically and morphologically is not a tumor of true histiocytic origin and that it should be reclassified on the basis of immunologic, cytogenetic, and molecular genetic data.

IL-2-dependent ATL cell lines with phenotypes differing from the original leukemia cells

Adult T-cell leukemia (ATL) cells have been shown to express the receptor for IL-2 by studies using anti-CD25 monoclonal antibody, but these cells usually show no or only a weak proliferative response to IL-2. In the present study, we established thirteen IL-2-dependent T-cell lines from four ATL patients. Examination of the clonalities of these cell lines by the rearrangement profiles of the TCR beta-chain gene and the integration sites of the HTLV-I proviral genome, revealed that two cell lines (KK-1 and KK-5) were of real ATL cell origin. The others were of normal T-cell origin and had been established by infection with HTLV-I. The KK-1 and KK-5 cell lines were derived from a single ATL patient (KK). Interestingly, these cells showed different phenotypic features from the majority of original leukemia cells (CD3 +/- CD4+ CD8-). The KK-1 cell line acquired CD8 antigen expression and became double-positive (CD3 +/- CD4+ CD8+), while the KK-5 cell line prominently expressed CD3 antigen (CD3+ CD4+ CD8-). These results indicate that the phenotypic feature of ATL cells are not fixed, but can change in vitro as has occasionally been observed in vivo.

Serum deoxythymidine kinase in adult T-cell leukemia-lymphoma and its related disorders

Serum deoxythymidine kinase (TK) was measured in 15 patients with the acute type of adult T-cell leukemia (ATL), in 4 with chronic ATL, in 10 with lymphoma type ATL, in 9 with pre-ATL, in 11 with human T-cell leukemia virus type I (HTLV-I) associated with myelopathy (HAM) and in 19 HTLV-I carriers. All these patients were positive for anti-HTLV antibody. The level of TK in pretreatment serum was highest in acute ATL (15.6-1600 U/l, median 107 U/l). It was elevated in chronic ATL (5.4-55.0 U/l, median 37.6 U/l) and lymphoma ATL (6.8-316 U/l, median 16.8 U/l) but normal in pre-ATL (1.8-4.7 U/l, median 2.8 U/l), HAM (1.2-6.0 U/l, median 3.0 U/l) and HTLV-I carriers (1.1-4.6 U/l, median 2.3 U/l). Statistical examination revealed a significant difference between the levels of acute ATL and chronic ATL/lymphoma ATL. In the patients of this series, a close correlation between the level of TK and lactic dehydrogenase (LDH) was statistically present (p less than 0.01). These facts indicate that TK level is a useful indicator of the aggressiveness of ATL cells.

Acute nonlymphocytic leukemia with normal karyotype. Is its in vivo drug susceptibility age-dependent?

Nineteen patients with acute nonlymphocytic leukemia (ANLL) de novo who had no detectable chromosomal abnormalities received intensive remission induction chemotherapy. After the first chemotherapy cycle, ten of 14 (71%) patients aged 60 years or less entered complete remission (CR) whereas none of five patients aged more than 65 years attained CR. On the other hand, leukemia showed a drug resistance in three (21%) of the former patients and in four (80%) of the latter patients. One patient in each group died during induction. Generally, older ANLL patients have an inferior CR rate after chemotherapy and a poor prognosis. This has been explained by the facts that the risk of induction death increases and that specific chromosomal abnormalities associated with poor prognosis are considerably more frequent in older patients. Our data may indicate, however, that in ANLL with normal karyotype older patients show a low initial response rate because of drug resistance.

Relationship between chromosomal breakpoint and molecular rearrangement of T-cell antigen receptors in adult T-cell leukaemia

The relationship between chromosome breakpoints associated with T-cell antigen receptor (TCR) genes and TCR-alpha/beta/tau/delta rearrangements of peripheral leukaemic cells in 8 Japanese patients with the acute type of adult T-cell leukaemia (ATL) was examined. Break of the 14q11 region with the assigned locus of TCR-alpha/delta was revealed in 6 patients, interstitial deletion of the 7q32-36 region with assigned locus of TCR-beta in 1 patient, and break of the 7p15 region with assigned locus of TCR-tau in 2 patients. Molecular analysis revealed TCR-alpha rearrangement in 7 patients, TCR-beta rearrangement in all patients, and TCR-tau rearrangement in 5 patients. TCR-delta was deleted in all patients. These findings indicate a close relationship between 14q11 anomaly and TCR-alpha rearrangement, which may play an important role in the leukaemogenesis of ATL.

Apparently beneficial effect of low to intermediate doses of A-bomb radiation on human lifespan

Among about 100,000 A-bomb survivors registered at Nagasaki University School of Medicine, 290 male subjects exposed to 50-149 cGy showed significantly lower mortality from non-cancerous diseases than age-matched unexposed males. This was deduced from the fitting of a U-shaped dose-response relationship. Reasons for this effect in males, but not in females, are discussed with reference to selection of individuals and to hormesis.

An early phase II study of CPT-11: a new derivative of camptothecin, for the treatment of leukemia and lymphoma

An early phase II study of a new camptothecin analog and an inhibitor of topoisomerase I, CPT-11, was conducted in 62 patients with refractory leukemia and lymphoma by four different treatment schedules in a multiinstitutional cooperative study. CPT-11 therapy resulted in four complete remissions (CRs) and three partial remissions (PRs) in 29 assessable non-Hodgkin's lymphoma (NHL) patients, one PR in three Hodgkin's disease (HD), one CR and one PR in 11 acute lymphoblastic leukemia (ALL), and one PR in 15 acute myelogenous leukemia (AML) patients. Single infusion of 200 mg/m2 every 3 to 4 weeks produced no response in both leukemia and lymphoma patients. Sixty-minute infusions of 40 mg/m2/d for 5 days every 3 to 4 weeks or for 3 days weekly produced four CRs (17%) and four PRs (17%) in 24 patients with malignant lymphoma. Sixty-minute infusions of 20 mg/m2 twice a day for 7 days every 3 to 4 weeks resulted in one CR and two PRs in 12 patients with acute leukemia. No response was seen in an acute leukemia patient by another treatment schedule. CPT-11 was effective in two (15%) of 13 primarily refractory leukemia and lymphoma cases, in two of four relapsed cases, and in seven (17%) of 41 relapsed and refractory cases. Major side effects were leukopenia (91%) and gastrointestinal (GI) (76%). CPT-11 was shown to be effective against refractory leukemia and lymphoma, and thus deserves further clinical study; the novel antitumor activity mode of this drug predicts no cross-resistance to presently available antitumor drugs.

Appearance time of leukemic cells with t(8;21) in bone marrow

A 30-year-old man was referred because of slight leukocytosis. The hematological findings, including those of the bone marrow, showed no evidence of leukemia. The level of neutrophil alkaline phosphatase (NAP) in the peripheral blood was normal, as were the chromosomes from bone marrow cells. Fifteen months later, the disease was diagnosed as M2 (according to the French-American-British classification) showing a t(8;21)(q22;q22) and a low NAP level as two markers of M2 cells. This is probably the first case of acute leukemia in which the cytogenetic analysis was performed before and after the appearance of a specific chromosome abnormality.

[Serum deoxythymidine kinase in adult T-cell leukemia and its related disorders]

Using Prolifigen TK kit "Daiichi", the serum TK level were determined in patients with adult T-cell leukemia (ATL) and its related disorders. The mean level of serum TK at diagnosis was 279.9 U/l in acute type ATL, 27.8 U/l in chronic type ATL, 59.0 U/l in lymphoma type ATL, 3.1 U/l in pre-ATL and 2.4 U/l in HTLV-I carriers. In these patients, six other kinds of tumor markers such as lactic dehydrogenase, beta 2-microglobulin, immunosuppressive acidic protein, ferritin, tissue polypeptide antigen and carcinoembryonic antigen were also examined. Among the seven tumor markers, TK level showed the most significant difference among clinical subtypes of ATL. This indicates that the TK level is one of the promising parameters indicative of aggressiveness of ATL cells.

Cytogenetic studies of human T-cell leukemia virus type I carriers. A family study

Recently, the chromosome 14q11 anomaly has been reported to be specific to adult T-cell leukemia (ATL), and this anomaly has also been confirmed in the preleukemic state of adult T-cell leukemia (pre-ATL) patients. Because the cytogenetic abnormality at the stage of human T-cell leukemia virus type I (HTLV-I) carrier remains uncertain, we performed cytogenetic studies of lymphocytes stimulated with phytohemagglutinin in three HTLV-I carriers and three non-HTLV-I carriers in an ATL family. As a result, in three HTLV-I carriers, four of 311 cells examined (1.3%) had chromosome 14q11 anomaly. However, in three non-HTLV-I carriers, none of 260 cells examined had chromosome 14q11 anomaly. These results suggest that chromosome 14q11 anomaly is already present at the stage of HTLV-I carrier and seems to be an important cytogenetic clue to the pathogenesis of ATL.

Rearrangements in the human T-cell-receptor alpha-chain locus in patients with adult T-cell leukemia carrying translocations involving chromosome 14q11

We describe 5 cases of adult T-cell leukemia (ATL) carrying translocations at chromosome 14q11, where the genes for alpha- and delta-chains of the T-cell receptor (TCR alpha/delta) reside (Croce et al., 1985; Isobe et al., 1988). Since the TCR alpha/delta locus is the region where several types of chromosome translocations occur in T-cell tumors, rearrangements of the TCR alpha/delta locus in those ATL cases were studied as a first step to characterize these translocations at the molecular level. For this purpose we have generated an extensive series of probes to define the specificity and the diversity of rearrangement occurring at the widely spanned J alpha-C alpha locus and the complex D delta-J delta-C delta-V delta 2 locus. Using a set of probes, we have found the deletion of the TCR delta locus in all ATL cases, and at least 2 rearrangements in the J delta locus in each case of ATL. It is possible that translocations in the TCR alpha locus may be involved in ATL.

Survey of anti-human T-cell leukemia virus type I antibody in family members of patients with adult T-cell leukemia

To evaluate the intrafamilial clustering of HTLV-I, we examined the sera or plasma of 296 healthy family members of patients with adult T-cell leukemia (ATL) for anti-HTLV-I antibodies. Of 296 subjects, 132 (44.6%) had anti-HTLV-I antibodies. Fifty-nine (41.0%) out of 144 males and 73 (48.0%) out of 152 females were seropositive. The positive rates of antibody to HTLV-I increased with age, especially between the 30-39 and the 40-49 age groups. Five out of 6 fathers, 3 out of 4 mothers, 31 (60.8%) out of 51 spouses, 40 (63.5%) out of 63 siblings and 46 (33.8%) out of 136 children of patients with ATL had anti-HTLV-I antibodies. Of 74 children with an ATL father, 14 (18.9%) were seropositive, while 32 (51.6%) out of 63 children with an ATL mother were seropositive. This difference was statistically significant (P less than 0.001). Of those children with an ATL father, 12 (26.1%) out of 46 whose mothers were HTLV-I carriers had antibodies to HTLV-I. In contrast, none of the 13 children whose mothers were not carriers were seropositive. These results supported the hypothesis that the mother-to-child transmission is one of the most important modes of HTLV-I transmission. In wives of male patients with ATL, the positive rate of antibody to HTLV-I was 65.6% (21/32), and in husbands of female patients, it was 52.6% (10/19). The high positive rate of antibody to HTLV-I not only in wives of male patients but also in husbands of female patients suggests that either HTLV-I is more frequently transmitted from wives to their husbands than we had originally expected, or that ATL may develop even in wives who acquire HTLV-I from their husbands after marriage.

[Donath-Landsteiner antibody of the IgM class with anti-I specificity and possible efficacy of azathioprine therapy in paroxysmal cold hemoglobinuria: a case report]

In October 1988, a 72-year-old man was admitted to Nagasaki Prefectural Shimabara Onsen Hospital because of hemoglobinuria on exposure to cold. On admission, the laboratory data were Hb 9.1 g/dl, LDH 2,337 U/L, and haptoglobin less than 6 mg/dl. The Donath-Landsteiner (DL) test was positive and serological tests for syphilis were negative. Anti-Coxsackie virus type A9 antibody titer was elevated. Accordingly, he was diagnosed as having paroxysmal cold hemoglobinuria (PCH) associated with viral infection. The DL antibody proved to be of the IgM class having anti-I specificity. The patient was treated unsuccessfully with prednisolone, but hemolysis was improved after azathioprine (AZP) therapy. PCH patients with DL antibody of the IgM class exhibiting anti-I specificity are very rare and only two patients including the present case have been reported in Japan. There has been no report on the efficacy of AZP in PCH, but our study suggests that AZP may have a potential therapeutic effect in some PCH patients.

[A Japanese family with hereditary HbH disease--a case report and its gene analysis]

Hereditary HbH disease was found in a Japanese family. The propositus showed hypochromic microcytic anemia and chronic hemolysis. HbH inclusion bodies were detected in red cells, and an abnormal band corresponding HbH was found in an isoelectric focusing of the hemolysate. Gene analysis of the propositus revealed double heterozygosity for alpha + and alpha zero thalassemias. Four of six his siblings shared the alpha zero thalassemia and one the alpha + thalassemia. Another one was normal. The alpha + thalassemia was of 3.7 kb-deletion type and alpha zero was close to Southeast Asian type. This is the fourth Japanese family with hereditary HbH disease.

16;21 translocation in acute nonlymphocytic leukemia with abnormal eosinophils: a unique subtype

Two patients with acute nonlymphocytic leukemia (ANLL) and t(16;21)(p11;q22) were studied. The patients exhibited such clinical and hematological pictures, characterized by M2 and M4 with eosinophilia (FAB classification), as relatively matured leukemic cells, low neutrophil alkaline phosphatase activity, abnormal eosinophils and a high count of monocytic cells in the bone marrow. The prognosis was poor in both patients. From these data, the chromosomal abnormality of t(16;21)(p11;q22) seems to be specifically associated with a unique subtype of ANLL.

Serum Gc, Hp and alpha 2HS phenotypes in human T-lymphotropic leukemia virus type I infection

The serum Gc, Hp and alpha 2HS phenotypes were examined in 64 subjects known to have the human T-lymphotropic leukemia virus type I (HTLV-I) infection and in 60 uninfected subjects. There were no significant differences in the distributions of Gc, Hp and alpha 2HS phenotype and allele frequencies between any grouping of HTLV-I-infected subjects and the controls. No association between the Gc, Hp and alpha 2HS genotypes and susceptibility to adult T-cell leukemia was found.

Antibodies against p40tax gene product of human T-lymphotropic virus type-I (HTLV-I) under various conditions of HTLV-I infection

We investigated antibodies against pX gene product, p40tax, by ELISA using recombinant p40tax protein in HTLV-I seropositive carriers as well as patients with adult T cell leukemia (ATL) and HTLV-I-associated myelopathy (HAM). Seventy (49.0%) out of 143 HTLV-I healthy carriers were found to be positive for antibody against p40tax antigen and the follow-up samples at two-year intervals revealed constant reactivity by ELISA in each carrier. The onset of antibody production was delayed 4 to 12 weeks as compared with anti-HTLV-I in primary infection cases. The anti-p40tax-positive rate (90%) in HAM patients was significantly higher than that of healthy carriers, acute and chronic ATL patients and their family members. Furthermore, HAM patients and a few healthy carriers showed high reactivities by ELISA. Children from mothers with anti-p40tax showed a higher anti-HTLV-I-positive rate than that of children from mothers without anti-p40tax (54.5% versus 12.5%). Two men without anti-p40tax and one female with low anti-p40tax developed ATL during follow-up studies. These results suggest that HTLV-I carriers could be divided into 2 or 3 sub-populations according to antibody response to p40tax. A smaller population with anti-p40tax, especially a high antibody reactivity, could have a high risk of developing HAM and of transmission from mother to child. In addition, ATL may occur in a population with low or absent anti-p40tax.

[Cytogenetic studies of healthy HTLV-I carriers (Report 1): Cytogenetic studies of an ATL family]

The chromosome 14q11 anomaly has been reported to be specific to adult T-cell leukemia (ATL) and this anomaly has also been confirmed in preleukemic state of ATL (pre-ATL) patients though the frequency is low. In an attempt to clarify if the same chromosome aberrations could be found also at the stage of HTLV-I carrier and if there is any cytogenetic difference from non-HTLV-I carriers, a cytogenetic study of lymphocytes stimulated with phytohemagglutinin in three HTLV-I healthy carriers and three non-HTLV-I carriers in an ATL family was performed. The results were as follows. 1. In three HTLV-I carriers, 7 of 311 cells examined (2.3%) showed chromosome aberrations, and 4 cells (1.3%) had 14q11 anomaly. 2. In three non-HTLV-I carriers, 4 of 260 cells examined (1.5%) showed chromosome aberrations, whereas no cells had 14q11 anomaly. These findings suggest that 14q11 anomaly is already present at the stage of HTLV-I carrier and seems to be an important cytogenetic clue to the pathogenesis of ATL.

[Study on pathophysiology of the myelodysplastic syndromes (MDS)--pattern of dysmegakaryopoiesis related to leukemic transformation]

A series of 116 patients with MDS consisted of 74 cases of RA, 10 cases of RARS, 14 cases of RAEB, 9 cases of RAEB-T and 9 cases of CMML, were studied on the quantity and morphological abnormalities of megakaryocytes in relation to over all survival and leukemic change. The amount of megakaryocytes was graded into four groups; marked hypoplasia (O), moderate hypoplasia (L), normoplasia (N) and hyperplasia (H), RA cases showed heterogeneous pattern; containing 14 cases (18.9%) of group (O), 18 cases (24.3%) of group (L), 31 cases (41.9%) of group (N) and 11 cases (14.9%) of group (H). RARS, RAEB, RAEB-T and CMML cases were classified into group (N) or group (H). The heterogeneous pattern of RA did not relate to leukemic change, but over all survival tended to be shorter in group (N) cases. A significant number of young female cases of RA were involved in group (O). Morphological abnormalities of MDS megakaryocytes were classified into five types; I, mononuclear micromegakaryocytes, II, binuclear micromegakaryocytes, III, mononuclear small megakaryocytes, IV, multiseparated-nuclear megakaryocytes and V, megakaryocytes with bizzare nuclei. RAEB and RAEB-T cases uniformly showed marked dysmegakaryopoiesis ranging from type I to V. whereas RA, RARS and CMML cases showed mild dysmegakaryopoiesis. Only five cases (6.4%) of RA cases had type I micromegakaryocytes. Eight RA cases with type I on diagnosis or obtaining it during the clinical course tended to develop acute myeloid leukemia (5 cases) or to transform to RAEB sooner or later. In two cases of RAEB in which hematological improvement was obtained with low dose cytosine arabinoside regimen, disappearance of type I micromegakaryocytes was noted. A female case with 5q-anomaly surviving more than 10 years showed marked megakaryocyte hyperplasia and almost exclusively type III and IV megakaryocytes. These findings indicated that pattern of dysmegakaryopoiesis, especially appearance of type I, was closely related to leukemic change in MDS. Thus quantitative and qualitative evaluations of MDS megakaryocytopoiesis seemed important to understand the further heterogeneity of pathophysiology in MDS subtypes.

CML-T1: a cell line derived from T-lymphocyte acute phase of chronic myelogenous leukemia

Most data suggest that malignant transformation in chronic myelogenous leukemia (CML) occurs in hematopoietic stem cell that is the progenitor of myelopoiesis and of B but not T lymphopoiesis. We established a T-lymphoid cell line (CML-T1) from a person with Ph-chromosome-negative CML in acute phase. Evidence of its T-lymphocyte origin includes the pattern cytochemical reactivity, reactivity with anti-T-cell monoclonal antibodies (MoAbs), and rearrangement of the beta-T-cell receptor (TCRB) gene. CML-T1 cells have features of type IV thymocytes. Cytogenetic analyses indicate a 47,XX, del(11), t(6;7)(q23;q24), +mar karyotype. CML-T1 cells exhibit molecular changes typical of CML, including translocation of the ABL protooncogene from chromosome 9 to 22, rearrangement of the BCR gene, and transcription of a chimeric BCR-ABL messenger RNA (mRNA). The ABL insertion on chromosome 22 appears interstitial, similar to other cases of Ph-chromosome-negative CML. These data clearly indicate that T cells can be involved in acute-phase CML. CML-T1 should be useful in studying this process as well as that underlying Ph-chromosome-negative CML.

[Empiric therapy with aztreonam for febrile neutropenic patients with hematological malignancies]

Combination of aztreonam/amikacin/ticarcillin (AAT) and latamoxef/amikacin/ticarcillin (LAT) were compared in a prospective randomized trial of empiric therapy for febrile neutropenic patients with hematological malignancies. Low dose amphotericin B was also added to each regimen from the beginning. Of 45 evaluable episodes, 23 were treated with AAT and 22 with LAT. The response rates were 61 percent for AAT and 50 percent for LAT, statistically not significant. There was one infection-related death among patients assigned to AAT therapy and also one among those assigned to LAT therapy. Dose escalation of amphotericin B seemed to be effective for those patients who did not improve with initial therapy.

[ATL (adult T-cell leukemia/lymphoma)]

128 cases of ATL (adult T-cell leukemia/lymphoma) were divided into 3 subgroups, 70 cases of acute type, 19 cases of chronic type and 39 cases of lymphoma type, and their prognosis were evaluated. Median survival time from the onset of acute type using Kaplan-Meier method was 8 months, that of lymphoma type was 14 months and that of chronic type was 50 months. Median survival time from the start of treatment of acute type was 5 months, that of lymphoma type was 11 months and that of chronic type was 22 months. Relatively short median survival time of chronic type may be due to they had some duration with observation only at first. No significant elongation of survival time could be obtained when acute type was divided into 2 stages, before and after 1982. Twelve patients with non-Hodgkins' lymphoma unresponsive to the first line combination chemotherapy were treated with combination therapy with cis-dichlorodiammineplatinum (CDDP). Ten patients were evaluable for response (4 cases of CR, 6 cases of PR). To stop the HTLV-1 carrier mothers milk for giving their children seems to be effective method to decrease the occurrence of ATL in future.

Adult T cell leukaemia cells are of CD4+ CDw29+ T cell origin and secrete a B cell differentiation factor

Cells from six cases of adult T cell leukaemia were studied with respect to phenotypical and functional features. All cells were reactive with anti-CD4 and anti-CDw29 monoclonal antibodies (antibody against helper inducer T cells) but were unreactive with anti-CD45R monoclonal antibody (antibody against suppressor inducer T cells). Functionally, these cells secreted a B cell differentiation factor detected by SKW6-CL4 cell differentiation to IgM-producing cells, this secretion being enhanced by culture with recombinant IL-2. Though these results indicate that adult T cell leukaemia cells are of mature helper inducer T cell origin, these cells strongly suppressed PWM-induced B cell differentiation in the absence of CD8+ suppressor effector T cells.

High risk of mother-to-child transmission of HTLV-I in p40tax antibody-positive mothers

A new enzyme-linked immunosorbent assay (ELISA) for detecting the antibody to a human T-lymphotropic virus type I (HTLV-I) tax gene product, p40tax, has been developed. By this ELISA method, we have investigated the relationship between the presence of p40tax antibody in HTLV-I-infected mothers and the virus transmission rate from mothers to their children. The rate of mother-to-child transmission of HTLV-I was higher in p40tax antibody-positive mothers than in antibody-negative ones. Thus, the presence of p40tax antibody may indicate an increased risk of vertical transmission of HTLV-I.

[Difference of antibody profile for human T-lymphotropic virus type-I (HTLV-I) among individuals]

Healthy carriers, patients with ATL and HTLV-I associated myelopathy (HAM) were examined for HTLV-I antibodies of IgG and IgM classes and anti-p 40x antibodies, using ELISA, western blot (WB) and particle agglutination (PA) techniques. IgG antibodies were almost always detectable in sera from all of patients with ATL and HAM and healthy carriers with high titer in the PA test (normal carriers), and the average value of OD 405 was 2.0 +/- 0.3, 1.6 +/- 0.6 and 1.3 +/- 0.7, respectively. In anti-p 40x antibodies, the detectable incidence of HAM, ATL, normal carriers and carriers with low titer of the PA (low-PA group) was 90%, 67%, 44%, and 3%; and, the average value of OD 405 of the antibodies was 2.3 +/- 1.0, 0.7 +/- 0.5, and 0.7 +/- 0.7, respectively. On the other hand, the incidence of IgM antibodies demonstrated in HAM, ATL, normal carriers and low-PA group was 90%, 41%, 33%, and 53%, respectively. Furthermore, the follow-up observation of these antibodies revealed that the antibody profile of individuals for a long time was constant, i.e. in each carrier the value with high OD remained high and the presence of anti-p 40x and/or IgM antibodies remained present. These data has demonstrated that there are considerably differences among individuals in responsivilities for HTLV-I. Then, the antibody profile is mainly classified into 3 groups; hyper-, common- and hypo-immune patterns.

[Significance of the chromosomal findings in acute myeloid leukemia with maturation (M2)]

Chromosomal banding studies were performed on 13 patients with acute myeloid leukemia with maturation (M 2). Six patients revealed t (8;21) (q22;q22), five normal karyotype, and the remaining two +8 and inv (16) (p13 q22), respectively. Apparent pseudo-Pelger-Huët anomalies in mature neutrophils were observed in all the 6 patients with t (8;21), but in only one of the 5 patients with normal karyotype. Neutrophil alkaline phosphatase (NAP) score decreased in all but one in the former group while it increased in all the patients in the latter group. The former group had a median follow-up of 20.8 months or more, whereas the latter group had a median survival of 4.4 months or more. Accordingly, it was suggested that two major chromosome subgroups may be present among patients diagnosed as having M 2: one subgroup with t (8;21) and the other with normal karyotype. One patient with M 2 and inv (16) showed almost the same hematologic features as those observed in patients with acute myelomonocytic leukemia (M 4) and inv (16) except for a small population (6.8%) of monocytoid cells in the bone marrow.

[Effects of low dose Ara-C regimen in acute leukemias and RAEB]

Recent increase of leukemia among elderly patients prompted us to investigate the types of leukemia which can be induced into remission by low-dose Ara-C (LDAC) regimen. LDAC regimen was performed in 30 cases with overt acute leukemia (A), hypoplastic leukemia (B), and RAEB (C); Group A consists of M1 (1 case), M2 (4 cases), M3 (1 case), M4 (4 cases), M6 (1 case), and ALL (2 cases), Group B AML (8 cases), ALL (2 cases), and null (1 case), Group C RAEB (2 cases), and RAEB-T (4 cases). Complete remission (CR) rate was 23% (3/13) in group A, 64% (7/11) in group B, 0% (0/6) in group C. Partial remission rate was 33% (2/6) in group C. In group A, patients with M2 were induced into CR. In group B, both AML and ALL were induced into CR. Hypocellular marrow indicating low leukemic burden related to good sensitivity to Ara-C. Duration of CR was rather short; mean duration being 5.3 months. In group C, 2 PR cases of RAEB showed partial hematological recovery. LDAC regimen is effective especially for most of hypoplastic leukemia and some of M2. Side effects were tolerable, but all CR cases passed through bone marrow hypoplasia and needed supportive cares.

Changes in T wave morphology during hypercalcemia and its relation to the severity of hypercalcemia

The effect of hypercalcemia on T wave morphology, polarity, and amplitude was studied in 14 patients with a primary diagnosis of malignant lymphoma (8 patients), adult T-cell leukemia (5 patients), and Hodgkin's disease (1 patient). Hypercalcemia was severe to extreme in 11 (14.9-22.8 mg/dl), moderate in 1 (13.4 mg/dl), and mild in 2 (11.8 and 12.2 mg/dl) patients. Ten of the 11 patients (91%) with severe hypercalcemia showed inverted, biphasic, and notched T waves, mainly in the chest leads. Notched T waves were observed in all 10 of these patients in anterior to lateral, mid to lateral, or lateral chest leads. Biphasic and/or inverted T waves in anterior or anterior to midchest leads were present in 4 of these 10 patients who had extreme hypercalcemia (greater than 16 mg/dl). Changes in T wave morphology were not observed in moderate or mild hypercalcemia. T wave amplitude showed significant inverse correlation with serum calcium (T mV vs Ca, r = -0.60, p less than 0.001; T/R ratio vs Ca, r = -0.68, p less than 0.001; n = 35). Decrease in T wave amplitude was marked in severe hypercalcemia (p less than 0.0001) and moderate hypercalcemia, but there was no change in mild hypercalcemia. Changes in T wave morphology, polarity, and amplitude either appeared with development of hypercalcemia or disappeared with normalization of serum calcium level. It was concluded that in addition to shortening the QT interval, severe to extreme hypercalcemia can cause development of inverted, biphasic, or notched T wave with a marked decrease in amplitude of T waves.

Immunoglobulin classes of antibody for human T-lymphotropic virus type-I (HTLV-I) in healthy donors and HTLV-I-associated disorders

Healthy blood donors, patients with adult T-cell leukemia (ATL) and HTLV-I-associated myelopathy (HAM) and recipients of unscreened blood (SR) who had seroconverted and were followed-up for more than 2 years were examined for HTLV-I antibodies of immunoglobulin G (IgG) and M(IgM) classes. The overall infection rate in donors was 4.9%, as determined by screening with a particle agglutination method (PA). The rate increased with increasing age. Positive sera with a low titer in the PA test (1/16, 1/32 and 1/64) contained IgM antibodies in 32.5% (titer 1/16) to 36.1% (titer 1/64) of the cases, but IgG antibodies were detected in only 5.6% of the sera with a titer of 1/16 and in 36.1% of the sera with a titer of 1/64. Conversely, in high titer sera (1/128 or higher) IgG antibodies were almost always detectable (99.0%) and IgM antibodies less frequently (25.5%). Sera from acute, chronic and pre-ATL, HAM and SR patients contained IgG antibodies in high titer in all cases. The incidence of IgM antibodies was 7.7, 30.0, 53.3, 72.3, and 77.8%, respectively. IgM antibodies were demonstrated repeatedly in some cases who were followed up for a year. Only IgM antibodies from HAM patients occurred in high titers and had strong reactivity to the p24 antigens of HTLV-I in Western blot testing. It is concluded that it is important to detect IgM antibodies not only in primary infections but also in persistent infections of HTLV-I.

[Translocation (8; 22) (q24; q11) and Epstein-Barr viral genome in a case of Burkitt's type of acute lymphoblastic leukemia (L3)]

A case of Burkitt's type of acute lymphoblastic leukemia (FAB L3) in an 80-year-old male patient is reported. At the time of diagnosis, 74% of the bone marrow cells were lymphoblastoid cells, which were large and homogeneous in size, and whose cytoplasm was abundant and intensely basophilic containing many vacuoles. Lambda-light chains were detected as surface immunoglobulin (Ig), but not heavy chains or kappa-light chains. Epstein-Barr (EB) viral genome was detected in the cultured bone marrow cells by spot hybridization method. Chromosomal banding studies of bone marrow cells revealed t(8; 22) (q24; q11) in all the 18 metaphases examined. This translocation brings the Ig lambda-light chain gene on chromosome 22q11 to chromosome 8q24 where the c-myc proto-oncogene is localized, which is thought to be closely associated with the leukemogenesis of this disorder, whereas EB viral genome is observed in African Burkitt's lymphoma. To our best knowledge, however, there have been no reported Japanese patients with L3 ALL in whom t(8; 22) or EB viral genome was observed.