Fludarabine plus reduced-intensity busulfan versus fludarabine plus myeloablative busulfan in patients with non-Hodgkin lymphoma undergoing allogeneic hematopoietic cell transplantation

Allogeneic hematopoietic cell transplantation (HCT) offers a possible cure for patients with relapsed and refractory non-Hodgkin lymphoma (NHL) through potentially beneficial graft versus lymphoma effects. However, allogeneic HCT is associated with high nonrelapse mortality (NRM). Fludarabine with reduced-intensity busulfan (Flu/Bu2) and myeloablative busulfan (Flu/Bu4) are commonly used in conditioning regimens for allogeneic HCT; however, data on their use in patients with NHL is limited. We investigated the effect of busulfan dose on outcomes by comparing Flu/Bu2 and Flu/Bu4 in patients with NHL who underwent allogeneic HCT. Our study included 415 adult patients with NHL who received Flu/Bu2 (315 patients) or Flu/Bu4 (100 patients) between January 2008 and December 2019. All patients were enrolled in the Transplant Registry Unified Management Program 2 of the Japanese Data Center for Hematopoietic Cell Transplantation. The primary endpoint was the 5-year overall survival (OS). To minimize potential confounding factors that may influence outcomes, we performed propensity score matching. The 5-year OS was 50.6% (95% confidence interval (CI), 39.4%-60.8%) and 32.2% (95% CI, 22.4-42.4%) in the Flu/Bu2 and Flu/Bu4 groups, respectively (p = 0.006). The hazard ratio comparing the two groups was 2.13 (95% CI, 1.30-3.50; p = 0.003). Both groups had a similar 5-year cumulative incidence of relapse (38.2% vs 41.3%; p = 0.581), and the Flu/Bu4 group had a higher cumulative incidence of 5-year NRM (15.7% vs 31.9%; p = 0.043). In this study, Flu/Bu4 was associated with worse OS compared with Flu/Bu2 because of high NRM in patients with NHL.

Expression of activated integrin β7 in multiple myeloma patients

Multiple myeloma (MM) is still extremely difficult to cure, and new therapeutic drugs are needed. We recently found that integrin β7 is constitutively activated in MM cells, and chimeric antigen receptor (CAR) T cells targeting activated integrin β7 have a significant anti-MM effect. In this study, we performed flow cytometry analysis of the expression of activated integrin β7 in bone marrow cells from 137 symptomatic MM patients. In 60/137 (44%) MM patients, activated integrin β7 was detected in most MM cells (> 80% of MM cells were in the positive gate). Activated integrin β7 was highly expressed in MM cells even in heavily treated patients. It also showed high expression in many CD38^lo/^-CD138^-CD19⁺B cells, which reportedly include clonotypic B cells, in the bone marrow of MM patients. Taken together, these results suggest that CAR T-cell therapy targeting activated integrin β7 has the potential to benefit many patients with relapsed or refractory MM.

Randomised phase II study to optimise melphalan, prednisolone, and bortezomib in untreated multiple myeloma (JCOG1105)

We conducted a randomised phase II study to determine the optimal dose and schedule of melphalan, prednisone, and bortezomib (MPB) (jRCTs031180097). Transplant‐ineligible untreated multiple myeloma patients were randomised to Arm A (twice weekly bortezomib in one six‐week cycle followed by eight five‐week cycles of four times once weekly bortezomib with melphalan and prednisolone on days 1–4) or Arm B (nine four‐week cycles of three times once weekly bortezomib with melphalan and prednisolone on days 1–4). The primary end‐point was complete response (CR) rate. Of 91 patients randomised to two arms, 88 were eligible. The median cumulative bortezomib doses were 45·8 and 35·1 mg/m², CR rate was 18·6% [95% confidence interval (CI) 8·4–33·4] and 6·7% (95% CI 1·4–18·3), and the median progression‐free survival (PFS) was 2·5 and 1·4 years in Arms A and B [hazard ratio (HR) 1·93 (95% CI 1·09–3·42)], respectively. Frequent grade ≥3 haematologic toxicities in Arms A and B were neutropenia (64·4% vs. 28·3%) and thrombocytopenia (35·6% vs. 10·9%). Grade 2/3 peripheral neuropathy was observed in 24·4/2·2% in Arm A and 8·7/0% in Arm B. In conclusion, Arm A was the more promising regimen, suggesting that the twice weekly schedule of bortezomib in the first cycle and higher cumulative dose of both bortezomib and melphalan influences the efficacy of modified MPB.

A prospective trial of vaccine to prevent hepatitis B virus reactivation after hematopoietic stem cell transplantation

Hepatitis B virus (HBV) reactivation reportedly occurs frequently after hematopoietic stem cell transplantation (HSCT) in resolved HBV-infected patients. Here, 50 patients with resolved HBV infections and scheduled to undergo HSCT were enrolled; all subjects were vaccinated with three doses of hepatitis B vaccine 12 months after HSCT and the incidence of HBV reactivation was monitored. The patients' characteristics were: median age, 61 (34-72) years; male/female, 27/19; allogeneic/autologous, 40/6; bone marrow/peripheral blood stem cells/cord blood, 26/16/4. Of the 46 patients who underwent HSCT, 19 were excluded and did not make it to vaccination due to relapse of underlying disease, HBV reactivation within 12 months of HSCT, or transfer of patients. The remaining 27 were vaccinated 12 months after HSCT and monitored for 2 years. Six showed HBV reactivation, with a 2-year cumulative reactivation incidence of 22.2%; the same incidence was 27.3% only in allogeneic HSCT patients. Factors associated with HBV reactivation included the discontinuation of immunosuppressants (P = 0.0379) and baseline titers of antibody against hepatitis B surface antigen (P = 0.004). HBV reactivation with vaccination following HSCT could occur despite maintenance of serum anti-HBs at more than protective levels.

[Systemic mastocytosis with refractory ascites successfully treated with interferon-α and a leukotriene receptor antagonist]

A 67-year-old male was referred to our hospital because of anemia, thrombocytopenia, and massive ascites. A diagnosis of systemic mastocytosis was made based on the observation of many mast cells in his bone marrow, elevated serum tryptase levels, and the presence of c-kit point mutation Asp816Val. Dasatinib and cladribine were ineffective, and a large volume of ascites was removed approximately every 3 days. Then, following an asthma attack, the patient was treated with pranlukast, a leukotriene receptor antagonist (LTRA). After LTRA treatment initiation, the frequency of ascites drainage decreased, and no puncture was necessary from the 10th day after the start of LTRA. Interferon α (IFN-α) was administered from the 15th day after the start of LTRA. Thereafter, his anemia and thrombocytopenia gradually improved, the ascites disappeared, the mast cells in his bone marrow were significantly reduced, and the Asp816Val mutation disappeared. Because persistent monocytosis was evident, he was suspected of chronic myelomonocytic leukemia but has not been diagnosed and is undergoing watchful waiting. This was considered to be a rare case of refractory ascites in which IFN-α was effective and LTRA might have been beneficial.

Clinical effects of recombinant thrombomodulin and defibrotide on sinusoidal obstruction syndrome after allogeneic hematopoietic stem cell transplantation

Sinusoidal obstruction syndrome (SOS) is a lethal complication after hematopoietic stem cell transplantation (HSCT). Defibrotide (DF) is the only drug internationally recommended for SOS treatment in Western countries. Recombinant human soluble thrombomodulin (rhTM), which is promising for the treatment of patients with disseminated intravascular coagulation, is also reported to be potentially effective for SOS. To clarify the safety and efficacy of DF and rhTM, we conducted a retrospective survey of these agents in Japan. Data from 65 patients who underwent allogeneic HSCT and received DF (n  =  24) or rhTM (n  =  41) for SOS treatment were collected. The complete response rates for SOS on day 100 were 50% and 54% in the DF and rhTM groups, respectively. The 100-day overall survival rates were 50% in the DF group, and 48% in the rhTM group. Several severe hemorrhagic adverse events were observed in one patient in the DF group and five patients in the rhTM group. The main causes of death were SOS-related death, and no patient died of direct adverse events of DF or rhTM. Our results suggest that rhTM, as well as DF, can be effective as a novel treatment option for SOS.

Increased non-relapse mortality due to high-dose cytarabine plus CY/TBI in BMT/PBSCT for acute lymphoblastic leukaemia in adults

The efficacy of high-dose cytarabine (HDCA) plus cyclophosphamide/total-body irradiation (CY/TBI) has been proved in cord blood transplantation (CBT) for acute lymphoblastic leukaemia (ALL), but not in bone marrow or peripheral blood stem cell transplantation (BMT/PBSCT). In this cohort study, we compared the prognosis of CY/TBI (N = 1244) and HDCA/CY/TBI (N = 316) regimens in BMT/PBSCT for ALL. The addition of HDCA decreased post-transplant relapse, while significantly increasing non-relapse mortality (risk ratio, 1·33), and overall survival was not improved. The positive effects of HDCA reported in CBT cannot be extrapolated to BMT/PBSCT, and HDCA may not be recommended in these procedures.

Prognostic model for mantle cell lymphoma in the rituximab era: a nationwide study in Japan

Mantle cell lymphoma (MCL) is essentially incurable with conventional chemotherapy. The MCL International Prognostic Index (MIPI) is a validated specific prognostic index, but was derived from patients with advanced-stage disease primarily in the pre-rituximab era. We analysed 501 MCL patients (median age, 67 years; range 22-90) treated with rituximab-containing chemotherapy, and evaluated the prognostic factors adjusted by the treatment. Five-year overall survival (OS) in the low, intermediate and high MIPI groups was 74%, 70% and 35%, respectively. Additional to MIPI risk factors, multivariate analysis revealed that low serum albumin and bone-marrow involvement were also significantly associated with a poor outcome. The revised-MIPI (R-MIPI) was constructed using six factors, namely age, performance status, white blood cell count, serum lactate dehydrogenase, bone-marrow involvement and serum albumin, which is divided into four prognostic groups. Five-year OS in low, low-intermediate (L-I), high-intermediate (H-I) and high R-MIPI groups was 92%, 75%, 61% and 19%, respectively. Hazard ratio for OS of L-I, H-I and high risk to low risk patients were 5·4, 8·3 and 33·0, respectively. R-MIPI, a new prognostic index with easy application to the general patient population, shows promise for identifying low- and high-risk MCL patients in the rituximab era.

Philadelphia chromosome positive acute lymphoblastic leukemia showing normal karyotype in G-banding chromosomal examination before chemotherapy

A 29-year-old male was admitted because of thrombocytopenia. A diagnosis of acute lymphoblastic leukaemia was made on the basis of a 61.6% infiltration of leukemic cells in his bone marrow. Standard G-binding chromosome analysis of bone marrow cells revealed a normal karyotype. He received combination chemotherapy, and achieved hematological complete remission. However, chromosomal analysis of bone marrow cells after 2 courses of consolidation therapy showed the Philadelphia (Ph) chromosome in two cells out of 20 analysed. We retrospectively examined the sample of bone marrow cells before chemotherapy; It showed minor BCR/ABL positivity with FISH and RT-PCR methods. The Ph chromosome disappeared after consolidation chemotherapy and allogeneic bone marrow transplantation, but the Ph chromosome reappeared at relapse. We postulated that there were two clones, both a Ph-positive clone and Ph-negative clone. At the initial diagnosis, Ph chromosome was not detected because the G-banding method analyzed only metaphase cells, which contained few Ph-positive clones. In order to offer effective therapy with molecular targeting agents, in this poor prognostic disease, it is necessary to detect Ph chromosome before the first chemotherapy and BCR/ABL detection with FISH or RT-PCR methods appears more useful than G-banding chromosome analysis.

CD56-positive diffuse large B-cell lymphoma: possible association with extranodal involvement and bcl-6 expression

Among B-cell non-Hodgkin's lymphomas, neural cell adhesion molecule/CD56 expression is exceptional. In this study, seven cases of CD56-positive diffuse large B-cell lymphoma (DLBCL) are described. The frequency of CD56-positive DLBCL was 7% in our hospital. Four of seven (57.1%) cases expressed both CD10 and bcl-6 suggestive of a germinal center B-cell phenotype. Six of seven (85.7%) cases expressed bcl-6. Two cases expressed aberrant T cell-associated antigens, one each of CD7 and CD8. However, none of these seven cases showed CD5 expression. No significant difference was observed between CD56-positive and CD56-negative DLBCL in terms of the five international prognostic index risk factors. However, all seven cases had at least one extranodal involvement and showed a good response to initial treatment. The predominance of extranodal involvement in our series may be associated with the adhesion-related function of CD56. A high frequency of bcl-6 expression may be associated with a more favorable clinical course and prognosis.

POSTOPERATIVE CHANGES OF SPERM CHROMATIN HETEROGENEITY, USING ACRIDINE ORANGE STAINING, IN VARICOCELE PATIENTS

The aim of this study was to evaluate postoperative changes in sperm chromatin heterogeneity in varicocele patients. In 15 infertile patients with varicocele, sperm parameters including concentration, motility, and morphology were evaluated before and after surgical correction of varicocele. Sperm motion analysis using computer-assisted semen analyzer (CASA) was also performed. To analyze the sperm nuclear proteins, the acridine orange staining method was used. On semen analysis, sperm concentration and motility significantly increased after surgery (p = 0.002, p = 0.003, respectively), although sperm morphology was unaltered postoperatively. CASA parameters, including velocity, linearity, amplitude of lateral head displacement and beat cross frequency were unaltered postoperatively. On the other hand, acridine orange staining significantly increased postoperatively (p = 0.002). Varicocele influences the sperm chromatin condition, as well as sperm concentration and motility.

t(14;18)(q32;q21)-bearing pleural MALT lymphoma with IgM paraproteinemia: value of detection of specific cytogenetic abnormalities in the differential diagnosis of MALT lymphoma and lymphoplasmacytic lymphoma

A 67-year-old woman presented with a pleural effusion and a tumor in the right pleural wall. Histological examination of thoracoscopic tumor and pleural biopsy specimens showed infiltration by medium sized cells, some of which showed plasmacytoid differentiation. In view of the presence of IgM paraproteinemia and bone marrow involvement by lymphoma cells, the patient was diagnosed tentatively as having lymphoplasmacytic lymphoma (LPL). However, chromosomal analysis of the cells in the pleural fluid detected t(14;18)(q32;q21), while fluorescence in situ hybridization was positive for 11% of the MALT1 split signal. Because of the presence of characteristic genetic abnormalities and notable extranodal involvement, the patient was diagnosed as having MALT lymphoma. She was treated with three courses of cladribine and rituximab, and achieved complete regression of the tumor. In this case the detection of t(14;18)(q32;q21) involving IGH and MALT1 was useful for the differential diagnosis of LPL and MALT lymphoma.

TREATMENT WITH PREDNISOLONE OF HORMONE-REFRACTORY PROSTATE CANCER

Fifteen patients 60 to 80 years old (a mean of 72 years) with hormone-refractory prostate cancer were treated with low dose prednisolone. All patients had previously undergone hormone therapy. Prostate specific antigen (PSA) values decreased in 11 cases (73%), of which 4 had PSA decreases of 50% or greater. Serum levels of DHEAS significantly decreased at 4 and 8 weeks after treatment (both intervals were p < 0.05 vs pretreatment). Of 8 patients with bone metastasis evaluation, 2 (25%) showed improvement of the lesion. In 5 patients (33%), relief of pain was observed one month after starting prednisolone. The one-year survival rate was 58%. The side effects were mild and manageable in an outpatient clinic.

Usefulness of sperm quality analyzer-V (SQA-V) for the assessment of sperm quality in infertile men

The aim of this study was to evaluate the correlation of new of Sperm Quality Analyzer (SQA-V) with the computer-assisted sperm analysis (CASA) and manual semen analysis estimates. One hundred five fresh semen samples were analyzed using SQA-V and CASA and manual semen analysis. Significant correlations of sperm concentration (p < 0.0001), sperm motility (p < 0.0001), and normal morphology (p < 0.0001) were observed between SQA-V variables and manual semen analysis estimates. There also were significant correlations of sperm concentration (p < 0.0001), sperm motility (p < 0.0001), and sperm velocity (p = 0.0235) between SQA-V variables and CASA estimates. Meanwhile, it did not correlate with amplitude of lateral head displacement, beat cross frequency, lineality assessed by CASA. The value of the sperm concentration and the sperm motility measured by SQA-V showed high correlations with the value of those measured by CASA and manual semen analysis. In addition, velocity and sperm morphology may also be evaluated to some extent using SQA-V.

[An adult case of precursor B cell lymphoblastic lymphoma extending from right neck to upper cervical spinal region]

We report the rare adult case of upper cervical spinal tumor diagnosed precursor B cell lymphoblastic lymphoma. A 48- year-old male had suffered from right neck pain and swelling for two months. He had no neurological symptoms. The serum level of IL-2 receptor was high (1,820 U/ml). The radiological examinations including MRI showed the tumor extending from right neck to the epidural space from medulla to the C4 level. The pathological diagnosis of biopsy specimens was malignant lymphoma. Since the early pre-B lymphoblast antigens were positive by the flow cytometry, the diagnosis was precursor B cell lymphoblastic lymphoma. This type of lymphoma is highly aggressive. The intensive chemotherapy regimen such as hyper-CVAD was superior to the lymphoma-like regimens. In the case showed the progressive neurological symptoms such as myelopathy and urinary incontinence, the immediate surgical decompression of the spinal cord may be necessary. Measurement of IL-2 receptor and biopsy with flow cytometry were necessary to work out the treatment strategy of the spinal malignant lymphoma. In this case, the complete response (CR) of the tumor was achieved with hyper-CVAD regimen and radiation therapy.

Usefulness of Sequential Automated Analysis of Fragmented Red Blood Cells for the Differential Diagnosis of Thrombotic Thrombocytopenic Purpura-Hemolytic Uremic Syndrome following Allogeneic Hematopoietic Cell Transplantation

Differentiating thrombotic thrombocytopenic purpura-hemolytic uremic syndrome (TTP-HUS) from other complications following allogeneic hematopoietic cell transplantation (HPCT) requires objective, reliable markers. To this purpose, we assessed the clinical usefulness of sequential quantified analysis of fragmented red blood cells (FRC) with the Sysmex XE-2100 automated hematology analyzer. The correlation between manual and automated counting was significant (r = 0.917; P < .0001). Of 25 cases, the peak FRC percentage (FRC%) exceeded 1.3% after allogeneic HPCT in 11 cases, and lactate dehydrogenase levels were elevated in 5 of these 11 cases. Two patients received diagnoses of TTP-HUS following allogeneic HPCT, and both had initial diagnoses of acute graft-versus-host disease. In both cases, the sharp increase in the FRC% to >3% simultaneously with clinical exacerbation was helpful for differentiating TTP-HUS following allogeneic HPCT from other complications. We conclude that FRC% data sequentially obtained by an automated count seem to be useful as an objective marker of TTP-HUS following allogeneic HPCT.

Assessment of sperm quality analyzer II B: comparison with manual semen analysis and CASA

Two hundred and seven patients with male infertility were investigated. Total sperm concentration and percent progressive motility by SQA IIB showed high correlations with those of conventional manual method. Percent of normal morphology showed a significant correlation among these techniques. The sperm motility index (SMI) and total functional sperm concentration (TFSC) demonstrated high correlations with any variables of manual analysis. Only velocity and amplitude of lateral head displacement showed significant correlations with the variables obtained by SQA IIB, especially with SMI and TFSC. It was suggested that SQA IIB could be a useful instrument in the clinical practice of infertility as a screening test for semen quality.

Cyclosporin neurotoxicity with Epstein-Barr virus-associated hemophagocytic syndrome

In September 2000, a 22-year-old female was admitted to our hospital due to high grade fever, liver enzymes elevation and pancytopenia. Bone marrow aspiration was performed, and hemophagocytosis was present. Epstein-Barr virus (EBV) DNA was positive in her peripheral blood, and we diagnosed the case as EBV-associated hemophagocytic syndrome (EB-VAHS) after excluding other malignancies. The initial therapy including etoposide and dexamethasone was started. As severe leukocytopenia developed, etoposide was stopped and cyclosporin A (CsA) was administered continuously. Four days after administration of CsA, she developed convulsive seizures with loss of consciousness. An MRI demonstrated decreased signal with T1-weighting and high signal with T2-weighting in the subcortical white matter including the posterior lobe. We stopped CsA infusion, and glycerol was administered. Soon the symptom disappeared. When patients developed an episode of convulsive seizure, other diagnostic possibilities were central nervous system (CNS) involvement of hemophagocytosis, EBV encephalitis and acute disseminated encephalomyelitis (ADEM). CsA neurotoxicity must be considered even in the case of EB-VAHS with administration of CsA. As previously reported, Fluid-attenuated Inversion Recovery (FLAIR) imaging improved diagnostic confidence and conspicuity of the T2 hyper intense lesions of CsA neurotoxicity, as well as tacrolimus encephalopathy, typically in the subcortical white matter. Key words; Cyclosporin neurotoxicity; Epstein-Barr virus associated-Hemophagocytic syndrome; Magnetic Resonance Image (MRI).

Second case of CML with aberrant BCR-ABL fusion transcript (e8/a2) with insertion of an inverted ABL intron 1b sequence

We found a case of Ph-positive chronic myelogenous leukemia (CML) patient with an atypical BCR-ABL transcript that was undetectable by a routine reverse transcription polymerase chain reaction (RT-PCR) for major BCR-ABL. Additional RT-PCR and sequence analyses have demonstrated that the aberrant transcript consists of a fusion of BCR exon 8 (e8) and ABL exon 2 (a2) with an insertion of a 55-bp inverted sequence of intron 1b between them. The nucleotide sequences of the aberrant transcript were identical to those of a previously reported CML patient. These are the only two CML cases in the literature with identical aberrant BCR-ABL transcripts.

Transurethral treatment of ejaculatory duct obstruction in infertile men

Ten cases of ejaculatory duct obstruction with midline cyst, complaining of male infertility, were treated with transurethral incision. They had azoospermia or oligozoospermia, and physical examination did not show any abnormal findings. Serum levels of testosterone, LH, and FSH were within normal limits. The diagnosis of ejaculatory duct obstruction with midline cyst was made by transurethral ultrasonography and vasography. Thereafter, patients underwent transurethral incision of the verumontanum with a cold knife. Semen volume increased in all patients, and sperm concentration and/or motility improved in 7 patients (70%). Pregnancy was achieved by 3 couples (30%). Incision of the ejaculatory duct via an endoscopic technique could improve seminal findings and subsequent fertility.

Tubularized incised plate urethroplasty for distal hypospadia, using overlapping dorsal subcutaneous flaps

This paper presents a newly developed simple procedure using overlapping vascularized dorsal dartos subcutaneous flaps to cover the neourethra after hypospadias correction. A 3-year old boy with distal hypospadias underwent the tubularized incised plate urethroplasty using this method. Postoperative complications, which include urethrocutaneous fistula, were not observed, but the glans did exhibit a vertical, slit-like meatus. Covering the neourethra with overlapping dorsal dartos flaps is expected to prevent the development of urethrocutaneous fistula in patients with distal hypospadias.

[Invasive pulmonary aspergillosis complicated by complete atrioventricular block and aspergillus pericarditis after induction chemotherapy in a patient with acute lymphoblastic leukemia]

A 50-year-old man developed invasive pulmonary aspergillosis after induction chemotherapy for acute lymphoblastic leukemia. He was treated with 5-fluorocytosine and intravenous amphotericin B (AMPH-B). During antifungal therapy, he developed aspergillus pericarditis and complete atrioventricular (A-V) block. The pericardial effusion was decreased and the A-V block was improved after treatment with intravenous and intrapericardial instillation of AMPH-B. Because the patient's renal function deteriorated, AMPH-B was replaced with itraconazol after the latex agglutination (LA) test for an aspergillus-specific antigen showed a negative result. The patient, however, died from disseminated aspergillosis. Aspergillus DNA was detected in retrospective analysis of the serum which had been negative with the LA test. This case indicates that LA is not sufficient for diagnosis and post therapy evaluation of invasive aspergillosis. PCR or other methods should be used concomitantly with LA. Intrapericardial instillation of AMPH-B might be effective for patients with aspergillus pericarditis in whom surgical treatment is not indicated.

A study of carotid intima-media thickness in GH-deficient Japanese adults during onset among adults and children

OBJECTIVES

Increased carotid intima-media thickness (IMT) has been reported among Caucasian adult GH-deficient (AGHD) patients, but not Japanese. Also, it is known that the clinical and biochemical characteristics of AGHD patients are somewhat different based on the onset of the disease in either childhood or adult life. Nevertheless, there has been no study comparing the magnitude of the deviation of their IMT from normal subjects between child-onset (CO) and adult-onset (AO) patients in terms of Z score. The aim of this study, therefore, was first to examine whether Japanese AGHD patients have a risk of early development of atherosclerosis similar to Caucasian patients and secondly to assess the difference in the onset and in progression of atherosclerosis.

DESIGN AND SUBJECTS

Thirty-four patients (17 CO-AGHD, age 29+/-7 Years, body mass index (BMI) 24+/-3.8 kg/m(2) and 17 AO-AGHD, age 48+/-12 Years, BMI 23+/-3.6 kg/m(2)) and 34 age- and sex-matched healthy controls (17 CO controls and 17 AO controls) were enrolled in the present study. Blood samples were taken for measurements of lipids, lipoproteins and IGF-I. Subsequently, patients underwent IMT assessment.

RESULTS

CO patients were significantly younger than AO patients. The duration of GH-deficiency in CO patients was significantly longer than that in AO patients. Serum triglyceride (TG) was significantly higher in CO patients than in CO controls (P<0.05). Serum total cholesterol and TG were significantly higher in AO patients than in AO controls (P<0.01). The IMT was significantly greater in CO and AO patients (0.82+/-0.08 and 0.79+/-0.03 mm) than in CO and AO controls (0.59+/-0.02 and 0.68+/-0.03 mm, P<0.01 and P<0.01 respectively). There was no significant difference in raw values of IMT between CO and AO patients. However, the Z score of IMT calculated using normal Japanese IMT values was significantly higher in CO than in AO patients (2.07+/-0.68 vs 0.35+/-0.48, P<0.05).

CONCLUSIONS

These findings suggest that GH deficiency appears to increase an atherosclerotic risk in Japanese AGHD patients, as with Caucasians, and to cause more extensive IMT thickening in CO-AGHD than AO-AGHD patients.

Evaluation of acrosome reactivity using the Acrobeads test in varicocele patients: findings before and after treatment

The Acrobeads test was performed on semen samples from 43 patients with varicocele before and after varicocelectomy. Sperm motility significantly increased after surgery (p <.05), while sperm concentration and motile sperm concentration did not alter postoperatively. Sperm motion analysis using CellSoft 3000 did not demonstrate a significant change after treatment. Acrobeads score significantly increased after the procedure (p<.005). Pregnancy was achieved in 10 patients (28%). Acrobeads score in cases that achieved pregnancy was increased postoperatively (p<.005). The percentage of patients with a postoperative increase in Acrobeads score in the group that achieved pregnancy was significantly higher than that observed in the unsuccessful group (p <.05). Sperm parameters other than the Acrobeads score did not show a significant difference between the successful and unsuccessful patients. The Acrobeads test assessed postoperatively can be useful in precisely evaluating fertility potential after varicocele repair.

An experience of percutaneous embolization to post-traumatic arterial priapism in a child

We report an experience of percutaneous transcatheter embolization to posttraumatic arterial priapism in a child. Priapism was successfully treated with this method. Angiography with subsequent selective embolization should be considered to be the treatment of choice for arterial priapism in children as well as in adults when less invasive treatments fail.

T-cell receptor gammadelta T-cell leukemia with the morphology of T-cell prolymphocytic leukemia and a postthymic immunophenotype

T-cell prolymphocytic leukemia (T-PLL) is a postthymic T-cell neoplasm with a characteristic morphology and heterogeneous immunophenotype. Most cases of T-PLL express membrane T-cell receptors (TCRs) of the alphabeta phenotype. We experienced a 30-year-old man suffering from TCRgammadelta T-cell leukemia with morphology compatible to T-PLL with a postthymic phenotype. He was admitted with skin eruption and pancytopenia. Peripheral blood and bone marrow were occupied with medium-sized lymphocytes, which had moderately condensed chromatin with a single nucleolus and sparse, nongranular basophilic cytoplasm. The immunophenotype was CD1a-, CD2-, CD3+, CD4-, CD5+, CD7+, CD8-, and terminal deoxynucleotidyl transferase negative. Hepatosplenomegaly was absent. He was diagnosed as having T-PLL and was treated with combination chemotherapy. Six months later the leukemic cell became chemoresistant. Although the patient showed transient improvement in response to pentostatin, he died 13 months after the diagnosis. To our knowledge, this is the first case of T-PLL with a TCRgammadelta phenotype.

Upregulation of the klotho gene expression by thyroid hormone and during adipose differentiation in 3T3-L1 adipocytes

A defect in the klotho gene expression in mice leads to a syndrome resembling human aging. The klotho gene encodes a single membrane protein whose extracellular domain carries homology to beta-glucosidases. However, either its function or regulatory mechanism of the gene expression still remains unknown. In the present study, we investigated the klotho gene expression in 3T3-L1 adipocytes using quantitative reverse transcription-polymerase chain reaction. Both membrane and secreted forms of the klotho gene were expressed in 3T3-L1 preadipocytes. Accompanied with adipose differentiation, not the secreted form but the membrane form was gradually increased. In 3T3-L1 adipocytes, triiodothyronine significantly increased the expression levels of membrane form of the klotho gene. These results suggest that the expression of membrane and secreted forms of klotho transcripts are regulated by different mechanisms and that the klotho gene product may play a role in adipose differentiation.

Kinetic analysis of cytokine gene expression in patients with GVHD after donor lymphocyte infusion

Patients who receive a donor lymphocyte infusion (DLI) for the treatment of relapsed leukemia after allogeneic BMT (alloBMT) often developed GVHD. To determine whether cytokines might have a role in GVHD, an intensive kinetic analysis of in vivo cytokine gene expression was performed on PBMC from three such patients. Expression of IL-1beta, IL-2, IFN-gamma, IL-4, IL-5, IL-8, IL-10, IL-12, TNF-alpha, and IL-2Ralpha was examined using a sensitive semi-quantitative reverse transcription (RT)-PCR assay system. Six normal controls were also analyzed for comparison. Expression of type 1 T helper (Th1) cytokines, IL-2 and IFN-gamma was greatly increased in all three patients. In particular, the changes in IL-2 gene expression correlated well with disease progression, suggesting that IL-2 has a critical role in the development of GVHD. Although the pattern of type 2 T helper (Th2) cytokine gene expression differed in each patient, the expression of IL-4 was inversely related to expression of Th1 cytokines. These results suggest that Th1 dominates in the development of human clinical GVHD.

Successful Cytoreduction with CAG (cytarabine, Aclarubicin and G-CSF) Therapy in Refractory Acute Myelogenous Leukemia before Allogeneic Stem Cell Transplantation

Refractory acute myelogenous leukemia (AML) has a poor prognosis, and a long-term survival cannot be expected in most patients even if allogeneic bone marrow transplantation (allo-BMT) or allogeneic peripheral blood stem cell transplantation (allo-PBSCT) is performed. An abundance of residual leukemic cells and poor performance status of patients before allo-BMT are often associated with a high relapse rate and high transplant-related mortality. Thus, to improve the prognosis of patients with refractory AML undergoing allo-BMT, it is necessary to reduce the leukemic cell volume as low as possible without severe complications. In this report, we used CAG (cytarabine, aclarubicin and granulocyte colony-stimulating factor (G-CSF)) therapy for cytoreduction before allo-BMT or allo-PBSCT in five patients with refractory AML. One of them achieved complete remission (CR) by CAG therapy alone and others achieved major tumor reduction prior to BMT and PBSCT. All patients achieved CR after allo-BMT and allo-PBSCT without severe complications. Three of them have remained CR for 9, 21 and 30 months, respectively. Although the results of this feasibility study are preliminary, the pre-transplant CAG therapy for refractory AML deserves further evaluation.

Long-term molecular remission induced by donor lymphocyte infusions for recurrent acute myeloblastic leukemia after allogeneic bone marrow transplantation

A case of acute myelogenous leukemia with a t(8;21) translocation relapsed 5 months after allogeneic bone marrow transplantation (allo-BMT). After chemotherapy-induced hematologic remission, the patient received donor lymphocyte infusions (DLI); 4.9 x 108/kg T cells were infused. After DLI, she achieved molecular CR for the first time after allo-BMT, which lasted for 40 months. However, she suffered from grade III acute GVHD of the skin and the liver. Hepatic GVHD was sustained and resulted in fatal outcome. The case demonstrates that DLI is a double-edged sword. Further study is necessary before DLI can be considered to be a beneficial therapy for acute leukemia. Bone Marrow Transplantation (2000) 26, 809-810.

Epstein-Barr virus-negative high grade B cell lymphoma of donor origin developing 19 months after unrelated allogeneic bone marrow transplantation

A 22-year-old man, in first complete remission of acute myelogenous leukemia, developed a high grade B cell lymphoma 19 months after an allogeneic bone marrow transplant (allo-BMT) from an HLA-identical unrelated donor. Biopsy of a cervical lymph node revealed a lymphoma that was negative for Epstein-Barr virus-encoded small nuclear RNAs (EBERs) in situ hybridization. Genotypic analyses identified the lymphoma to be of donor origin, and there was no evidence of the Epstein-Barr virus (EBV) DNA in the lymphoma by Southern blot analysis. The lymphoma went into complete remission, following four courses of combination chemotherapy, but relapsed after a month and the patient died of congestive heart failure. The patient was thought to be persistently immunosuppressed 11 months after cessation of immunosuppressants, and the lymphoma was thought to be induced by one or more factors other than EBV.

[Progression of refractory thrombocytopenia to chronic myelomonocytic leukemia accompanied by various inflammatory reactions]

A 51-year-old man was admitted for treatment of severe thrombocytopenia in May 1997. A diagnosis of MDS RA (refractory thrombocytopenia; RTC) was made by bone marrow examination, which revealed mild marrow hypoplasia and a reduced number of megakaryocytes accompanied by micromegakaryocytes and hypolobular megakaryocytes. Chromosome analysis demonstrated 46, XY, t(5;7) (q31;q22) in all 20 cells examined. The patient received only supportive therapy including platelet transfusion, until leukocytosis and monocytosis gradually developed in November 1998. In view of a marked increase in the number of monocytes (more than 3,000/microliter), a diagnosis of CMML was made in December 1998. As the leukocytosis progressed, various inflammatory symptoms such as facial erythema and endophthalmitis developed. Administration of interferon alpha (IFN alpha) unexpectedly worsened the leukocytosis and monocytosis, suggesting abnormal responses of these cells to IFN alpha. Detailed molecular analysis of these cells might reveal a novel mechanism of leukemogenesis associated with 5q31.

Multifocal fibrosclerosis as a possible cause of panhypopituitarism with central diabetes insipidus

Multifocal fibrosclerosis denotes a combination of similar fibrous disorders occurring at different anatomical sites. We encountered a 53-year-old male patient with orbital pseudotumor, chronic paranasal sinusitis, fibrous nodules of the lungs, intracranial pachymeningitis, and panhypopituitarism with central diabetes insipidus (DI) as a possible manifestation of multifocal fibrosclerosis. It has been reported that intracranial pachymeningitis or orbital pseudotumor associated with multifocal fibrosclerosis could invade the sella turcica causing a variety of anterior and/or posterior pituitary dysfunctions. In our case, intracranial pachymeningitis apparently involved the pituitary stalk and gland. Isolated gonadotropin deficiency, in addition to central DI, preceded panhypopituitarism. Although panhypopituitarism with central DI due to multifocal fibrosclerosis is quite rare and only one case has ever been reported, this systemic fibrotic disorder can be a possible cause of panhypopituitarism with central DI.

A phase III randomized study comparing doxifluridine and 5-fluorouracil as supportive chemotherapy in advanced and recurrent gastric cancer

We conducted a phase III randomized study to investigate effects of supportive chemotherapy with oral doxifluridine (group A, 75 patients) or 5-fluorouracil (group B, 75 patients) in advanced gastric cancer when intensive chemotherapy was not an option. Although there were no significant differences between the groups with regard to survival, hospital-free survival and time to progression, median values of 3 endpoints were superior in group A. Secondary analysis showed that group A patients with prior chemotherapy tended to have longer survival and hospital-free survival and significantly longer time to progression.

Stimulation by eicosapentaenoic acids of leptin mRNA expression and its secretion in mouse 3T3-L1 adipocytes in vitro

Recent evidence indicates that both leptin and eicosapentaenoic acids (EPA) improve insulin sensitivity. In the present study, we examined the effect of EPA on endogenous leptin expression in 3T3-L1 adipocytes to clarify whether the EPA's effect is exerted through leptin expression. EPA caused a time- and dose-dependent increase of leptin mRNA levels in 3T3-L1 adipocytes. Leptin mRNA expression was significantly increased up to 309.4 +/- 17.0% of the control by 24 h (P < 0.01; n = 6). Leptin secretion was also significantly increased up to 193.3 +/- 12.1% of the control by 24 h (P < 0.01; n = 6). EPA is a ligand for peroxisome proliferator-activated receptors (PPARs) with the highest affinity to PPARalpha. We examined the effect on leptin expression of clofibrate, a ligand for PPARalpha, bezafibrate, for PPARbeta, or troglitazone, for PPARgamma, to clarify whether these ligands for PPARs could mimic EPA-induced stimulation of leptin expression. Neither clofibrate nor bezafibrate affected leptin mRNA expression, whereas troglitazone significantly suppressed leptin mRNA expression. On the other hand, inhibition by 6-diazo-5-oxo-l-norleucine of the rate-limiting enzyme in hexosamine biosynthesis blunted EPA-induced stimulation of leptin mRNA expression and its secretion. These data suggest that EPA up-regulates leptin gene expression and its secretion probably through a hexosamine biosynthetic pathway.

Leptin stimulates basal and GHRH-induced GH release from cultured rat anterior pituitary cells in vitro

Leptin, the product of ob gene, is secreted from adipocytes and appears to regulate food intake and energy expenditure through its receptor in the hypothalamus. In addition, leptin is reported to modulate pituitary hormones including LH, FSH and ACTH, probably via the hypothalamus. In obesity, growth hormone (GH) secretion is impaired, while serum leptin levels are elevated. To investigate the possibility that leptin serves as a metabolic signal that influences GH secretion from the pituitary, we studied the effect of leptin on GH secretion from primary monolayer cultures of rat anterior pituitary cells. Twenty micrograms/ml leptin increased GH secretion, but did not increase GH release at a physiological concentration up to 200 ng/ml. However, 200 ng/ml leptin stimulated GH release in the presence of GH-releasing hormone (GHRH) ranging from 10(-8) to 10(-7) M. Twenty ng/ml leptin tended to increase 10(-7) M GHRH-induced GH release, whereas 20 ng/ml leptin did not increase either 10(-9) or 10(-8) M GHRH-induced GH release. This result suggests that leptin has a direct effect on the pituitary to enhance GHRH-induced GH secretion.

[Intraperitoneal and intrathoracic administration of hydroxyapatite-carboplatin (HAp-CBDCA)]

We have investigated the efficacy of intraperitoneal or intrathoracic administration of hydroxyapatite particles (HAp) loaded carboplatin (CBDCA). HAp-CBDCA (HAp; 200 mg, CBDCA; 4 mg) was administered intraperitoneally to rats with peritoneal carcinomatosis. The area under the curve of the ascitic platinum (Pt) increased significantly with rats given HAp-CBDCA, and the omental Pt levels in the HAp-CBDCA group remained higher and longer. Additionally, the HAp-CBDCA group showed a trend toward longer survival when compared with the CBDCA alone group. In clinical use, HAp-CBDCA (HAp; 5 g, CBDCA; 150 mg) was administered intrathoracically to a patient who had undergone esophagectomy. The Pt in serum was detected until 7 days after administration of HAp-CBDCA.

[An effective case of arterial infusion therapy of low-dose CDDP and continuous 5-FU for isolated hepatic recurrence of gastric carcinoma]

We report an effective case of arterial infusion therapy of low-dose CDDP and continuous 5-FU for isolated hepatic recurrence of gastric carcinoma. An 83-year-old man was admitted for epigastric pain and vomiting due to a huge liver metastasis of gastric carcinoma in May, 1997. Nineteen months earlier, in October of 1995, he had undergone distal gastrectomy and D2 lymph node dissection with Billroth I reconstruction. His conclusive stage and pathological findings were as follows. The conclusive stage was stage II: t3, n0, P0, H0. Histological typing was tub 2. Lymph node involvement was not detected, but venous invasion was found in the surrounding regional lymph nodes. CEA had been getting elevated from November, 1996. But he had been well until March, 1997, when CT scans revealed huge hepatic recurrence. The artery-side port was placed for hepatic arterial infusion therapy for liver metastasis. Intra-arterial bolus injection of low-dose CDDP (5 mg) and continuous intra-arterial infusion of 5-FU (250 mg/day for 7 days) were started. Through 4 courses of this arterial infusion therapy, the patient improved. CT scans revealed shrinking of liver metastasis after 3 months of this therapy. The patient was followed in an outpatient clinic and continued to receive this arterial infusion therapy once every 4 weeks. New lung metastasis was detected 9 months after the start, but liver metastasis continued to be responded. The patient died from bleeding into the bile duct from the liver metastasis 16 months after the start of arterial infusion therapy, when metastatic lesions of liver continued to shrink. Arterial infusion therapy of low-dose CDDP and continuous 5-FU may be effective for isolated hepatic recurrence of gastric carcinoma.

Cloning and characterization of the 5'-flanking region of the human growth hormone-releasing hormone receptor gene

We cloned the 5'-flanking region of the human growth hormone-releasing hormone receptor (GHRH-R) gene and determined the nucleotide sequence of 2.7 kilobases upstream from the translation start site. RNase protection analysis showed the major transcription start site is 122 base pairs upstream from the translation start site. The 5'-end of the longest product of 5'-rapid amplification of cDNA ends was close to the site. There were no typical TATA homologies but several putative regulatory elements including Pit-1-binding site-like element. Transient transfection studies using a luciferase reporter gene demonstrated that 5'-flanking region had promoter activity in GH3 cells (derived from rat pituitary tumor) but not in nonpituitary cells, BeWo and HeLa cells. However, co-transfection of Pit-1 expression vector increased luciferase activity in BeWo cells. Deletion study showed that the regions from -310 to -130 and from -130 to -120 were important for the GHRH-R gene expression in GH3 cells, although the latter contributed less to the gene expression. In BeWo cells co-transfected with Pit-1 expression vector, the region from -310 to -130 was essential for the Pit-1-dependent expression of GHRH-R gene. The region from -310 to -120 has two putative Pit-1-binding sites, P1 and P2, located from -129 to -123 and from -171 to -160, respectively. Both mobility shift assay and DNase-I footprint analysis showed that P2 had much higher Pit-1 binding affinity than P1. Mutation of P2 decreased GHRH-R gene expression in GH3 cells. These findings were consistent with the results that the region from -310 to -130 is an important element for Pit-1-dependent expression of GHRH-R gene.

[Disseminated carcinomatosis of the bone marrow occurring 11 years after subtotal gastrectomy for gastric cancer]

A 44-year-old man was admitted to our hospital because of purpura, increased serum alkaline phosphatase, and thrombocytopenia. He had undergone subtotal gastrectomy for gastric cancer 11 years earlier. A biopsy specimen of the bone marrow revealed metastatic mucin-forming, moderately differentiated adenocarcinoma. Because the primary tumor was not detected in any other organ, the gastric cancer the patient was treated for 11 years earlier was suspected as the primary tumor. Microangiopathic hemolytic anemia and disseminated intravascular coagulation developed during the clinical course, and the patient deteriorated despite treatment with anticoagulants. Finally, he died of pulmonary carcinomatous lymphangitis. Autopsy revealed a small number of adenocarcinomatous cells in the lymphoduct of the remaining stomach in spite of its mucosa being intact. We concluded that the bone marrow was infiltrated by cancer cells which originated in the stomach 11 years before. It is unclear why adenocarcinoma cells remained dormant for as long as 11 years in the gastric lymphoduct and bone marrow.

[Multicentric Castleman's disease with lymphoid interstitial pneumonia and polyneuropathy]

A 51-year-old woman was admitted to a local hospital because of pneumonia, and received a diagnosis of cervical lymphadenopathy, anemia, and hyperimmunoglobulinemia with suspected multicentric Castleman's disease (MCD). At the age of 53 she was transferred to our hospital because of numbness and muscle weakness. Polyclonal hyperimmunoglobulinemia was observed, and biopsy specimens of lymph node tissue revealed infiltration of plasma cells in the interfollicular areas, thus leading to a diagnosis of MCD. A chest computed tomography scan revealed diffuse nodular shadows in all lung fields, and a transbronchial lung biopsy disclosed infiltration of plasma cells in the alveolar septa. Together, these findings indicated lymphoid interstitial pneumonia (LIP). Polyneuropathy was diagnosed by neurological examination and nerve conduction studies. Treatment with prednisolone and cyclophosphamide was ineffective against LIP probably because the patient had coexising pulmonary fibrosis. Since pulmonary complications of MCD determine its prognosis, their early detection and treatment are essential.

[A case of gastric cancer with decreased dihydropyrimidine dehydrogenase activity]

We analyzed the pyrimidine metabolite in the urine of a patient with severe mucositis and hand and foot syndrome, who was administered 5-fluorouracil for recurrence of gastric cancer. From our analysis, it was suggested that the patient had decreased dihydropyrimidine dehydrogenase activity. Dihydropyrimidine dehydrogenase activity is usually measured in peripheral blood mononuclear cells, but this time it was estimated from the analysis of uracil, dihydrouracil, thymine, and dihydrothymine in the urine. We concluded that urinary analysis of the pyrimidine metabolism is effective as screening for the prediction and prevention of 5-fluorouracil toxicity.

[Chemotherapy targeting regional lymph nodes by gastric submucosal injection of liposomal adriamycin in patients with gastric cancer]

We investigated the delivery of adriamycin (ADR) to the regional lymph nodes of the stomach following the gastric submucosal injection of liposomal adriamycin (Lipo-ADR) in 34 gastric carcinoma patients, as well as following intravenous administration of free ADR (F-ADR) in 18 patients, then followed these patients for a minimum of 5 years or until death. Prior to radical gastrectomy. Lipo-ADR was endoscopically injected into the gastric submucosa adjacent to the primary tumor via a needle-tipped catheter. After Lipo-ADR injection, the ADR concentration in the primary and secondary drainage lymph nodes was higher than in the other regional lymph nodes. Thus, the regional nodes more susceptible to the involvement of metastasis showed higher levels of ADR. In contrast, the intravenous administration of F-ADR produced a similar and far lower ADR concentration in all the nodes. Delivery of ADR to the primary drainage lymph nodes following injection of 5 mg of Lipo-ADR (n = 19) was compared with delivery to the left gastric artery lymph nodes after intravenous administration of an equal dose of Lipo-ADR. The ADR levels (microgram/g) after gastric submucosal injection were 15.1 +/- 8.30 on day 1 (n = 4) and 11.9 +/- 4.80 on day 4 (n = 6), whereas, the ADR levels after intravenous administration were 0.29 +/- 0.10 on day 1 (n = 4) and 0.36 +/- 0.0 on day 4 (n = 2). The differences between the two groups were significant (p < 0.05). The ADR levels after the gastric submucosal injection were far higher than those after intravenous administration. These findings indicate that the gastric submucosal injection of Lipo-ADR can specifically deliver ADR to the regional lymph nodes at high concentrations. Disease-free survival of the stage III a-b patients (n = 7) with this regional lymph nodes-targeted chemotherapy was 71.4% in 5 years, while that with intravenous F-ADR administration (n = 5) was 60.0%. This preoperative adjuvant chemotherapy targeting the regional lymph nodes may be effective in preventing the recurrence of gastric carcinoma.