Influential Factors for Engraftment in Autologous Peripheral Hematopoietic Stem Cell Transplantation (APBSCT)

BACKGROUND: Autologous peripheral hematopoietic stem cell transplantation (APBSCT) has been widely used to treat various types of hematological disorders, metabolic diseases and congenital immunodeficiency. Hematopoietic recovery is important because prolonged duration of neutropenia and thrombocytopenia is associated with a higher risk of infection, bleeding and treatment related mortality. Many investigators have studied the factors that affect hematopoietic recovery after stem cell transplantation. METHODS: We retrospectively investigated the factors influencing hematopoietic engraftment in 112 patients with hematological malignancies and solid tumors who received APBSCT. We evaluated the gender, age, CD34+ cell number, conditioning regimens, and the type of tumor and their association with neutrophil and platelet engraftment. RESULTS: Post-transplant neutrophil engraftment (>500/microL) required a median of 11 days (range 6~50) and platelet engraftment 12 (range 1~78) days (>20,000/microL). The univariate analysis showed that the factors that positively affected hematopoietic recovery were: the type of conditioning regimens such as BEAM (BCNU, etoposide, cytosine arabinoside, melphalan) and BEAC (BCNU, etoposide, cytosine arabinoside, cyclophosphamide) versus BC (busulfan, cyclophosphamide), the CD34+ cell number and the disease diagnosis such as multiple myeloma versus acute myelogenous leukemia. The multivariate analysis showed only the CD34+ cell number (5~10 x 10(6)/kg) to be significantly associated with early neutrophil and platelet engraftment (P<.001). CONCLUSION: These findings suggest that measurement of the CD34+ cell count may be sufficient to predict the time to engraftment after APBSCT.

Co-transplantation of Human Mesenchymal Stem Cells Promotes Human CD34+ Cells Engraftment in a Dose-dependent Fashion in NOD/SCID Mice

Mesenchymal stem cells (MSCs) have recently been identified and characterized in humans. Moreover, MSC secrete cytokines that can support hematopoietic progenitor growth. In the present study, we evaluated whether the efficacy of hematopoietic stem cell transplantation is improved by their co-transplantation with MSC, and whether this is positively correlated with the dose of infused MSCs. Accordingly, irradiated NOD/SCID mice were transplanted with 1x10(5) human CD34+ cells in the presence or absence of culture expanded MSCs (1x10(6) or 5x10(6)). We evaluated human hematopoietic cell engraftment by flow cytometry and assessed MSC tissue distributions by fluorescence in situ hybridization. We found that CD45+ and CD34+ cell levels were significantly elevated in a dose-dependent manner in cotransplanted mice 4 weeks after transplantation. The engraftments of CD33+ and CD19+ cells also increased dose-dependently. However, the engraftment of CD3+ cells did not increase after co-transplantation with MSCs. Human Y chromosome+ cells were observed in multiple tissues and were more frequently observed in mice co-transplanted with 5x10(6) rather than 1x10(6) MSCs. These results suggest that MSCs are capable of enhancing hematopoietic cell engraftment and distribution in multiple organs in a dose-dependent fashion.

Solitary Extramedullary Plasmacytoma of the Liver without Systemic Monoclonal Gammopathy

Extramedullary plasmacytoma of the liver is a very rare tumor. Although a few cases of extramedullary plasmacytoma of the liver have been reported, we could not find any report on truly localized extramedullary plasmacytoma of the liver in the literature. The patient was a 63-yr-old man who exhibited a solitary liver mass on dynamic computed tomography and magnetic resonance imaging. Histologically, the tumor was composed of mature plasma cells with mild atypia. Immunohistochemistry demonstrated monoclonal IgG and Kappa light chain expression. Bone marrow examination revealed no abnormalities. There was no evidence of a monoclonal protein in the serum and urine, lytic bone lesions, anemia, renal insufficiency, and hypercalcemia. The patient was treated with 5,000 cGy of radiotherapy, and the tumor disappeared 6 months after treatment.

Autoimmune Hemolytic Anemia in Myelodysplastic Syndrome

Autoimmune paraneoplastic syndromes are encountered in patients with myelodysplastic syndromes. A review of case reports suggested 10% of myelodysplastic syndrome patients may experience various autoimmune syndromes, associated with immunological-mediated hematologic abnormalities, such as Coombs' negative hemolytic anemia. In patients with myelodysplastic syndrome, Coombs' negative hemolytic anemia may be underdiagnosed due to its association with reticulocytopenia. Therefore, the findings from a peripheral blood smear and measurement of haptoglobin level are important. Autoimmune manifestations respond to immunosuppressive agents, including steroids. Herein, a case with Coombs' negative hemolytic anemia, diagnosed with myelodysplastic syndrome from a bone marrow biopsy, is reported, with a review of the previously reported literature.

A Phase II Study of Irinotecan, 5-Fluorouracil and Leucovorin for Treatment in Patients with Previously Untreated Advanced Colorectal Cancer / Journal of the Korean Cancer Association, 대한암학회지

PURPOSE: We prospectively conducted a non-randomized phase II trial to evaluate the efficacy and safety of combination irinotecan, leucovorin (LV) and 5-fluorouracil (FU) as a first-line regimen for treating patients with previously untreated advanced colorectal cancer (CRC). MATERIALS AND METHODS: Twenty-six previously untreated patients with advanced, recurrent or metastatic CRC were enrolled in this study. The patients received either irinotecan 180 mg/m2 on day 1 with LV bolus of 200 mg/m2 and FU bolus of 400 mg/m2, and this was followed by FU continuous infusion of 600 mg/m2 on day 1 and day 2 (the FOLFIRI regimen), or they were treated with LV bolus of 400 mg/m2 and FU bolus of 400 mg/m2 followed by FU continuous infusion of 2,400 mg/m2 for 46 hours (the simplified FOLFIRI regimen), and these treatments were repeated every 2 weeks until disease progression. RESULTS: The objective response rate was 23.1% (6/26) respectively, for both treatments. The median time to progression was 5.3 months (range: 0.4~19.9), and the overall survival was 11.2 months (range: 0.5~52.3). The prognostic factor for longer survival was the Eastern Cooperative Oncology Group (ECOG) performance status (PS). The non-hematological toxicities were similar for both treatment groups, with more frequent grade > or =3 neutropenia being noted for the simplified FOLFIRI regimen. CONCLUSION: The biweekly irinotecan based regimen was demonstrated to have a moderate antitumor activity with acceptable toxicity profiles, and the ECOG PS was the independent prognostic factor.

Arsenic Trioxide Induces Erythroid Differentiation and Apoptosis of K562 Human Leukemia Cells through the Down-Regulation of Bcl-2

BACKGROUND: Arsenic trioxide (As2O3) has been identified as an effective drug for the treatment of acute promyelocytic leukemia (APL). However, the role of As2O3 during the erythroid differentiation of human leukemic cells remains unknown. In this study, we investigated the in vitro effects of As2O3 on the erythroid differentiation of the K562 cell line and also on the expression and regulation of the apoptotic modulators of this process. METHODS: The K562 cells were cultured in the presence of 0.1, 0.5 and 1.0micrometer As2O3, or they were cultured in the presence of 1.0 and 10micrometer all trans retinoic acid (ATRA). The expression of glycophorin A before and after treatment with As2O3 or with ATRA in the K562 cells was assessed by flow cytometry and western blotting. The expressions of Bcl-2 and caspase-3 were determined by western blotting. RESULTS: The viability of the K562 cells was not decreased after treating with 0.1 and 0.5micrometer of As2O3, but the viability was significantly reduced at a dose of 1.0micrometer Caspase 3 activation was not observed at 0.1 and 0.5micrometer of As2O3 until 12 days, but Caspase 3 was activated by 1.0micrometer of As2O3 from day 3. The expression of glycophorin A was increased in dose dependent manner by As2O3 treatment, but this was not changed in the ATRA treated K562 cells. The expression of Bcl-2 was increased by 0.1 and 0.5micrometer of As2O3, but it was abruptly reduced by 1.0micrometer of As2O3. CONCLUSION: These results suggest that As2O3 induces the erythroid differentiation of K562 cells and that 1.0micrometer of As2O3 induces apoptosis through the down-regulation of Bcl-2.

Combination of Gemcitabine and Cisplatin as First-Line Therapy in Advanced Non-Small-Cell Lung Cancer / Journal of the Korean Cancer Association, 대한암학회지

PURPOSE: The prognosis of patients with advanced non-small-cell lung cancer (NSCLC) is extremely poor. Many prospective randomized trials on patients with advanced NSCLC suggested systemic chemotherapy improves both the survival and quality of life. A phase II trial was conducted to evaluate the efficacy and safety profile of the combination chemotherapy of gemcitabine and cisplatin in advanced NSCLC. MATERIALS AND METHODS: Forty-four patients with locally advanced or metastatic NSCLC were enrolled. The patients received a cisplatin, 75 mg/m(2), infusion over 30 minutes on days 1, followed by a gemcitabine, 1, 250 mg/m(2), infusion over 30 minutes on days 1 and 8 every 3 weeks. RESULTS: The median age of the patients was 64 years (range: 27~75). Forty-one patients were assessable for response and toxicity analyses. The overall response rate was 53.6%, but with no complete remissions. The median time to progression was 5.6 months (range: 1~15.4). The median survival was 14.2 months (95% confidence interval (CI), 13.8~22.5). A total of 179 cycles were administered, with a median of 4 cycles of chemotherapy, ranging from 2 to 9 cycles. The most common hematological toxicities were NCI grades 3/4 neutropenia (24%) and thrombocytopenia (7.8%). The most common non-hematological toxicity was fatigue (42.4%). There were no life-threatening toxicity or treatment related mortalities. The median duration of follow up was 9.4 months, ranging from 1.6 to 30.3 months. CONCLUSION: In this trial, the combination of gemcitabine and cisplatin showed significant activity, with acceptable and manageable toxicities as a first-line regimen for patients with advanced NSCLC.

Restoration of the TRAIL Resistance with a Low Dose Doxorubicin in Acute Leukemia Cell Lines / 대한혈액학회지

BACKGROUND: Tumor necrosis factor-related apoptosis-inducing ligand (TRAIL) has been reported to induce apoptosis in various tumor cells but not in normal cells, which suggests its potential use as a tumor-specific antineoplastic agent. In the present study, we examined here that the treatment of TRAIL-resistant leukemia cells with a low dose doxorubicin in combination of TRAIL induces a synergistic apoptotic response. METHODS: Cell growth inhibition was assessed by MTT assay, and the induction of apoptosis was examined using flow cytometry after stained with Annexin V. To find out the molecular change of the TRAIL receptors and caspase expression in acute leukemia cell lines and human umbilical cord blood (UCB) mononuclear cells, RT-PCR for TRAIL receptors and western blot analysis for DR4, DR5, and caspase 3, 7, 8, and 9 were performed. RESULTS: The Jurkat cell line was TRAIL sensitive and TRAIL-resistant Molt-4 cell line became sensitive after treatment with TRAIL and a low dose of doxorubicin (0.1micrometer), but UCB mononuclear cells remained resistant. DR4 expression was increased when TRAIL-sensitive Jurkat cells were treated with TRAIL. DR5 expression was increased after exposing TRAIL- resistant Molt-4 cell line to TRAIL plus a low dose of doxorubicin for 24 hours. The expression of DR4 and DR5 in UCB mononuclear cells was unchanged after treatment with TRAIL, a low dose doxorubicin, or TRAIL plus a low dose of doxorubicin. Activated caspase 3 expression was augmented by TRAIL plus a low dose of doxorubicin than TRAIL or a low dose of doxorubicin alone in TRAIL-resistant Molt-4 cells. CONCLUSION: A low dose doxorubicin in combination with TRAIL may effectively promote caspase activation in TRAIL-resistant leukemia cells. Apoptosis synergistically induced by the combination of a low dose doxorubicin and TRAIL might be considered as an effective and safe tool in treating TRAIL-resistant acute leukemia.

Pseudomembranous Gastritis due to Aspergillus in a Patient with Relapsed Acute Myelogenous Leukemia / 대한혈액학회지

Development of pseudomembranes in the gastrointestinal tract during acute inflammatory or vascular disease has been confined to the small and/or large bowel, with rare occurrences in the esophagus. Primary gut involvement by Aspergillus is a rare and often fatal complication of intensive antileukemic therapy. To our knowledge, there has been only two case reports of pseudomembranous gastritis. We experienced a case of isolated pseudomembranous gastritis due to Aspergillus after chemotherapy for relapsed acute myelogenous leukemia. The diagnosis was made by gastrofiberscopic findings and histologically.

The role of mesenchymal stem cells in hematopoietic stem cell transplantation / 대한내과학회지

BACKGROUND: Human bone marrow contains mesenchymal stem cells (MSCs) which are capable of differentiation into a number of mesenchymal cell lineages when stimulated under appropriate conditions. Many studies indicate that the bone marrow stroma is damaged following bone marrow transplantation. Animal models suggest that the transplantation of healthy stromal elements, including MSCs, may enhance the ability of the bone marrow microenvironment to support hematopoiesis after stem cell transplantation. However, it remains to be seen whether transplantation of MSCs has significant value and pre-culture of hematopoietic stem cells with MSCs prior to transplantation changes their engraftment. METHODS: We investigated the differentiation potential and the potential plasticity of MSCs. And we also studied whether they have any effects on hematopoietic engraftment in xenotransplantation animal model. RESULTS: Culture-expanded human MSCs exhibited a spindle-shaped fibroblastic morphology and were differentiated into adipocytes, osteoblasts, and chondrocytes in specific culture conditions. In xenograft animal model, human ex vivo expanded marrow-derived MSCs were cotransplantated with human CD34+ cells into NOD/SCID mice and demonstrated about a two-fold increase in bone marrow engraftment as determined by human CD45+ and CD34+ expression as compared to transplantation of CD34+ cells alone. Also MSCs resulted in a two-fold to three-fold increase in bone marrow engraftment of CD45+- CD33+ cells and CD45+- CD13+ cells, whereas no such effect were observed in engraftment of CD45+- CD3+ cells and CD45+- CD19+ cells. To determine the homing and engraftment of MSCs, we performed cotransplantation of human CD34+ cells with ex vivo expanded human MSCs that had been retrovirally transduced with GFP transgene into NOD/SCID mice. Expression of GFP was found in the bone marrow of 1 of 5 NOD/SCID mice by DNA-PCR analysis. Using DNA-PCR, we found human beta2-microglobulin expression in liver, spleen, thymus, lung, heart, kidney, and small intestine. CONCLUSION: These results suggest that MSCs are capable of enhancing hematopoietic engraftment and they also may possess therapeutic value for the repair of damaged mesenchymal tissues following hematopoietic stem cell transplantation.

Metastasis to the Thigh Skeletal Muscle from an Adenocarcinoma of the Duodenum / Journal of the Korean Cancer Association, 대한암학회지

Skeletal muscle is one of the most unusual metastatic sites for any malignancy. Duodenal cancer is extremely rare, and no cases of skeletal muscle metastasis from duodenal cancer have been reported. We report here in a case of metastasis to the skeletal muscle of the left thigh from duodenal cancer. Our patient was a 47-year-old man, exhibiting a painful mass in the posterior aspect of his left thigh over a 4 month period. An imaging study, and a biopsy, revealed a duodenal adenocarcinoma metastasize to the skeletal muscle. The patient refused chemotherapy and has followed up for 4 months.

Increased Expression of Fas Antigen and Apoptosis in Aplastic Anemia Bone Marrow Cells

BACKGROUND: Clinical observations and laboratory studies have supported an immune basis for most acquired aplastic anemias, with the majority of patients responding to immunosuppressive therapy. Fas, a member of the tumor necrosis factor (TNF) receptor superfamily is a critical downregulator of cellular immune responses. Proinflammatory cytokines like interferon gamma (IFN-gamma) and TNF-alpha can induce Fas expression and render hematopoietic progenitor cells susceptible to Fas-induced growth suppression and apoptosis. METHODS: In order to investigate the involvement of apoptosis in the pathogenesis of aplastic anemia (AA), we measured the expression of Fas antigen and caspase-3 on bone marrow (BM) mononuclear cells (MNCs) of AA in the presence or absence of IFN-gamma, TNF-alpha, or macrophage inflammatory protein 1-alpha (MIP-1alpha). RESULTS: We confirmed that AA BM MNCs were more apoptotic and highly expressed Fas antigen than normal donors. Stimulation by IFN-gamma, TNF-alpha, or MIP-1alpha increased Fas antigen and caspase-3 expression in AA BM MNCs than BM MNCs of normal donors. Anti-Fas monoclonal antibody enhanced IFN-gamma, TNF-alpha, or MIP-1alpha mediated caspase-3 expression in BM MNCs of normal donors. Among these three cytokines, IFN-gamma enhanced apoptosis most strongly via Fas-caspase-3 pathway. CONCLUSION: These results suggest that Fas signal pathway may play a role in the pathophysiology of aplastic anemia and negative hematopoietic regulators like IFN-gamma can induce apoptosis of bone marrow progenitors in part by Fas induction.

High Dose Chemotherapy and Autologous Peripheral Blood Stem Cell Transplantation for Persistent/Relapsed Ovarian Cancer / Journal of the Korean Cancer Association, 대한암학회지

PURPOSE: High dose chemotherapy (HDC) is increasingly being used for ovarian cancer. Although early studies of autotransplantation for advanced ovarian cancer have been encouraging, most reported series were small, and no randomized trials have been reported. HDC and autologous hematopoietic stem cell transplantation were rarely performed in patients with ovarian cancer in Korea, and no results have been reported with the exception of one case report. MATERIALS AND METHODS: We retrospectively analyzed 10 patients with refractory or relapsed ovarian cancer having received HDC and autologous peripheral blood stem cell transplantation (APBSCT), between January 1996 and September 1998, at the Soon Chun Hyang and Ajou University Hospitals. RESULTS: Ten patients were treated with HDC and APBSCT. Six patients achieved complete response (CR) and 1 a partial response (PR), with a response rate of 70%. Three patients did not respond following mobilization chemotherapy, and failed to respond after HDC. The median duration of progression free survival (PFS) and overall survival (OS) were 6 (4~46) and 13 (3~50+) months, respectively. The median duration of OS of the responders following mobilization chemotherapy was 23 (8~50+) compared with 12 (3~18) months of the non- responders. With regard to the treatment related toxicity, 8 patients had neutropenic fevers, and bacteremia was documented in 4. The non-hematological toxicities were never life threatening, and there were no treatment related deaths. CONCLUSION: HDC, followed by APBSCT, is well-tolerated patients with refractory or relapsed ovarian cancer, and following mobilization chemotherapy the responders survived longer than the non-responders.