Fatal necrotizing stomatitis due to Trichoderma longibrachiatum in a neutropenic patient with malignant lymphoma: a case report.

Primary invasive mold infection of the oral cavity is a rare but serious complication in immunocompromised hosts. We report a case of fatal Trichoderma longibrachiatum stomatitis in a 66-year-old female patient with malignant lymphoma. The infection rapidly disseminated from the oral mucosa to the lungs during neutropenia. Despite intensive antifungal therapy with amphotericin B and itraconazole, there was a fatal progression of the condition. While Trichoderma species have been recognized to be pathogenic in profoundly immunosuppressed hosts, this is the first report of the primary oral focus causing a fatal infection.

[Evaluation of non-surgical therapy for the malignant lymphomas located mainly in the stomach and duodenum].

We evaluated the effects of the conservative treatment to 29 patients with non-Hodgkin lymphomas located mainly in stomach and duodenum. We could induce complete remission in all the cases of stage I, II, and III including MALT lymphomas by the combination therapy of Helicobacter pylori (H. pylori) eradication, chemotherapy, and radiation, and the complete remission persisted in all except for the three cases who died of other causes. Even in stage IV lymphomas mainly located in stomach and duodenum, we could induce complete remission in 50% of them. Considering the quality of life of patients with lymphomas located mainly in stomach and duodenum, the conservative treatment may be of benefit more than the surgical approach.

Restricted chromosome breakpoint sites on 11q22-q23.1 and 11q25 in various hematological malignancies without MLL/ALL-1 gene rearrangement.

We analyzed 32 patients with various hematological malignancies including acute myelocytic leukemia and non-Hodgkin lymphoma with a breakpoint at 11q22-q25 of chromosome 11, but who did not have rearrangements of the MLL/ALL-1 gene. The breakpoint in each patient was identified by fluorescence in situ hybridization using 21 cosmid probes and 2 YAC probes. Breakpoints for each "rearrangement" involving translocations such as t(1;11), t(2;11), inv(11), t(11;15), and t(10;11) found in 5 of the 11 patients had breakpoints in a small region from Ccl11-430 to Ccl11-526 at 11q22-q23.1. Furthermore, breakpoints for chromosome deletions at 11q21-q23 in 10 patients were located in the same region as that of translocations. A commonly deleted region among 8 patients was identified from Ccl11-526 to Ccl11-555 at 11q23.1. Fluorescence in situ hybridization analysis revealed that breakpoints for additive chromosome [add(11)] aberrations, which had additional material of unknown origin at 11q23 to 11q25 in 11 patients, were not located at 11q23 but rather at the more telomeric site of Ccl11-503 to VIJ(2)2072 at 11q25. These results indicated that the patients had several restricted breakpoint sites, which means that these chromosomal regions have recurrent oncogenes and tumor suppressor genes for pathogenesis for leukemia and lymphoma.

[Hematopoietic stem cell transplantation for malignant lymphoma].

The clinical results and indications for hematopoietic stem cell transplantation (HSCT) including malignant lymphoma(ML) will be reviewed in this paper. In aggressive non-Hodgkin's lymphoma, patients with chemosensitive relapses and induction failures are appropriate candidates for HSCT. Purged HSCT may improve outcome of patients with relapses in follicular lymphoma and mantle cell lymphoma. High dose therapy with HSCT is proposed as a potentially curative treatment for ML that is not curable with conventional chemotherapy such as induction failure, relapse, poor-risk and indolent lymphoma.

Interphase fluorescence in situ hybridization overcomes pitfalls of G-banding analysis with special reference to underestimation of chromosomal aberration rates.

Fluorescence in situ hybridization (FISH) is suitable for detecting different types of chromosome aberrations on interphase nuclei even in specimens with no or few chromosome metaphases. However, it is not known why FISH is superior to conventional G-banding analysis. The sensitivity of interphase FISH was compared to that of G-banding analysis in 288 leukemia/lymphoma patients for 10 different types of chromosome aberrations: t(9;22) (M- and m-BCR), t(8;21), 11q23 abnormalities, t(15;17), del(5)/-5, del(13)/-13, +8, -7, and +12. The results revealed that t(15;17) positive cells could not proliferate well in culture, leading to underestimation of abnormality by G-banding. Monosomy 7 in acute myelocytic leukemia (AML) and myelodysplastic syndrome (MDS) as well as trisomy 12 and deletion chromosome 13 in chronic lymphocytic leukemias (CLL) were also severely underestimated by G-banding. On the other hand, no discrepancies were observed in t(8;21), t(9;22), translations involving 11q23, or in trisomy 8. These findings indicate the superiority of interphase FISH over conventional cytogenetics for detecting chromosome abnormalities in small clones, especially for monosomy 7 or (15;17) translocations.

Frequent allelic loss of the RB, D13S319 and D13S25 locus in myeloid malignancies with deletion/translocation at 13q14 of chromosome 13, but not in lymphoid malignancies.

In order to identify a commonly deleted region of 13q14 on chromosome 13, we performed fluorescence in situ hybridization (FISH) on 17 patients with myeloid malignancies and 12 patients with lymphoid leukemia/lymphoma who exhibited either deletion or translocation at 13q14. Three cosmid probes (RB, D13S319 and D13S25) hybridizing to sequences on 13q14 were used. Fourteen of the 17 patients with myeloid malignancies (82.4%) exhibited allelic loss at the RB, D13S319 and D13S25 locus, whereas only three of the 12 patients with lymphoid malignancies (25.0%) exhibited loss within these loci. These three patients had chronic lymphocytic leukemia (CLL). Six, two and one of the remaining nine lymphoid leukemia/lymphoma patients had breakpoints centromeric to the RB gene, telomeric to D13S25 and within the D13S319 locus, respectively. A high frequency of allelic loss was found using these probes in patients with myeloid malignancies, compared to in patients with leukemia in the lymphoid origin, except CLL patients. These results indicate that loss of the RB gene itself or a region between RB and D13S319, which includes commonly deleted loci, may play an important role in myeloid leukemogenesis.

MPC-1-CD49e- immature myeloma cells include CD45+ subpopulations that can proliferate in response to IL-6 in human myelomas.

Using three-colour phenotypic analysis, we detected five subpopulations of myeloma cells (CD38++) in the bone marrow mononuclear cells of human myeloma patients: MPC-1-CD45-CD49e-, MPC-1-CD45+CD49e-, MPC-1+CD45-CD49e-, MPC-1+CD45+CD49e- and MPC-1+CD45+CD49e+. Most of the myeloma cells did not express CD45 but a few MPC-1- immature myeloma cells and some MPC-1+ myeloma cells expressed CD45 and CD45RO but not CD45RA, whereas all of normal early plasma cells in the peripheral blood, lymph node plasma cells and bone marrow plasma cells expressed CD45 and CD45RA, CD45RB but not CD45RO. In order to clarify the biological character of these myeloma subpopulations, we examined the expression of Ki-67 antigen. Proliferating myeloma cells (Ki-67+) were found in the MPC-1- fractions and the MPC-1-CD45+ fractions rather than MPC-1-CD45- fractions. Next, in order to further clarify the biological difference of two immature subpopulations (MPC-1-CD45-CD49e- and MPC-1- CD45+CD49e-), determined cell viability and phenotypic change after culturing with interleukin 6 (IL-6) in vitro. In the presence of IL-6, MPC-1-CD45+ cells kept their viability more than MPC-1-CD45- cells and some MPC-1-CD45- cells could be converted to MPC-1-CD45+ cells. In conclusion, these data suggest that human myeloma cells are phenotypically subdivided into five subpopulations, and among these subpopulations MPC-1-CD45+CD49e- but not MPC-1-CD45-CD49e- immature cells contain proliferating cells in response to IL-6, and IL-6 can also induce expression of CD45 on MPC-1-CD45- subpopulation of immature myeloma cells.

Protein expression of cell cycle regulator, p27Kip1, correlates with histopathological grade of non-Hodgkin's lymphoma.

The protein p27Kip1 is one of the cyclin-dependent kinase inhibitors that are known to play important roles in the regulation of cell-cycle progression. Low levels of p27 expression in malignant cells are associated with poor prognosis in patients with breast, lung, colorectal and gastric cancers. To determine the relation of cyclin-dependent kinase inhibitors to histopathological grades of B-cell non-Hodgkin's lymphomas, the expression of p27, cyclin D1 and cyclin E in lymph node tissues was investigated in 56 patients with B-cell non-Hodgkin's lymphomas by western blotting and immunohistochemical techniques. High levels of p27 expression were observed in most lymph node tissue samples (93%) obtained from patients with low grade B-cell non-Hodgkin's lymphomas, while expression was low in lymph node tissue taken from all patients with intermediate and high grade B-cell non-Hodgkin's lymphomas. The difference in p27 expression in lymphoma tissues was significant among the different histopathological grades of B-cell non-Hodgkin's lymphomas (P<0.01). The analysis of the survival time of patients showed that the reduction of p27 expression correlated with poor prognosis. Cyclin D1, showed a high level of expression in mantle cell lymphomas and high grade B-cell non-Hodgkin's lymphomas. Cyclin E showed limited expression in 18 of 31 lymphoma tissues. Both cyclin D1 and E protein expression were not significantly different among the grades of B-cell non-Hodgkin's lymphomas. These results demonstrate that the level of p27 expression in lymphoma tissue is an important parameter in the classification of B-cell non-Hodgkin's lymphomas and in the prediction of prognosis.

Expressions of p53 and PCNA do not correlate with the international index or early response to chemotherapy in non-Hodgkin's lymphoma.

The expression of p53 and PCNA on deparaffinized sections of tumor was assessed in relation to the International Index and response to chemotherapy. Thirty-five non-Hodgkin's lymphoma (NHL) patients were divided into three groups: aggressive NHL, mantle cell lymphoma (MCL), and low-grade NHL. None of the expressions correlated with the International Index or early response to chemotherapy in any group. In low-grade NHL, none of the patients expressed p53. Only one of three patients with overexpression of p53 showed conformational change and alteration of sequence in exon 7 by PCR-SSCP and DNA sequencing. The results showed that p53 and PCNA staining were not useful for predicting early response to chemotherapy, and that their expressions had no correlation with the International Index.

A specific chromosome abnormality of t(4;12)(q11-12;p13) in CD7+ acute leukaemia.

Three cases of acute leukaemia with t(4;12) (q11-12;p13) karyotypic abnormalities were analysed. They had the following common clinical and biological characteristics: (1) dysplasia of three haemopoietic lineages: (2) absent or low myeloperoxidase activity: and (3) retention of platelets in the peripheral blood and megakaryocytes in the bone marrow. There were increased numbers of basophils in the bone marrow and peripheral blood in two of the cases. In all, the blast cells displayed the unique immunophenotype CD7+CD13+CD34+HLA-DR+. The blasts analysed in one case expressed c-kit on the membrane surface. These findings suggest that the t(4;12) (q11-12;p13) abnormality is associated with a particular type of acute leukaemia, one in which the morphology and immunophenotype suggest that the translocation may have occurred at an early stage of haemopoiesis.

Emergence of karyotypically unrelated clone in remission of de novo acute myeloblastic leukaemias.

Serial cytogenetic analysis revealed karyotypically unrelated clones in four patients with acute myeloblastic leukaemia (AML) in remission. At diagnosis, three patients had t(8;21)(q22;q22) and one had an inv(16)(p13q22). After 18-22 months in remission, different clones emerged in each patient with myelodysplastic features of the bone marrow cells. The emergence of clones with abnormalities of chromosome 7 in remission seems to be an unfavourable factor for prognosis.

Phenotypic difference of normal plasma cells from mature myeloma cells.

We have recently shown that two-color analysis with fluorescein isothiocyanate (FITC)-anti-CD38 antibody could clearly distinguish myeloma cells (plasma cells) from other hematopoietic cells in the bone marrow. Myeloma cells (plasma cells) alone were located at CD38strong positive (++) fractions. To further distinguish normal plasma cells from mature myeloma cells phenotypically, we examined immunophenotypes of normal plasma cells and myeloma cells by two-color flow cytometry with FITC-anti-CD38 antibody and phycoerythrin staining with antibody to VLA-4, MPC-1, CD44, CD56, CD19, CD20, CD24, or CD10. Normal plasma cells were all VLA-4+VLA-5+MPC-1+CD44+ CD19+CD56- in the bone marrows from seven healthy donors, tonsils from four patients with chronic tonsillitis, a spleen from one patient with idiopathic thrombocytopenic purpura, and lymph nodes from two patients with chronic lymphadenitis, respectively. On the other hand, mature myeloma cells (12 of 20 cases), VLA-4+VLA-5+MPC-1+, were all CD19- and most of them CD56+, and there were no myeloma cells with the CD19+CD56- phenotype in the 20 cases of myelomas we tested. Thus, as for the expression of CD19 and CD56, normal plasma cells from various tissues are all CD19+CD56-, whereas no myeloma cells have the CD19+CD56- phenotype. According to this finding, we investigated the expression of CD19 and CD56 on plasma cells (CD38++ fractions) in monoclonal gammopathy of undetermined significance (MGUS). Both CD19+CD56- and CD19-DC56+ plasma cells were found in all five cases of MGUS we tested, suggesting that MGUS consists of phenotypically normal plasma cells and myeloma cells. Therefore, it is reasoned that phenotypic analysis of plasma cells with anti-CD19 and anti-CD56 antibodies can distinguish normal plasma cells from malignant plasma cells (myeloma cells), and can detect malignant plasma cells even in MGUS or premyeloma states.

Expressions of DNA topoisomerase I and II gene and the genes possibly related to drug resistance in human myeloma cells.

In order to clarify the mechanism of drug resistance in human myeloma cells, we investigated the expressions of DNA topoisomerase I and topoisomerase II gene and the genes possibly related to drug resistance; multi-drug resistant gene 1 (MDR-1), glutathione S-transferase class pi gene (GST-pi), by Northern blotting. Myeloma cells in eight of 15 cases prior to chemotherapy expressed topoisomerase I mRNA considerably, while the expression of topoisomerase II mRNA was detected weakly in only one of 16 myeloma patients. There was not any correlation between expression of topoisomerase I mRNA and clinical drug resistance. Significant expression of MDR-1 mRNA and P-glycoprotein was not detected in 25 cases of multiple myeloma prior to chemotherapy and even after several courses of VAD (vincristine, adriamycin and dexamethasone) therapy by Northern blotting and immunostaining using monoclonal anti-P-glycoprotein antibody (MRK-16), respectively. On the other hand, 16 of 21 myeloma cases showed significant expression of GST-pi protein and GST-pi mRNA with the various strengths, but there was no apparent correlation between GST-pi mRNA expression and clinical response. Therefore these data suggest that expression of the genes we tested may not determine the level of drug resistance in multiple myeloma, but lower or no significant expression of topoisomerase II mRNA in most myeloma cells indicates the possibility that topoisomerase II inhibitors such as VP-16 and topoisomerase II-mediated cytotoxic drugs such as adriamycin, are not so effective for the treatment of multiple myeloma.

A high frequency of N-RAS oncogene mutations in multiple myeloma.

Mutation of the RAS oncogene was studied in ten patients with multiple myeloma, and the DNA from nude mouse tumors formed by cells obtained from tumorigenecity assays (in vivo selection assays) in these patients was analyzed by PCR and oligonucleotide hybridization. Mutations of the N-RAS oncogene were identified in two of three patients investigated by in vivo selection assay and in five of ten patients investigated by PCR analysis of DNA from myeloma cells. In the two former patients, mutation of the N-RAS oncogene was observed at the 61st codon. Of the five N-RAS mutant-positive patients investigated by the PCR analysis, one had a mutation at codon 12, two had mutations at codon 13, and two had mutations at codon 61. None of the patients had mutations of the K-RAS oncogene. These results suggest that the frequency of RAS gene mutation in multiple myeloma is higher than in other lymphoid malignancies such as acute lymphocytic leukemia, chronic lymphocytic leukemia, and malignant lymphoma. As the mutation was observed only at the N-RAS oncogene level, it is speculated that N-RAS oncogene activation might play an important role in the progression of multiple myeloma.

[Study on the therapy of multiple myelomas--initial induction therapy (MP, IFN alpha, steroid pulse) and maintenance therapy (VMP, MP continuous, VEP, MCNU)].

Untreated twenty patients of multiple myeloma were treated with the chemotherapy protocol as follows: Initial induction therapy;MP continuous or MP intermittent----IFN alpha----steroid pulse. Maintenance therapy;alkylating agents which have no cross resistance were used ((V) MP----(MP)----(V) EP----MCNU). Remission rate (CR+PR) after the initial MP therapy was 45%, and that after including IFN alpha and steroid pulse therapy was 50%, Fifty percent survival rate was almost as same as those reported previously (34M). Our protocol presented here was based on the idea that, initially, myeloma cells with proliferative activity could be affected by MP therapy, and subsequent IFN alpha therapy would have effect even on the residual myeloma cells. Serial checks of 3H-TdR uptake of myeloma cells during the therapy supported this idea. During the maintenance therapy, clinical responses to the initial induction therapy were not aggravated in the responded cases when evaluated by the variation of serum M-protein level. We propose that considering from a point of proliferative activity of myeloma cells is important for designing therapeutic protocols for multiple myeloma.

Cytogenetic, molecular biological and clinical study of B-cell lymphomas with 14;18 translocation in Japanese patients.

To investigate the role of the BCL-2 gene in Japanese patients with B-cell non-Hodgkin's lymphoma, karyotypic analysis, DNA analysis and clinical characterization were studied. Ten of 73 patients showed t(14;18) and two patients had variant translocations [t(2;18) and t(18;22), respectively]. Of 42 patients examined at the molecular level, eight patients showed the BCL-2 gene rearrangement detected by mbr probe and two patients by 5'BCL-2 probe. Of the eight patients with the BCL-2 gene rearrangement by the mbr probe, t(14;18) was detected in six patients. A discrepancy in the relationship between the occurrence of t(14;18) and BCL-2 gene rearrangement was recognized. Two patients with obvious t(14;18) showed no rearrangement of the BCL-2 gene by mbr, mcr, nor 5' probe. Cytogenetic analysis is an indispensable tool for investigating lymphomogenesis. The two patients with the variant translocations, t(2;18) and t(18;22), showed breakpoints at the 5' site of the BCL-2 gene and both were histologically of the small lymphocytic type. No examples with the co-existence of both the BCL-2 and c-MYC gene rearrangements were found. The median survival time of the patients with the BCL-2 rearrangement and/or t(14;18) was longer than the patients without the BCL-2 gene rearrangement and translocation and also patients with the c-MYC gene rearrangement and/or translocation. Racial and geographical heterogeneities, variant translocations of t(14;18) and the clinical characteristics of B-cell non-Hodgkin's lymphoma with t(14;18) are discussed.

[A clinical study on intrathoracic malignant lymphoma with chronic tuberculous pyothorax].

The authors reported 3 male patients of malignant lymphoma developing from long-standing pyothorax. They had been suffering from tuberculous pyothorax for more than 30 years, after artificial pneumothorax therapy for pulmonary tuberculosis. The most common symptom was chest pain. It was difficult to detect the tumor mass by chest X-ray because of old inflammatory changes. Computed tomography and 67Ga scintigraphy were useful. The lesions tended to grow destroying the surrounding lung, chest wall and ribs. Histologically, 2 cases were diffuse large cell type and one was diffuse intermediate sized cell type. Immunologically, 2 cases were B-cell type lymphoma but one was not clearly classified. They received radiotherapy, but 2 cases died of respiratory failure. These findings suggest that B cell lymphoma might arise following chronic tuberculous pyothorax. Therefore such cases should be followed up carefully.