Clinicopathological features of pyothorax-associated lymphoma; a retrospective survey involving 98 patients.

To investigate clinicopathological features of pyothorax-associated lymphoma (PAL), we examined medical records of 98 patients (88 males and 10 females) with PAL at a median age of 70 years (range 51-86). Seventy-nine patients had a history of artificial pneumothorax. Median interval between diagnosis and artificial pneumothorax was 43 years (range 19-64). At diagnosis, performance status (PS) was 0-1 (n=56) and 2-4 (n=42). Clinical stages were I (n=42), II (n=26), III (n=8) and IV (n=22). Pathological diagnosis comprised diffuse large-B-cell (n=78) and peripheral T-cell lymphoma (n=1). Seventeen were treated supportively. The other 81 received aggressive treatments; chemotherapy (n=52), radiotherapy (n=7), surgery (n=4) and combination (n=18). Five-year overall survival (OS) was 0.35 (95% confidence interval, 24% to 45%). Causes of deaths were PAL (n=39), respiratory failure (n=13) and others (n=12). Multivariate analysis identified prognostic factors for OS; lactate dehydrogenase levels [hazard ratio (HR)=2.36; P=0.013], sex (female versus male) (HR=0.15; P=0.01), PS (2-4 versus 0-1) (HR=2.20; P=0.02), clinical stages (III/IV versus I/II) (HR=1.95; P=0.037) and chemotherapy (HR=0.31; P=0.01). Most patients with PAL are elderly and have comorbidities, while some of them achieve durable remission with appropriate treatments. These findings prompt us to establish an optimal treatment strategy on the basis of risk stratification of individual patients.

Durable molecular complete remission induced by low-dose imatinib plus low-dose interferon alpha in a patient with chronic myelogenous leukaemia.

A 50-year-old male was diagnosed with chronic myelogenous leukaemia (CML) in chronic phase in March 2000. He was treated initially with hydroxyurea, administered orally. This was changed to interferon alpha (IFN) 5 million units (5 MIU) subcutaneously daily in May 2000; complete cytogenetic response was achieved 11 months later. IFN dosage was reduced to 5 MIU, alternate days, in June 2001 and a cytogenetic relapse occurred 3 months later. Since April 2002, he has received IFN 5 MIU three times weekly in combination with imatinib 200 mg/day. The Philadelphia chromosome disappeared from his peripheral blood cells in July 2002 and a complete molecular response was achieved in January 2003. Serial molecular studies between January 2004 and January 2005 showed no detectable major BCR/ABL chimeric transcript. Grade 2 neutropenia and grade 1 non-haematological adverse effects have been observed. This case report suggests the combination of low-dose imatinib and IFN would be tolerable and effective for CML patients in chronic phase.

Pure red cell aplasia and myelofibrosis in B-cell neoplasm.

We describe an unusual case of B-cell neoplasm accompanied by pure red cell aplasia (PRCA) and myelofibrosis in a 67-year-old male presenting with severe anaemia. A few unclassified, myeloperoxidase-negative blastoid cells were seen on bone marrow aspiration, and erythroid cell hypoplasia and myelofibrosis on bone marrow biopsy. An autoimmune PRCA was suspected, as serum CH50, C3 and C4 levels were consistently low. Ciclosporin was effective in treating the anaemia, but anaemia returned when the drug was discontinued. Thirteen months later, the patient was admitted with pleural effusion and ascites that contained monoclonal CD19+ CD20+ immature blast cells with a complex karyotype, thought to be neoplastic B-cells. The unclassified blastoid cells seen earlier may therefore have been from the same origin. The patient deteriorated rapidly and died. Only one case of non-Hodgkin's lymphoma with PRCA and myelofibrosis has been reported previously. We discuss the possibility that dysregulated T-cells induced by neoplastic B-cells may have given rise to concomitant PRCA and myelofibrosis.

WT1 expression level and clinical factors in multiple myeloma.

Although Wilm's Tuomor gene (WT1) was first identified as a tumor suppressor gene for Wilm's tumor, WT1 overexpression has been detected in different malignant cell types including leukemia. Increased expression of WT1 in acute leukemia is potentially used as a marker of minimal residual disease. However, the significance of the gene for multiple myeloma is still not clear. To determine the clinical relevance of WT1 expression in multiple myeloma, we examined the association of clinical parameters and WT1 expression in bone marrow for 17 newly diagnosed multiple myeloma patients. WT1 was assessed by real-time quantitative polymerase chain reaction (RQ-PCR) and calculated standardized WT1 expression level per 100 plasma cells in the bone marrow specimen as "corrected WT1". The expression of standardized WT1 and corrected WT1 in myeloma was 59 to 1,600 copies/microg RNA and 0.05 to 406.3 copies/microg RNA/100 plasma cells, respectively, lower than in leukemia. WT1 transcripts increased when clinical factors worsen, including the stage, amount of M protein, Hb, platelet count, blood urea nitrogen (BUN), creatinine, serum alkaline phosphatase (ALP), calcium, beta2-microglobulin, thymidine kinase activity (TK), and C-reactive protein (CRP). In conclusion, the expression level of WT1 could be an additional marker to the standard parameters considered in risk assessment for multiple myeloma.

Huge IgD plasmacytoma in the abdomen presenting coagulation necrosis.

A 65-year-old Japanese woman was diagnosed in 1996 with a pathological fracture of the left femur caused by immunoglobulin D-type myeloma (IgD myeloma). She responded well to combination chemotherapy followed by irradiation. The patient experienced renal failure and became dependent on haemodialysis. In 1999, large plasmacytomas developed in the abdomen and left humerus. The abdominal tumour appeared to induce gastroduodenal ulcers and jejunal obstruction. We initiated irradiation therapy without chemotherapy to prevent further growth of the plasmacytoma, although treatment-resistant gastroduodenal ulcers developed. Continued blood loss from the gastroduodenal ulcers resulted in a deterioration in the patient's health, which prevented successful haemodialysis. An autopsy showed that the plasmacytoma had undergone coagulation necrosis. We conclude that the use of combination chemotherapy with topical irradiation was an acceptable treatment measure against IgD plasmacytoma; irradiation without chemotherapy was the most likely cause of the coagulation necrosis seen in the plasmacytoma at autopsy.

Clinical significance of nm23-H1 proteins expressed on cell surface in non-Hodgkin's lymphoma.

The nm23 gene was isolated as a metastasis suppressor gene that exhibits low expression in high-level metastatic cancer cells. Its gene is related to the prognosis of acute myelogenous leukemia (AML) and non-Hodgkin's lymphoma (NHL). In this study, we examined the expression of nm23-H1 protein on the lymphoma cell surface of NHL. In 28 of 108 cases (25.9%), we observed > or = 20% of cell surface nm23-H1 protein expression and expression was especially high in peripheral T cell lymphomas and extranodal NK/T cell lymphomas. We also observed a significant correlation between serum nm23-H1 level and cell surface nm23-H1 expression levels. In patients with high levels of cell surface nm23-H1 expression, overall and progression-free survival rates were significantly lower than those in patients with low surface nm23-H1 expression levels. When surface nm23-H1 and serum nm23-H1 were combined, patients with high levels of both exhibited a poorer prognosis than patients with a high level of one or the other. These results indicate that in addition to serum nm23-H1, cell surface nm23-H1 may be used as a prognostic factor in planning a treatment strategy. The nm23-H1 protein appears to be intimately related to biological aggressiveness of lymphoma and, therefore, might be a molecular target of NHL treatment.

Application of hypothermia to autologous stem cell purging.

Autologous stem cell transplantation is used widely after high-dose chemotherapy for treating hematological and other malignancies. Bone marrow harvested for autologous bone marrow transplantation may contain residual malignant cells even when the cancer is judged to be in remission. Attempts to purge marrow of its putative residual malignant cells may delay hemopoietic reconstitution and are of uncertain efficacy. In this report, we demonstrate the possibility of applying hypothermia to autologous stem cell purging. Using clonogenic assay, we compared the surviving fraction of human leukemia (HL60, K562) and human small cell lung cancer (H69) cell lines with that of normal human bone marrow CFU-GM and BFU-E cells after incubation at 4 +/- 0.1 degrees C for 24 and 48 h. Hypothermia decreased the surviving fraction of HL60, H69, and K562 cells. In contrast, the surviving fractions of stem cells were not affected by the temperature shift. The surviving fraction of HL60 cells at 4 degrees C cooling was significantly lower than that at 22 degrees C cooling. These findings suggest that in vitro hypothermia may selectively purge residual malignant cells in stored remission bone marrow and may be applicable before autologous bone marrow transplantation. In addition, the method is very simple and cost effective.

[Severe thrombocytopenia induced by radiographic non-ionic contrast medium].

A 70-year-old man was admitted to our hospital because of right hemiparesis. He had no allergies or previous exposure to radiographic contrast medium, and the platelet count on admission was within the normal range. On day 8 of hospitalization, he underwent computed tomography of the brain with 100 ml of iopamidol administered intravenously. Three hours later, his platelet count fell to 5,000/microliter, and he developed purpura. Because drug-induced thrombocytopenia was suspected, platelet transfusion was undertaken and corticosteroids were administered. The platelet count returned gradually to normal in 2 days. At the time, we were unable to ascertain the cause of the thrombocytopenia. To clarify whether the contrast medium had been responsible, iopamidol was added to the patient's heparinized whole blood. Subsequent platelet aggregation was observed microscopically and the platelet count decreased, suggesting that the thrombocytopenia had been due to contrast medium-induced platelet aggregation. Although thrombocytopenia after injection of contrast medium is extremely rare, such cases should be evaluated carefully because the condition can be life-threatening if severe.

Detection of reciprocal fusion 5'-BCL6/partner-3' transcripts in lymphomas exhibiting reciprocal BCL6 translocations.

It has been believed that replacement of the endogenous promoter and the non-coding first exon of the BCL6 gene by a sequence derived from the translocational partner gene is a main mechanism of the BCL6 dysregulation resulting from translocation. In this study, we found that reciprocal BCL6 translocation led to the expression of not only the 5'-partner/BCL6-3' fusion transcripts but also the 5'-BCL6/partner-3' fusion transcripts, suggesting that reciprocal 5'-BCL6/partner-3' fusion genes are transcriptionally active. These findings raise the possibility that reciprocal BCL-6 translocation may lead to dysregulation of the partner gene as well as the BCL6 gene.

[Development of Sweet's syndrome during all-trans retinoic acid therapy for acute promyelocytic leukemia].

A 54-year-old woman visited our hospital because of gingival bleeding on May 31, 1998. After hematological and bone marrow examinations, she was diagnosed as having acute promyelocytic leukemia (APL) and given all-trans retinoic acid (ATRA) therapy starting on June 1. Anti-cancer drugs were administered for 5 days from June 12 because of an increase in the number of APL cells. The patient developed fever on June 20, and nodular erythematous eruptions appeared on June 23. Sweet's syndrome was diagnosed from biopsy samples of the eruption. ATRA was therefore discontinued, and prednisolone was started on June 29. The fever and skin eruptions improved rapidly, and complete remission was obtained on July 13. Sweet's syndrome due to ATRA may be a partial form of retinoic acid syndrome, in which the differentiated leukemic neutrophils increase and invade various organs. However, Sweet's syndrome must be considered regardless of the WBC count because in this case the syndrome occurred even when the WBC count was not high.

[Evaluation of hematopoiesis by granulocyte elastase after hematopoietic stem cell transplantation].

To evaluate hematopoietic restoration after hematopoietic stem cell transplantation (HSCT), we sequentially monitored the post-HSCT level of granulocyte elastase (GE), a sensitive parameter of qualitative and quantitative changes in granulopoiesis. We compared it with routinely used hematopoietic recovery indices, such as leukocyte and reticulocyte count. We also compared levels of GE in the clinical administration of different colony stimulating factors (granulocyte-colony stimulating factor (G-CSF) versus macrophage-colony stimulating factor (M-CSF) and in different types of hematopoietic stem cell transplantation (allogeneic bone marrow transplantation (BMT) versus autologus peripheral blood stem cell transplantation (PBSCT)). Days to first increase of GE after HSCT were 3.0 and 2.3 days earlier than increase of leukocytes in allo-BMT and auto-PBSCT, respectively. Recovery of highly fluorescent reticulocytes and monocytes were later than recovery of GE. These results indicated that granulopoiesis after transplantation started before the increase in peripheral leucocyte count, and that GE was the earliest indicator of hematopoietic recovery. On the basis of GE level, M-CSF had the same stimulating effect on granulopoiesis as G-CSF. The nadir of GE in PBSCT was significantly higher than that in BMT, indicating continuous granulopoiesis in PBSCT. From these results, we concluded that measurements of GE can be used for the clinical evaluation of myelosuppression by different conditioning regimens as well as of granulopoiesis induced by various cytokines.

Glomerular and extraglomerular immune complex deposits in a bone marrow transplant recipient.

A 44-year-old man developed nephrotic syndrome 9 months after HLA-identical sibling bone marrow transplantation. Membranous changes consisted mainly of alterations of glomeruli, which were interpreted as chronic graft-versus-host disease (GVHD) caused by lodging of the circulating immune complex. In the tubules, a lumpy deposition of IgG and complement breakdown products was distributed along the tubular basement membrane, which coincided with the peculiar deposits ascertained by electron microscopy. These findings suggest that an extraglomerular reaction should be considered in evaluating renal involvement of GVHD.

[Plasma cell leukemia presenting with circulating villous lymphocytes and an indolent clinical course].

A 73-year-old man was admitted to our hospital in July 1996 because of lymphoctyosis and lumbago. Physical examination revealed hepatomegaly and anemia. Hematologic examination showed a hemoglobin concentration of 9.6 g/dl and a leukocyte count of 32,700/microliter with 74% abnormal mononuclear cells. In Wright-Giemsa stained blood films, these cells had short villi arising from 1 or 2 poles. Immunophenotyping of peripheral mononuclear cells showed moderate to strong expression of CD10, CD24, CD38, and sIg lambda, but not of CD19, CD20, or CD25. Southern blot analysis of the peripheral mononuclear cells demonstrated rearranged monoclonal bands in the C lambda. Urine immunoelectrophoresis detected a monoclonal band identifiable as lambda-type Bence Jones protein. In addition, bone X-ray studies disclosed multiple osteolytic lesions. A diagnosis of plasma cell leukemia was made, and the patient was placed on chemotherapy consisting of cyclophosphamide and prednisolone. No notable improvement in laboratory findings was seen but the patient experienced an indolent clinical course. He died of pneumonia in January 1998. The morphological and clinical findings were unusual for a case of plasma cell leukemia. This case study suggested that signs of lymphocytosis require immunophenotypic and electron microscopic studies for the differential diagnosis of plasma cell leukemia.

[Analysis of pulmonary function in leukemia patients after bone marrow transplantation: effects of prior chemotherapy].

To evaluate the effects of prior chemotherapy on pulmonary function after bone marrow transplantation(BMT), pulmonary function tests were performed prior to and after BMT on 7 acute leukemia (AL) and 13 chronic myelogenous leukemia (CML) patients given with CY (60 mg/kg x 2 days), total body irradiation (3 Gy x 4 days, 10 cGy/min), and CyA plus short-term MTX. No patient had graft-versus-host disease or lung complications. Pulmonary function after BMT did not deteriorate in the AL patients; however, both %Vital Capacity(%VC) and DL/VA decreased significantly in the CML patients (%VC before BMT: 112.1 +/- 11.5%, after BMT: 93.7 +/- 9.4%; DL/VA before BMT: 79.2 +/- 14.6%, after BMT: 54.1 +/- 10.6%). Although prior regimens of busulfan (BU) or interferon (IFN) were equal risk factors for decreased %VC after BMT, decreases in DV/VA were more significant in CML patients who received IFN. CML patients, especially those who have received BU or IFN, should be carefully monitored for pulmonary function to prevent respiratory failure after BMT.

Non-ionic detergent Tween 80 modulates VP-16 resistance in classical multidrug resistant K562 cells via enhancement of VP-16 influx.

The non-ionic detergent Tween 80, which is used as a solvent for lipophilic drugs such as VP-16 and Taxotere, was found to reverse VP-16 resistance of the P-glycoprotein-associated multidrug resistance phenotype via increasing VP-16 influx. In adriamycin-resistant human chronic myelogenous leukemia K562 cells (K562/ADM), which overexpress mdr1 mRNA, the accumulation of VP-16 was only about 10% that in wild-type K562 cells. Tween 80 enhanced VP-16 accumulation in K562/ADM cells but did not influence VP-16 accumulation in parental K562 cells. VP-16 efflux was rapid and similar in both sensitive and resistant cell lines and was not blocked by Tween 80 or verapamil. Under glucose-free conditions, VP-16 accumulation in K562/ADM cells was only half of that in K562 cells. Tween 80 increased VP-16 accumulation in K562/ADM cells in glucose-free medium. In growth inhibition assay, Tween 80 reversed K562/ADM sensitivity to VP-16 without cell damage. Taken together, Tween 80 reverses VP-16 sensitivity in multidrug-resistant K562 cells by increasing influx, which is considered to be the primary mechanism of VP-16 resistance in K562/ADM cells.

[Phenotypic classification of malignant lymphoma].

The phenotypic characters of the lymphoma cell are important in the diagnosis of this disease. We recently tested whether the flow cytometry with fresh biopsy sample might be useful in the diagnosis of the lymphoma. In our date, 1. a rise and fall of the surface immunoglobulin kappa/lambda ratio indicated the monoclonal proliferation of the B-cell, 2. the increased proportion of the CD5/CD23 double positive cells indicated B-cell chronic lymphocytic leukemia or small lymphocytic lymphoma, 3. the decreased proportion of the CD2 positive cells and the increased proportion of the CD19 positive cells indicated B-cell lymphoma. These findings suggest that the flow cytometry is of adjunctive importance in making a diagnosis of the lymphoma.

[Treatment of intermediate and high grade non-Hodgkin's lymphoma].

Since the study by SWOG in 1993, CHOP regimen has been the standard therapy for patients with advanced stage intermediate-grade or high-grade non-Hodgkin's lymphoma. Three-year estimated survival for all patients was about 50%. However, five-year disease free survival of the patients with high or high-intermediate risk by age-adjusted international prognostic index(IPI) is less than 30%. For the patients with low and low-intermediate IPI, high cure rate can be achieved by CHOP, or modified CHOP therapy. For the patients in high or high-intermediate risk groups, the CHOP regimen is not satisfactory. High-dose chemotherapy with haematopoietic stem cell rescue has been tried for those patients. We are conducting pilot study of high-dose chemotherapy with peripheral blood stem cell transplant(PBSCT) following induction with double CHOP regimen. Although the results are encouraging, confirmation with randomized prospective trials are necessary.

A case of anaplastic large cell (Ki-1) lymphoma of B-cell phenotype, occurring in Waldenström's macroglobulinemia.

A case of anaplastic large cell (Ki-1) lymphoma of B-cell lineage occurred in a 59-year-old male with Waldenström's macroglobulinemia. Immunostaining of the lymphoma cells showed sporadic positivity for IgM and occasional positivity for kappa chain. This immunoglobulin specificity is the same as that of plasmacytoid lymphocytes in the bone marrow; therefore anaplastic transformation of Waldenström's macroglobulinemia was strongly suggested. This seems to be the first reported case of anaplastic large cell lymphoma, confirmed by CD30 expression, arising in Waldenström's macroglobulinemia.