Bungo Saito

Impact of T Cell Chimerism on Clinical Outcome in 117 Patients Who Underwent Allogeneic Stem Cell Transplantation with a Busulfan-Containing Reduced-Intensity Conditioning Regimen

Within the concept of reduced-intensity stem cell transplantation (RIST) there is a wide range of different regimens used, and little information is available on the clinical impact of chimerism status in patients conditioned with a busulfan-containing regimen. Therefore, we retrospectively reviewed lineage-specific chimerism and the subsequent clinical outcome in 117 patients (median age, 55 years; range: 29-68) who underwent busulfan-containing RIST. The conditioning regimen consisted of busulfan (oral 8 mg/kg or i.v. 6.4 mg/kg) and fludarabine (180 mg/m(2), n = 64) or cladribine (0.66 mg/kg, n = 53), with or without 2-4 Gy total-body irridiation (TBI) (n = 26) or antihuman T-lymphocyte immunoglobulin (ATG; 5-10 mg/kg; n = 31). Chimerism was evaluated with peripheral blood samples taken on days 30, 60, and 90 after transplantation by polymerase chain reaction (PCR)-based amplification of polymorphic short tandem repeat regions. The median follow-up of surviving patients was 1039 days (153-2535). The percent donor-chimerism was significantly higher in granulocyte than T cell fraction throughout the entire course, and the median (mean) values were, respectively, 100% (96%) versus 95% (83%), 100% (98%) versus 100% (89%), and 100% (98%) versus 100% (91%) at days 30, 60, and 90 after RIST. In a multivariate analysis, having received <2 types of chemotherapy regimens before RIST was the only factor that was significantly associated with low donor T cell chimerism (<60%) at day 30 (hazard ratio [HR]: 6.1; 95% confidence interval [CI], 2.1-18.4; P < .01). The median percentage of donor T cell chimerism at day 30 was 9% (0%-63%) in 5 patients who experienced graft failure, which was significantly lower than that (97%; 15%-100%) in the rest of the patients (P < .01). No correlation was found between the kinetics of T cell chimerism and the occurrence of acute or chronic GVHD (aGVHD, cGVHD). The stem cell source and the addition of TBI or ATG were not associated with the degree of T cell chimerism, overall survival (OS) or event-free survival (EFS). In a Cox proportional hazard model, low donor T cell chimerism of <60% at day 30 was associated with both poor OS (HR: 2.2; 95% CI, 1.1-4.5; P = .02) and EFS (HR: 2.0; 95% CI, 1.1-3.8; P = .02). In conclusion, we found that 43% of the patients retained mixed donor T cell chimerism (<90% donor) at day 30, whereas 92% achieved complete chimerism in granulocyte fraction. Low donor T cell chimerism of <60% at day 30 may predict a poor outcome, and a prospective study to examine the value of early intervention based on chimerism data is warranted.

Intensive glucose control after allogeneic hematopoietic stem cell transplantation: a retrospective matched-cohort study

Some studies have shown that intensive glucose control (IGC) improves outcome in the intensive care unit setting. However, it is the benefit of IGC in hematopoietic SCT (HSCT) that is not well defined. Between June 2006 and May 2007, IGC was maintained prospectively after allogeneic HSCT and clinical outcomes were compared with a cohort matched for conditioning regimen, source of stem cells, age and relation to donor. A stratified Cox regression model was used. There were no significant differences in baseline clinical characteristics. The median age was 43.5 years in both groups. The primary diagnosis was a hematologic malignancy. Patients in the IGC group had a lower glucose level (least-square mean, 116.4 vs 146.8 mg per 100 ml, P<0.001) compared to the standard glucose control group. The incidences of documented infections and bacteremia were significantly lower in the IGC group (14 vs 46%, P=0.004, 9 vs 39%, P=0.002, respectively). IGC tended to reduce the incidence of renal dysfunction (19 vs 37%, P=0.36) and the elevation of C-reactive protein (18 vs 38%, P=0.13). This study suggests that IGC has may have a beneficial effect after HSCT. IGC should be evaluated further in a large prospective, randomized study.

Acute Respiratory Distress Syndrome during the Third Infusion of Rituximab in a Patient with Follicular Lymphoma

We present the case of a 66-year-old man with follicular lymphoma who developed acute respiratory distress syndrome (ARDS) during a third infusion of rituximab. High fever, tachypnea, and progressive hypoxemia accompanied by massive bilateral pleural effusions appeared suddenly approximately 3 hours after the third infusion was started, although the 2 prior infusions of rituximab had produced only mild adverse effects. The patient was treated successfully with high-dose methylprednisolone and 3 days of mechanical ventilatory support. No evidence was obtained to indicate that the ARDS had been caused by either cytokine release or tumor lysis, and serum human antichimeric antibody was not detected.Although the cause of ARDS was not confirmed, our experience in this case suggested that an anaphylactic reaction induced by repeated infusion of rituximab was involved in the onset of pulmonary disease. Although ARDS is rarely seen with rituximab infusion, careful management is required for safe administration of the newly developed rituximab therapy. This management includes monitoring biological reactions not only during the initial infusion but also during subsequent infusions of the antibody.

Elevated levels of transferrin receptor 2 mRNA, not transferrin receptor 1 mRNA, are associated with increased survival in acute myeloid leukaemia

Transferrin receptor 1 (TfR1) is a type II membrane protein that mediates cellular iron uptake. Transferrin receptor 2(TfR2), another receptor for transferrin (Tf), has recently been cloned. We examined expression levels of TfR1, TfR2‐α (membrane form) and TfR2‐β (non‐membrane form) transcripts in cells from 67 patients with de novo acute myeloid leukaemia (AML) using reverse transcription‐polymerase chain reaction (RT‐PCR), and correlated the results with a variety of clinical features and disease outcomes of these patients. Significant correlations were noted between the levels of both TfR1 and TfR2‐α (r = 0·771, P < 0·001) and TfR1 and TfR2‐β (r = 0·534, P < 0·001). Unexpectedly, initial white blood cell (WBC) counts were inversely correlated with levels of expression of either TfR1(r = −0·357, P = 0·003), TfR2‐α (r = −0·486, P < 0·0001), or TfR2‐β (r = −0·435, P = 0·0003). Only TfR2 expression was significantly associated with either serum iron (r = −0·270, P = 0·045) or serum ferritin (r = −0·364, P = 0·008). Multivariate analyses using Coxs proportional hazard model showed that elevated TfR2‐α, but not TfR1 or TfR2‐β mRNA levels significantly contributed to a better prognosis for AML patients. Furthermore, a group with high expression levels of both TfR2‐α and TfR2‐β survived significantly longer than a group without high expression of both of them (P < 0·01 by log‐rank). The present study suggests that (i) TfRs‐independent iron uptake might have an important role in in vivo proliferation of AML cells; (ii) expression of TfR2 (especially the α form) is a novel prognostic factor for patients with AML.

Outcome of 93 patients with relapse or progression following allogeneic hematopoietic cell transplantation

Relapse/progression after allogeneic hematopoietic cell transplantation (allo‐HCT) remains the major cause of treatment failure. In this study, the subsequent clinical outcome was overviewed in 292 patients with leukemia/myelodysplastic syndrome who received allo‐HCT. Among them, 93 (32%) showed relapse/progression. Cohort 1 was chosen to receive no interventions with curative intent (n = 25). Cohort 2 received reinduction chemotherapy and/or donor lymphocyte infusion (n = 48), and Cohort 3 underwent a second allo‐HCT (n = 20). Sixty‐three patients received reinduction chemotherapy, and 27 (43%) achieved subsequent complete remission (CR). The incidence of nonrelapse mortality (NRM) was similar among the three cohorts (4, 15, and 5%). The 1‐year overall survival (OS) after relapse was significantly better in patients with a second HCT (58%) than in others (14%, Cohorts 1 and 2; P <.001). However, the 2‐year OS did not differ between the two groups, which suggests that it is difficult to maintain CR after the second HCT. Multivariate analysis showed that reinduction chemotherapy, CR after intervention, second HCT, and longer time to post‐transplant relapse were associated with improved survival. In conclusion, for patients with relapse after allo‐HCT, successful reinduction chemotherapy and a second HCT may be effective for prolonging survival without excessive NRM. However, effective measures to prevent disease progression after a second HCT clearly need to be developed. Am. J. Hematol. 2009.

Hemojuvelin hemochromatosis receiving iron chelation therapy with deferasirox: improvement of liver disease activity, cardiac and hematological function.

To the Editor: As hemojuvelin hemochromatosis is a severe subtype of hemochromatosis, in affected persons, intensive iron removal is essential to prevent the irreversible multiorgan damage (1). Although phlebotomy is the standard treatment, compliance with this therapy can vary. The once-daily, oral iron chelator deferasirox (DFX) (Exjade; Novartis Pharma AG, Basel, Switzerland) is an option to phlebotomy treatment for patients with hemochromatosis and iron overload, although the safety and efficacy of DFX remain unproven for this option (2, 3). Herein, we report the case of a 29-yr-old Japanese man with hemojuvelin hemochromatosis who was treated with DFX. He was diagnosed with hemochromatosis at the age of 13. He was treated with phlebotomy, but discontinued treatment at the age of 20. After 9 yrs, he visited our hospital because of symptomatic heart failure. He had no history of excessive iron ingestion, alcohol consumption, or transfusion. He was not married and did not have children. One of his brothers had been diagnosed with type 1 diabetes mellitus at the age of 31. His mother was healthy and his father suffered from hepatic dysfunction and arrhythmia; however, iron deposition was not evident. Consanguinity was not known to be present in this kinship. There was no sign of hepatosplenomegaly. White blood cells (WBC) were 2.8 · 10 ⁄L, red blood cells were 3.76 · 10 ⁄L, reticulocytes were 26.3 · 10 ⁄L, and platelets were 99.0 · 10 ⁄L. Aspartate transaminase (AST) level was 83 U ⁄L, and alanine transaminase (ALT) level was 80 U ⁄L. Serum ferritin was 6624 ng ⁄mL, serum iron was 306 lg ⁄dL, and the total iron binding capacity was 324 lg ⁄dL. Bone marrow aspiration showed the nucleated cell count to be 20 000 ⁄ lL. Iron deposition was observed in macrophages, and no dysplastic blood cells were observed. Cardiac and liver iron overload was evident on magnetic resonance imaging, and the left ventricular ejection fraction (EF) was 24% by echocardiography. The genes analyzed in this patient included HFE, HJV, human antimicrobial peptide (HAMP), transferrin receptor 2 (TFR2), and SLC40A1 (4–6). The protocol was approved by the ethics committees in both Showa University Hospital and Aichi Gakuin University. The patient provided written informed consent for genetic testing, measurement of all biochemical markers, and treatment with DFX according to the Declaration of Helsinki. Molecular analysis revealed a homozygous genotype 515_6insC mutation in exon 3 of HJV, without detectable mutations of HFE, HAMP, TFR2, and SLC40A1 genes. The novel mutation predicts a stop signal at codon 196 (D172fsX196). The patient was treated daily with DFX 10 mg ⁄kg. Serum liver enzyme levels and ferritin decreased rapidly. The symptoms of the cardiac failure disappeared, and the EF improved up to 40%. At 28 weeks, the platelet increased to the normal range, and reticulocyte and WBCs increased further to 34.9 · 10 and 4.9 · 10 ⁄L, respectively (Fig. 1). The DFX dose of 10 mg ⁄kg ⁄day reduced the serum levels of ferritin and transaminases. It is a lower dose than that generally recommended for patients with transfusion-induced iron overload (2, 3, 7). He continued iron chelation therapy and did not experience any adverse events. This suggests that a small dose of DFX is effective to remove iron deposits in several organs, although iron accumulation in the tissues was not directly evaluated. During DFX treatment, we observed a substantial increase in WBCs, reticulocytes, and platelet counts, although the levels were below normal range at diagnosis. The mechanisms by which iron chelation may lead to hematologic improvement are unclear. He did not receive any specific therapeutics or blood transfusion during this period. Decreased splenic consumption of blood cells was not a plausible explanation for these increases, because splenomegaly was not evident throughout the clinical course. In some patients with myelodysplastic syndrome, iron chelation therapy appears to stimulate hematopoiesis, leading to a reduction or even complete weaning from the need for transfusion (8, 9). Iron overload itself exhibits a suppressive effect on erythroid progenitors and seems to increase transfusion requirement (10). Iron chelators promote iron release from storage sites, facilitating its usage for hematopoietic tissues. Iron excess is associated with increased oxidative stress. It would appear that the level of oxidative stress is directly responsible for organ dysfunction, including bone doi:10.1111/j.1600-0609.2011.01693.x European Journal of Haematology 87 (467–469)

Senile EBV-associated B-cell lymphoproliferative disorder of indolent clinical phenotype with recurrence as aggressive lymphoma

Senile EBV‐associated B‐cell lymphoproliferative disorder (LPD) was proposed as a new disease entity in 2003. This condition has a high incidence in elderly people without underlying immunodeficiencies, and is characterized by EBV‐positive B‐cell proliferation with a polymorphic composition. Histologically, the disease has two subtypes. The polymorphic LPD (PLPD) subtype has a preferable prognosis, whereas the large cell lymphoma (LCL) subtype involves aggressive disease progression. Reported herein is a case of senile EBV‐BLPD with indolent clinical features and PLPD subtype in the initial phase that recurred as an aggressive lymphoma 3 years after the initial diagnosis. In the recurrent phase, Southern blotting confirmed monoclonal proliferation of large lymphoid B‐cells. In both the initial and recurrent phases, polymerase chain reaction (PCR) yielded a single discrete band of a similar size due to an immunoglobulin heavy‐chain gene rearrangement, indicating that the large lymphoid B‐cells retained identical monoclonality throughout the histological progression and over the whole clinical course. These results suggest that the PLPD subtype is a histological finding in early phase senile EBV‐BLPD and that the LCL subtype reflects the progressive phase of the disease.

Autopsy case of CD4/CD8 cutaneous T-cell lymphoma presenting disseminated pagetoid reticulosis with aggressive granulomatous invasion to the lungs and pancreas.

Pagetoid reticulosis is a rare cutaneous T‐cell lymphoma with striking epidermotropism similar to that present in Pagets disease. There are two forms of pagetoid reticulosis: localized and disseminated. Reported herein is an autopsy case of disseminated pagetoid reticulosis with CD4–/CD8– phenotype T cells and massive invasion of the lungs and pancreas. The abnormal cells in the epidermis expressed a protein derived from a rearranged T‐cell receptor β gene, and this feature was used to confirm the monoclonality of these cells by polymerase chain reaction. At present, the World Health Organization (WHO) classification system considers pagetoid reticulosis to be an indolent form of primary cutaneous T‐cell lymphoma and a variant of mycosis fungoides/Sézary syndrome with prominent epidermotropism. Some differences have been observed between pagetoid reticulosis and mycosis fungoides in terms of clinical course, tumor cell phenotype, and genetic findings; and these differences are highlighted in the present case. The relation between disseminated pagetoid reticulosis,  CD4–/CD8–  cutaneous  T‐cell  lymphoma,  and γδ  T‐cell lymphoma, including whether pagetoid reticulosis is a variant of mycosis fungoides, remains unclear.

Patient-reported quality of life after allogeneic hematopoietic cell transplantation or chemotherapy for acute leukemia.

When discussing treatment options for patients with acute leukemia, it is important to acknowledge the impact of allogeneic hematopoietic cell transplantation (allo-HCT) or chemotherapy on quality of life (QOL). We performed a cross-sectional questionnaire study that administered SF-36, FACT-Leukemia and EuroQOL5D to 524 acute leukemia survivors, to compare patient-reported QOL between chemotherapy and allo-HCT, and to elucidate predictors of QOL. Patients who received chemotherapy alone had a better physical QOL than those who received allo-HCT. On the other hand, the allo-HCT group reported a better mental QOL. In the comparison of QOL in the allo-HCT patients according to the presence of GVHD at survey, patients who had GVHD symptoms experienced statistically and clinically significantly worse QOL than those who did not. In the allo-HCT patients without GVHD, the physical QOL was comparable to that in the chemotherapy patients, and they experienced significantly better mental and general QOL than the chemotherapy patients. GVHD and immunosuppressive drugs at survey were strongly associated with worse QOL after allo-HCT. In the chemotherapy group, a shorter time between treatment completion and survey was significantly associated with worse QOL. Further evaluation of QOL by a longitudinal assessment with quantitative and qualitative analyses are warranted.

CD20 gene deletion causes a CD20-negative relapse in diffuse large B-cell lymphoma.

In diffuse large B‐cell lymphoma (DLBCL), a CD20‐negative relapse is clinically significant because it is associated with chemo‐refractory phenotypes and loss of a therapeutic target. The alteration of the CD20 gene is reported as infrequent in CD20‐negative relapse in B‐cell lymphoma. We established a DLBCL cell line with loss of CD20 expression (SD07) from a patient at CD20‐negative relapse. She was initially diagnosed with CD20‐positive DLBCL and received repeated immuno‐chemotherapy that included rituximab. SD07, which has an immunoglobulin κ rearrangement identical to that of lymphoma cells at CD20‐negative relapse, showed homozygous deletion of the CD20 gene with loss of the copy number of 11q12. SD07 is the first case in which it is proven that the loss of CD20 expression in relapsed DLBCL is the result of deletion of the CD20 gene. Deletion of the CD20 gene is a molecular mechanism of CD20‐negative relapse in a subset of DLBCL.