Fumihito Tajima

Incidence of hepatitis virus infection and severe liver dysfunction in patients receiving chemotherapy for hematologic malignancies

Abstract: Hepatitis virus infection through virus reactivation has a high risk of mortality in patients with hematological malignancies receiving chemotherapy. We examined the incidence of both hepatitis B virus (HBV) and hepatitis C virus (HCV) infection and severe liver dysfunction (alanine aminotransferase >ten times the normal upper limit and total bilirubin >5 mg/dl) during chemotherapy in 268 patients with hematological malignancies. Eight patients (3.0%) were infected with HBV and 22 patients (8.2%) were infected with HCV. One patient (0.4%) was infected with both HBV and HCV. HBV‐ or HCV‐infected patients showed severe liver dysfunction at a significantly higher incidence than non‐infected patients (11/31 (35.5%) vs. 0/237 (0%), p<0.0001). Furthermore, the incidence of severe liver dysfunction in HBV‐infected patients was significantly higher than in HCV‐infected patients (6/8 (75.0%) vs. 4/22 (18.2%), p<0.01). Three of eight HBV‐infected patients were initially negative for hepatitis B surface antigen (HBsAg) by latex agglutination and became positive for HBsAg during chemotherapy. Furthermore, all three patients developed severe liver dysfunction and two developed fatal fulminant hepatitis. From an examination of the original stock of serum samples before chemotherapy, two patients were found to be positive for HBV‐DNA by polymerase chain reaction (PCR). Although post‐transfusion HBV infection was suspected in the one remaining patient, the cause of HBV infection could not be clarified due to the impossibility of examination in blood donors. Since HBV‐infected patients develop severe liver dysfunction at a higher incidence than either patients not infected with virus or HCV‐infected patients before chemotherapy for hematological malignancies, it is recommended that HBV‐DNA should be tested by PCR to detect HBV marker‐negative carriers and liver function tests should be carefully monitored.

Hepatic differentiation of human bone marrow–derived mesenchymal stem cells by tetracycline-regulated hepatocyte nuclear factor 3β†

Human bone marrow–derived mesenchymal stem cells (BM‐MSCs) are expected to be a potential source of cells for transplantation. Although recent reports have shown that isolated MSCs can differentiate into hepatocytes, the efficiency of differentiation is insufficient for therapeutic application. To circumvent this problem, it is necessary to understand the mechanisms of hepatic differentiation of human BM‐MSCs. Hepatocyte nuclear factor 3β (HNF3β), a forkhead/winged helix transcription factor, is essential for liver development. In the present study, we established a tetracycline (Tet)‐regulated expression system for HNF3β in UE7T‐13 BM‐MSCs. HNF3β expression significantly enhanced expression of albumin, α‐fetoprotein (AFP), tyrosine amino transferase (TAT) and epithelial cell adhesion molecule (EpCAM) genes. The differentiated cells showed hepatocyte‐specific functions including glycogen production and urea secretion. During treatment with the Tet‐on system for 8 days, over 80% of UE7T‐13 cells turned out to express albumin. Furthermore, the combination of Tet with basic fibroblast growth factor (bFGF) efficiently induced the genes such as albumin and TAT, which are associated with maturity of hepatocytes; however, it suppressed genes such as AFP and EpCAM, which are associated with immaturity of hepatocytes, suggesting that Tet‐induced HNF3β expression sensitizes BM‐MSCs to bFGF signals. Finally, the results of the present study suggest that down‐regulation of Wnt/β‐catenin signals caused by translocation of β‐catenin to cytoplasmic membrane is associated with hepatic differentiation of human BM‐MSCs. Conclusion: HNF3β expression induced efficient differentiation of UE7T‐13 human BM‐MSCs. (HEPATOLOGY 2008;48:597–606.)

Serum soluble c‐kit receptor and expression of c‐kit protein and mRNA in acute myeloid leukemia

Abstract: To investigate the clinical role of the soluble form of c‐kit receptor (s‐kit) in patients with acute myeloid leukemia (AML), we determined the levels of serum s‐kit and expression of c‐kit antigens and mRNA in leukemic cells. The serum s‐kit level was measured using ELISA assay in 30 AML patients and 20 normal controls. C‐kit antigens of leukemic blasts were stained immunohistologically, and c‐kit mRNA was detected by RT‐PCR. The serum s‐kit level in M1 and M2 were significantly increased (p<0.01) and that in M4 or M5 was significantly decreased (p<0.05) compared to that in the controls. In the comparisons among subtypes of FAB classification, M1 and M2 showed significantly higher levels than M4 or M5 (p<0.05 and p<0.01, respectively). Both expression of c‐kit antigens and mRNA were observed in M0 (1/4), M1 (2/4) and M2 (6/8), but neither was observed in M4 or M5. The serum s‐kit levels were correlated with the absolute number of AML blasts in peripheral blood (r=0.564, p<0.05). These results indicate that the serum s‐kit level is related to the stage of differentiation of AML blasts in accordance with the expression of c‐kit protein and mRNA in AML blasts, and is useful for assessment of leukemic cell burden.

Fulminant hepatitis type B after chemotherapy in a serologically negative hepatitis B virus carrier with acute myelogenous leukemia.

We report a case of a 41-year-old man with acute myelogenous leukemia who developed fulminant hepatitis from reactivation of trace hepatitis B virus (HBV) 2 months after complete remission.Although he became positive for HB surface antigen at the onset of fulminant hepatitis, he had been negative for HBV serum markers, and only HBV DNA was detected by polymerase chain reaction (PCR) amplification on admission. The original stocks of serum samples from all blood donors were tested again for HBV DNA by PCR, and all samples were negative. This case demonstrates that testing for HBV DNA by PCR is necessary before chemotherapy, because silent HBV carriers are rare and fulminant hepatitis may be induced by chemotherapy in patients with hematologic malignancies.

Autoperipheral blood mononuclear cell transplantation improved giant ulcers due to chronic arteriosclerosis obliterans

We report the case of a 74-year-old man with Fontaine stage IV chronic arteriosclerosis obliterans who had been suffering from inveterate giant skin ulcers on the dorsum and heel of the right foot. As conventional medical treatments had not improved these ulcers and surgical treatment was considered unfeasible, amputation of the right lower limb below the knee appeared to represent the only option. The patient was admitted to Tottori University Hospital to attempt a new angiogenic therapy using auto-mononuclear cell transplantation to avoid amputation. On admission, neither right ankle blood pressure nor transcutaneous partial pressure of oxygen at the right toe were detectable. The patient had a history of multiple cerebral infarctions, and collection of mononuclear cells from bone marrow was considered too difficult, so collection of peripheral blood mononuclear cells was selected. Transcutaneous partial pressure of oxygen and skin temperature in the treated limb started to improve from 2 weeks after implantation. Ulcer size was recognizably reduced by 1 month after treatment. Partial auto-skin implantation on the right heel was performed 2 months after treatment, and the giant skin ulcer was finally completely covered. No adverse effects were noted during follow-up lasting 1 year. These results suggest that peripheral blood mononuclear cell implantation may offer a suitable alternative rescue therapy for patients with critical limb ischemia whose general condition is not good.

Hepatocyte growth factor mobilizes and recruits hematopoietic progenitor cells into liver through a stem cell factor‐mediated mechanism

Aims:   Although bone marrow cells are reported to migrate to the liver under circumstances of severe liver injury, the bone marrow cell type and the mechanisms in this process, remain to be clarified. We examined the involvement of hepatocyte growth factor (HGF) in this process and the cell type of migrated hematopoietic cells by HGF.

Phase I/II study of tandem high-dose chemotherapy with autologous peripheral blood stem cell transplantation for advanced multiple myeloma

The efficacy and safety of high-dose chemotherapy with tandem autologous peripheral blood stem cell transplantation (auto-PBSCT) were evaluated in a multicenter clinical study of patients with advanced multiple myeloma. Eligible patients (n = 40) were consecutively enrolled in the phase I/II study and received 2–4 cycles of vincristine–adriamycin–dexamethasone regimen. The responding patients underwent PBSC harvesting following high-dose cyclophosphamide and filgrastim administration. The first auto-PBSCT (n = 32) following high-dose melphalan (200 mg/m2) was performed within 2 months of PBSC harvesting; the second auto-PBSCT (n = 28) was scheduled 3–6 months later. Treatment-related mortality was 2.5% (n = 1) throughout the protocol. Grade 4 nonhematologic toxicity occurred in 12.5 and 14.3% of the first and second auto-PBSCT patients, respectively. All but one patient (who died) achieved hematopoietic recovery. For the 28 patients completing the second auto-PBSCT, the results were favorable with a response rate of 65% (complete response rate = 27.5%, n = 11); the five-year progression-free survival and overall survival were 20.3 and 66.5%, respectively. In conclusion, high-dose chemotherapy with tandem auto-PBSCT is feasible and safe with a favorable response rate in treating advanced multiple myeloma in Japan.

Serum soluble IL-6 receptor levels during the mobilization of stem cells to peripheral blood.

Serum soluble interleukin-6 receptors (sIL-6R) have been demonstrated to play an important role in hematopoiesis. We report here that serum sIL-6R levels reflect proliferative kinetics of the progenitors after stimulation by chemotherapy plus granulocyte colony-stimulating factor. Serum sIL-6R were serially evaluated in 26 courses of peripheral blood (PB) stem cell collections in 16 patients using enzyme-linked immunosorbent assay. Expressions of IL-6R and CD34 on PB mononuclear cells were examined by flow cytometric analysis and expressions of IL-6R mRNA were examined by reverse transcriptase polymerase chain reaction. There were no significant differences between the serum sIL-6R levels on day 0 in patients (27.8 ± 2.1   ng/ml, mean ± SEM) and those in controls (27.5 ± 1.5   ng/ml). Following chemotherapy the serum sIL-6R levels were significantly decreased, reaching a minimal level on day 14 (22.3 ± 1.2   ng/ml, p<0.01) and then significantly increased to above the baseline levels on day 21 (32.0 ± 2.1   ng/ml, p<0.01). Similar oscillations in the number of white blood cells, IL6R + cells, CD34 + cells and colony-forming unit-granulocyte/macrophage (CFU-GM) in PB could be observed and the peak expression of mRNA was compatible with the expression of antigen. Serum sIL-6R levels on day 17 and 19 were positively correlated with the number of CD34 + cells, IL-6R + cells, CFU-GM in PB and the number of collected CD34 + cells in leukapheresis products. In addition, when comparing the 2 groups divided by the number of prior chemotherapies, the status of disease or dose of the mobilizing regimen, the serum sIL-6R levels were significantly increased after day 17 in the group that received fewer courses of prior chemotherapy, the group in complete remission and the group of high-dose chemotherapy. These findings indicated that sIL-6R levels do not reflect the hematopoietic ability in the steady state, or the capability of the hematopoiesis after stimulation. Thus, sIL-6R levels may be a marker for the timing of PBSC collection or the prediction of the number of collected CD34 + cells.

Effect of screening of donors for antibodies to hepatitis C virus by second-generation assay on incidence of HCV infection in acute leukemia

Abstract We examined the incidence of hepatitis C virus (HCV) infection in 42 patients with acute leukemia before and after blood donor screening for the HCV Ab using the first-generation assay and the second-generation assay. Although 14 (93%) of the 15 patients before screening and 6 (50%) of the 12 patients after screening by the first-generation assay became seropositive for HCV RNA, none of the 15 patients became seropositive after screening by the second-generation assay. These findings indicate that the second-generation assay is effective in preventing HCV infection in multitransfused patients with acute leukemia.

Effect of Interferon-α on Patients with Previously Untreated Chronic Myelogenous Leukemia in the Early Chronic Phase: Comparison between Interferon-α Continued Patients and Interferon-α Discontinued Patients.

In order to confirm the effect of interferon-α (IFN-α) in inducing a prolonged duration of the chronic phase (CP) on patients with chronic myelogenous leukemia (CML), we retrospectively compared the duration of CP between patients who continued on IFN-α and the patients in whom IFN-α was discontinued before the blast phase. Of the 32 patients not pretreated for CML in the early CP who received IFN-α therapy, 25 continued on IFN-α while seven discontinued the therapy (side effects, 5; resistance, 1; patients refusal, 1). Only four of the 25 patients in whom IFN-α was continued (16.0%) progressed to the blast phase or accelerated phase, but six of the seven patients who discontinued IFN-α (85.7%) progressed to the blast phase or accelerated phase. Fourteen of the 25 patients who continued on IFN-α therapy showed cytogenetic response (complete cytogenetic response, 3; minimal cytogenetic response, 11) whereas 11 patients showed no cytogenetic response. However, non-responders showed a longer duration of CP than the patients whom IFN-α was discontinued. Although elderly patients showed a high incidence of side effects, and some patients progressed early after the beginning of IFN-α therapy, our data clearly demonstrated that in accordance with previous large multi-centric randomized studies the continuation of IFN-α, even in low doses, prevents disease progression.