Hee Soon Cho

Individual Variation in Growth Factor Concentrations in Platelet-rich Plasma and Its Influence on Human Mesenchymal Stem Cells

Background The objective of this study was to explore whether individual variations in the concentration of growth factors (GFs) influence the biologic effects of platelet-rich plasma (PRP) on human mesenchymal stem cells (HMSCs). Methods The concentrations of 7 representative GFs in activated PRP (aPRP) were measured using ELISA. The effects of PRP on the proliferation and alkaline phosphatase (ALP) activity of HMSCs were examined using several concentrations of aPRP from 3 donors; the relationships between the GF levels and these biologic effects were then evaluated using 10% aPRP from 5 subgroups derived from 39 total donors. HMSCs were cultured in DMEM with the addition of aPRP for 4 or 12 days; then, DNA content and ALP activity were measured. Results The quantity of DNA increased significantly at a 10% concentration of aPRP, but the ALP activity was suppressed at this concentration of aPRP. The GF concentrations varied among donors, and 5 subgroups of characteristic GF release patterns were identified via cluster analysis. DNA levels differed significantly between groups and tended to be higher in groups with higher concentrations of transforming growth factor-beta1 (TGF-β1) and platelet-derived growth factors (PDGFs). DNA quantity was positively correlated with TGF-β1 concentration, and was negatively correlated with donor age. ALP activity was negatively correlated with PDGF-BB concentration. Conclusions The varying GF concentrations may result in different biologic effects; thus, individual differences in GF levels should be considered for reliable interpretation of the biologic functions and standardized application of PRP.

VEGFA and VEGFR2 genetic polymorphisms and survival in patients with diffuse large B cell lymphoma.

We evaluated the impact of functional polymorphisms in the vascular endothelial growth factor A (VEGFA) and vascular endothelial growth factor 2 (VEGFR2) genes on the survival of patients with diffuse large B cell lymphoma (DLBCL). Five potentially functional polymorphisms in the VEGFA (rs699947, rs2010963 and rs3025039) and VEGFR2 (rs1870377 and rs2305948) genes were assessed in 494 DLBCL patients treated with rituximab plus CHOP chemotherapy. The associations of genotype and haplotype with overall survival (OS) and progression‐free survival (PFS) were analyzed. Of the five polymorphisms, VEGFR2 rs1870377T>A was significantly associated with both OS and PFS; in the dominant model, patients with the AA + TA genotypes had significantly better OS (P = 0.002) and PFS (P = 0.004) than those with the TT genotype. The association between significantly better OS and the AA + TA genotypes was observed separately in patients with low (0–2; P = 0.035) and high (3–5; P = 0.043) International Prognostic Index scores. Multivariate analysis showed that, relative to the AA + TA genotypes, the TT genotype was an independent prognostic factor for poor OS (HR, 1.71; 95% CI, 1.21–2.43; P = 0.002) and PFS (HR, 1.57; 1.13–2.17; P = 0.004). Other independent significant predictors of survival in patients with DLBCL were International Prognostic Index score, age > 60 years, lactate dehydrogenase concentration >normal, extranodal disease >1 and presence of B symptoms. The VEGFR2 rs1870377 polymorphism might affect survival in patients with DLBCL, suggesting that angiogenesis might be related to poor survival in these patients. (Cancer Sci 2012; 103: 497–503)

Meningeal Relapse in a Patient with Acute Promyelocytic Leukemia : A Case Report and Review of the Literature

The involvement of central nervous system is rare in acute promyelocytic leukemia (APL). We report a APL patient of a 41 yr-old Korean male who presented with fever and petechia. Complete molecular remission was achieved with all-trans retinoic acid (ATRA), idarubicin, and cytarabine. Ten months later, he complained of a mild headache. The results of the physical examination and the complete blood counts were normal. The examination of cerebrospinal fluid showed the presence of promyelocyte. Bone marrow studies showed cytogenetic remission but with molecular relapse. He was treated with intrathecal and systemic chemotherapy.

Therapeutic Experience of Bing-Neel Syndrome Associated with Waldenstrom's Macroglobulinemia

Waldenstroms macroglobulinemia is an uncommon low-grade B-cell lymphoproliferative disorder in which monoclonal immunoglobulin M is produced. Neurological symptoms due to hyperviscosity are frequent manifestations of Waldenstroms macroglobulinemia. However, central nervous system infiltration by plasmacytoid lymphocytes (Bing-Neel syndrome) has only rarely been reported. We report a case of a 51-yr-old woman suffering from Waldenstroms macroglobulinemia who complained of persistant headache. Brain magnetic resonance imaging revealed an extra-axial soft tissue mass along the left cavernous sinus, left tentorium, right tentorium, and falx cerebri. A stereotactic biopsy of dural tissue from the falx was performed and showed plasmacytoid lymphocyte infiltration. The patient became symptom- free with irradiation of the whole brain followed by chemotherapy with fludarabine.

Biological Characterization of Nodal versus Extranodal Presentation of Diffuse Large B-Cell Lymphoma using Immunohistochemistry

INTRODUCTION Diffuse large B cell lymphoma (DLBCL) of primary nodal (PN) or primary extranodal (PEN) origin may differ immunophenotypically, in that PEN lymphoma cells may originate from activated rather than germinal center B (GCB) cells. We evaluated the relationship between DLBCL clinicopathological features, including expression of B-cell differentiation markers, and primary tumor site. PATIENTS AND METHODS Expression of CD10, Bcl-6, Bcl-2, and MUM1 was determined in paraffin-embedded tissues from 123 patients with DLBCL. RESULTS Of the 123 patients with DLBCL, 40 (32.5%) had the GCB and 83 (67.5%) had the non-GCB phenotype. Fifty-one patients (42%) showed disease involvement at PEN sites, including 29 with disease in the gastrointestinal (GI) tract (14 in the stomach, 15 in the intestine). Of these 51 patients, 16 (31.4%) were classified with the GCB and 35 (68.5%) with the non-GCB subtype. There were no differences in the frequencies of GCB and non-GCB subtypes among primary sites. Of the 72 patients with PN DLBCL, 22 (31%) had the GCB and 50 (69%) had the non-GCB subtype. There were no differences in the frequencies of GCB and non-GCB subtypes between patients with PN and PEN DLBCL. Although lactate dehydrogenase (LDH) concentration > normal, stage >II, and rituximab-cyclophosphamide, doxorubicin, vincristine, and prednisone (RCHOP) treatment were independent predictors of overall survival (OS), GCB subtype, and presence of PEN disease failed to predict survival upon multivariate analysis. CONCLUSION There was no difference in GCB and non-GCB phenotypes between patients with PN and PEN DLBCLs. Additional studies are needed to further assess molecular differences between the two groups.

Chronic myeloid leukemia as a secondary malignancy after diffuse large B-cell lymphoma

To the Editor, Diffuse large B-cell lymphoma (DLBCL) is an aggressive subtype of non-Hodgkin lymphoma. The occurrence of chronic myeloid leukemia (CML) as a secondary malignancy in patients diagnosed with DLBCL is extremely rare [1]. We report a unique case of secondary CML 10 years after chemotherapy and local irradiation for the treatment of tonsillar DLBCL. We also review the literature related to secondary CML. A 40-year-old male with a sore throat and a right tonsillar mass was evaluated at a local clinic in September 2000. A biopsy revealed a malignant lymphoma (DLBCL). He was then transferred to our hospital, where a staging work-up was performed. There were no metastatic lesions except for the right tonsillar mass. There was also no marrow invasion or chromosomal abnormalities in his bone marrow. The patient had a stage IA DLBCL. He received six cycles of CHOP regimen (750 mg/m2 cyclophosphamide, 50 mg/m2 adriamycin, and 2 mg vincristine on day 1, and 100 mg prednisolone on days 1 to 5) chemotherapy every 3 weeks. Chemotherapy was followed by radiotherapy to the right tonsillar region (total, 25 Gy). A complete response was achieved and sustained for 10 years. In July 2010, he sought evaluation at our hospital for easy fatigue and a febrile sensation of several months duration. His white blood cell count was 173,900/mm3, his hemoglobin concentration was 11.3 mg/dL, and platelet count was 735,000/mm3. Splenomegaly was noted on physical examination, but the remaining physical findings were nonspecific. Diffuse fluorodeoxyglucose (FDG) uptake in the bone marrow and mild and diffuse FDG uptake in the spleen were noted on a positron emission tomography and computerized tomography scan (Fig. 1). His platelet count was increased and a complete spectrum of granulocytic forms, from blasts to mature neutrophils, was noted on a peripheral blood smear (Fig. 2A). Hypercellular marrow with increased megakaryocytes and a markedly proliferated myeloid series were noted on a bone marrow study; however, the erythroid series was suppressed (Fig. 2B). A bone marrow chromosome analysis was then performed. Twelve cells were characterized by the presence of the Philadelphia translocation [t(9;22)(q34;q11)] in all analyzed mitoses; no other abnormalities were found (Fig. 3). PCR revealed a major BCR/ABL gene rearrangement in peripheral blood and bone marrow cells. The patient was diagnosed with CML. Figure 1 (A) Diffuse fluorodeoxyglucose (FDG) uptake in the bone marrow and mild and diffuse FDG uptake in the spleen with splenomegaly were noted on a positron emission tomography and computerized tomography (PET/CT) scan. (B) Abdominal CT revealed massive splenomegaly. ... Figure 2 (A) Platelet counts were increased and a complete spectrum of granulocytic forms, from blasts to mature neutrophils, was noted on the peripheral blood smear (H&E, ×400). (B) Hypercellular marrow with increased megakaryocytes and a markedly ... Figure 3 A representative karyotype shows 46, XY, t(9;22) (q34;q11.2). He was treated with 400-mg/day imatinib beginning on 29 July 2010. After treatment for 1 month, his white blood cell count was 5,660/mm3, hemoglobin concentration was 10.9 mg/dL, and platelet count was 257,000/mm3 in the peripheral blood, which indicated a complete hematologic response. After treatment for 3 months, the CR/ABL gene rearrangement was not detected in peripheral blood and bone marrow cells, and the Philadelphia chromosome was not detected during a cytogenetic study of the bone marrow. Therefore, a complete cytogenetic response was obtained after 3 months of therapy with imatinib. He continued to be treated with 400-mg/day imatinib until March 2013, and the complete cytogenic response was maintained. Secondary hematologic malignancies after neoplastic diseases are commonly reported as important late complications in cancer patients due to chemotherapy and/or radiotherapy. Advances in the treatment of malignancies have been accompanied by an increased frequency of secondary acute myeloid leukemia (AML) and myelodysplastic syndrome (MDS); however, secondary CML is a rare event [2]. Recently, a relationship was reported between patients treated with cytotoxic therapy for malignancies and increased AML and MDS [3]. However, definitive evidence that the cytotoxic therapies used in cancer treatment increase the risk of CML has not been reported. AML and MDS are genetically diverse, and numerous genetic abnormalities have been linked to their onset. In contrast, CML is homogeneous; the BCR-ABL oncogene is the single genetic lesion that results in the development of CML [3]. This suggests that the risk of CML after exposure to a chemical incitant is markedly lower than the risk of AML or MDS. A recent study reported that 40% of patients with therapy-related AML (tr-AML) and MDS received chemotherapy, 14% received radiation therapy, and 46% underwent a combination of chemotherapy and radiation therapy for a prior malignancy. Of the patients treated with chemotherapy, 78% received alkylating agents, and 39% received topoisomerase II inhibitors. The most common primary tumors of tr-AML and MDS were Hodgkin and non-Hodgkin lymphoma [3]. In a similar study assessing patients with tr-CML, 44% of patients received combination therapy. In addition, the chemotherapy agents used to treat the primary disease included alkylating agents and topoisomerase II inhibitors. The most common primary tumor in this cohort of tr-CML patients was Hodgkins lymphoma [1]. The occurrence of CML is increased in survivors of the atomic bomb detonations in Hiroshima and Nagasaki, and in patients irradiated for ankylosing spondylitis or cervical cancer [4,5], all of whom were exposed to high doses of ionizing radiation. This suggests that CML may be more likely to occur after acute high dose radiation exposure than other types of leukemia. A previous study reported that the median interval to diagnosis of CML in patients treated with combination chemotherapy and radiotherapy, radiotherapy alone, and chemotherapy alone was 60 months (range, 27 to 240), 53 months (range, 27 to 109), and 35 months (range, 23 to 148), respectively. There was no statistically significant difference between these groups of patients [1]. In our study, the interval between diagnosis of DLBCL and CML was 118 months. Our patient received six cycles of CHOP chemotherapy, including an alkylating agent, followed by local irradiation (total, 25 Gy) for the treatment of tonsillar DLBCL. However, the total dose of irradiation was low, and was divided into several fractions. In addition, there was a long interval to the diagnosis of CML (10 years). Therefore, it is unlikely that the treatment for DLBCL was related to the development of CML; however, tr-CML could not be excluded. Therefore, we were unable to discriminate between tr-CML and non-tr-CML in this patient. Nevertheless, chemotherapy or irradiation therapy for malignancies can cause tr-CML.

Two cases of trisomy 19 as a sole chromosomal abnormality in myeloid disorders.

Trisomy 19 is frequently encountered in cases of chronic myeloid leukemia (CML) as a secondary abnormality: however, trisomy 19 rarely occurs as a sole chromosomal abnormality and, to date, it has only been reported in 48 hematopoietic malignancies, 1 case of adenocarcinoma and 1 case of astrocytic tumor. Here, we report two additional cases of trisomy 19 as a sole karyotypic aberration in myeloid malignancies. One of these cases involved a 6-month-old male who was diagnosed with acute myeloid leukemia minimally differentiated. His karyotype was 47,XY,+19[20]. He expired 5 days after diagnosis. Another case occurred in an 80-yr-old female who had refractory anemia with excess blasts. Her karyotype was 47,XX,+19[16]/46,XX[4]. Four months later, her peripheral blood smears suggested that the disease had progressed, but she refused further evaluation. Based on a review of the existing literature and the results of this report, trisomy 19 not only as a secondary abnormality but also as a sole karyotypic aberration is strongly associated with myeloid disorder; however, it is not preferentially found in specific FAB subgroups of myelodysplasic syndrome or acute myeloid leukemia.

A case of partial trisomy 2p23-pter syndrome with trisomy 18p due to a de novo supernumerary marker chromosome.

Partial trisomy 2p is a rare but relatively well-defined syndrome with distinctive clinical features, including marked psychomotor delay, dysmorphic face, and congenital heart disease. The phenotype of trisomy 18p is variable, from normal appearance to moderate mental retardation. Most cases of trisomy 2p and trisomy 18p result from the inheritance of an unbalanced segregant from a balanced parental translocation or due to de novo duplication. Here, we present the first report of a combined partial trisomy 2p and trisomy 18p due to a supernumerary marker chromosome (SMC). The final karyotype of the patient was 47,XX,+der(18)t(2;18)(p23.1;q11.1)[22]/46,XX[8]. The patient had typical dysmorphic features of partial trisomy 2p23-pter syndrome and congenital heart disease. SMCs are remarkably variable in euchromatic DNA content and mosaicism level. The precise identification of the origin and composition of SMCs is essential for genotype-phenotype correlation and genetic counseling.

The Hematologic Response to Anti-apoptotic Cytokine Therapy: Results of Pentoxifylline, Ciprofloxacin, and Dexamethasone Treatment for Patients with Myelodysplastic Syndrome

TNF-α mediated apoptosis of the hematopoietic cells has been thought to contribute to the ineffective hematopoiesis observed in myelodysplastic syndrome (MDS). The combination of pentoxifylline (P) and ciprofloxacin (C) has been shown to reduce the serum levels of TNF-α, and an earlier trial of P and C with dexamethasone (D) provided good palliation for patients with MDS. The purpose of this study is to assess the hematologic response to PCD therapy for patients suffering with MDS. 21 of 25 patients who completed at least of 12 weeks of treatment were evaluable for the treatment efficacy. At baseline, the patients median age was 60 yr (range: 18-75 yr). The diagnoses according to WHO classification included: RA (n=5), RCMD (n=10), RARS (n=1), RCMD/RS (n=1), RAEB (3), and CMML (n=1). 11 patients (52%) had at least single lineage response. 3 patients (11%) showed improvement of triple lineage cytopenia. There were no differences in the response rates between the FAB subtypes. The median time to response was 4 weeks (range: 2-12 weeks), and it is interesting that 9 of 11 patients who had a response remained without relapse for a median of 177 days (range: 78-634 days). These preliminary results indicate that anti-cytokine therapy with PCD is an effective and well tolerated palliative treatment for patients with MDS.

A Novel Missense Mutation Asp506Gly in Exon 13 of the F11 Gene in an Asymptomatic Korean Woman with Mild Factor XI Deficiency

Factor XI (FXI) deficiency is a rare autosomal recessive coagulation disorder most commonly found in Ashkenazi and Iraqi Jews, but it is also found in other ethnic groups. It is a trauma or surgery-related bleeding disorder, but spontaneous bleeding is rarely seen. The clinical manifestation of bleeding in FXI deficiency cases is variable and seems to poorly correlate with plasma FXI levels. The molecular pathology of FXI deficiency is mutation in the F11 gene on the chromosome band 4q35. We report a novel mutation of the F11 gene in an 18-year-old asymptomatic Korean woman with mild FXI deficiency. Pre-operative laboratory screen tests for lipoma on her back revealed slightly prolonged activated partial thromboplastin time (45.2 sec; reference range, 23.2-39.4 sec). Her FXI activity (35%) was slightly lower than the normal FXI activity (reference range, 50-150%). Direct sequence analysis of the F11 gene revealed a heterozygous A to G substitution in nucleotide 1517 (c.1517A>G) of exon 13, resulting in the substitution of aspartic acid with glycine in codon 506 (p.Asp506Gly). To the best of our knowledge, the Asp506Gly is a novel missense mutation, and this is the first genetically confirmed case of mild FXI deficiency in Korea.