Hirotsugu Ariizumi

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)

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.

Over-expression of CCL3 MIP-1α in a blastoid mantle cell lymphoma with hypercalcemia

We analyzed a case with the blastoid variant of mantle cell lymphoma (MCL‐BV), a rare subtype of B‐cell lymphoma, presenting with marked hypercalcemia at diagnosis. Enzyme‐linked immunosorbent assay (ELISA) showed elevated serum levels of interleukin‐6 (IL‐6), tumor necrosis factor‐α (TNF‐α), macrophage inflammatory protein‐1α (MIP‐1α), and type I collagen telopeptide, but not parathyroid hormone, calcitriol or parathyroid hormone‐related peptide at diagnosis, suggesting local osteoclastic hypercalcemia in this case. By reverse transcription polymerase chain reaction (RT‐PCR) analysis, we found predominant expression of mRNA for MIP‐1α in addition to those for receptor‐activator of nuclear‐factor kappa B ligand (RANKL), TNF‐α, and IL‐6 in lymphoma cells obtained from the patient. Furthermore, recombinant MIP‐1α significantly stimulated 3H‐thymidine uptake by isolated MCL cells in vitro. Treatment with intravenous fluids, bisphosphonate, and methylprednisolone followed by combination chemotherapy promptly corrects the hypercalcemia and successfully induced complete remission, which was accompanied by a decrease of these cytokines in the serum, including MIP‐1α. In the present case, MIP‐1α, an osteoclast‐activating factor produced by mantle lymphoma cells, may contribute to the development of hypercalcemia. It likely acts through RANKL expression in tumor cells and/or stroma cells, as indicated in multiple myeloma (MM) and adult T‐cell leukemia/lymphoma (ATLL). Furthermore, MIP‐1α is also involved in the development of an aggressive phenotype on MCL by stimulating proliferation of these lymphoma cells. In summary, the present study demonstrated that MIP‐1α is an important factor in the development of both hypercalcemia and an aggressive phenotype in some types of B‐cell lymphoma.

Improvement of the thermal amplitude after rituximab treatment for cold agglutinin disease with Waldenström’s macroglobulinemia

Dear Editor, Cold agglutinin disease (CAD) is an uncommon autoimmune hemolytic anemia characterized by the production of cold agglutinins (CA) [1]. CA exhibits the strongest affinity for the antigen at 0–4°C but binding may occur at temperatures approaching the normal body temperature of mammals, depending on the thermal amplitude of the antibody. Rituximab has been demonstrated to be useful in treating CAD that is refractory to conventional therapies [2]. However, CA titers did not concur with the observed clinical and hematologic responses, and it has become apparent that the CA titer is not an important index for the clinical features of CAD. The detailed effect(s) of rituximab on CAD have not been reported. We present a case of a 68-year-old man who was diagnosed with Waldenstrom’s macroglobulinemia with CAD in 1999, in whom the thermal amplitude was improved after rituximab treatment. His Hb level was 4.9 g/dL, and an immunoglobulin M (IgM) kappa monoclonal protein was evident at diagnosis (IgM, 58.2 g/L). His bone marrow was diffusely infiltrated with CD20+ lymphoplasmacytoid lymphocytes. The direct antiglobulin test was positive for complement (C3d). CAwas positive with a titer of 8,192 at 4°C. He underwent six courses of cyclophosphamide, adriamycin, vinctistine, and prednisolone and low-dose prednisolone up to July 2007. Due to worsening anemia with acrocyanosis, he was treated with rituximab alone at 375 mg/m four times every 8 weeks. Although the CAD-related symptoms were improved, the high-CA titers at 4°C remained. He relapsed 42 weeks after the initial treatment, and the duration to response was 10 months. After informed consent was obtained, we determined the agglutination titer and tested the thermal amplitude of the patient’s plasma and serum, as described previously [3]. As shown in Table 1, 4 weeks after the initial injection of rituximab, increases of hemoglobin and improvement of the thermal amplitude of the antibody were observed simultaneously. Up to 24 weeks later, the improvement of the thermal amplitude remained. Hemoglobin increased progressively up to 28 weeks. Based on the changes of the thermal range in reactivity of the antibody, the clinical sign(s), such as acrocyanosis, improved along with amelioration of the symptoms related to anemia. Temperatures of 30°C and lower normally occur in the superficial skin vessels of the parts of the body exposed to cold air or water. The thermal range of the antibody is more important than the agglutination titer for clinical symptoms [4]. The present findings suggested that both elevation of hemoglobin and resolution of clinical sign(s) are closely associated with improvement of thermal amplitude of the CA after rituximab treatment. The present case suggested that hemoglobin was elevated as a consequence of the improvement of thermal amplitude after rituximab treatment. Schoellkopf et al. observed a significant and persistent reduction of serum IgM concentration after rituximab Ann Hematol (2010) 89:103–104 DOI 10.1007/s00277-009-0773-z

p53 Protein Expression in Chronic Myelomonocytic Leukemia-1 Correlates with Progression to Leukemia and a Poor Prognosis

CMML-1 is controversial. Herein, we performed a retrospective study of the clinical features of patients with CMML-1 in a single institution. In our institution, 20 patients with CMML-1 reclassified retrospectively based on the WHO (2008) criteria and diagnosed as having CMML based on the FAB or WHO (2001) classification were included in this study. Rearrangement of PDGFRA or PDGFRB was excluded in case of eosinophilia. Our series excluded cases of secondary CMML associated with therapy-related MDS/AML. Patients were followed up from 1996 to 2008. Mutational analysis was performed on DNA from BM cells from the study participants. All samples were obtained with informed consent, and the protocols were approved by our institution’s ethics committee. The clinical characteristics and laboratory data were determined by a review of medical records. Laboratory and physical examination data of all patients were obtained at diagnosis. BM aspiration and biopsy samples were taken and analyzed at diagnosis and at the time of transformation to AML. Chromosomal analyses of BM cells were performed by G-banding techniques. Hydroxyurea was used as a cytoreductive drug in some of the CMML patients. After the Chronic myelomonocytic leukemia (CMML) is characterized by persistent monocytosis and by features of a myeloproliferative neoplasm and a myelodysplastic syndrome (MDS). CMML is subdivided into CMML-1, with

Association of red cell distribution width with clinical outcomes in myelodysplastic syndrome.

Studies showed red cell distribution width (RDW) can improve the detection of morphological changes in red blood cells and the understanding of their contribution to dyserythropoiesis in myelodysplastic syndrome (MDS). The purpose of the study was to evaluate dyserythropoiesis in MDS by RDW analysis and to explore the utility of RDW in clinical practice. We retrospectively analyzed laboratory and clinical data of 101 patients (59 patients was refractory anemia (RA) according to the French-American-British (FAB) classification). In patients with RA, RDW was showed weak inverse correlation with both hemoglobin concentration (Hb) (rs = -0.37, P = 0.0035) and mean corpuscular hemoglobin concentration (MCHC) (rs = -0.36, P = 0.0047). On the other hand, RDW was showed weak correlation with the number of ringed sideroblasts in bone marrow (rs = 0.31, P = 0.023). The increased RDW (≥15.0%) was associated with shorter overall survival (OS) (P = 0.0086). In patients with refractory anemia with excess blasts (RAEB) and RAEB in transformation (RAEB-t), effect of RDW on OS was less evident. These results suggested that increased RDW might reflect dyserythropoiesis, associated with deregulated hemoglobin synthesis and iron metabolism in MDS. Furthermore, increased RDW may have potential to be a prognostic significance in RA.

Status of Natural Killer Cell Recovery in Day 21 Bone Marrow after Allogeneic Hematopoietic Stem Cell Transplantation Predicts Clinical Outcome

Rapid immune recovery following allogeneic hematopoietic stem cell transplantation (allo-HSCT) is important for clinical outcome prediction. In most studies, immune recovery after allo-HSCT is monitored via peripheral blood. However, few reports regarding the status of absolute lymphocyte subsets in the bone marrow (BM) microenvironment have been undertaken. Therefore, we evaluated the clinical impact of immune recovery in the early period following allo-HSCT using BM samples. We showed that delayed natural killer cell recovery was independently associated with a poor prognosis for overall survival (hazard ratio [HR], 3.07; 95% confidence interval [CI], 1.37- 6.89; P = .007), progression-free survival (HR, 3.42; 95% CI, 1.47-7.94; P = .004), and nonrelapse mortality (HR, 6.68; 95% CI, 1.82-25.0; P = .004) by multivariate analysis. In addition, low NK cell counts were associated with the presence of 1 or more bacterial, viral, or fungal infections. Our results indicate that investigating absolute lymphocyte subsets in BM in the early phase following allo-HSCT can be useful for predicting and improving survival outcomes.

Association of Soluble Interleukin-2 Receptor and C-Reactive Protein with the Efficacy of Bendamustine Salvage Treatment for Indolent Lymphomas and Mantle Cell Lymphoma

Bendamustine has demonstrated favourable efficacy in relapsed or refractory indolent lymphoma and mantle cell lymphoma. We retrospectively evaluated the pre-treatment clinical and laboratory factors and their correlation with the clinical outcome of these lymphomas. We analysed 53 patients who had been treated with bendamustine alone (n = 6) or rituximab plus bendamustine (n = 47). The overall response rate was 81.1%, with a complete response (CR) rate of 39.6%. The CR rate was significantly low in patients who had elevated levels of soluble interleukin-2 receptor (p = 0.024) and C-reactive protein (CRP; p = 0.004). The 1-year overall survival (OS) rate was 79.3%. An elevated CRP was associated with a short OS (p = 0.056). The present findings suggest that the lymphoma microenvironment and immune response were involved in the effects of bendamustine. These findings are also important in order to understand the pathophysiology of refractory lymphoma and to find effective strategies using bendamustine.

Post-cytokine-release Salt Wasting as Inverse Tumor Lysis Syndrome in a Non-cerebral Natural Killer-cell Neoplasm

The pathogenesis of cerebral/renal salt-wasting syndrome remains unknown. We herein present a case of salt-wasting syndrome with a natural killer-cell neoplasm without cerebral invasion. A 78-year-old man with hemophagocytic syndrome received two cycles of chemotherapy that did not induce tumor lysis syndrome, but repeatedly caused polyuria and natriuresis. The expression of tumor necrosis factor-α in the neoplasm led us to hypothesize that an oncolysis-induced cytokine storm may have caused renal tubular damage and salt wasting. Our theory may explain the pathogenic mechanism of cerebral/renal salt-wasting syndrome associated with other entities, including cerebral disorders, owing to the elevation of cytokine levels after subarachnoid hemorrhage.

Umbilical cord blood transplantation for adults using tacrolimus with two-day very-short-term methotrexate for graft-versus-host disease prophylaxis

Cord blood transplantation (CBT) is an alternative approach to allogeneic stem cell transplantation. However, CBT is associated with issues including pre-engraftment immune reaction (PIR), engraftment syndrome (ES), and graft failure (GF). Tacrolimus (TAC) and short-term methotrexate (sMTX: days 1, 3, 6, and/or 11) are used for graft-versus-host disease (GVHD) prophylaxis during CBT; however, sMTX does not accelerate neutrophil engraftment. Therefore, we hypothesized that lower doses of sMTX [very-short-term MTX (vsMTX): 10 and 7mg/m(2) on days 1 and 3, respectively] with TAC reduce the risk of GF without increasing post-transplantation immune reactions during CBT. We retrospectively analyzed 40 patients who received TAC with vsMTX for GVHD prophylaxis. PIR and ES developed in 4 patients. The cumulative incidence of neutrophil engraft at day 60 was 92.5%. No cases of primary graft failure were noted. The cumulative incidence of grades II-III GVHD was 48.1% at day 100, and the cumulative 100-day incidence of nonrelapse mortality was 12.5%. This study suggests that TAC with vsMTX reduces the risk of PIR and ES during CBT and stimulates neutrophil engraftment, but may be associated with slightly higher aGVHD compared with calcineurin inhibitor and sMTX. Therefore, we recommend vsMTX plus TAC as an option for GVHD prophylaxis during CBT.