Kazuyoshi Ishii

Evaluation of Angiopoietins and Cell-Derived Microparticles after Stem Cell Transplantation

Although stem cell transplantation (SCT) is being used for hematopoietic reconstitution following high-dose chemotherapy for malignancy, it involves certain serious transplant-related complications such as graft-versus-host disease (GVHD). Angiopoietins play important roles in angiogenesis. However, the role of angiopoietins after SCT is poorly understood. In this study, 52 patients underwent SCT; 26 patients received allogeneic SCT, while the remaining 26 received autologous SCT. In 48 of 52 patients, levels of angiopoietins, cytokines, and soluble factors were measured by enzyme-linked immunosorbent assay. Soluble Fas ligand (sFasL) and endothelial cell-derived microparticle (EDMP) exhibited significant elevation in the early phase (2-3 weeks) after SCT. In addition, the elevation of interleukin (IL)-6, tumor necrosis factor (TNF)-alpha, and sIL-2 receptor (sIL-2R), which are GVHD markers after allogeneic SCT was observed. The level of angiopoietin (Ang)-2 in allogeneic SCT continued to increase for up to 4 weeks, although the level of Ang-1 did not show significant changes. The patients with high Ang-2 exhibited significant increase of sFasL and EDMP compared with those with low Ang-2. In addition, the patients with high-grade GVHD exhibited a significant increase in Ang-2 compared to patients with low-grade GVHD. In the in vitro experiment using endothelial cells, the suppressive effect of Ang-1 on EDMP generation by TNF-alpha was partially inhibited by the addition of Ang-2. Furthermore, multivariate regression analysis showed that EDMP and sFasL were significant factors in Ang-2 elevation. Our results suggest that Ang-2 generation after allogeneic SCT relates to GVHD.

The correlation between platelet activation markers and HMGB1 in patients with disseminated intravascular coagulation and hematologic malignancy

To the editor Disseminated intravascular coagulation (DIC) frequently complicates hematologic malignancy and infections [1]. Coagulation abnormalities and thrombocytopenia are common in DIC, and the extent of hemostatic disorders appears to correlate with disease severity [2]. In particular, low platelet count is predictive of poor outcome [3, 4]. In DIC patients, the thrombin generated may react with thrombin receptors (PAR-1) located on the platelets and result in platelet activation. On the other hand, high mobility group-B1 DNA binding protein (HMGB1) is a nuclear architectural chromatin binding protein released by necrotic cells that has been identified as a mediator of endotoxin-induced lethality, and acts at least in part as a proinflammatory cytokine [5–7]. Moreover, HMGB1 also plays a role in the pathogenesis of DIC because plasma HMGB1 levels correlate with DIC scores [8]. However, the significance of activated platelets related to HMGB1 in DIC patients is poorly understood. Here, we describe the correlation between platelet activation markers and HMGB1 in DIC patients with hematologic malignancy. In addition, we investigated the effect of recombinant thrombomodulin (rTM) on these markers. Patients with DIC associated with hematologic malignancy were recruited. DIC was diagnosed according to the diagnostic criteria established by the Japanese Ministry of Health, Labor and Welfare [9]. In total, 45 patients comprised of 27 males and 18 females were enrolled. The median age was 54 years (range 21–78 years). Serum samples collected at baseline and 14 days after rTM therapy were tested by ELISA for antibodies against the markers. All ELISA kits were used according to the manufacture’s instructions. For DIC patients with hematologic malignancy, univariate analysis showed that prothrombin time (PT), fibrinogen, C-reactive protein (CRP), plateletderived microparticle (PDMP), soluble CD40 ligand (sCD40L), interleukin (IL)-6, and tissue necrotizing factor (TNF)! regulated on activation of normal T-cell expressed and secreted (RANTES) and monocyte chemotactic peptide-1 (MCP-1) were significantly associated withHMGB1 (Table I). In addition, fibrinogen, CRP, PDMP, sCD40L, TNF! and RANTES were significant factors in the multivariate model with HMGB1 (Table I). DIC patients exhibited a significant decrease inHMGB1 levels after rTM therapy (before vs. after, 26.3! 8.4 vs. 12.1! 5.9 ng/ ml, p< 0.001). In addition, the levels of platelet activation markers and cytokines were significantly decreased after rTM therapy in DIC patients (before vs. after, PDMP: 19.9! 3.3 vs. 11.7! 2.9 U/ml, p< 0.001; sCD40L: 3.45! 1.18 vs. 2.00! 0.79 ng/ml, p< 0.001; RANTES: 92.6! 14.5 vs.

Can recombinant thrombomodulin play a preventive role for veno-occlusive disease after haematopoietic stem cell transplantation?

Can recombinant thrombomodulin play a preventive role for veno-occlusive disease after haematopoietic stem cell transplantation? -

A Case of Hemophagocytic Lymphohistiocytosis After the Primary Epstein-Barr Virus Infection:

The Epstein-Barr virus (EBV) infection is known to result in infectious mononucleosis, hemophagocytic syndrome, chronic active EBV infection, and lymphoma. Among them, hemophagocytic syndrome sometimes causes thrombocytopenia, which is often life threatening because of its hemorrhagic complications such as gastrointestinal bleeding and pulmonary alveolar hemorrhage. A young adult case of critical hemophagocytic syndrome after primary EBV infection is presented. Chemotherapy was performed using methyl prednisolone succinate, prednisolone, cyclosporin A, and 20 mg/kg of cyclophosphamide. The patient received intensive care, including plasma exchange for hepatic failure, extracorporeal membrane oxygenation for acute respiratory failure, and splenectomy for hemophagocytosis; however, the patient died of multiple organ failure, including fulminant hepatic failure. The pathologic examination of the resected specimen demonstrated infiltrated macrophages containing many phagocytosed erythrocytes. Further immunopathologic examination of these cells showed that the histiocyte markers were positive, whereas the T-cell marker was negative. In view of these findings, definite diagnosis of EBVrelated hemophagocytic lymphohistiocytosis could not be made at that time. The immunohistologic examinations on the liver necropsy specimen provided the evidences suggesting the morbid activation of the hepatic stellate macrophage by EBV-infected T/NK cells and subsequent apoptosis induction of the liver cells through the Fas ligand pathway.

TGFβ1 and sCTLA-4 levels are increased in eltrombopag-exposed patients with ITP

Some thrombopoietin receptor-agonists (TPR-As) have been developed and shown to be highly effective in the treatment of immune thrombocytopenic purpura (ITP). Soluble cytotoxic T-lymphocyte-associated antigen 4 (sCTLA-4) can modulate and terminate the immune response. Several reports have shown that sCTLA-4 levels are elevated in patients with some autoimmune disorders. However, sCTLA-4 levels have not previously been investigated in TPR-A exposed patients with ITP. We investigated the levels of transforming growth factor (TGF) β(1) and sCTLA-4 in ITP patients to determine the clinical association with TGFβ(1) and sCTLA-4 in TPR-A-exposed patients with ITP. Thirty-seven ITP patients were divided into 2 groups (TPR-A-exposed: 13 patients; unexposed: 24 patients). Doses of eltrombopag ranging from 12.5mg to 50mg were administered daily, and biochemical data obtained before and after eltrombopag administration were compared. Eltrombopag therapy significantly increased sCTLA-4 and TGFβ(1) levels relative to baseline in patients with ITP. In addition, plasma TGFβ(1) was positively correlated with platelet counts and sCTLA-4 in patients with ITP in the eltrombopag-exposed group. However, no significant change in the detection rate for anti-glycoprotein antibody was observed before and 24 weeks after eltrombopag treatment. These results suggest that eltrombopag can partially modulate some immune responses by TGFβ(1) and sCTLA-4, but it does not induce immune tolerance by 24 weeks after treatment.

Adult T-cell leukemia after immunosuppressive therapy for systemic lupus erythematosus

Retroviruses, including human T-cell leukemia virus (HTLV)-1, are possible etiological factors for autoimmune diseases such as systemic lupus erythematosus (SLE) [1]. In particular, SLE patients can produce autoantibodies to the HTLV-1-related endogenous sequence (HRES)-1/p28 [2]. Adult T-cell leukemia (ATL) is a human malignancy associated with HTLV-1 and its diagnosis based on the clinicopathological findings and the presence of integrated HTLV-1 provirus in the DNA of tumor cells [3]. Here, we describe HTLV-1 carrier patient with SLE, who was presented with ATL after immunosuppressive therapy. The patient was a 63-year-old Japanese woman. Five years earlier, she had been diagnosed with SLE based on Raynoud’s phenomenon, polyarthralgia, malar rash, decreased serum complement levels, and positive results for antinuclear and anti-RNP antibodies. She was from Kyushu Island, a HTLV-1 endemic area in Japan, and was tested seropositive for HTLV-1. However, peripheral blood smear and bone marrow examinations showed no abnormalities. She was treated with high-dose steroids (intravenous 1,000 mg methylprednisolone daily for 3 days) followed by 20 mg dexamethasone, also daily. During the course of immunosuppressive therapy, she developed new flashing on her whole body with the occurrence of many abnormal cells in peripheral blood. Skin biopsy revealed the invasion of ATL cells. She was diagnosed with ATL. The time lag between the immunosuppressive therapy and the develop

Therapeutic efficacy of leukocytapheresis for procoagulant microparticles during hemophagocytic syndrome.

Hemophagocytic syndrome (HPS) presents with signs of persistent remittent fever, hepatosplenomegaly, pancytopenia, hepatic dysfunction, and disseminated intravascular coagulation because of hypercytokinemia caused by activated T lymphocytes and macrophages. In recent years leukocytapheresis using a leukocyte removal filter (known as lymphocytapheresis, LCAP) has been applied to the treatment of various autoimmune diseases. The removal of activated monocytes during LCAP treatment appears useful for hypercytokinemia. We experienced a 32-year-old Japanese man with HPS with elevated tissue factor-enriched monocyte-derived microparticles (MDMPs) and pro-inflammatory cytokines/chemokines. Improvements in the level of MDMPs and hypercytokinemia were observed after LCAP treatment. LCAP treatment performed for HPS can be considered a therapeutic strategy for patients with a risk of fetal hemorrhage.

Delayed HBV reactivation in rituximab-containing chemotherapy: How long should we continue anti-virus prophylaxis or monitoring HBV-DNA?

Reactivation of hepatitis B virus (HBV) infection is a well-recognized and potentially fatal complication in patients treated with chemotherapy for lymphoid malignancies. Although several guidelines recommend antiviral prophylaxis and/or monitoring for HBV-DNA, there is no consensus over what time period these should occur. Clinically, we have encountered delayed reactivation of HBV infections and have reported 12 cases of reactivation in patients. Among them, five patients developed HBV reactivation more than a year after they completed their chemotherapy. This means there can be a delayed HBV reactivation and prolonged monitoring of more than a year after cessation of chemotherapy may be needed. Hence, the current recommendation of stopping antiviral prophylaxis 6-12 months after the cessation of chemotherapy may not fully protect all patients from HBV reactivation. The optimal duration of follow-up needs to be determined, and until better guidelines are set, there is no choice but to keep monitoring patients for reactivation for as long as practicable.

Relationship between HMGB1 and PAI-1 after allogeneic hematopoietic stem cell transplantation

Background Conditioning regimens including total body irradiation (TBI) or cyclophosphamide can mobilize high-mobility group box 1 (HMGB1) to peripheral blood. Additionally, increased plasminogen activator inhibitor (PAI)-1 levels are associated with post-allogeneic hematopoietic stem cell transplantation (aHSCT). However, changes to circulating levels of HMGB1 after aHSCT are poorly understood. Materials and methods The study cohort included 289 patients who underwent aHSCT at one of 25 institutions in Japan. We have investigated the relationship between HMGB1 and PAI-1 following aHSCT. A significant increase in HMGB1 levels occurred after conditioning treatment. Additionally, levels of HMGB1 at day 0 were significantly increased in TBI+ patients and cyclophosphamide/TBI patients. Conclusion Our data revealed that an increased level of HMGB1 at day 0 following aHSCT correlates with increased PAI-1 after aHSCT, which is consistent with previous reports. Increased HMGB1 at day 0 after a conditioning regimen may play a role in transplantation-associated coagulopathy following aHSCT, because PAI-1 can accelerate procoagulant activity.

VNCOP-B plus rituximab therapy in elderly patients with aggressive B-cell non-Hodgkin lymphoma: a multicenter experience.

CHOP (cyclophosphamide, adriamycin, vincristine, and prednisolone) plus rituximab is a standard chemotherapy used to treat patients with aggressive B-cell non-Hodgkin lymphoma (B-NHL). However, among elderly patients, this regimen has not been completely satisfactory in its efficacy and safety. We report our clinical experience in 8 collaborative institutions to determine if the VNCOP-B (etoposide, mitoxantrone, cyclophosphamide, vincristine, prednisolone, and bleomycin) combination therapy plus rituximab was effective and safe to treat elderly patients with aggressive B-NHL. Between September 2004 and December 2007, 23 previously untreated patients, median age 73 years, 50.0% classified as high-intermediate/high-risk on the standard International Prognostic Index (IPI) entered this trial. Complete remission rate was 90.5%, with a 100% overall response rate (RR) at the end of induction therapy; overall survival (OS) rate at 3 years was 76.4% (median follow-up 744 days), with an 82.6% 3-year progression-free survival (PFS) rate (median follow-up 744 days). The most common grade 3/4 toxicities were hematologic, including neutropenia in 75.0% of the patients despite prophylactic administration of granulocyte colony-stimulating factor (G-CSF), febrile neutropenia in 30.0%, respectively. There was no treatment-related mortality (TRM). Rituximab not only combined with chemotherapy but also given sequentially improved survival. R-VNCOP-B could be another option for elderly patients who are not considered to tolerate in receiving R-CHOP.