Kyoji Ueda

Successful treatment with Erwinia L-asparaginase for recurrent natural killer/T cell lymphoma.

We describe a patient with natural killer (NK)/T cell lymphoma who relapsed after autologous peripheral blood stem cell transplantation (auto-PBSCT) and was successfully treated with Escherichia coli (E. coli ) and Erwinia l -asparaginase. A 38-year-old male patient with ulcerated tumor at the left thigh was diagnosed as having nasal type NK/T cell lymphoma on the basis of histopathological and flowcytometric findings of tumor, revealing diffuse infiltration of atypical lymphoid cells into blood vessels and expression of CD7 and CD56 antigens, but not CD3. He had tumor infiltration in the bone marrow and at the right lower lung field. After five cycles of CHOP (cyclophosphamide, doxorubicin, vincristine and prednisolone) therapy, the patient achieved complete remission and received high-dose chemotherapy with auto-PBSCT, although the tumor recurred in the right leg 10 months later. Despite salvage chemotherapy, followed by local irradiation and surgical amputation, a tumor recurred at the left upper gingiva 10 days after. Using E. coli l -asparaginase (6000 U/m 2 /day), the tumor regressed, fever was alleviated and the serum lactate dehydrogenase decreased to normal range after several days. The asparagine synthetase expression in tumor cells was immunohistochemically negative on paraffin-embedded tissues. Because of the anaphylactoid reaction developing after E. coli l -asparaginase, alternative Erwinia l -asparaginase (6000 U/m 2 /day) was administered, resulting in regression of tumor and fever lysis. l -asparaginase is a promising agent for the treatment of NK/T cell lymphoma.

Differentiation of follicular from mucosa-associated lymphoid tissue lymphoma by detection of t(14;18) on single-cell preparations and paraffin-embedded sections.

A 57‐year‐old woman was referred to the Kyoto Prefectural University of Medicine because of multiple polypoid lesions in the duodenum. On the basis of the histopathologic findings, mucosa‐associated lymphoid tissue lymphoma had been diagnosed. The polypoid lesions did not show any improvement in spite of antimicrobial therapy for elimination of Helicobacter pylori. Because the disease remained stable during the clinical course, no other specific treatment was administered. We performed fluorescence in situ hybridization (FISH) analysis on a single‐cell preparation obtained from the duodenal lesions, to assess the specific chromosome translocation. We identified BCL2/IGH fusion at a frequency of 83%. Two‐color FISH was also performed on paraffin‐embedded tissue sections, which demonstrated BCL2/IGH fusion–positive cells in neoplastic follicles. These findings, together with the CD10+ immunophenotyping of tumor cells, led to a diagnosis of primary follicular lymphoma of the duodenum. Interphase FISH with the IGH gene and oncogene probes is a rapid and powerful tool for assessing genomic changes in gastrointestinal lymphoma on single‐cell preparations and tissue sections. This technique is particularly useful in view of the increasingly small core biopsy samples and needle aspirations obtained for diagnostic purposes.

Complete cytogenetic and molecular response to treatment with imatinib mesylate for philadelphia chromosome positive acute myeloid leukemia with multilineage dysplasia

The Philadelphia (Ph) chromosome positive acute myeloid leukemia (AML) is an uncommon disorder with poor prognosis when treated with conventional chemotherapy [1,2]. Here, we report long-lasting complete molecular remission (CMR) induced by imatinib mesylate monotherapy in a patient of Phþ AML with multilineage dysplasia. A 64-year-old female presented in November 2002 with asymptomatic anemia and neutropenia without a significant past medical history. The initial WBC count was 2.7610/L without a circulating myeloblast. Hb level and platelet count were 9.7 g/dl and 334610/L, respectively. The NAP score was 284 and serum vitamin B12 was 810 pg/ml. There was no splenomegaly or lymphadenopathy. Bone marrow (BM) aspiration showed a hypercellular marrow with immature blasts of 22.8% of all nucleated cells and morphological dysplasia including micromegakaryocytes, hypogranulated pseudo Pelger-Hüet neutrophils and megaloblastoid erythroblasts. Cytogenetic analysis of cultured BM cells identified 46,XX,t(9;22)(q34;q11) karyotype in all twenty analysed metaphases. The bcr-abl fusion signal was positive in 37 of 100 analyzed interphase peripheral mononuclear cells by double color fluorescence in situ hybridization (FISH) analysis using BCR/ ABL ES dual color translocation probe (Vysis, USA) following the manufacturer’s protocol. The blast cells were positive for myeloid antigens comprising CD13, CD33, HLA-DR and MPO. Lymphoid markers were negative. Lack of myeloproliferative features and existence of morphological dysplasia did not meet the criteria for chronic myeloid leukemia (CML); consequently, the patient was diagnosed with de novo Phþ AML with multilineage dysplasia. She was initially treated with oral vitamin D3, as is used for myelodysplastic syndrome (MDS). Eight months after the initial diagnosis, the initial treatment had no effect on either the WBC or the Hb level and the number of blasts increased to reach 50.4% with the cytogenetic findings of the same as the initial abnormal karyotype. The major bcr-abl transcription was detected by means of quantitative reverse transcription polymerase chain reaction (RT-PCR), and identified 230 copies/mg RNA in BM cells. Instead of conventional chemotherapy, imatinib was solely administered at a daily dose of 400 mg/ body after written informed consent was obtained because of the patient’s age and the existence of multilineage dysplasia, which could be associated with poor sensitivity for chemotherapeutic agents [1,2]. After the start of imatinib administration, NCI-CTC grade IV leukocytopenia and thrombocytopenia occurred and imatinib was transiently ceased between day 30 and 42 (Figure 1). Therafter, imatinib was restarted at a daily dose of 300 mg/body. On day 59, complete hematologic remission (CHR) was achieved with 4.8% blasts in BM without a circulating blast,

Multiple bone lesions after allogeneic bone marrow transplantation in a patient with relapsed adult acute lymphoblastic leukemia: minimal residual disease analysis may predict extramedullary relapse.

We describe a patient with acute lymphoblastic leukemia (ALL, L2) who relapsed with multiple bone lesions after allogeneic bone marrow transplantation (allo-BMT). Allo-BMT was performed from an HLA-identical sibling during the first hematological complete remission (CR). Minimal residual disease (MRD) assessed by polymerase chain reaction (PCR) with primers for T cell receptor δ (TCRδ) gene became positive in the bone marrow sample on day 46 after allo-BMT. On day 113, the patient complained of a painful tumor at the right clavicle. The examination of biopsy specimen revealed infiltration of leukemic cells. After partial response was achieved by local radiotherapy, disseminated bone lesions were demonstrated by 99mTC scintigraphy scan, followed by bone marrow relapse on day 137. The patient died of cardiac tamponade on day 236 after Allo-BMT. MRD assessed by PCR assay for TCRδ gene in the bone marrow is useful for the prediction of extramedullary as well as medullary relapse after BMT.

Method — Intra-bone marrow transplantation of hematopoietic stem cells in non-human primates: long-term engraftment without conditioning

It has recently been reported that bone marrow cells can efficiently engraft without marrow conditioning when implanted directly into the bone marrow cavity (intra-bone marrow transplantation, iBMT) in mice. We have successfully examined the efficacy of autologous iBMT in a cynomolgus monkey model in conjuction with an in vivo expansion of transplanted cells by a selective amplifier transgene (Ueda et al., 2004) and provide here the detailed parameters of our iBMT method. We injected retrovirally-marked autologous CD34+ cells directly into the non-conditioned marrow cavity of the femur and humerus after gently irrigating the cavity with saline. This transplant procedure was safely performed without pulmonary embolism. Gene-marked cells were not detectable in the peripheral blood at one hour and one day after iBMT as assessed by sensitive PCR, indicating that iBMT hardly generated a systemic delivery of transplanted cells. On the other hand, 2 to 30% of clonogenic hematopoietic colonies produced from the implanted marrow were gene-marked at 6–12 months after iBMT. Our iBMT method for non-human primates is thus discussed in terms of long-lived hematopoietic stem/progenitor cells, bone marrow niche and long-term engraftment after iBMT without myeloablative conditioning.

Long-term molecular remission after nonmyeloablative stem cell transplantation in a patient with chronic myelogenous leukemia in the chronic phase.

cytogenetic analysis demonstrated the Philadelphia (Ph) chromosome in 100% metaphases. A diagnosis of CML was made and hydroxyurea at 40 mg/kg and interferon· 2b at 4 MU/m 2 s.c. were initiated until the WBC count was normalized. Afterwards, hydroxyurea was given for at least 10 months, whereas interferon treatment was stopped for 2 months because of the appearance of melancholia. Considering his age, we performed a nonmyeloablative peripheral blood SCT from his HLA-identical brother in November 2001. The conditioning regimen consisted of fl udarabine at 30 mg/m 2 i.v. on days –8 to –3 and busulfan p.o. at 4 mg/kg in divided doses. To prevent graft-versus-host disease (GVHD), cyclosporin A was administered starting on day –1 at 3 mg/kg per day as a continuous intravenous infusion and methotrexate at 10 mg/m 2 i.v. on day 1 and at 7 mg/m 2 i.v. on days 3 and 6. The dose of total CD34+ cells infused was 2.7 ! 10 6 /kg recipient weight. Posttransplant hematological recovery was prompt. Neutrophils reached 6 0.5 ! 10 9 /l by day 11 and platelets 6 50 ! 10 9 /l by day 14. The chimerism evaluated by PCR for microsatellite regions showed that peripheral blood mononuclear cells were 100% donor type on day 58. Cytogenetic analysis of bone marrow asSeveral groups have explored a nonmyeloablative conditioning regimen for patients ineligible for myeloablative stem cell transplantation (SCT). The use of nonmyeloablative regimens reduces the risk of treatment-related toxicity and can extend the use of allotransplantation for older patients [1] . This approach allows engraftment and generation of graft-versus-leukemia effects. Nonmyeloablative SCT for chronic myelogenous leukemia (CML) is being evaluated in this context and may successfully replace myeloablative SCT [2] . We successfully performed a nonmyeloablative SCT in an elderly patient with chronic phase CML, who had been forced to stop interferon· because of side effects. A 57-year-old man with a cough and fever was admitted in January 2001. The physical examination did not reveal hepatosplenomegaly. His peripheral blood cell count revealed Hb 10.7 g/dl, platelets 2,056 ! 10 9 /l, WBC 74.21 ! 10 9 /l, myeloblasts 2.5%, promyelocytes 1.0%, myelocytes 5.0%, metamyelocytes 12.0%, bands 24.5%, segments 27.5%, eosinophils 10.0%, basophils 10.0%, monocytes 2.0%, and lymphocytes 5.0%. Bone marrow aspirate showed hypercellularity (nucleated cell count 480 ! 10 9 /l), increased to a 66.0% myeloid lineage with 8.0% eosinophils and 8.8% basophils. Bone marrow Received: November 17, 2003 Accepted after revision: April 5, 2004