Masanobu Morioka

Analysis of reactivation of hepatitis B virus in the treatment of B cell non-Hodgkin's lymphoma in Hokkaido.

Dear Editor, Despite the low immunosuppressive effects of rituximab, severe viral infections due to varicella zoster virus, parvovirus B19, cytomegalovirus, and JC papovavirus are sometimes associated with its use [1–5]. Several investigators have also reported fatal hepatitis due to hepatitis B virus (HBV) reactivation [6–9]. Because HBV reactivation has been observed frequently since the administration of rituximab was approved in Japan, we analyzed HBV reactivation in non-Hodgkin’s lymphoma patients treated with chemotherapy at seven institutions in Hokkaido between 1997 and 2007. We sent research heads at these institutions questionnaires asking them to evaluate HBV reactivation after chemotherapy with and without rituximab and lamivudine prophylaxis. The physicians at all seven institutions responded to these questionnaires, and in this retrospective analysis we evaluated the data for non-Hodgkin’s lymphoma patients with HBsAg (HBV carriers). All the patients enrolled in this retrospective study were examined for HBsAg and HBsAb positivity, and some were also examined for HBcAb, HBeAg, and HBeAb positivity. Our analysis showed that HBV reactivation was associated with rituximab-containing chemotherapy and rituximab monotherapy. Eight hundred and twenty-nine patients were treated with chemotherapy during this period. Fifty patients were positive for HBsAg, and the records of 47 of those patients could be analyzed (Table 1). Twenty-two of the patients were treated with chemotherapy without rituximab, five patients were treated only with rituximab, and the other 20 were treated with chemotherapy and rituximab. Twelve of the patients treated with chemotherapy without rituximab had also been given a steroid, as had three of the patients Ann Hematol (2009) 88:375–377 DOI 10.1007/s00277-008-0585-6

Establishment of a novel granulocytic sarcoma cell line which can adhere to dermal fibroblasts from a patient with granulocytic sarcoma in dermal tissues and myelofibrosis

Summary A novel human myeloid cell line, designated HSM‐1, has been established from the pleural effusion of a patient with granulocytic sarcoma (GS) who had been followed as having primary myeiofibrosis for 10 years. When he was diagnosed as having granulocytic sarcoma in dermal tissues, no evidence of malignant transformation into leukaemia was found in both the peripheral blood and bone marrow. The established cell line was positive for myeloperoxidase, Sudan black B. Naphthol AS‐D chloroacetate esterase. Surface marker analysis revealed that HSM‐1 expressed CD4. CD13, CD11a, CDllb, Leu8. CD49b. CD49d, CD49e, CD29 and HLA‐DR.

Inhibitory effect of bestatin on the growth of human leukemic cells.

We examined the effect of bestatin (Ubenimex) on the growth of human leukemic cells (i.e, HL-60, K562, MT-1, MT-2, Molt-4, and Raji cells). The growth of each cell line was inhibited by the cocultivation with bestatin at higher concentrations than employed for clinical use in Japan. [3H]TdR incorporation was also inhibited in MT-1 and MT-2 cells by treatment with bestatin. Degenerated cell-to-cell adhesion was observed among the treated cells. These findings suggest that the inhibitory effect on some leukemic cells, especially on MT-1 cells, results from the inhibition of DNA synthesis.

Epstein–Barr virus-positive ileal extraosseous plasmacytoma containing plasmablastic lymphoma components with CD20-positive lymph node involvement

We report a case of Epstein–Barr virus (EBV)-positive ileal extraosseous plasmacytoma containing plasmablastic lymphoma components with CD20-positive lymph node involvement. A 34-year-old healthy Japanese male developed intussusception due to an ileal plasmacytoma. The lesion was positive for EBV-encoded small nuclear RNA in in situ hybridization, with the surrounding lymph nodes showing the expression of CD20. Tumor cells in the ileal and lymph node lesions contained high-grade malignant features compatible with plasmablastic lymphoma. Because his abdominal lymph nodes recurred 6 months after resection, he received six cycles of R-CHOP chemotherapy (rituximab, cyclophosphamide, doxorubicin, vincristine, and prednisolone), and had a complete remission. Although his case was complicated by acute promyelocytic leukemia, he has so far survived, recurrence-free, for more than 7.5 years after chemotherapy for extraosseous plasmacytoma.

Primary Gastric Hodgkin’s Lymphoma Expressing a B-Cell Profile Including Oct-2 and Bob-1 Proteins

Classic Hodgkin’s lymphoma (cHL) most often involves lymph nodes, and gastric involvement is rare. Hodgkin’s and Reed-Sternberg (H-RS) cells in cHL are known to often lack expression of several B-lineage markers, such as CD20, CD79a, Oct-2, and Bob-1. We present an extremely rare case of mixed-cellularity cHL in the stomach in which expression of these B-cells was detected immunohistochemically. The patient was an 83-year-old Japanese woman who developed a sensation of abdominal fullness and appetite loss. Endoscopic and abdominal computed tomography examinations revealed a gastric ulcer lesion and swelling of para-aortic lymph nodes, respectively. A subtotal gastrectomy was performed, and the histopathologic diagnosis was established as a typical cHL compatible with stomach origin. The patient underwent postoperative chemotherapy of 3 cycles of ABVD (doxorubicin, bleomycin, vinblastine, and dacarbazine) and has since been in complete remission. Immunohistochemically, the H-RS cells in the cHL were positive not only for CD30 but also for CD20, CD79a, Oct-2, and Bob-1, whereas they were negative for CD3, CD15, CD45, EMA, and ALK1. Our patient may have had an intermediate cHL disease overlapping that of non-Hodgkin’s peripheral B-cell lymphoma, possibly reflecting derivation from germinal-center B-cells.

Effects of rhG-CSF on Infection Complications and Impaired Function of Neutrophils Secondary to Chemotherapy for Non-Hodgkin's Lymphoma

It has been previously demonstrated that the administration of recombinant human granulocyte-colony stimulating factor (rhG-CSF) ameliorates the decrease of the polymorphonuclear neutrophils (PMNs) count after the cytotoxic chemotherapies, thereby reducing the infection complications associated with neutropenia. In this multi-center study, we studied the prophylaxtic effect of rhG-CSF administration on infection complications in patients with non-Hodgkin malignant lymphoma, who received cytotoxic chemotherapies (CHOP or ProMACE/CytaBOM). rhG-CSF administration reduced the frequency of infection complications, and there was no obvious difference in its frequency between the CHOP-treated and the ProMACE/CytaBOM-treated groups when administered with rhG-CSF, thereby indicating that third generation therapy for NHL may be safely completed in Japanese in combination with rhG-CSF administration. Furthermore, we investigated both the in vitro and the in vivo effects of rhG-CSF on the function of PMNs in patients with NHL and healthy donors, and revealed that the administration of rhG-CSF for NHL patients receiving cytotoxic chemotherapy brought on an improvement of the production of active oxygen but did not affect serum levels of IFNs, IL-1-beta, and IL-6, inspite of a slight elevation of TNF-alpha. Consistent with these results, in vitro treatment of PMNs with rhG-CSF induced no significant production of these inflammatory cytokines and their mRNA expressions. Furthermore, rhG-CSF administration showed no significant effects in vivo on the expression of CD11a, CD11b and LECAM-1 on PMNs and integrins on platelets.

A first bout of thrombotic thrombocytopenic purpura triggered by herpes simplex infection in a 45-year-old nulliparous female with Upshaw-Schulman syndrome.

Dear Sir, Upshaw-Schulman syndrome (USS) is a congenital deficiency of ADMTS13 (a disintegrin-like and metalloprotease with thrombospondin type 1 motifs, 13) activity caused by gene mutations. ADAMTS13 specifically cleaves unusually large von Willebrand factor multimers produced in and released from vascular endothelial cells under high shear stress conditions in the microvasculature1,2. Thus, in the absence of ADAMTS13 activity, the uncleaved unusually large von Willebrand factor multimers are released into the circulation, causing a life-threatening systemic disease termed thrombotic thrombocytopenic purpura (TTP). Most cases of TTP are induced by acquired autoantibodies against this enzyme. USS is an extremely rare disease, and to date approximately 100 affected patients have been reported in the literature, of whom 43 are in Japan3. According to our experience in Japan, bouts of TTP in USS patients are triggered by various stimuli, including pregnancy, severe infection, administration of 1-deamino-8-D-arginine vasopressin (DDAVP) and drinking large amounts of alcohol. Pregnancy is the single most common trigger in female patients. In fact, in an analysis of the natural history of our 43 USS patients in Japan, we found that 26 (60%) were diagnosed during childhood (early-onset phenotype), and the remaining 17 (40%) were diagnosed after 15 years of age (late-onset phenotype). In the early-onset group, the female:male ratio was 13:13, while it was 14:3 in the late-onset group. These 14 female patients were aged between 15 and 45 years, and nine were diagnosed during pregnancy. In contrast, all three male patients had their first bouts after 45 years of age. With regards to ADAMTS13 activity, 35 patients had extremely low levels (<0.5% of normal), seven had trace amounts (0.5–0.8% of normal), and one male patient (USS-GG2) who had his first bout of TTP at 63 years of age had some activity (2.4–3.6%). Thus, one important determinant of the late-onset phenotype in USS patients is the level of ADAMTS13 activity. However, here we present the late-onset phenotype found in a middle-aged nulliparous USS female with severe deficiency of ADAMTS13 activity (<0.5% of the normal), whose first bout of TTP was triggered by an oral herpes simplex infection at the age of 45. The proband (USS-Y3), born in Sapporo in 1960, was the first of three siblings born to non-consanguineous parents. Her parents and two brothers have had no episodes of thrombosis or excessive bleeding. Her perinatal medical history was unclear, but she did not have any exchange blood transfusions as a neonate. By the age of 3, she suffered from repeated episodes of thrombocytopenia and was diagnosed with idiopathic thrombocytopenic purpura, for which she received transfusions of fresh whole blood on a few occasions. Further details of her medical history during childhood were unavailable. Since the age of 38, her platelet count has been occasionally evaluated at a nearby hospital. The counts were almost normal (104–175×109/L). However, when she has a cold, her platelet count temporarily drops to less than 50×109/L (minimum 19×109/L), but normalises without any specific medical therapy. At the age of 45, she suffered from an oral herpes simplex infection complicated by thrombocytopenia (11×109/L), for which the antiviral aciclovir (1,000 mg/day) was prescribed. Subsequently, she has had repeated episodes of oral herpes simplex infection; therefore, she received a prescription of acyclovir for 5 months but has not had an appreciable clinical improvement. She was referred to our hospital for analysis of the cause of her thrombocytopenia. Laboratory findings on admission were as follows: thrombocytopenia (9×109/L), haemolytic anaemia (red cell count 1.84×109/L, haemoglobin 6.7 g/dL, reticulocyte 168‰, schistocytes on a peripheral smear [2+], total bilirubin 2.8 mg/dL, lactate dehydrogenase 872 IU/L, and haptoglobin <10 mg/dL), near-normal renal function (blood urea nitrogen 19 mg/dL, creatinine 1.07 mg/dL, and positive occult blood in urine), C-reactive protein 0.1 mg/dL, negative direct and indirect Coombs’ tests, and normal haemostatic tests. She was initially treated with oral prednisolone (50 mg/day) for a diagnosis of Coombs-negative Evans syndrome, but soon thereafter her general condition worsened, and ADAMTS13 analyses were performed for diagnostic purposes. The family pedigree of this patient is shown in Figure 1A (left). The patient had very low ADAMTS13 activity ( A, exon 10) from her father and p.R1206* (c.3616 C>T, exon 26) from her mother. Her parents were heterozygous carriers of each of the two mutations (Figure 1B). These two mutations were not found in her younger brother. p.Q448E was reported as a single nucleotide polymorphism causing a missense mutation4. All mutations found in this family are shown in Figure 1C, including common single nucleotide polymorphism without amino acid substitutions. We previously reported the p.R1206X nonsense mutation in a USS-I4 patient5. The p.G385E missense mutation presented here is novel. Our experience indicates that the clinical phenotype of females with USS who have never been pregnant is almost indistinguishable from that of males. Figure 1 The family pedigree of USS-Y is shown in Figure 1A (left). Squares and circles indicate males and females, respectively, and the arrow with P indicates the proposita. Filled symbols represent a patient of USS-Y3. The half-filled symbols represent asymptomatic ...

Effect of granulocyte colony-stimulating factor on IL-12 p40 production during chemotherapy for B-cell lineage non-Hodgkin's lymphoma patients

Abstract:  Interleukin (IL)‐12 is a 70‐kDa cytokine comprised of two disulfide‐linked proteins (p35 and p40) and is essential for the initiation of effective immune response. Granulocyte‐colony stimulating factor (G‐CSF) affects the balance in the production of anti‐inflammatory cytokines. We investigated the serum IL‐12 p40 and IL‐12 Mix (p40 and p70) production in 28 patients with B‐cell lineage non‐Hodgkins lymphoma (NHL) treated with chemotherapy (e.g., CHOP regimen) with or without G‐CSF administration and eight healthy volunteers. We found that serum levels of IL‐12 p40 (191.2 ± 150.0 pg/mL) and IL‐12 Mix (277.4 ± 274.5 pg/mL) in the patients before chemotherapy were higher than those in the healthy volunteers (IL‐12 p40: 76.4 ± 25.3 pg/mL, IL‐12 Mix: 48.5 ± 33.4 pg/mL) (P = 0.04 and 0.02, respectively). Next, we examined the serum IL‐12 p40 and IL‐12 Mix levels in nine patients receiving chemotherapy with administration of G‐CSF (CG group, n = 9) and without G‐CSF (C group, n = 9). Serum IL‐12 p40 and IL‐12 Mix levels were decreased on 10 d after chemotherapy in both groups, and those in CG groups were significantly lower than those in C group. These results indicated that administration of G‐CSF decreased serum IL‐12 p40 and IL‐12 Mix levels. Overall survival (OS) at 24 months was not significantly different in the two groups (58.3% in group C vs. 80.0% in group CG, P = 0.67). However, the survival rate of patients at clinical stages III and IV in CG group (n = 6, 66.0%) was significantly better than that of patients in C group (n = 4, 25.0%) (P = 0.02). Long‐term administration of G‐CSF appears to influence the survival rate by reducing immunosuppressive IL‐12 p40 production.

^18F-FDG PET/CT imaging for a gastrointestinal mantle cell lymphoma with multiple lymphomatous polyposis

Multiple lymphomatous polyposis (MLP) is an uncommon type of gastrointestinal lymphoma characterized by the presence of multiple polyps along the gastrointestinal tract. Most of this entity is in fact considered the counterpart of gastrointestinal tract involvement for mantle cell lymphoma (MCL). To our knowledge, there have been no reports on [fluorine-18]-fluorodeoxy-glucose ((18)F-FDG)-positron emission tomography (PET)/computed tomography (CT) imaging for gastrointestinal MCL with MLP. We present the results of (18)F-FDG PET/CT imaging in a patient with gastrointestinal tract involvement of MCL showing continuous MLP from the stomach to the rectum and intestinal intussusception. FDG-PET/CT findings were false negative in typical MLP spreading widely over the gastrointestinal tract, but uptake was noted in large lesions with deep infiltration considered atypical as MLP. On FDG-PET/CT imaging, the Ki-67 proliferative index, which is a cell proliferation marker, showed neither correlation with the presence of uptake nor the maximum standardized uptake value.

Biphenotypic Acute Leukemia with t(15;17) Lacking Promyelocytic-retinoid Acid Receptor α Rearrangement.

Biphenotypic acute leukemias (BAL) account for less than 4% of all cases of acute leukemia. Philadelphia chromosome and 11q23 rearrangement are the most frequently found cytogenetic abnormalities. Since t(15;17) is almost always associated with acute promyelocytic leukemia, t(15;17) in BAL cases is extremely uncommon. We report here a rare and instructive case of BAL with t(15;17) and the successful treatment approach adopted. A 55-year old woman was referred to our hospital for an examination of elevated white blood cell (WBC) counts with blasts (WBC 13.4×109/L; 76% blasts). The blasts with acute lymphoblastic leukemia (ALL-L2, FAB) morphology co-expressed B-lymphoid and myeloid lineages, and a cytogenetic study revealed 4q21 abnormalities and t(15;17). However, promyelocytic-retinoid acid receptor α rearrangement was not detected by fluorescence in situ hybridization on interphase nuclei. Our patient was treated with chemotherapy for ALL and gemtuzumab ozogamicin without all-trans-retinoic acid, and has remained in hematologic first complete remission for more than 3.7 years.