Morio Sawamura

Immunomodulation by vitamin B12 : Augmentation of CD8+ T lymphocytes and natural killer (NK) cell activity in vitamin B12-deficient patients by methyl-B12 treatment

It has been suggested that vitamin B12 (vit.B12) plays an important role in immune system regulation, but the details are still obscure. In order to examine the action of vit.B12 on cells of the human immune system, lymphocyte subpopulations and NK cell activity were evaluated in 11 patients with vit.B12 deficiency anaemia and in 13 control subjects. Decreases in the number of lymphocytes and CD8+ cells and in the proportion of CD4+ cells, an abnormally high CD4/CD8 ratio, and suppressed NK cell activity were noted in patients compared with control subjects. In all 11 patients and eight control subjects, these immune parameters were evaluated before and after methyl‐B12 injection. The lymphocyte counts and number of CD8+ cells increased both in patients and in control subjects. The high CD4/CD8 ratio and suppressed NK cell activity were improved by methyl‐B12 treatment. Augmentation of CD3−CD16+ cells occurred in patients after methyl‐B12 treatment. In contrast, antibody‐dependent cell‐mediated cytotoxicity (ADCC) activity, lectin‐stimulated lymphocyte blast formation, and serum levels of immunoglobulins were not changed by methyl‐B12 treatment. These results indicate that vit.B12 might play an important role in cellular immunity, especially relativing to CD8+ cells and the NK cell system, which suggests effects on cytotoxic cells. We conclude that vit.B12 acts as an immunomodulator for cellular immunity.

Immunological abnormalities in splenic marginal zone cell lymphoma

The clinical features of patients with splenic marginal zone cell lymphoma (SMZCL) have rarely been reported. In the present study, immunological abnormalities, particularly hematological abnormalities, observed in SMZCL were described. Autoimmune hemolytic anemia, immune thrombocytopenia, and appearance of lupus anticoagulant were observed in 2 of 3 patients with SMZCL. Other abnormal data including monoclonal gammopathy and cold agglutinin were also observed in 2 of the 3 patients. Immunological abnormalities may be characteristic complications in patients with SMZCL and must be followed carefully, since they may be a reliable marker of this type of lymphoma activity. Am. J. Hematol. 56:173–178, 1997.

JAK2-V617F mutation analysis of granulocytes and platelets from patients with chronic myeloproliferative disorders: advantage of studying platelets

There have been conflicting reports over the JAK2‐V617F mutation status of platelets in chronic myeloproliferative diseases (CMPDs). The aim of this study was to analyse JAK2‐V617F status, not only in granulocytes but also in platelets. The JAK2‐V617F mutation was analysed in both granulocytes and platelets in 115 patients with CMPDs using direct sequencing. JAK2‐V617F was detected in granulocytes from 71 of those patients, all 71 of whom also had platelet JAK2‐V617F expression. The remaining 44 patients showed negative JAK2‐V617F expression on granulocytes, but positive JAK2‐V617F expression was detected on the platelets from nine of the 33 essential thrombocythaemia (ET) patients, one of the eight polycythaemia vera patients, and two of the three primary myelofibrosis patients. When ET patients were divided into three groups according to granulocyte and platelet JAK2‐V617F status (both‐positive, platelets‐only positive and both‐negative), the both‐positive and platelets‐only positive groups shared the clinical features of higher white blood cell count and frequent thrombosis. These results suggest that analysis of platelets is a more sensitive approach for detecting JAK2‐V617F in CMPD patients than analysis of granulocytes. They also suggest that previous reports of the incidence of JAK2‐V617F in CMPD patients, obtained using only analysis of granulocytes, could be underestimations.

Low-dose thalidomide plus low-dose dexamethasone therapy in patients with refractory multiple myeloma

We report the results of a non‐randomized phase II study of low‐dose thalidomide plus low‐dose dexamethasone therapy in 66 patients with refractory multiple myeloma. The overall response rate (near complete, partial and minimal response) was 63.6%, and progression‐free and overall survival periods were 6.2 and 25.4 months. In adverse events, the incidence of peripheral neuropathy and deep vein thrombosis was lower than the data reported in USA and Europe. On the other hand, leukopenia was observed in 41% of patients, including 11% of those with Grade 3. Leukopenia was closely related to pretreatment pancytopenia, especially thrombocytopenia. The incidence of adverse events related to dexamethasone was low. In conclusion, low‐dose thalidomide plus low‐dose dexamethasone therapy was as effective as high‐dose thalidomide plus high‐dose dexamethasone therapy in patients with refractory multiple myeloma. Leukopenia is one of the most serious adverse events in Japanese patients, especially in patients with pretreatment pancytopenia.

PLASMA CELL LEUKAEMIA WITH ALPHA-INTERFERON THERAPY IN MYELOMA

Alpha-interferon (IFN-alpha) is a commonly used therapeutic agent for myeloma. Although its adverse effects are widely recognized, less attention has been given to other possible hazards for myeloma. We report a myeloma patient who developed a plasma cell leukaemia (PCL) apparently triggered by IFN-alpha therapy. A 66-year-old previously untreated Japanese man with IgG kappa type myeloma at clinical stage IIIA was referred to our hospital on 24 March 1992. Investigation revealed: WBC 3.6 x 109/1 with 2.5% plasma cells: serum IgG-kappa Mprotein 71 g/l, lactate dehydrogenase (LDH) 2.49 pkat/l, interleukin 6 (IL-6) 16.2 pg/ml and Bence Jones proteinuria (BJP). Bone marrow aspiration revealed 80% atypical plasma cells. The patient was treated with natural IFN-alpha, sumiferon produced by Sumitomo (Osaka, Japan), along with intermittent melphalan and prednisolone. IFN-alpha was injected intramuscularly at 3 million units daily for 9 d. Treatment was stopped because the number of circulating plasma cells increased, while M-protein and BJP decreased. LDH and IL-6 increased rapidly, showing 12-4 pkat/l and 32.6 pg/ml, respectively. 12 d after starting therapy, the diagnosis of plasma cell leukaemia was established on the basis of a WBC count of 13.1 x 10y/l with 42.5% of circulating plasma cells which were demonstrated by immunohistochemical staining to be monoclonal for cytoplasmic gamma heavy chains and kappa light chains. Chemotherapy with vincristine, adriamycin and dexamethasone (VAD regimen) was begun. However, the patient developed renal failure and died of sepsis and disseminated intravascular coagulation on 22 April 1992. Blade et aZ (1991) described a myeloma patient who had developed PCL triggered by IFN-alpha therapy. IFN-alpha has been shown to stimulate the proliferation of IL-6-dependent myeloma cells by inducing an autocrine IL-6 production (Klein et al, 1990). IL-6 is a growth factor for myeloma (Kawano et a/, 1988; KIein et a!, 1990). In our case, PCL and rise in the serum IL-6 level was recognized during the IFNalpha therapy. Our experience in this case suggests the potential of tumour growth stimulation by IFN-alpha and the need for careful observation of the number of circulating plasma cells and serum IL-6 level under IFN-alpha therapy.

Chronic inflammatory demyelinating polyneuropathy accompanied by chronic myelomonocytic leukemia: possible pathogenesis of autoimmunity in myelodysplastic syndrome

Paraneoplastic neuropathies have rarely been reported in patients with hematological malignancies. We report herein the case of a 65-year-old Japanese woman with chronic myelomonocytic leukemia (CMML) accompanying chronic inflammatory demyelinating polyneuropathy (CIDP). She had been diagnosed with refractory anemia and subsequently developed CMML with cytogenetic abnormalities including t(3;8)(q26;q24). While regenerating bone marrow following induction chemotherapy, she complained of numbness in the lower legs and then became unable to walk. Clinical and electrophysiological features were consistent with CIDP. Intravenous immunoglobulin treatment was insufficient, although corticosteroids reduced neurological symptoms. This case suggests CIDP as one of the autoimmune phenomena associated with myelodysplastic syndrome and immunosuppressive treatment represents an effective therapy.

Circulating plasmacytoid dendritic cells in patients with primary and Helicobacter pylori-associated immune thrombocytopenia.

Objectives:  Immune thrombocytopenia (ITP) is an autoimmune disorder characterized by the production of autoreactive antibodies against platelet antigens. Although dysfunction of multiple aspects of cellular immunity is considered to be important in the pathogenesis of ITP, it has not been clarified which cell types play a principal role.

Methylation status of fragile histidine triad (FHIT) gene and its clinical impact on prognosis of patients with multiple myeloma

Abstract:  Aberrant methylation of tumor suppressor genes (TSG) has been studied in multiple myeloma (MM). We determined the methylation status of the FHIT (fragile histidine triad) gene, a putative TSG, in 48 patients with MM. Clinical association with its methylation status was then analyzed. The FHIT gene methylation was observed in 21 of the 48 patients (44%). No association between FHIT gene methylation and clinical variables such as age, gender and clinical stage was found. However, the estimated 50% survival time of the methylated group was significantly shorter than that of the unmethylated group (18.2 vs. 45.1 months, P < 0.05). Univariate analysis revealed adverse prognostic factors: FHIT gene methylation (P = 0.028), poor performance status (I to IV, P = 0.002), anemia (≤8.5 g/dL, P = 0.007), hypoalbuminemia (≤3.5 g/dL, P < 0.002), high serum C‐reactive protein levels (>0.5 mg/dL, P = 0.002), elevated beta‐2‐microglobulin serum levels (>6.5 mg/L, P < 0.001), and treatments not including autologous peripheral blood stem cell transplantation (auto‐PBSCT) (P = 0.007). Multivariate analysis identified FHIT gene methylation [hazard ratio (HR) 1.722, 95% confidence interval (CI) 1.150–2.603, P = 0.009], elevated beta‐2‐microglobulin serum levels (>6.5 mg/L, HR 2.005, 95% CI 1.035–3.937, P = 0.004), and treatments not including auto‐PBSCT are independent predictive variables. These findings indicate that aberrant methylation of the FHIT gene is an independent adverse prognostic factor in MM.

TUMOR NECROSIS FACTOR-ALPHA AND INTERLEUKIN 4 IN MYELOMA CELL PRECURSOR DIFFERENTIATION

Multiple myeloma is a B-cell malignancy characterized by the accumulation of a clonal population of plasma cells in the bone marrow that secrete a monoclonal immunoglobulin protein. It has been regarded as a tumor arising at the B, pre-B lymphocyte, or even stem cell level. Precursor cells are presumed to proliferate and differentiate, giving rise to clonal expansion in plasma cells. Peripheral blood mononuclear cells (PBMC) from 36 patients with multiple myeloma, 12 with monoclonal gammopathy of undetermined significance (MGUS), and 21 healthy controls were cultured in vitro in the presence of tumor necrosis factor-alpha (TNF-alpha) and interleukin 4 (IL-4). We have demonstrated that monoclonal plasma cells can be induced in different proportions from PBMC obtained from myeloma patients when exposed in vitro to TNF-alpha and IL-4. Although myeloma cell precursors cannot be distinguished from other cells by morphology, a high number of monoclonal plasma cells was detected in our culture system on day 4 even when plasma cells accounted for less than 0.2% of the cells seeded on day 0. In 16 of the 36 patients with myeloma, monoclonal plasma cells appeared after 4 days. These changes were not observed in PBMC from patients with MGUS or from controls. These findings thus suggest that circulating myeloma cell precursors differentiate into plasma cells in the presence of TNF-alpha and IL-4, and the variation in the number of myeloma cell precursors in peripheral blood could therefore be used as a prognostic parameter in response to chemotherapy in myeloma patients.

Trends of survival in patients with multiple myeloma in Japan: a multicenter retrospective collaborative study of the Japanese Society of Myeloma.

Trends of survival in patients with multiple myeloma in Japan: a multicenter retrospective collaborative study of the Japanese Society of Myeloma