Naoki Shingai

CD25 expression on residual leukemic blasts at the time of allogeneic hematopoietic stem cell transplant predicts relapse in patients with acute myeloid leukemia without complete remission

Abstract Recent studies have shown that CD25 expression at the time of diagnosis of acute myeloid leukemia (AML) may be associated with an unfavorable outcome. We focus on patients with AML without complete remission (CR) and examine the clinical correlation between surface CD25 expression at the time of transplant and subsequent transplant outcomes. We observed a significant difference in overall survival (OS), disease-free survival (DFS) and cumulative incidence of relapse (CIR) between CD25 positive (+) (n = 22) and negative (−) groups (n = 44) (2-year OS; CD25 (+) group: 5% vs. CD25 (−) group: 40%, p < 0.0001, 2-year DFS; 5% vs. 29%, p < 0.0001, 2-year CIR; 77% vs. 52%, p = 0.03). Multivariate analysis showed that CD25 expression was an independent adverse factor for OS (p = 0.002) and relapse (p = 0.001). Patients with AML with residual CD25 positive blasts at the time of transplant may require additional therapy before or after transplant to improve survival.

Overexpression of RUNX1 short isoform has an important role in the development of myelodysplastic/myeloproliferative neoplasms

RUNX1a, but not RUNX1b, is overexpressed in CD34+ cells from patients with myelodysplastic/myeloproliferative neoplasms.SRSF2P95H mutation induces RUNX1a overexpression and a monocytic phenotype in TF-1 cells.

Allogeneic hematopoietic stem cell transplant overcomes poor prognosis of acute myeloid leukemia with myelodysplasia-related changes

Recent studies have shown that acute myeloid leukemia with myelodysplasia-related changes (AML-MRC) exhibits a worse clinical outcome than AML not otherwise specified (AML-NOS). However, transplant outcomes of patients with AML-MRC have not been reported compared to patients with AML-NOS. We analyzed transplant outcomes among 147 patients with AML-MRC or AML-NOS who underwent allogeneic hematopoietic stem cell transplant (allo-HSCT) in a single institution. There were no significant differences in the 2-year overall survival (OS), cumulative incidence of relapse (CIR), and non-relapse mortality (NRM) between the two groups (2-year OS: 48% vs. 59%; 2-year CIR: 37% vs. 35%; 2-year NRM: 19% vs. 13%). Subgroup analysis adjusting for age and disease status demonstrated the same results between the two groups. Furthermore, multivariate analysis showed that AML-MRC was not an independent prognostic factor for poor prognosis in the setting of allo-HSCT (p = 0.7). These results suggest that allo-HSCT may overcome the poor prognosis of AML-MRC.

Clinical and radiological CLIPPERS features after complete remission of peripheral T-cell lymphoma, not otherwise specified

Chronic lymphocytic inflammation with pontine perivascular enhancement responsive to steroids (CLIPPERS) is a recently reported inflammatory disease of the central nervous system (CNS) [1–2]. Peripheral T-cell lymphoma, not otherwise specified (PTCL-NOS) is an uncommon form of non-Hodgkin lymphoma [3]. We report the case of a patient who developed CLIPPERS within 1 year of remission of PTCL-NOS after chemotherapy.

Clinical impact of CD25 expression on outcomes of allogeneic hematopoietic stem cell transplant for cytogenetically intermediate-risk acute myeloid leukemia

Approximately 50% of adult patients with acute myeloid leukemia (AML) do not show clonal chromosome aberrations at diagnosis, and although this group shows an intermediate prognosis, a minority of patients eventually become long-term survivors. [1]. Th is emphasizes the need for new molecular markers that can be used to predict disease aggressiveness and to determine the leukemic response to treatment, including allogeneic hematopoietic stem cell transplant (allo-HSCT) [2]. Recent data have shown that molecular analysis of the presence of mutated FMS-like tyrosine kinase-3 (FLT3), nucleophosmin 1 (NPM1), CCAAT/ enhancer-binding protein alpha (CEBPA), mixed lineage leukemia (MLL) or neuroblastoma RAS viral oncogene homolog (N-Ras) may be useful for this purpose [3]. However, molecular analyses may be costly and not always available, as not all the mutations are detected by sequencing. As an alternative approach, we may be able to focus on distinct clinical features that depend on specifi c genetic aberrations. For example, patients with a FLT3-internal tandem duplication (ITD) mutation tend to have higher white blood cell count and blast count [4], and moreover a high percentage of these patients may have high CD25 (the α -chain of the interleukin-2 [IL-2] receptor) antigen expression as observed with fl ow cytometry [5 – 7]. Recent studies have shown that CD25 is highly expressed in chemotherapy-resistant, cell cycle-quiescent leukemic stem cells, and high CD25 expression may be associated with an unfavorable outcome after conventional chemotherapy, including autologous and allogeneic transplant [5 – 7]. Th us, evaluation of CD25 expression may be an alternative, cost-eff ective non-molecular tool for cytogenetically intermediate (CI)-AML. Here we report the clinical impact of surface expression of the CD25 antigen on transplant outcomes in a total of 40 patients with CI-AML who underwent allo-HSCT in a single institution. In this study, intermediate-risk AML included patients with a normal or indeterminate karyotype. Bone marrow and peripheral blood samples from 40 patients with CI-AML were available for analysis of CD25 expression at the initial diagnosis. Th ese patients eventually underwent allo-HSCT in our institution between January 2001 and January 2013. We list the chemotherapies, conditioning regimens and outcomes (Supplementary Table I to be found online at http://informahealthcare.com/doi/ abs/10.3109/10428194.2014.974044). Patients with French – American – British (FAB) classifi cation M3 were excluded. Flow cytometry analyses were performed in-house using standard immunofl uorescence methods with monoclonal antibodies directed against CD2, CD3, CD4, CD5, CD7, CD8, CD10, CD11b, CD13, CD14, CD19, CD20, CD25, CD33, CD34, CD38, CD41, CD56 and human leukocyte antigen (HLA)-DR antigens, and were considered to be positive if at least 20% of leukemic blasts expressed the antigen [5]. Th e cut-off level of CD25 depends on the report, for example 10% [6,7] and 20% [5]. Generally the cut-off level of 20% has been known as the standard, and we consider this as the best cut-off level to exclude false-positive results. Transplant procedures have been described in detail elsewhere [8]. Myeloablative conditioning mainly included busulfan (3.2 mg/kg for 4 days) and cyclophosphamide (60 mg/kg for 2 days). Th e main preparative regimen for the reduced-intensity procedure consisted of fl udarabine (30 mg/m 2 for 6 days), melphalan (40 mg/m 2

Neutropenia associated with antihuman neutrophil antibodies following allogeneic hematopoietic stem cell transplantation

Dear Sirs, Although detection of antibodies reactive with neutrophils (ARN) following hematopoietic stem cell transplantation (HSCT) is not uncommon [1,2], neutropenia because of antihuman neutrophil antigen (HNA) antibody is rare, and very few cases have been reported to be associated with anti-HNA-2 antibody [3,4]. We herein present a case of anti-HNA antibody-associated neutropenia following allogeneic HSCT. By monitoring representative anti-HNA antibodies, the patient showed a variety of anti-HNA antibodies; we speculated that the anti-HNA-2 antibody played a crucial role in the development of neutropenia. A 58-year-old man with chronic myeloid leukemia carrying T315I mutation received a bone marrow transplantation from an unrelated, human leukocyte antigen identical donor on March 3, 2011. The initial post-transplant clinical course was unremarkable except for mild acute graft-versus-host disease of the gut, which was improved by low-dose (0.5 mg/kg) prednisolone (PSL). Neutrophil engraftment was confirmed on day 15 after HSCT. However, the neutrophil counts gradually decreased on day 240 and finally fell below 500/ll on day 285. Then, the patient was admitted to our hospital because of acute pharyngitis on day 303. At that time, the white blood cell count was 1800/ll with 130/ll of neutrophils, hemoglobin 8.3 g/dl, and platelets 7.3 9 10/ll. The pharyngitis was subsided with tazobactam/piperacillin (TAZ/PIPC); however, the neutrophil counts remained below 100/ll despite the administration of granulocyte colony-stimulating factor (G-CSF). Bone marrow aspiration performed on day 309 showed normocellular marrow with marked decrease in metamyelocytes (2.0%) and mature granulocytes (3.8%). Bcr/abl chimeric transcripts were not detected. G-CSF was stopped on day 322 because of no response. With a suspicion of immune-mediated neutropenia, the patent received a screening test for both anti-G-CSF and antiHNA antibody. Although anti-G-CSF antibody was not detected, anti-HNA antibody tests were positive for antiHNA-2 and -5a/b (Table 1). Therefore, the patient was diagnosed as immune-mediated neutropenia and received 1 mg/kg of PSL after day 336. As early as the next day after starting PSL, the neutrophil counts increased to 525/ ll and returned to normal range in a week and then discharged on day 346. However, 1 month later, although the patient was put on 1 mg/kg of PSL, the neutrophil counts again abruptly decreased to 310/ll. The further dose escalation of PSL was considered to be less effective; instead, PSL was tapered. On day 406, the patient developed urinary tract infection by Enterococcus faecalis, which was successfully treated with TAZ/PIPC and vancomycin. During this clinical event, the neutrophil counts were gradually recovered and eventually returned to normal range without any specific interventions. Anti-HNA antibodies tests performed on day 636 were negative for HNA-2, but positive for HNA-4a/b, -5a/b (Table 1). Our patient had no obvious infection, which might induce the neutropenia, and neutropenia progressed despite the discontinuation of possible drugs that might cause cytopenia. Moreover, anti-HNA-2-antibody level well-traced the clinical course. Based on these findings, the patient was eventually diagnosed as immune-mediated neutropenia, and we assumed that anti-HNA-2-antibody might play a pivotal role. HNA-2 was highly expressed on metamyelocyte and mature neutrophil in both adult and fetal marrow cells, whereas the high expression of HNA-2 on myelocyte was observed only in adult marrow cells [5]. This implies that myelocytes at 10 months after HSCT in our patient might have expressed HNA-2 at a low level and been slightly affected. We performed extracted granulocyte immunofluorescence assay for assessment of antiHNA antibodies, which was modified from monoclonal antibody-specific immobilization of granulocyte antigens (MAIGA) and had superior sensitivity and specificity to granulocyte indirect immunofluorescence test (GIFT) [6]. Briefly, HNAs were extracted from gene-transfected cell

Mycophenolate mofetil is effective only for involved skin in the treatment for steroid-refractory acute graft-versus-host disease after allogeneic hematopoietic stem cell transplantation

Dear Editor, Recently, mycophenolic acid (MPA), the active metabolite of mycophenolate mofetil (MMF), has been used for acute graft-versus-host disease (aGVHD) prophylaxis and as a treatment for steroid-refractory aGVHD (SR-aGVHD) [1–4]. In the setting of treatment for SR-aGVHD, only a few studies [2–4] have analyzed the individual response in three involved organs (only skin, only liver, and only gut) in a small number of patients treated with MMF. No study has reported the response in two or more involved organs. We evaluated whether MMF is effective for one, two, or three involved organs in patients who had received MMF for SR-aGVHD. From 2004 to 2014, we identified 42 patients who received oral MMF for the treatment of SR-aGVHD (grade I, n = 7; grade II–IV, n = 35) (Supplemental Table 1). Transplant procedures have been described in detail elsewhere [5]. All patients received aGVHD prophylaxis with cyclosporine (CsA) or tacrolimus (FK) as well as short-term methotrexate. aGVHD, SRaGVHD, and responses to MMF were diagnosed and graded according to previously established criteria [2, 6]. MMF was orally administered at a median dose of 1333 mg/day (range 500–3000) in addition to standard CsA or FK with more than 1 mg/kg steroid. Twice the initial amount of MMF was administered when aGVHD had not improved or worsened after the initiation of MMF treatment. The median duration of MMF administration was 97 days (range 11–674 days). Four weeks after the initiation of MMF, 24 patients achieved complete response (CR), 4 had partial response (PR), and 14 patients had no response (NR). The response including all organs was comparable in related or unrelated donor transplantation, and in bone marrow transplantation or peripheral blood stem cell transplantation (Supplemental Fig. 1a, d). All three recipients from human leukocyte antigen (HLA)-haploidentical donors received conditioning with antithymocyte globulin, and the response was NR (Supplemental Fig. 1b, c). However, the response was similar in HLA matched and one mismatched donor transplantation (Supplemental Fig. 1b). Regarding the involved organs, the response rate in patients who developed only skin GVHD was higher than in those with only liver, only gut, skin and liver, liver and gut, skin and gut, or all three organs (92.3 vs. 0, 0, 20, 0, 37.5, 0 %, respectively, p < 0.001, Fig. 1a). The response in skin was similar to that in liver among patients who developed skin and liver SR-aGVHD (CR and PR rate 20 vs. 20 %, Fig. 1b). Moreover, the response in skin was similar to that in gut among patients who developed skin and gut SRaGVHD (CR rate 50 vs. 37.5 %, Fig. 1c). This study demonstrated that patients with only skin SRaGVHD responded to MMF better than those with only liver, only gut, skin and liver, or skin and gut aGVHD. Furthermore, the response rate in skin was low, similar to that in liver or gut Electronic supplementary material The online version of this article (doi:10.1007/s00277-016-2854-0) contains supplementary material, which is available to authorized users.

Occurrence of Donor Cell-derived Lymphoid Blast Crisis 24 Years Following Related Bone Marrow Transplantation for Chronic Myeloid Leukemia.

We herein report a unique case of donor cell leukemia (DCL), as donor cell-derived lymphoid blast crisis of chronic myeloid leukemia (CML) was observed 24 years after related bone marrow transplantation for CML in the chronic phase. Short tandem repeat testing of the leukemic blast sample revealed full donor chimerism, strongly indicative of DCL. The original donor is healthy with a normal complete blood cell count for the past 24 years. This rare case may provide a precious opportunity to consider not only the underlying mechanism of DCL, but also the pathogenesis of CML.

Impact of prior azacitidine on the outcome of allogeneic hematopoietic transplantation for myelodysplastic syndrome

To clarify the clinical impact of prior use of azacitidine (AZA) on outcomes of allogeneic hematopoietic stem cell transplantation (allo-HSCT) for myelodysplastic syndrome (MDS), we retrospectively reviewed the clinical outcomes of 15 MDS patients who were treated with AZA before allo-HSCT (AZA group). We compared the outcomes of these 15 patients with 52 MDS patients who were solely given the best supportive care (BSC) before allo-HSCT (BSC group). Although patients in the AZA group were older with higher International Prognostic Scoring System (IPSS) scores compared to patients in the BSC group, no significant differences were found between the two groups in overall survival (OS), disease-free survival (DFS), cumulative incidence of relapse (CIR) or non-relapse mortality. However, in patients with a higher IPSS score (Int-2/High), pre-transplant AZA may provide better OS and DFS and lower CIR. Acute graft-versus-host disease rates were similar between the two groups. These results should be reassuring to patients with high-risk MDS receiving AZA before allo-HSCT.

Impact of splicing factor mutations on clinical features in patients with myelodysplastic syndromes

Splicing factor gene mutations are found in 60–70% of patients with myelodysplastic syndromes (MDS). We investigated the effects of splicing factor gene mutations on the diagnosis, patient characteristics, and prognosis of MDS. A total of 106 patients with MDS were included. The percentage of patients with MDS with ring sideroblasts (14.15%) as per the 2017 WHO classification was significantly higher than that of patients with refractory anemia with ring sideroblasts (2.88%) as per the 2008 WHO classification (P = 0.005). Splicing factor mutations were detected in 32 patients (13 SF3B1, 8 U2AF1, and 11 SRSF2), and the mutations were mutually exclusive. Significant differences were observed in the mean corpuscular volume, platelet count, bone marrow myeloid:erythroid ratio, and megakaryocyte count in patients with different mutations. SRSF2 mutations were associated with a high cumulative incidence of red blood cell transfusion dependence, while SF3B1 mutations were associated with a low cumulative incidence of platelet concentrate transfusion dependence. Presence of SF3B1 mutation was a significant univariate predictor of overall survival, but become nonsignificant in the multivariate model. Although many factors also could affect survival, these results suggest that splicing factor mutations contribute to distinct MDS phenotypes, including patient characteristics and clinical courses.