Shinichiro Kawamoto

Prospective study of dental intervention for hematopoietic malignancy.

Various chemotherapeutic agents used in patients with hematopoietic malignancy cause serious side effects, including myelosuppression and immunosuppression. Immunosuppression makes patients more susceptible to infection, resulting in an increased risk of infectious complications, including the development of severe septicemia that may be life-threatening. It is necessary for dental staff to be familiar with an appropriate protocol in such cases and to share information about the chemotherapy with a hematologist. To verify the effectiveness of our dental intervention protocol, we conducted a prospective study on the incidence of complications for each myelosuppressive grade of chemotherapy in patients with hematopoietic malignancy. We compared the incidence of complications between treatment P (patients who finished all the dental treatments according to the protocol) and treatment Q (patients who did not) per grade (A, B, C, D) and incidence of systemic or oral findings. We also compared the incidence of oral complication related to the residual teeth between first chemo (patients who were undergoing chemotherapy for the first time) and prior chemo (not the first time). There were significant differences in inflammatory complications between treatment P and treatment Q. We found that both systemic and oral inflammatory complications increased with higher-grade myelosuppressive chemotherapy. Additionally, there was a significant difference between the incidence of oral complications related to the residual teeth between first chemo and prior chemo. Complete implementation of the dental intervention protocol was associated with fewer oral and systemic infectious and inflammatory complications in patients with hematopoietic malignancies undergoing chemotherapy. The incidence of oral and systemic complications also increased with grade of chemotherapy. These results support the validity of our dental intervention protocol. We should pay close attention to the oral state of de novo hematopoietic malignancy patients.

NANOG Expression as a Responsive Biomarker during Treatment with Hedgehog Signal Inhibitor in Acute Myeloid Leukemia

Aberrant activation of the Hedgehog (Hh) signaling pathway is involved in the maintenance of leukemic stem cell (LSCs) populations. PF-0444913 (PF-913) is a novel inhibitor that selectively targets Smoothened (SMO), which regulates the Hh pathway. Treatment with PF-913 has shown promising results in an early phase study of acute myeloid leukemia (AML). However, a detailed mode of action for PF-913 and relevant biomarkers remain to be elucidated. In this study, we examined bone marrow samples derived from AML patients under PF-913 monotherapy. Gene set enrichment analysis (GSEA) revealed that PF-913 treatment affected the self-renewal signature and cell-cycle regulation associated with LSC-like properties. We then focused on the expression of a pluripotency factor, NANOG, because previous reports showed that a downstream effector in the Hh pathway, GLI, directly binds to the NANOG promoter and that the GLI-NANOG axis promotes stemness and growth in several cancers. In this study, we found that a change in NANOG transcripts was closely associated with GLI-target genes and NANOG transcripts can be a responsive biomarker during PF-913 therapy. Additionally, the treatment of AML with PF-913 holds promise, possibly through inducing quiescent leukemia stem cells toward cell cycling.

Human CD134 (OX40) expressed on T cells plays a key role for human herpesvirus 6B replication after allogeneic hematopoietic stem cell transplantation

BACKGROUND CD134 (OX40), which is a cellular receptor for human herpesvirus-6B (HHV-6B) and expresses on activated T cells, may play a key role for HHV-6B replication after allogeneic hematopoietic stem cell transplantation (allo-HSCT). OBJECTIVES Therefore, we examined the CD134 expression on T cells and HHV-6B replication after allo-HSCT, and analyzed the correlation between them. STUDY DESIGN Twenty-three patients after allo-HSCT were enrolled. The percentages of CD134-positive cells within the CD4+ and CD8+ cell populations were measured by flow cytometry, and the viral copy number of HHV-6B was simultaneously quantified by real-time PCR. The correlation between CD134 and HHV-6B viral load was then statistically analyzed. RESULTS HHV-6B reactivation occurred in 11 of 23 patients (47.8%). CD134 expression was seen on T cells and was coincident with the time of peak viral load. The percentage of CD134-positive cells decreased significantly when HHV-6B DNA disappeared (p = .005 in CD4+ T cells, p = .02 in CD8+ T cells). In the 4 patients who underwent umbilical cord blood transplantation (UCBT), the viral load varied with the percentage of CD134-positive cells. In the comparison between the HHV-6B reactivation group and non-reactivation group, maximum percentages of CD134-positive cells among CD4+ T cells in reactivation group were significantly higher than those in non-reactivation group (p = .04). CONCLUSIONS This is the first study to show that a correlation of CD134 expression on T cells with HHV-6B replication after allo-HSCT, especially in UCBT. The results possibly indicate that CD134 on T cells plays a key role for HHV-6B replication after allo-HSCT.

Intensity and duration of neutropenia relates to the development of oral mucositis but not odontogenic infection during chemotherapy for hematological malignancy

Background D-index which combines the intensity and duration of neutropenia is reported as a tool for evaluating the dynamics of neutropenia. This study aimed to analyze the relationship between D-index and oral complications (i.e., oral mucositis [OM] and odontogenic infection [OI]) during chemotherapies for hematological malignancies. Methods A total of 421 chemotherapeutic courses in 104 patients were analyzed. Chemotherapeutic courses in patients who finished all of the prophylactic dental treatments were defined as “treatment Finish”. Chemotherapeutic courses in patients who did not finish prophylactic dental treatments were defined as “treatment not-Finish”. OM was evaluated according to the Common Terminology Criteria for Adverse Events, version 4.0. D-index was compared between chemotherapeutic courses with versus without oral complications. Results D-index was significantly higher in chemotherapeutic courses with grade 1 or 2 OM (p < 0.001) than courses without OM. In contrast, higher D-index did not relate to the development of OI (p = 0.18). The occurrence of OI (p < 0.001) but not OM (p = 0.56) during chemotherapy was significantly higher in chemotherapeutic courses without the completion of dental intervention. Conclusions Higher D-index relates to the development of OM. In contrast, OI occurs due to untreated odontogenic foci, and its occurrence does not relate to higher D-index.

Mixed Phenotype Acute Leukemia with t(12;17)(p13;q21)/TAF15-ZNF384 and Other Chromosome Abnormalities

The t(12;17)(p13;q11∼21) translocation is a very rare but recurrent cytogenetic aberration observed predominantly in early pre-B acute lymphoblastic leukemia (ALL) with CD19+CD10-CD33+ phenotype. This translocation was shown to form a fusion gene between TAF15 at 17q12 and ZNF384 at 12p13. On the other hand, der(1;18)(q10;q10) has been detected as a rare unbalanced whole-arm translocation leading to trisomy 1q in myeloid malignancies. We describe here the first case of mixed phenotype acute leukemia (MPAL) with a t(12;17)(p13;q21)/TAF15-ZNF384, which also had der(1;18)(q10;q10) as an additional abnormality. A 74-year-old woman was diagnosed with MPAL, B/myeloid, because bone marrow blasts were positive for myeloperoxidase, CD19, and CD22. Chromosome analysis showed 46,XX, +1,der(1;18)(q10;q10),t(2;16)(q13;q13),t(12;17)(p13;q21). Expression of the TAF15-ZNF384 fusion transcript was confirmed: TAF15 exon 6 was fused in-frame to ZNF384 exon 3. This type of fusion gene has been reported in 1 acute myeloid leukemia case and 3 ALL cases. Thus, at present, it is difficult to find a specific association between the structure of the TAF15-ZNF384 fusion gene and the leukemia phenotype. The TAF15-ZNF384 fusion may occur in early common progenitor cells that could differentiate into both the myeloid and lymphoid lineages. Furthermore, der(1;18)(q10;q10) might play some role in the appearance of an additional myeloid phenotype.

Expression of a novel ZMYND11/MBTD1 fusion transcript in CD7+CD56+ acute myeloid leukemia with t(10;17)(p15;q21)

The t(10;17)(p15;q21) translocation is a very rare but recurrent cytogenetic aberration in acute myeloid leukemia (AML), which would be classified as AML, not otherwise specified by World Health Organization (WHO), generally with classification as M0 or M1 by French–American–British (FAB) criteria [1–8]. Recently, co-localization between the ZMYND11 (zinc finger MYND-type containing 11, alias BS69) gene on 10p15.3 and the MBTD1 (mbt domain containing 1) gene on 17q21.33 was shown by fluorescence in situ hybridization (FISH) in two cases of AML M1 with t(10;17)(p15;q21) [7]. Furthermore, molecular analyses identified a ZMYND11/MBTD1 fusion transcript in a recent case of AML M0 with t(10;17) [8]. Nucleotide sequencing revealed an in-frame fusion of ZMYND11 exon 12 to MBTD1 exon 3 generated on der(17)t(10;17). The resultant ZMYND11/MBTD1 fusion protein was supposed to contribute to HOXA overexpression, which is a leukemogenic pathway to AML, whereas the reciprocal MBTD1/ZMYND11 fusion was predicted to lack a productive start codon [8]. Here, we describe an unusual case of AML with t(10;17)(p15;q21), demonstrating a novel ZMYND11/MBTD1 fusion transcript and a CD7þCD56þ immunophenotype. A 67-year-old man was admitted to our hospital because of the appearance of blasts in his peripheral blood. He did not show any extramedullary mass, including lymphadenopathy. The peripheral blood counts 6 months before were normal: hemoglobin 147 g/L, platelets 190 10/L, and leukocytes 4.2 10/L with no blasts. Peripheral blood values on admission were hemoglobin 126 g/L, platelets 199 10/L, and leukocytes 3.8 10/L with 31% segmented neutrophils, 4% monocytes, 45% lymphocytes, and 20% blasts. His bone marrow was normocellular with 18.2% blasts, 2.6% myelocytes, 3.8% metamyelocytes, 1.0% band forms, 20.8% segmented neutrophils, 3.2% monocytes, 22.4% lymphocytes, and 25.0% erythroblasts. Dysplastic changes of bone marrow cells were not apparent. Mediumto large-sized blasts showed fine nuclear chromatin, prominent nucleoli, a pale cytoplasm, and a lack of azurophilic granules (Figure 1(A)). These blasts were negative for myeloperoxidase (MPO) and periodic acid–Schiff staining (Figure 1(B)). Immunophenotyping by three-color flow cytometry using CD45/side scatter gating revealed that gated cells (21.0% of all bone marrow cells) were positive (>20%) for CD7 (94.2%), CD13 (39.0%), CD33 (97.7%), CD34 (91.3%), CD41 (60.7%), CD56 (94.4%), and HLA-DR (40.9%), but negative for other lymphoid markers, including CD3 (0.8%; Figure 1(C)). A diagnosis of de novo AML M0, or AML with minimal differentiation, was made. The patient received induction therapy with idarubicin and cytarabine according to a JALSG-AML201 protocol and achieved complete remission (CR). He then received a further four courses of conventional consolidation therapy, and has remained in hematological and cytogenetic CR for more than 14 months. Chromosome analysis of bone marrow cells on admission showed 47,XY,þY,t(10;17)(p15;q21)[8]/47,sl,del(12)(p?) [8]/46,XY[4] (Figure 1(D)). At hematological CR after induction therapy, the karyotype returned to 46,XY[20]. Spectral karyotyping (SKY) confirmed der(10)t(10;17)(p15;q21), whereas the small segment, 10p15!10pter, on der(17)t(10;17)(p15;q21) could not be visualized (Figure 1(E)). This segment may be smaller than the minimum genomic alteration detectable by SKY [9]. FISH with a PML/RARA probe revealed that the RARA signal at 17q21 remained on the der(17)t(10;17), indicating that the 17q21 breakpoint of t(10;17) was telomeric to RARA, as previously reported (data not shown) [6]. We next performed reverse transcription–polymerase chain reaction (RT–PCR) for the possible detection of ZMYND11/MBTD1 fusion transcripts. We designed a forward primer, ZMYND11-F (from ZMYND11 exon 11, 50GAGGACCGAGGTGAGGAAGA-30, cDNA positions 1443–1462 according to NCBI reference sequence NM_006624.5), and a reverse primer, MBTD1-R (from MBTD1 exon 3, 50-

A Case of Classical Hodgkin Lymphoma with Total Lymph Node Infarction

Lymph node infarction is very rare, and is frequently associated with neoplasms, such as malignant lymphoma and non-neoplastic disease, or interventions such as fine-needle aspiration (FNA). A 76-year-old-man presented with cervical lymph node swelling. Although FNA was performed, the findings were insufficient for a definitive diagnosis. Consequently, surgical biopsy of the cervical lymph node was performed, which revealed total infarction; a diagnosis of classical Hodgkin lymphoma was made later. Both lymphoma itself and FNA may cause total lymph node infarction, which makes diagnosis confusing. Therefore, it is important to repeat the biopsy rather than repeat FNA to correctly diagnose malignant lymphoma, including Hodgkin lymphoma.

Invasive Scopulariopsis alboflavescens infection in patient with acute myeloid leukemia

Scopulariopsis alboflavescens is a soil saprophyte that is widely distributed in nature. Recently, there have been increasing number of reports of invasive infections with Scopulariopsis species in immunocompromised patients. In this report, we described an adult woman with acute myeloid leukemia and who developed S. alboflavescens pneumonia. Liposomal amphotericin B and voriconazole combination therapy was unsuccessful and the patient died because of pneumonia. Scopulariopsis is highly resistant to available antifungal agents and almost invariably fatal. This case report should alert clinicians to the importance of listing Scopulariopsis as a pathogenic fungus in immunocompromised patients.

Ectopic expression of band 3 anion transport protein in colorectal cancer revealed in an autoimmune hemolytic anemia patient

Cancer patients occasionally have anemia with high mean corpuscular volume in addition to iron deficiency anemia. Secondary autoimmune hemolytic anemia (AIHA) following cancer is also observed with low frequency. To date, no causal mechanisms for these disease states have been reported. Here, we present the case of an 80-year-old woman with AIHA that was resistant to prednisolone. Further examinations revealed primary adenocarcinoma of the sigmoid colon and primary squamous cell carcinoma in the right lung. After resections of these tumors, her anemia partially improved until a colon cancer-derived metastatic tumor was detected in the left lung. Immunoprecipitation of erythrocyte membrane proteins with an autoantibody followed by mass spectrometry/Western blotting identified band 3 as the target of the autoantibody. Immunohistochemical analysis revealed ectopic expression of band 3 in the colon adenocarcinoma. To our knowledge, this is the first report that identifies the cause in a case of anemia without bleeding in a cancer patient and that defines a mechanism underlying secondary AIHA following cancer progression.

MYC Amplification in the Form of Ring Chromosomes 8 in Acute Myeloid Leukemia with t(11;16)(q13;p11.2)

Oncogene amplification is uncommon in acute myeloid leukemia (AML). Cytogenetically, it is primarily found as double minute chromosomes (dmin) or homogeneously staining regions (hsr). A 62-year-old woman was admitted to our hospital because of anemia and thrombocytopenia. Her bone marrow was hypercellular with 78.6% myeloperoxidase- positive blasts. Some had micronuclei. The patient was diagnosed with AML M2 and remains in complete remission (CR) after induction therapy. G-banding at diagnosis showed 51,XX,t(11;16)(q13;p11.2),+r1,+mar1×4. Spectral karyotyping confirmed t(11;16) and revealed that the ring and the marker chromosomes were derived from multiple copies of ring chromosome 8. Fluorescence in situ hybridization (FISH) with a MYC probe at 8q24 detected amplified MYC signals on 1 large and 4 small ring chromosomes 8. One MYC signal was deleted from one of the 2 chromosomes 8. FISH with a FUS probe at 16p11.2 showed monoallelic deletion of FUS. Immunohistochemistry demonstrated MYC protein overexpression at diagnosis and almost negative expression in CR. These results indicate that MYC amplification could occur in ring chromosomes without dmin. A cryptic MYC deletion suggests that an episome model could be applicable to MYC amplification in ring chromosomes as observed for dmin and hsr. Furthermore, considering 2 further reported cases, t(11;16)(q13;p11) may be a very rare but recurrent translocation in AML.