Toshikazu Akioka

Antifungal prophylaxis with micafungin in neutropenic patients with hematological malignancies.

The aim of the study was to assess the antifungal prophylactic efficacy, safety, and tolerability of micafungin, 150 mg daily, and to evaluate the usefulness of monitoring 1,3-β-d-glucan (BG) in neutropenic patients undergoing chemotherapy for hematological malignancies. This investigation was a retrospective, non-randomized study. A group of patients who did not receive systemic antifungal prophylaxis was compared to another group of patients who received micafungin 150 mg daily. All patients admitted with hematological malignancy and undergoing chemotherapy or stem cell transplant were included. The plasma BG level was measured once weekly. The clinical endpoint was the diagnosis of invasive fungal infection (IFI). Antifungal prophylaxis led to a significant decrease in the occurrence of IFI (from 12.3% to 1.5%, p = 0.001). Few severe adverse effects clearly attributable to micafungin were seen. Sensitivity, specificity, positive predictive value, negative predictive value, and efficiency of BG values >8.9 pg/mL for diagnosis of IFI were 0.90, 0.99, 0.82, 0.99, and 0.99, respectively. Micafungin, 150 mg daily, is an effective and safe drug for antifungal prophylaxis, and monitoring of BG antigenemia is a useful tool for diagnosis of IFI in neutropenic patients with hematological malignancies.

Successful treatment with micafungin of invasive pulmonary aspergillosis in acute myeloid leukemia, with renal failure due to amphotericin B therapy.

Invasive aspergillosis is an important factor in the morbidity and mortality of patients suffering from hematologic disorders treated with chemotherapy. Treatment with amphotericin B is often limited because of toxicity, particularly nephrotoxicity. We describe a case of invasive pulmonary Aspergillus fumigatus infection in acute myeloid leukemia with renal failure due to amphotericin B therapy, which responded to treatment with a new antifungal agent, micafungin. Micafungin appears to be an effective and safe therapy for Aspergillus infections with renal failure due to amphotericin B.

TNF-α expression in tumor cells as a novel prognostic marker for diffuse large B-cell lymphoma, not otherwise specified.

Several cytokines promote malignant cell growth and are therefore believed to contribute to disease aggressiveness. The cytokine tumor necrosis factor-&agr; (TNF-&agr;) acts as a tumor-promoting factor and has been linked to all tumorigenic stages in many cancers. Here, we evaluated 62 lymphoma tissue specimens from patients having diffuse large B-cell lymphoma, not otherwise specified (DLBCL, NOS) by immunostaining with anti–TNF-&agr; antibody. Cytoplasmic TNF-&agr; reactivity in ≥20% of the tumor cells was considered positive. Our results demonstrated that tumor specimens from DLBCL, NOS patients could be divided into 2 types—TNF-&agr; positive (38 cases, 61%) and TNF-&agr; negative (24 cases, 39%)—and that TNF-&agr; positivity in DLBCL, NOS was correlated with poorer overall survival (OS; P=0.0005, log rank test) and progression-free survival (PFS; P=0.0330, log rank test) compared with TNF-&agr; negativity. Cox regression analysis showed that TNF-&agr; expression was a significant prognostic factor for OS (P<0.0001) and PFS (P=0.0323). Regarding OS and PFS, multivariate analysis showed that TNF-&agr; expression in tumor cells was an independent prognostic factor for the International Prognostic Index (IPI). Therefore, TNF-&agr;-positive DLBCL, NOS may constitute a unique subtype of DLBCL, NOS with an aggressive clinical course. The addition of TNF-&agr; expression to the IPI may significantly improve the predictive prognostic value. The therapeutic strategy of DLBCL, NOS patients should be based on correct prognosis; therefore, patients with poor prognoses could be more accurately detected by evaluating both TNF-&agr; expression levels and the IPI.

Vascular endothelial growth factor and interleukin 6 expression by Hodgkin/Reed-Sternberg cells

A 20-year-old Japanese man presented with a 4-month history of progressive fatigue, fever, cervical lymphadenopathy and oedema. Physical examination showed bilateral cervical, axillary, mediastinal and inguinal lymphadenopathy and gynecomastia (top left, computed tomography). The white blood cell count was 12Æ9 · 10/l, haemoglobin concentration 10Æ5 g/dl and platelet count 719 · 10/l. The serum lactate dehydrogenase and C-reactive protein levels were 602 IU/l and 156Æ3 mg/l respectively. Plasma levels of interleukin 6 (IL-6) and vascular endothelial growth factor (VEGF) were elevated to 446 pg/ml (normal <4Æ0 pg/ml) and 1710 pg/ml (normal range, 62–707 pg/ml) respectively. A right cervical lymph node biopsy showed nodular sclerosing Hodgkin’s disease (top right). Immunoperoxidase staining showed Hodgkin/ReedSternberg cells to be positive for IL-6 (bottom left) and VEGF (bottom right) antibodies. Following one course of combination chemotherapy, the clinical signs disappeared, the laboratory data normalized and the plasma levels of IL-6 and VEGF decreased to 5Æ0 pg/ml and 100 pg/ml respectively.

Pulmonary parenchymal infiltrates in a patient with CD20‐positive multiple myeloma

Abstract:  A 53‐yr‐old woman developed a dry cough after the completion of multi‐agent chemotherapy. The biopsy specimens showed diffuse infiltrates with multiple myeloma (MM) cells. Immunohistochemistry revealed positive staining in MM cells with surface CD20, surface CD38, and cytoplasmic IgG. This report represents the first reported case of pulmonary parenchymal infiltrates in a patient with CD20‐positive MM.

Expression of tumour necrosis factor‐α and its receptors in Hodgkin lymphoma

mus-associated post-transplant autoimmune hemolytic anemia. Pediatric Transplantation, 10, 358–361. Zhan, P., Tey, S.K., Koyama, M., Kuns, R.D., Olver, S.D., Lineburg, K.E., Lor, M., Teal, B.E., Raffelt, N.C., Raju, J., Levegue, L., Markey, K.A., Varelias, A., Clouston, A.D., Lane, S.W., MacDOnald, K.P. & Hill, G.R. (2013) Induced regulatory T cells promote tolerance when stabilized by Rapamycin and IL-2 in vivo. Journal of Immunology, 191, 5291–5303.

Minimal-change nephrotic syndrome preceding Hodgkin lymphoma by 5 years with expression of tumor necrosis factor α in Hodgkin-Reed-Sternberg cells ☆

A 76-year-old man developed minimal-change nephrotic syndrome (NS). After treatment with prednisolone failed to induce sustained remission, cyclosporin was added. The NS improved, and prednisolone and cyclosporin doses were gradually decreased. However, he had repeated relapses of the syndrome, and at each relapse, the drug doses were increased. After 5 years, the patient developed left inguinal lymphadenopathy. The histological diagnosis was mixed cellularity classical Hodgkin lymphoma. He received 6 courses of ABVD (doxorubicin, bleomycin, vinblastine, and dacarbazine), and mixed cellularity classical Hodgkin lymphoma and NS both showed complete response. Although the association between Hodgkin lymphoma and minimal-change NS is well known, the pathogenesis is unknown. To the best of our knowledge, this is the first case report of minimal-change NS associated with Hodgkin lymphoma in which Hodgkin-Reed-Sternberg cells were immunostained for tumor necrosis factor-alpha (TNF-alpha) clearly demonstrating that Hodgkin-Reed-Sternberg produced TNF-alpha and in which the plasma level of TNF-alpha normalized after improvement of Hodgkin lymphoma by chemotherapy. The production of TNF-alpha by Hodgkin-Reed-Sternberg cells might play a key role as a potential mediator of minimal-change NS.

An approach for diagnosing plasma cell myeloma by three-color flow cytometry based on kappa/lambda ratios of CD38-gated CD138+ cells

BackgroundWorld Health Organization (WHO) criteria are commonly used to diagnose plasma cell myeloma (PCM); however, these criteria are complex and require several laboratory parameters. For differentiating reactive plasmacytosis from clonal plasma cell (PC) neoplasms such as PCM, it is important to accurately determine the expression of cytoplasmic immunoglobulin light chains.MethodsWe retrospectively analyzed the records of 27 selected patients with PCM who underwent bone biopsies for confirmative diagnosis according to WHO criteria. Twenty-three controls were also investigated. In the present study, all the samples were analyzed using flow cytometry (FC) in the side scatter vs. CD38 histogram mode, and the CD38-gated PC population was identified. Bivariate histograms of CD138/kappa and CD138/lambda were assessed, and the ratios of dual-positive cells to the CD138+ PC population were calculated. The kappa/lambda ratio was defined as the ratio of CD138/kappa to CD138/lambda.ResultsPCM cells were distinguished from normal PCs using cutoff levels between 0.76 and 1.5, at a sensitivity of 96.3% and specificity of 95.7%.ConclusionsThree-color FC analysis is simple to perform and inexpensive, with clinically relevant data obtained soon after the completion of FC measurements. The detection of the cytoplasmic kappa/lambda ratio of CD38-gated CD138+ PCs may be a useful tool in the diagnosis of PCM. To the best of our knowledge, this report represents the first diagnostic assessment of the cytoplasmic kappa/lambda ratio in CD38-gated CD138+ PCs using FC analysis. This method may help in more simple, efficient, rapid, and accurate diagnosis of PCM.Virtual slidesThe virtual slide(s) for this article can be found here: http://www.diagnosticpathology.diagnomx.eu/vs/1568085959771735

Hypercalcaemia induced by tumour-derived parathyroid hormone-related protein and multiple cytokines in diffuse large B cell lymphoma, not otherwise specified

oedema. The pathogenesis of ARDS is believed to involve diffuse alveolar capillary injury. Activated neutrophils are the major cellular elements that mediate acute inflammation and have been implicated in the pathogenesis of microvascular injury that occurs in ARDS. Interactions between polymorphonuclear neutrophils (PMN) and cytokines play an important role in this process. Proinflammatory cytokines such as IL-6 and TNF-a have been found to prime or activate certain PMN functions. IL-6 is a multifunctional cytokine that is produced during acute inflammatory response. It stimulates neutrophilia and thrombopoiesis and induces the synthesis of acute-phase proteins. Sustained elevations of IL-6 in the plasma and bronchoalveolar lavage of patients with ARDS have been demonstrated and negatively correlated with disease outcome and patient survival. The presence of IL-6 in the lung alone is sufficient to promote PMN infiltration and pulmonary oedema. Recent studies have demonstrated that IL-6 contributes to tissue recruitment of PMN by chemokine induction; however, little is known about the mechanisms involved in IL-6 mediated local chemokine production. IL-6 activated Stat3 may contribute to local chemokine production through transcriptional activation of chemokine genes such as those for IL-8. TNF-a is a monocyte/macrophage-derived cytokine that is known to have a broad range of activities, including tumour cytotoxicity, antiviral effects, and potent inflammatory effects. During the course of ARDS, high levels of TNF-a are present in the blood and alveolar lining fluid. TNF-a affects the functions of PMN and vessel endothelial cells, which play a major role in the pathogenesis of ARDS. TNF-a also activates endothelial phosphodiesterase 2 (PDE2), which sensitises endothelial cells to thrombin, thereby leading to endothelial hyperpermeability. Furthermore, TNF-a increases neutrophil degranulation, superoxide production, and lysozyme release, thereby causing tissue injury. To the best of our knowledge, this is the first case report of ARDS with DLBCL, NOS, showing the lymphoma cells to be immunostained for IL-6 and TNF-a. These proinflammatory cytokines produced by the lymphoma cells might play an important role in the pathogenesis of ARDS associated lung injury in some cases of DLBCL, NOS.

Primary effusion lymphoma of T-cell origin with t(7;8)(q32;q13) in an HIV-negative patient with HCV-related liver cirrhosis and hepatocellular carcinoma positive for HHV6 and HHV8

Dear Editor, A 67-year-old man with chronic hepatitis C since 1981 was found to have a few mass lesions that were detected in an abdominal echogram performed in 2006. Hepatitis C virus (HCV) viremia was confirmed by a quantitative assay of viral load of 7.8 log IU/mL in the plasma (Cobas TaqMan HCV, Roche, Branchburg, NJ). Computed tomography (CT) detected one mass in S6 and another mass in S8 in his liver. On the basis of angiographic findings and liver biopsy, he was diagnosed with HCV-associated liver cirrhosis (LC) and hepatocellular carcinoma (HCC). Lipiodol-transcatheter arterial embolization and percutaneous ethanol injection therapy were administered for the lesions, and HCC relapse was not detected. The patient was admitted in 2008 because of an enlarging abdomen and early satiety. CT scan showed massive fluid accumulation within the peritoneal cavity but there were no new HCC lesions (Fig. 1a). A gallium-67 scintigram revealed abnormal accumulation of the isotope in the abdominal cavity. The results of serological tests for human immunodeficiency virus (HIV), Epstein–Barr virus, and human T-lymphotropic virus 1 were negative. DNA of human herpesvirus (HHV) 6 (>2.0×10 copies/10 cells) and HHV8 DNA (>2.0× 10 copies/10 cells) were detected in peripheral blood leukocytes. The smear preparations showed noncohesive large lymphoma cells with abundant cytoplasm and prominent nucleoli (Fig. 1b). Most lymphoma cells were positive for CD45RO (Clone UCHL 1, DAKO, Carpinteria, CA; Fig. 1c) and negative for CD79a and CD20. The nucleoli of lymphoma cells were positive for latent HHV6 (2002, Thermo Fisher Scientific, Wattham, MA; Fig. 1d) and HHV8 (LN53, Diagnostic BioSystems, Pleasanton, CA; Fig. 1e) infections. Southern blotting revealed a clonal rearrangement of the T cell receptor Jγ chain gene. No clonal rearrangement of the immunoglobulin heavy chain gene was found by Southern blotting. Cytogenetic analysis of GTG banding was performed, where the specimen was cultured at 37°C for 24 h in an RPMI 1640 medium containing 10% fetal calf serum and antibiotics. After adding 0.04 μg/mL colcemide for 16 h, the cell suspension was exposed to 75 mM KCL and fixed with a mixture of methanol and acetic acid (3:1). Spreads of chromosomes were made by dropping the cell suspension onto glass slides S. Nakayama-Ichiyama (*) : T. Yokote :K. Kobayashi : Y. Hirata :N. Hiraoka :K. Iwaki :A. Takayama : T. Akioka : S. Oka : T. Miyoshi : T. Hanafusa Department of Internal Medicine (I), Osaka Medical College, 2-7 Daigakumachi, Takatsuki City, Osaka 569-0801, Japan e-mail: in1304@poh.osaka-med.ac.jp