Wen-li Zheng

Use of all-trans retinoic acid in combination with arsenic trioxide for remission induction in patients with newly diagnosed acute promyelocytic leukemia and for consolidation/maintenance in CR patients.

In the present study, 90 patients with newly diagnosed acute promyelocytic leukemia (APL) were studied for all-trans retinoic acid (ATRA) and arsenic trioxide (As2O3) combination treatment in remission induction and postremission therapy. In addition, 20 APL patients who had achieved complete remission (CR) with an ATRA-based regimen received ATRA/As2O3 combination for consolidation and maintenance were also enrolled. The results showed that ATRA/As2O3 combination therapy yielded a high CR rate of 93.3% and a significantly shorter time to enter CR (median: 31 days; range: 18–59 days) compared to the ATRA-based regimen (n = 72; median: 39 days; range: 25–62 days). With the ATRA/As2O3 combination for CR maintaining, regardless of the way by which CR was attained, the relapse-free survival was significantly better than with an ATRA plus cytotoxic chemotherapy regimen (92.9 ± 3.2% vs. 72.4 ± 7.6%, for the 3-year Kaplan-Meier estimate of relapse-free survival). The drug toxicity profile showed that with the use of As2O3, the incidence of hepatotoxicity was obviously high during remission induction but decreased significantly during postremission treatment. We conclude that APL patients may benefit from the early use of the combination of ATRA and As2O3, in either remission induction or consolidation/maintenance.

Decreased 5-hydroxymethylcytosine levels are associated with TET2 mutation and unfavorable overall survival in myelodysplastic syndromes

Abstract The clinical significance and mechanisms of TET2 are not well defined in myeloid malignancies. We detected TET2 mutations and assayed its catalyzing conversion product 5-hydroxymethylcytosine (5-hmC) in 61 Chinese patients with MDS. Ten patients were identified to have TET2 mutations (16.4%). 5-hmC levels in patients with MDS with TET2 mutations were significantly lower than in those without mutations, and CD34+ cells of patients with MDS exhibited a lower 5-hmC content than that of controls. TET2 expression and 5-hmC in patients with MDS with P15 methylation were both significantly lower than in those without P15 methylation. We did not observe a correlation between TET2 mutations and overall survival (OS) in MDS. Interestingly, we found that patients with MDS with higher 5-hmC levels or in lower risk groups of the Revised International Prognostic Scoring System (IPSS-R) had a longer overall survival, suggesting that 5-hmC levels may be a new molecular marker for prognostic assessment of MDS and that revised IPSS criteria are also applicable to the risk categories of Chinese patients with MDS.

Deregulation of Mitochondrial ATPsyn-β in Acute Myeloid Leukemia Cells and with Increased Drug Resistance

The mechanisms underlying the development of multidrug resistance in acute myeloid leukemia are not fully understood. Here we analyzed the expressions of mitochondrial ATPsyn-β in adriamycin-resistant cell line HL-60/ADM and its parental cell line HL-60. Meanwhile we compared the differences of mitochondrial ATPsyn-β expression and ATP synthase activity in 110 acute myeloid leukemia (AML, non-M3) patients between relapsed/refractory and those in remission. Our results showed that down-regulation of ATPsyn-β expression by siRNA in HL-60 cells increased cell viability and apoptotic resistance to adriamycin, while up-regulation of mitochondrial ATPsyn-β in HL-60/ADM cells enhanced cell sensitivity to adriamycin and promoted apoptosis. Mitochondrial ATPsyn-β expression and ATP synthase activity in relapsed/refractory acute myeloid leukemia patients were downregulated. This downregulated ATPsyn-β expression exhibited a positive correlation with the response to adriamycin of primary cells. A lower expression of ATPsyn-β in newly diagnosed or relapsed/refractory patients was associated with a shorter first remission duration or overall survival. Our findings show mitochondrial ATPsyn-β plays an important role in the mechanism of multidrug resistance in AML thus may present both a new marker for prognosis assessment and a new target for reversing drug resistance.

Coexistence of JAK2V617F mutation and BCR-ABL1 transcript in two Chinese patients with chronic myelogenous leukemia.

phils, 9% basophils, 4% nucleated red cells and 5% lymphocytes, Hb of 6.1 g/dl and PLT of 718 ! 10 9 /l. The neutrophil alkaline phosphatase score was 16.5 (reference range: 30.0–70.0). A bone marrow biopsy showed megakaryocytic hyperplasia and marked marrow reticulin fibrosis. There was a positive JAK2V617F mutation according to an allele-specific PCR assay. The BCR-ABL1 specific fusion signal was detected in bone marrow cells by fluorescence in situ hybridization (FISH), and the percentage of positive BCR-ABL1 was 90.9% (60/66 cells). Major BCR-ABL1 transcripts were found above the threshold levels ( BCR-ABL1/ABL1 ratio: 0.11%) by quantitative realtime PCR. The patient was diagnosed as having coexistent myelofibrosis and chronic-phase CML. Because of economic factors, the patient chose HU therapy at a dose of 1.0 g/day, thalidomide at 100 mg per night and aspirin (100 mg/day). Afterwards, due to a severe lung infection complicated by type I pulmonary insufficiency, the patient refused further treatment and was discharged voluntarily. Patient 2 was a 46-year-old female being evaluated for acute diarrhea who was found to have thrombocythemia in April 2010. Physical examination was unremarkable. Her Hb was 7.3 g/dl, PLT was 2,273 ! 10 9 /l and WBC was 17.1 ! 10 9 /l, with a differential count of 73.3% neutrophils, 1.5% eosinophils and 1.3% basophils. The neutroEssential thrombocythemia (ET), myelofibrosis, polycythemia vera (PV) and chronic myeloid leukemia (CML) belong to the category of myeloproliferative dis orders (MPDs). Although these diseases share some similar clinical features and clonal neoplastic proliferation in bone marrow, the BCR-ABL1 fusion transcript is still an important molecular marker in CML, while the mutation of the Janus kinase 2 gene (JAK2V617 F) has been reported to be associated with Philadelphia chromosome (Ph)-negative MPDs [1] . The general viewpoint is that a positive BCRABL1 transcript and the JAK2V617F mutation are exclusive to each other. Here, we report two patients with CML in whom the JAK2V617F mutation was positive. Patient 1 was a 77-year-old male who presented with splenomegaly. Twelve years prior to this presentation, he was diagnosed with PV, but he did not receive any special treatment. Then, in 2005, he had increased platelet counts, and bone marrow aspiration yielded a dry tap. The patient was administered hydroxyurea (HU) and aspirin irregularly. In 2007, he suffered a cerebral infarction and was found to have an increase in WBC of 26 ! 10 9 /l and was given HU at a dose of 2.0 g/day for more than 1 month. Because of pronounced splenomegaly, the patient was referred to our hospital in May 2010. Physical examination revealed remarkable splenomegaly (2.5 cm under the umbilicus). Laboratory tests showed a WBC of 19.9 ! 10 9 /l, with a differential count of 1% myeloblasts, 2% promyelocytes, 5% myelocytes, 3% metamyelocytes, 5% eosinoReceived: June 23, 2011 Accepted after revision: August 9, 2011 Published online: October 19, 2011

Thrombotic thrombocytopenic purpura complicating Graves disease: dramatic response to plasma exchange and infusion.

Dear Sir, Thrombotic thrombocytopenic purpura (TTP) is an uncommon but fatal disease if untreated. It is associated with microangiopathic hemolytic anaemia, thrombocytopenia and microvascular thrombosis that results in variable injury of the central nervous system, kidney and other organs. Most cases are caused by autoantibodies to ADAMTS-13, a metalloprotease that cleaves von Willebrand factor (VWF) and inhibits VWF-dependent platelet aggregation (Kenneth et al., 2010). TTP can complicate autoimmune diseases such as systemic lupus erythematosus, Sjögren’s syndrome and polymyositis (Noda et al., 1990). TTP as major presentation of Graves disease is rare. There is only one documented case in the literature, searched via Pubmed, associating these two disorders (Chaar et al., 2007). Here we report a second case of Graves disease presenting with TTP having dramatic response to plasma exchange and infusion. A 51-year-old female was admitted to our hospital in November 2008 for a 10-day history of fatigue, dizziness and confusion. Ten days before admission, she had a sudden onset of fatigue, dizziness and palpitations but no fever, diarrhoea or oliguria. On examination she had jaundice, petechiae, goitre and proptosis. Further inquiry revealed a 2 year history of weight loss with increased appetite. Laboratory tests showed hemoglobin (Hb) of 57 g/L, platelet count of 11 × 109/L, reticulocytes of 12%, total bilirubin (TBIL) of 88·3 μmol/L (reference 5·0–16·7 μmol/L) and direct bilirubin (DBIL) of 11·8 μmol/L (0·0–5·7 μmol/L). Thyroid function tests showed FT3 of 11·3 pg/mL (1·45–3·48 pg/mL), FT4 of 3·7 ng/dL (0·71–1·85 ng/dL) and TSH of 0·001 μIU/mL (0·47–4·64 μIU/mL). Ultrasonic scan of the thyroid revealed diffuse enlargement. Hyperthyroidism was diagnosed. Therefore, propylthiouracil was commenced a week before together with treatment of transfusion with packed RBC of 3 Units and platelet suspension of 6 Units to prevent cerebral bleeding. However, after transfusion she developed slight fever around 38 ◦C and episodes of confusion persisting for 30 min to

Analysis of clinical and laboratory characteristics in 42 patients with thrombotic thrombocytopenic purpura from a single center in China.

Thrombotic thrombocytopenic purpura (TTP) is a life-threatening disease characterized by microvascular platelet deposition and thrombus formation with resulting microangiopathic hemolytic anemia. Deficiency of the von Willebrand factor cleavage protease, also known as ADAMTS 13, has been implicated as an important etiological factor in TTP. Little studies were obtained on Chinese patients with TTP until now. Our aim was to analyze the clinical features, outcome and laboratory characteristics of Chinese TTP patients, and determine whether plasma ADAMTS 13 activity is decreased in TTP and its diagnostic value for TTP. Forty-two TTP patients (29 females; 13 males) admitted to our hospital from 1998 to 2010 were analyzed. There were 34 patients (81%) with the triad of TTP, including hemolytic anemia, thrombocytopenia and neurologic abnormalities; 7 (16.7%) had the classical pentad of TTP. Major etiologic factors were acquired autoimmunological abnormalities (31%); no familial TTP was identified in this series. The schistocytes of peripheral blood smears were present in all cases with a mean frequency of 4.6% (range from 0.3% to 13.4%). Plasma ADAMTS 13 activity was determined in 22 patients with the FRET-vWF86 assay. Only 4 idiopathic TTP patients (18.2%) had severe ADAMTS 13 deficiency (activity<10%); 9 (40.9%) had moderate decrease of ADAMTS 13 activity (activity: 10-40%); another 9 (40.91%) had normal ADAMTS 13 activity (>40%). T lymphocyte subpopulation was measured in 23 TTP patients with FACS Calibur; 14 of the 23 (60.9%) had significantly decreased CD4 cells count and CD4/CD8 ratio, suggesting cellular immune dysfunction may be involved in the pathogenesis of TTP. In the studies, plasmapheresis is the main therapeutic method. 26 of 31 patients (83.9%) accepting plasmapheresis achieved complete remission; those patients who only underwent plasma infusion had low remission rate (18.2%) and high mortality (9/11; 81.8%). Four patients with packed RBC infusion manifested transient exacerbation of neurologic or psychiatric symptoms. In conclusion, the diagnosis of TTP in China is still based on clinical features including evidence of microangiopathic hemolysis. Severe ADAMTS 13 activity deficiency might be a valuable indicator for idiopathic TTP diagnosis. Further studies are needed to determine the real value of ADAMTS 13 activity for TTP diagnosis and whether T lymphocytes subset dysregulation plays important role in TTP pathogenesis.

A TET2 rs3733609 C/T genotype is associated with predisposition to the myeloproliferative neoplasms harboring JAK2V617F and confers a proliferative potential on erythroid lineages

Common germline single-nucleotide polymorphisms (SNPs) at JAK2 locus have been associated with Myeloproliferative neoplasms (MPN). And, the germline sequence variant rs2736100 C in TERT is related to risk of MPN, suggesting a complex association between SNPs and the pathogenesis of MPN. Our previous study (unpublished data) showed that there was a high frequency distribution in rs3733609 C/T genotype at Ten-Eleven Translocation 2 (TET2) locus in one Chinese familial primary myelofibrosis. In the present study, we evaluate the role and clinical significance of rs3733609 C/T genotype in JAK2V617F-positive sporadic MPN (n = 181). TET2 rs3733609 C/T genotype had a higher incidence (13.81%; 25/181) in JAK2V617F-positive sporadic MPN patients than that in normal controls (n = 236) (6.35%; 15/236), which was predisposing to MPN (odds ratio(OR) = 2.361; P = 0.01). MPN patients with rs3733609 C/T genotype had increased leukocyte and platelets counts, elevated hemoglobin concentration in comparison with T/T genotype. Thrombotic events were more common in MPN patients with rs3733609 C/T than those with T/T genotype (P < 0.01). We confirmed that rs3733609 C/T genotype downregulated TET2 mRNA transcription, and the mechanism may be involved in a disruption of the interaction between CCAAT/enhancer binding protein alpha (C/EBPA) and TET2 rs3733609 C/T locus.TET2 rs3733609 C/T genotype stimulated the erythroid hematopoiesis in MPN patients. Altogether, we found a novel hereditary susceptible factor-TET2 rs3733609 C/T variant for the development of MPN, suggesting the variant may be partially responsible for the pathogenesis and accumulation of MPN.