Young Uk Cho

Myelomatous Pleural Effusion: A Case Series in a Single Institution and Literature Review

Background Myelomatous pleural effusion (MPE) is rare in myeloma patients. We present a consecutive series of patients with MPE in a single institution. Methods We retrospectively reviewed the medical records of 19 patients diagnosed with MPE between 1989 and 2008 at the Asan Medical Center. Diagnoses were confirmed by cytologic identification of malignant plasma cells in the pleural fluid. Results Our patients showed dominance of IgA (36.8%) and IgD (31.6%) subtypes. Of 734 myeloma patients, the incidence of MPE was remarkably high for the IgD myeloma subtype (16.7%), compared to the other subtypes (1.4% for IgG and 4.6% for IgA). At the time of diagnosis of MPE, elevated serum β2-microglobulin, anemia, elevated serum lactate dehydrogenase, and elevated creatinine levels were found in 100%, 89.5%, 83.3%, and 57.9% of the patients, respectively. Approximately one-third (31.3%) of the patients had adenosine deaminase (ADA) activities in their pleural fluid exceeding the upper limit of the reported cutoff values for tuberculous pleural effusion (55.8 U/L). Chromosome 13 abnormality was seen in 77.8% of the tested patients. The median survival period from the development of MPE was 2.8 months. Conclusions Patients with MPE have aggressive clinical and laboratory characteristics. The preponderance of IgD myeloma in MPE patients is a noteworthy finding because IgD myeloma is a rare subtype. Elevated ADA activity in the pleural fluid is also noteworthy, and may be helpful for detecting MPE. Physicians treating myeloma patients should monitor the development of MPE and consider the possibility of a worse clinical course.

High CXCR4 and low VLA-4 expression predicts poor survival in adults with acute lymphoblastic leukemia

Data regarding the prognostic significance of CXCR4 and VLA-4 in ALL are limited. Especially, VLA-4 has not been evaluated at the time of diagnosis in both adult and childhood ALL patients. We prospectively analyzed the expression of VLA-4 and CXCR4 in 54 patients (VLA-4 in 29 adults and 25 children and CXCR4 in 22 adults and 24 children) newly diagnosed with ALL by flow cytometry. Expression levels of VLA-4 and CXCR4 were not different between adults and children with ALL. High CXCR4 and low VLA-4 expression each correlated with worse prognosis in adults; patients with high CXCR4 expression had shorter disease-free survival (p=0.01) and overall survival (p=0.04) and patients with low VLA-4 expression had shorter disease-free survival (p=0.02). Expression levels of CXCR4 and VLA-4 did not predict patient prognosis in children. Analysis of CXCR4 and VLA-4 expression at diagnosis in adults with ALL can provide useful information on patient prognosis.

JAK2 V617F, MPL, and CALR Mutations in Korean Patients with Essential Thrombocythemia and Primary Myelofibrosis.

Mutations in the calreticulin gene, CALR, have recently been discovered in subsets of patients with essential thrombocythemia (ET) or primary myelofibrosis (PMF). We investigated Korean patients with ET and PMF to determine the prevalence, and clinical and laboratory correlations of CALR/JAK2/MPL mutations. Among 84 ET patients, CALR mutations were detected in 23 (27.4%) and were associated with higher platelet counts (P=0.006) and lower leukocyte counts (P=0.035) than the JAK2 V617F mutation. Among 50 PMF patients, CALR mutations were detected in 11 (22.0%) and were also associated with higher platelet counts (P=0.035) and trended to a lower rate of cytogenetic abnormalities (P=0.059) than the JAK2 V617F mutation. By multivariate analysis, triple-negative status was associated with shorter overall survival (HR, 7.0; 95% CI, 1.6-31.1, P=0.01) and leukemia-free survival (HR, 6.3; 95% CI, 1.8-22.0, P=0.004) in patients with PMF. The type 1 mutation was the most common (61.1%) type among all patients with CALR mutations, and tended toward statistical predominance in PMF patients. All 3 mutations were mutually exclusive and were never detected in patients with other myeloid neoplasms showing thrombocytosis. CALR mutations characterize a distinct group of Korean ET and PMF patients. Triple-negative PMF patients in particular have an unfavorable prognosis, which supports the idea that triple-negative PMF is a molecularly high-risk disease. Graphical Abstract

Immature Platelet Fraction in Septic Patients: Clinical Relevance of Immature Platelet Fraction is Limited to the Sensitive and Accurate Discrimination of Septic Patients From Non-Septic Patients, Not to the Discrimination of Sepsis Severity

Background The immature platelet fraction (IPF) reflects the degree of reticulated platelets. We evaluated performances of IPF as a biomarker for the discrimination of septic patients from non-septic patients and sepsis severity. Methods Total 312 patients admitted between March and July 2013 were enrolled and samples were obtained at admission. Lactate (LA), procalcitonin (PCT), C-reactive protein (CRP), immature granulocyte fraction (IG), immature reticulocyte fraction (IRF), and IPF were analyzed as sepsis biomarkers and their performances were compared. Results The performance of IPF (area under the curve [AUC]=0.868) in the discrimination of septic patients from non-septic patients was comparable to PCT/CRP/LA/IG (AUC=0.923/0.940/0.781/0.812, P=0.233/0.106/0.186/0.353, respectively), and was significantly better than the IRF (AUC=0.658, P=0.007). Sensitivity (89.8%, 95% confidence interval [CI] 84.9-99.8%) and accuracy (83.2%, 95% CI 78.8-90.0%) of IPF were the best among all biomarkers. The performance of IPF in discriminating septic patients from non-septic patients with local infection showed similar results. However, the IPF could not efficiently discriminate sepsis severity (AUC=0.599), similar to other biomarkers (AUC=0.519-0.752). Conclusions The IPF possessed high sensitivity/accuracy in discriminating septic patients from non-septic patients, regardless of local infection status. However, the IPF did not efficiently discriminate sepsis severity. The clinical relevance of IPF as a sepsis biomarker is, therefore, limited to sensitive and accurate discrimination of septic patients from non-septic patients, not discrimination of sepsis severity.

Establishment of Age- and Gender-Specific Reference Ranges for 36 Routine and 57 Cell Population Data Items in a New Automated Blood Cell Analyzer, Sysmex XN-2000

We established age- and gender-specific reference ranges for the 36 routine complete blood cell (CBC) and 57 cell population data (CPD) items in the Sysmex XN-2000 (Sysmex, Japan). In total, 280 peripheral blood samples were obtained from an equal number of healthy adults. Values for 36 routine items and 57 CPD items were obtained for each sample, and the results were categorized into six subgroups (N>39 in each subgroup) according to patient age (20-40, 41-60, and >60 yr) and gender (male and female), and compared with respect to age and gender differences. The majority of data items (22 of 36 routine CBC items and 44 of 57 CPD items) exhibited significant differences (P≤0.05) in their results with respect to age or gender, and several red cell-, lymphocyte-, and platelet-related data tended to decrease in women or older adults. These results provide a basis for establishing age- and gender-specific reference ranges for routine and CPD items in Sysmex XN-2000. Furthermore, these reference ranges could be used to determine clinical significance for new items of Sysmex XN-2000 in further studies.

Correlation of NPM1 Type A Mutation Burden With Clinical Status and Outcomes in Acute Myeloid Leukemia Patients With Mutated NPM1 Type A

Background Nucleophosmin gene (NPM1) mutation may be a good molecular marker for assessing the clinical status and predicting the outcomes in AML patients. We evaluated the applicability of NPM1 type A mutation (NPM1-mutA) quantitation for this purpose. Methods Twenty-seven AML patients with normal karyotype but bearing the mutated NPM1 were enrolled in the study, and real-time quantitative PCR of NPM1-mutA was performed on 93 bone marrow (BM) samples (27 samples at diagnosis and 56 at follow-up). The NPM1-mutA allele burdens (represented as the NPM1-mutA/Abelson gene (ABL) ratio) at diagnosis and at follow-up were compared. Results The median NPM1-mutA/ABL ratio was 1.3287 at diagnosis and 0.092 at 28 days after chemotherapy, corresponding to a median log10 reduction of 1.7061. Significant correlations were observed between BM blast counts and NPM1-mutA quantitation results measured at diagnosis (γ=0.5885, P=0.0012) and after chemotherapy (γ=0.5106, P=0.0065). Total 16 patients achieved morphologic complete remission at 28 days after chemotherapy, and 14 (87.5%) patients showed a >3 log10 reduction of the NPM1-mutA/ABL ratio. The NPM1-mutA allele was detected in each of five patients who had relapsed, giving a median increase of 0.91-fold of the NPM1-mutA/ABL ratio at relapse over that at diagnosis. Conclusions The NPM1-mutA quantitation results corresponded to BM assessment results with high stability at relapse, and could predict patient outcomes. Quantitation of the NPM1-mutA burden at follow-up would be useful in the management of AML patients harboring this gene mutation.

Immunophenotypic markers in adult acute lymphoblastic leukemia: the prognostic significance of CD20 and TdT expression

Background Efforts to overcome poor outcomes in patients with adult acute lymphoblastic leukemia (ALL) have focused on combining new therapeutic agents targeting immunophenotypic markers (IPMs) with classical cytotoxic agents; therefore, it is important to evaluate the clinical significance of IPMs. Methods Baseline characteristics and clinical outcomes of patients with adult ALL were retrospectively analyzed. The percentage of blasts expressing IPMs at diagnosis was measured by multicolor flow cytometry analysis. Samples in which ≥20% of blasts expressed an IPM were considered positive. Results Among the total patient population (N=230), almost all (92%) were in first or second hematological complete remission (HCR) and 54% received allogeneic hematopoietic cell transplant (allo-HCT). Five-year hematologic relapse-free survival (HRFS) and overall survival (OS) rates were 36% and 39%, respectively, and 45.6% and 80.5% of patients were positive for the IPMs CD20 and terminal deoxynucleotidyl transferase (TdT), respectively. Expression of CD20, CD13, CD34, and TdT was associated with HRFS rate, and expression of CD20 and CD13 was associated with OS rate, as was the performance of allo-HCT. In multivariate analysis, positivity for CD20 (HRFS: hazard ratio [HR], 2.21, P<0.001; OS: HR, 1.63, P=0.015) and negativity for TdT (HRFS: HR, 2.30, P=0.001) were both significantly associated with outcomes. When patients were categorized into three subgroups according to positivity for CD20 and TdT, there were significant differences in HRFS and OS among the subgroups. Conclusion Positivity for CD20 and TdT expression and clinical risk group were prognostic factors in adult ALL.

CD34 and p53 Immunohistochemical Stains Differentiate Hypocellular Myelodysplastic Syndrome (hMDS) from Aplastic Anemia and a CD34 Immunohistochemical Stain Provides Useful Survival Information for hMDS

Background The presence of significant dysplasia in bone marrow (BM) aspirates helps to distinguish between hypocellular myelodysplastic syndrome (hMDS) and aplastic anemia (AA). Occasionally, diluted BM aspirates make it difficult to recognize dysplastic changes and can also negatively affect the detection of cytogenetic abnormalities in hMDS. We evaluated the usefulness of CD34 and p53 immunoreactivity for discriminating between hMDS and AA and for estimating survival outcomes in hMDS patients. Methods BM clot section (BMC) or BM biopsy (BMB) specimens were obtained from 64 hMDS/AA patients (33 with hMDS and 31 with AA) and seven controls. Immunohistochemical (IHC) staining for CD34 and p53 was performed by using the EnVision detection system (Dako, Denmark). We compared the results of IHC staining, BM findings, and chromosomal analyses, and determined overall survival outcomes. Results The number of CD34- and p53-positive BM cells was higher among the patients with hMDS than among the patients with AA (P<0.001 and P=0.001, respectively). hMDS patients with increased CD34-positive cells had significantly poorer survival outcomes compared with those with normal number of CD34-positive cells (P=0.013). Conclusions CD34 and p53 IHC stains of BMC or BMB provide useful information for differentiating between hMDS and AA. CD34 IHC staining of BMC or BMB also provides useful information for estimating survival outcomes in hMDS patients.

Increased circulating plasma cells detected by flow cytometry predicts poor prognosis in patients with plasma cell myeloma: CIRCULATING PLASMA CELLS IN PLASMA CELL MYELOMA

Flow cytometry (FC) is a reliable tool for diagnosing and monitoring of plasma cell myeloma (PCM). Recent studies used FC for quantifying plasma cells (PCs) in peripheral blood (PB) using various panels, and an adverse prognostic effect of circulating PCs (cPCs) has been reported. We investigated the prognostic implication of cPCs quantified using a simple panel in patients with PCM.

The first case report of composite bone marrow involvement by simultaneously developed peripheral T-cell lymphoma, not otherwise specified, and diffuse large B-cell lymphoma.

Lymphomas of different histological types can occur at the same anatomical site (composite lymphoma) or at different sites, and can arise simultaneously or sequentially [1, 2]. Reports of patients in whom histologically distinct lymphomas occur simultaneously at different sites are rare [3, 4]. Among these rare cases, the simultaneous occurrence of T- and B-cell lymphomas is extremely rare [5]. To the best of our knowledge, composite involvement of T- and B-cell lymphomas in the bone marrow (BM) have not been reported so far. We report a case of composite BM involvement by T- and B-cell lymphomas. A 52-yr-old woman presented with abdominal discomfort. She had a history of hepatitis B-related liver cirrhosis and was taking lamivudine. She had lost 4 kg of weight in the previous 4 months. Laboratory investigation revealed pancytopenia (white blood cells, 1.7×109/L [reference range: 4-10×109/L]; hemoglobin, 11.0 g/dL [12-16 g/dL]; and platelets, 75×109/L [150-350×109/L]), elevated levels of liver enzymes (aspartate transaminase, 75 IU/L [0-40 IU/L]; alkaline phosphatase, 129 IU/L [40-120 IU/L]; γ-glutamyltransferase, 99 IU/L [8-35 IU/L]), and an increased level of lactate dehydrogenase (315 IU/L [120-250 IU/L]). Dynamic computed tomography revealed an ill-defined, 3-cm lesion in the left lateral segment of the liver and multiple abdominal and mediastinal lymphadenopathies. Esophagogastroduodenoscopy revealed a 3-cm ulcerofungating mass between the antrum and the lower body of the stomach. A liver core needle biopsy identified a peripheral T-cell lymphoma, not otherwise specified, and an endoscopic biopsy of the stomach identified a diffuse large B-cell lymphoma (DLBL). A BM biopsy revealed BM involvement by DLBL with a nodular infiltration pattern, which was corroborated by positive immunohistochemical staining for CD3 and CD20. CD20-positive lymphocytes were present in nodular aggregates. CD3-positive lymphocytes were present in small lymphocytes surrounding CD20-positive lymphocytes suggesting reactive T lymphocytes. A cytogenetic study of BM revealed an apparently normal karyotype. The patient was started on the combination chemotherapy regimen including rituximab, cyclophosphamide, doxorubicin, vincristine and prednisolone (R-CHOP). After 6 cycles of R-CHOP, the liver mass and lymphadenopathies had disappeared. However, a follow-up BM biopsy revealed BM involvement by T-cell lymphoma and DLBL. Immunohistochemical staining showed medium to large sized PAX5-positive lymphocytes with a marked interstitial infiltration pattern (Fig. 1A, B), and the cells were also CD79a-positive. Peritrabecular and interstitial infiltration of small to medium sized CD3-positive lymphocytes was also prominent (Fig. 1C, D). Rearrangements of the T-cell receptor gamma locus (TRG) and immunoglobulin heavy locus (IGH) were studied in BM (after the 6th cycle of R-CHOP), liver, and stomach (at diagnosis) specimens using the BIOMED-2 multiplex PCR protocol [6]. A 170-bp monoclonal TRG rearrangement was detected in the liver sample (Fig. 2A), while TRG in the BM had a larger 160-bp peak with a smaller 170-bp peak (Fig. 2B). IGH gene rearrangements were not detected in the stomach sample or in the BM aspirate, and the BM aspirate had a normal karyotype. After the 8th R-CHOP cycle, computed tomography and positron emission tomography findings suggested involvement of multiple lymph nodes (celiac, splenic hilar, and abdominal paraaortic lymph nodes). The patient died of pneumonia 1 yr after diagnosis. Fig. 1 Bone marrow biopsy after 6 cycles of rituximab, cyclophosphamide, doxorubicin, vincristine and prednisolone (R-CHOP) combination chemotherapy. (A, B) Neoplastic B lymphocytes infiltrating in an interstitial pattern was immunohistochemically analyzed by ... Fig. 2 T cell receptor gamma locus (TRG) rearrangement analyzed by using BIOMED-2 multiplex PCR. Horizontal axis represents amplicon size (base pairs) and vertical axis represents fluorescence intensity. (A) A monoclonal TRG rearrangement was detected at 170 ... In our TRG rearrangement study, monoclonal TRG rearrangements were detected in both liver and BM samples, but the sizes of amplicons were slightly different, that is a finding that may be explained by clonal evolution [7]. We speculate that there is BM involvement on the basis of a subclone from the hepatic T-cell lymphoma. Moreover, a small peak corresponding to a 170-bp PCR product was observed in a BM sample, which suggests that the same clone present in the liver sample was also present in the BM sample. Monoclonal IGH rearrangements were not detected in the stomach or BM sample. As monoclonal IGH rearrangements are detected in approximately 80% of DLBL cases using BIOMED-2 multiplex PCR [8], the fact that rearrangement of IGH was not detected in the stomach sample is not unusual. T- and B-cell lymphomas simultaneously developed in this patient. Moreover, a follow-up examination suggested BM involvement by both these lymphomas. To our knowledge, this is the first report of a patient with BM involvement by both T- and B-cell lymphomas. Factors contributing to the development of synchronous primary lymphomas have not been investigated, and a case with involvement of the same site by two different lymphomas has not been reported; however, primary composite lymphomas have been reported [9]. The clinical significance of BM involvement by both T- and B-cell lymphomas is unknown, although the simultaneous development of more than one histological type of lymphoma is associated with a poor prognosis [1]. The present patient died 1 yr after her diagnosis, suggesting that composite BM involvement may also be associated with a poor prognosis.