Yumiko Inui

Methotrexate-associated lymphoproliferative disorders: management by watchful waiting and observation of early lymphocyte recovery after methotrexate withdrawal

No optimum treatment of iatrogenic immunodeficiency-associated lymphoproliferative disorders due to methotrexate in patients with rheumatoid arthritis (MTX-LPD) has yet been established, although MTX withdrawal is known to have a substantial effect on tumor regression. Here, we retrospectively analyzed 20 cases of MTX-LPD. Tumor shrinkage occurred in 18 of 20 cases, but only following MTX withdrawal. This tumor regression ratio was considerably better than in previous reports, and appeared due to longer “watchful waiting.” Lymphocyte recovery at 2 weeks after MTX withdrawal was significantly higher in cases with tumor regression in 1 month than in those without tumor regression (p = 0.001). Median time to maximal efficacy after MTX cessation in cases without chemotherapy was 12 weeks (range 2–76). In conclusion, watchful waiting for a longer period after MTX cessation with observation of early lymphocyte recovery and uninterrupted continuation of other anti-rheumatoid drugs may be an acceptable management plan for MTX-LPD.

Excessive MET signaling causes acquired resistance and addiction to MET inhibitors in the MKN45 gastric cancer cell line

SummaryThe clinical efficacy of MET tyrosine kinase inhibitors (MET-TKIs) is hindered by the emergence of acquired resistance, presenting an obstacle to drug discovery. To clarify the mechanisms underlying acquired resistance to MET-TKIs, we established resistance models by continuous exposure of the MET-amplified gastric cancer cell line MKN45 to MET-TKIs, PHA665752 (MKN45-PR) and GSK1363089 (MKN45-GR). Baseline expression and phosphorylation of MET were elevated in MKN45-PR and MKN45-GR compared to MKN45 cells, and higher concentrations of MET-TKIs were required to inhibit MET phosphorylation compared to parental cells. Alterations in MET previously associated with resistance to MET-TKIs were observed in resistant cells, including elevated MET copy number, observed in both resistant lines compared to MKN45 cells, and the Y1230H mutation, detected in MKN45-PR cells. Notably, the growth of resistant lines was lower in the absence of MET-TKIs, suggesting “addiction” to inhibitors. While MKN45-PR cells exhibited a higher S-phase fraction in the absence of PHA665752, bromodeoxyuridine (BrdU) uptake was identical. Baseline phosphorylation of ATR, Chk1 and p53 and p21waf1/Cip1 expression was higher in MKN45-PR compared to MKN45 cells, and levels were reduced to those observed in untreated MKN45 cells following PHA665752 treatment. Furthermore, targeted knockdown of MET enhanced the growth of MKN45-PR cells. These findings suggest that alterations in MET leading to acquired MET-TKI resistance, may cause excessive MET signaling, subsequent replication stress and DNA damage response, and intra-S-phase arrest in the absence of MET-TKIs. Thus, partial MET inhibition is necessary for resistant cells to proliferate, a phenomenon we refer to as MET-TKI “addiction”.

Myelosuppression grading of chemotherapies for hematologic malignancies to facilitate communication between medical and dental staff: lessons from two cases experienced odontogenic septicemia

BackgroundOdontogenic diseases can be a risk factor for life-threatening infection in patients with hematologic malignancies during chemotherapy that induces myelosuppression of variable severity. Previous studies noted the necessity of the elimination of all odontogenic foci before hematopoietic stem cell transplantation. To enable planning for the adequate dental intervention, the oral medicine team must understand the general status of patient and the intensity of the chemotherapy, which is sometimes difficult to be fully appreciated by dental staff. Therefore, a simplified grading would facilitate the sharing of information between hematologists, dentists and oral hygienists. This study aimed to introduce our myelosuppression grading of chemotherapies for hematologic malignancies and analyze the timing of occurrence of severe odontogenic infection.Methods37 patients having received various chemotherapies for hematologic malignancies were enrolled. The chemotherapy regimens were classified into four grades based on the persistency of myelosuppression induced by chemotherapy. Mild myelosuppressive chemotherapies were classified as grade A, moderate ones as grade B, severe ones as grade C, and chemotherapies that caused severe myelosuppression and persistent immunodeficiency (known as conditioning regimens for transplant) as grade D. The timing of occurrence of severe odontogenic infection was retrospectively investigated.ResultsTwo patients (5.4%) had severe odontogenic infections after grade B or C chemotherapy. One occurred after extraction of non-salvageable teeth; the other resulted from advanced periodontitis in a tooth that could not be extracted because of thrombocytopenia. Both were de novo hematologic malignancy patients. During grade D chemotherapy, no patients had severe odontogenic infections.ConclusionsThe simplified grading introduced in this study is considered a useful tool for understanding the myelosuppressive state caused by chemotherapy and facilitating communication between medical and dental staff. During the period around the primary chemotherapy, especially for de novo hematologic malignancy patients who often received grade B to C myelosuppression chemotherapy, caution should be exercised for severe odontogenic infection by the oral medicine team, irrespective of whether invasive treatment is to be performed.

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.

A novel recurrent translocation t(7;17)(q22;p13) and a late-appearing t(2;3)(p13;q26.2) with dysmegakaryopoiesis in acute myeloid leukemia.

Deletions of the long arm of chromosome 7 are commonly found n a variety of myeloid malignancies including myelodysplastic yndrome (MDS) and acute myeloid leukemia (AML) [1–3]. These bnormalities are detected as a part of more complex karyotypes, nd are generally associated with very poor prognosis. Molecular ytogenetic analyses revealed that 7q22 could be one of the critical egions in the pathogenesis of MDS/AML with del(7q), and the presnce of tumor suppressor genes at 7q22 has been suggested [1]. On he other hand, less information is available for balanced transloations involving 7q22, and only limited cases have been analyzed n MDS/AML [2,3]. The t(2;3)(p13–23;q26) is a non-random translocation observed n approximately 0.5% of myeloid malignancies [4,5]. Similar to nv(3)(q21q26)/t(3;3)(q21;q26), t(2;3) is shown to be associated ith multilineage dysplasia, dysmegakaryopoiesis, an immature yeloid phenotype of blasts, and unfavorable prognosis although latelet counts are low to normal. More than 50 cases with t(2;3) ave been reported in spite of the marked heterogeneity of 2p reakpoints, and almost all cases showed t(2;3) at the initial diagosis [4,5]. Here, we describe a unique case of AML with a novel ecurrent translocation involving 7q22, t(7;17)(q22;p13), at the iagnosis, and with a late-appearing t(2;3)(p13;q26.2) accompaied by dysmegakaryopoiesis at the relapse.

Reed-Sternberg-like cells of ALK-positive anaplastic large cell lymphoma with near-tetraploidy.

A 37-year-old woman was admitted to our hospital because of fever lasting for 1 month. Computed tomography (CT) scans revealed massive hepatomegaly and osteolytic lesions in the lumbar vertebra and sacrum. Peripheral blood values were hemoglobin 98 g ⁄L, platelets 516 · 10 ⁄L, and leukocytes 11.6·10 ⁄L with no atypical cell. Serum levels of lactate dehydrogenase (LDH), C-reactive protein (CRP), and soluble interleukin-2 receptor (sIL-2R) were elevated to 219 IU ⁄L (normal range, 115–217), 10.28 mg ⁄dL (<0.3), and 3151 U ⁄mL (124–446), respectively. Bone marrow examination showed normocellular marrow with 0.8% abnormal large lymphoid cells, which had one or two nuclei, fine nuclear chromatin and nucleoli, basophilic cytoplasm, and multiple vacuoles (Fig. 1A). These mononuclear or binuclear cells resembled Hodgkin or Reed–Sternberg (RS) cells, suggesting the possible diagnosis of Hodgkin lymphoma (HL). However, immunohistochemistry revealed that large lymphoid cells were strongly positive for ALK as well as CD30 (Fig. 1B, C). ALK staining was cytoplasmic, nuclear, and nucleolar staining pattern characteristically associated with t(2;5) and NPM ⁄ALK protein. Actually, G-banding analysis of the bone marrow cells demonstrated near-tetraploidy with double t(2;5) translocations as follows: 90 92.XXXX,t(2;5)(p23;q35)· 2,)4,+5,)8,del(8)(q?),)14,+18[cp5] ⁄ 46,XX[15] (Fig. 1D). Fluorescence in situ hybridization (FISH) confirmed rearrangements of the ALK gene at 2p23: two sets of split centromeric and telomeric ALK signals were detected (Fig. 1E). These hematological, pathological, and cytogenetic findings indicated the diagnosis as bone marrow infiltration of ALK-positive anaplastic large cell lymphoma (ALCL) with near-tetraploidy. Bone biopsy

Megakaryoblastic transformation of therapy-related myeloid neoplasms with concomitant MYC amplification on double minute chromosomes

After 3 months, the bone marrow cell differential was normocellular, showing 37.0% blasts, which were positive for myeloperoxidase staining and immunophenotypically positive for CD13, CD19, CD33, CD34, and HLADR, but negative for CD41. Following these observations, a diagnosis of transformation from t-MDS to t-AML was made. The disease progressed even though the patient had received induction therapy with low-dose cytarabine and aclarubicin. After 3 months, peripheral blood values were as follows: hemoglobin 65 g/L, platelets 17 × 109/L, and WBCs 0.3 × 109/L with 12% blasts. The bone marrow was infiltrated with two types of blasts: 40.4% large and 22.2% small blasts. The former were myeloblasts observed at the diagnosis of t-AML (Fig. 1a). In contrast, small blasts showed cytoplasmic blebs, suggestive of megakaryoblasts (Fig. 1b). These blasts were immunologically positive for CD7, CD13, CD33, CD34, CD41, and HLA-DR. The patient died of progressive disease 6 months after the initial diagnosis of t-MDS. Chromosome analysis at the initial diagnosis of t-MDS showed 45–49,XY,del(5)(q?),+8,+add(8)(p11.2), −17,+mar1[cp13]/48,sl,del(7)(q?),−add(8),add(8) (p21),+add(8),+r1,−mar1[6]/46,XY[1]. The karyotype at the transformation to t-AML was 46–49,XY,del(5) (q?),del(7)(q?),+add(8)(p21)×2,−7,+r1[cp12]/48,sl, +6,+7,−del(7),−add(8)×2,der(8)add(8)(p11.2)add(8) (q22),+der(8)add(8)add(8),+20,add(21)(q22),−r,12–42 dmin[4]/45,X,−Y[3]/46,XY[1]. The final karyotype after chemotherapy was 47–50,X,−Y,del(5)(q?),+6,+8,der(8) add(8)(p11.2)add(8)(q22)×2,+15,−17,+20,add(21) (q22),7–95dmin[cp20]. Fluorescence in situ hybridization (FISH) with IGH/MYC/CEP 8 probes on metaphase spreads revealed multiple MYC signals on dmin (Fig. 1c). Notably, interphase nuclei were strongly labeled with MYC signals.

Coexpression of NUP98/TOP1 and TOP1/NUP98 in de novo Acute Myeloid Leukemia with t(11;20)(p15;q12) and t(2;5)(q33;q31)

The t(11;20)(p15;q11∼12) translocation is a very rare but recurrent cytogenetic aberration that occurs in myelodysplastic syndrome/acute myeloid leukemia (MDS/AML). This translocation was shown to form a fusion gene between NUP98 at 11p15 and TOP1 at 20q12. Here, we describe a new case of de novo AML M2 with t(11;20) which was associated with another balanced translocation. An 81-year-old man was admitted to undergo salvage therapy for relapsed AML. G-banding and spectral karyotyping showed 46,XY,t(2;5)(q33;q31),t(11;20)(p15;q12)[20]. Expression of the NUP98/TOP1 fusion transcript was confirmed: NUP98 exon 13 was in-frame fused with TOP1 exon 8. The reciprocal TOP1/NUP98 fusion transcript was also detected: TOP1 exon 7 was fused with NUP98 exon 14. After achieving hematological complete remission, the karyotype converted to 46,XY,t(2;5)(q33;q31)[19]/46,sl,t(11;20)(p15;q12)[1]. FISH analysis demonstrated that the 5q31 breakpoint of t(2;5) was centromeric to EGR1. In all 10 cases described in the literature, the NUP98 exon 13/TOP1 exon 8 fusion transcript was expressed, indicating that it may be responsible for the pathogenesis of MDS/AML with t(11;20). On the other hand, the TOP1/NUP98 transcript was coexpressed in 4 cases of de novo AML, but not in 3 cases of therapy-related MDS. Thus, this reciprocal fusion may be associated with progression to AML.

Rhabdomyolysis Caused by Candida parapsilosis in a Patient with Acute Myeloid Leukemia after Bone Marrow Transplantation

Rhabdomyolysis is characterized by a marked elevation of the creatine kinase (CK) levels and myoglobinuria, thus leading to renal dysfunction. Various viruses or bacteria can be etiologic agents, but mycosis has only rarely been reported to be a cause of rhabdomyolysis. In this report, we describe an adolescent male with acute myeloid leukemia who underwent allogeneic bone marrow transplantation and thereafter developed rhabdomyolysis and Candida parapsilosis fungemia almost at the same time. Following treatment for C. parapsilosis, the transaminase and CK levels both satisfactorily decreased. This case illustrates that C. parapsilosis infection may be a causative agent of rhabdomyolysis in immunocompromised patients.

A mimicking "multiple liver metastasis" of breast cancer by recurrent B lymphoblastic leukemia.

Dear Editor, A 60-year-old female presented with progressive headache and fatigue. Twelve years ago, she had suffered from estrogen receptor (ER)-positive breast cancer and received radical excision followed by radiotherapy and endocrine therapy. Complete blood cell analysis showed a white blood cell count of 4.6× 10/L with 11 % of blasts and a hemoglobin concentration of 7.9 g/dL. Bonemarrowwas hypercellular with 83.8% of blasts, which were positive for CD10, CD19, and HLA-DR, and were negative for membrane-bound light chains by flow cytometric analysis. Cytogenetic abnormalities were not found. She was diagnosed with B lymphoblastic leukemia, not otherwise specified (pre-B-ALL), in accordance with the WHO classification (fourth edition) [1]. She received induction chemotherapy and eventually achieved complete remission. During the postremission therapy and the outpatient follow-up period, there was no evidence of leukemic recurrence. Eleven months after completion of the chemotherapy, she underwent an abdominal computed tomography (CT) scan for a periodical follow-up of inveterate ureterolithiasis. A non-enhanced CT scan of the liver showed multiple low-density masses (Fig. 1a), which were not observed at the onset of pre-B-ALL 2 years before. After intravenous administration of contrast material, these hepatic masses appeared to be more attenuated compared with normal parenchyma (Fig. 1b). These radiographic characteristics seemed to be consistent with multiple liver metastasis of breast cancer in consideration of her medical history. However, laboratory tests showed normal liver function, except for a slightly elevated LDH (230 U/L; reference range, 118– 221 U/L), and serum levels of tumor-specific markers such as carcinoembryonic antigen, CA19-9, CA15-3, and Nation Cancer Center-Stomach-439 were not elevated. Furthermore, a liver biopsy revealed that small round cells with high N/C ratio occupied the hepatic lesions with relatively clear boundaries (Fig. 1c, d). Immunohistochemistry demonstrated that these abnormal cells were negative for cytokeratin AE1/AE3 (Fig. 1e), ER, and mammaglobin, suggesting that recurrence of breast cancer was negative. On the other hand, these cells were diffusely positive for CD79a (Fig. 1f) and partially positive for CD20 and TdT. These pathological findings were similar to those of the bone marrow at the initial diagnosis of pre-B-ALL. Finally, we made a correct diagnosis of pre-B-ALL recurrence, multi-focal infiltration of leukemic cells in the liver. Although there were more than 15 % of blasts in the bone marrow, blasts and cytopenia were not observed in the peripheral blood. Because hormone receptor-positive breast cancer is slowly progressive in general, a recurrence after a latency period of more than 10 years is not rare in long-term follow-up patients [2]. Thus, it is possible that multiple hepatic nodules in this case comprised of recurrent breast cancer cells. Leukemic cells often infiltrate into the liver diffusely, and to our knowledge, multi-focal lesions have not been reported in patients with leukemia relapse [3, 4]. However, by a liver biopsy, we could confirm that these lesions actually consisted of recurrent lymphoblasts. Lossos et al. emphasized that re-biopsy should be performed in every patient with follicular lymphoma to evaluate the presence of transformation [5]. In patients with breast cancer, re-biopsy is also recommended to assess the switches in biomarker status such M. Nishimura :A. Okamura :Y. Inui :Y. Imamura : K. Yakushijin :H. Matsuoka :K. Yamamoto :H. Minami Division of Medical Oncology/Hematology, Department of Medicine, Kobe University Graduate School of Medicine, Kobe, Japan