Factors influencing leukemic transformation in refractory anemias with excess of blasts, with ringed sideroblasts, and without ringed sideroblasts.

The association between leukemic transformation and various features recorded at presentation in patients with refractory anemia with excess of blasts and with or without ringed sideroblasts was analyzed in 255 patients using the proportional hazard model. Features associated with higher transformation rates were: higher values of blasts in peripheral blood or bone marrow; serum haptoglobin; vitamin B12; megakaryocytes in bone marrow; morphological abnormalities in granulo- or megakaryocyte series; male sex; circulating megakaryocytes in peripheral blood; older age; and lower ringed sideroblast proportion. Multivariate analysis was also performed using the following predictor variables: presence or absence of refractory anemia with excess of blasts; sex; abnormal granules in granulocytes; age; and mononuclear large megakaryocytes. Patients were divided arbitrarily into low (hazard ratio, less than 0.45), intermediate (hazard ratio, 0.45-1.85) and high (hazard ratio, greater than 1.85) risk groups. The cumulative leukemia-free rates in the low and intermediate risk groups showed long plateau phases at 95 and 71%, respectively, while in the high risk group, the rate was 10% at 5 years. For clinical purposes, the low risk group should be considered to have nonpreleukemia and the high risk group to have preleukemia.

Varying probability of the development of acute nonlymphoblastic leukemia in refractory anemia patients with an excess of blasts.

The cumulative leukemia-free survival rate of refractory anemia with excess of blasts was fitted to three parametric failure time models, i.e., the usual exponential and Weibull, and exponential mixture models. Among the three, the best fit model was the exponential mixture model, which was 119 times more likely to assume that samples came from the exponential mixture distribution than to assume that those were from the usual Weibull distribution. This strongly suggests that refractory anemia with excess of blasts consists of subgroups with very high and very low probability to develop acute nonlymphoblastic leukemia. The estimated proportion of the very low probability group was about 30%. Analysis by the exponential mixture model with covariates revealed that the probability of a patient to develop acute nonlymphoblastic leukemia could be estimated by three covariates, i.e., bone marrow blast percentage; abnormal granules of granulocytes; and mononuclear large megakaryocytes. The estimated probabilities ranged from 17 to 99%, according to the model.

Factors influencing nonleukemic death in refractory anemia, refractory anemia with ring sideroblasts, and refractory anemia with excess of blasts.

The association between nonleukemic death and various features recorded at presentation in patients with refractory anemia (RA), RA with ring sideroblasts, and RA with excess of blasts was analyzed in 251 patients using the proportional hazards model. Features associated with higher nonleukemic death rates were: 1% or more metamyelocytes in peripheral blood (PB); lower 59Fe incorporation rate; 1% or more blasts in PB; lower hematocrit or hemoglobin; presence of giant platelets; 1 microgram/liter or higher serum vitamin B12 levels; higher periodic acid-Schiff positive erythroblasts; and 1% or higher promyelocytes in PB. Multivariate analysis was also performed using the following predictor variables: metamyelocytes in PB, micromegakaryocytes, hemoglobin, giant platelets, presence or absence of RA with excess of blasts, and mononuclear large megakaryocytes. Patients were divided arbitrarily into low (hazard ratio, less than 0.55), intermediate (hazard ratio, 0.55-1.5), and high (hazard ratio, greater than 1.5) risk groups. The cumulative nonleukemic death rates in the high and intermediate risk groups reached a median at 602 and 1984 days from presentation, respectively, while the rate reached a plateau level of 49.4% after 2644 days in the low risk group. The risk factors for leukemic transformation and nonleukemic death were found to be different and to need separate consideration.

Accelerated declining tendency of human T-cell leukemia virus type I carrier rates among younger blood donors in Kumamoto, Japan.

The annual age- and sex-specific human T-cell leukemia virus type I carrier rate of blood donors in Kumamoto, Kyushu, Japan from 1986 to 1990 revealed that the carrier rates of all the age groups below 50 years declined linearly in both sexes (P less than 0.005). Furthermore, the annual declining rates relative to the carrier rates of 16-19-year-old and 20-29-year-old males were higher than those of all of the older males (P less than 0.02), and all female age groups below 50 years had higher relative declining rates than 50-64-year-old females (P less than 0.05). Although several factors, such as a notification program at obstetric clinics, methodological and technical improvement of the assays, wider knowledge of human T-cell leukemia virus type I infection in the latter years, and immigration of individuals from a nonendemic area, might cause an absolute decline of the carrier rate of the blood donors, these factors could not explain the acceleration of the relative declining rate among younger donors. Therefore, this acceleration represents the tendency of the general population.

The UW solution for canine kidney preservation. Its specific effect on renal hemodynamics and microvasculature.

The preservation effects of UW solution on renal hemodynamics and microvascular systems were studied in canine kidney autografts. In 72-hr UW-preserved kidneys, the microvessels of both cortex and medulla were completely visualized with silicon rubber compound 1 hr after reperfusion. Histology also showed extremely well-preserved arterioglomerular and tubular systems. These results were correlated with good renal blood flow, prompt recovery of posttransplant graft function, and 100% two-week survival of dogs. In contrast, kidneys preserved for 72 hr with Euro-Collins solution showed necrotic and obstructive changes of the microvasculature and deterioration of renal hemodynamics. In 120-hr UW-preserved kidneys, the microcirculation of the medullary region became poor after reflow when there was fairly intact perfusion of the cortical region, indicating an ischemia-related intrarenal blood flow maldistribution. The 120-hr kidneys subsequently failed in spite of having a good blood flow and morphologically well-maintained microvasculature after reperfusion. These data demonstrated that much, but not all, of the beneficial effect of UW solution in kidney preservation might be attributed to its remarkable protection of renal microvasculature. Correction of intrarenal blood maldistribution caused by a discrepancy in tolerance to ischemia of the vascular and tubular systems might be important in successfully preserving the kidney for 120 hr.

Clinical features of long-term survivors of refractory myelodysplastic anemias. A Japanese cooperative study.

Eighty-one of 473 patients with refractory myelodysplastic anemias registered by the Japanese Cooperative Study Group prior to January 1987 survived more than 5 years. At presentation, most patients had mild cytopenia, a less aggressive form of the disease (48 with refractory anemia, 23 with refractory anemia with ring sideroblasts, 10 with refractory anemia with excess of blasts), less blast cells in the marrow and blood, and onset at younger ages. Their clinical profiles 5 years after presentation showed no significant improvement. The results suggest that the long-term survivors were found in a subpopulation of patients with a favorable prognosis and that it is a part of the natural course rather than the results of treatment.

Mode of disease progression in primary myelodysplastic syndromes: a Japanese co-operative study. The Refractory Anemia Study Group of The Ministry of Health and Welfare, Japan.

Chronological changes in hematological findings were analyzed in 225 patients with myelodysplastic syndromes (MDS). They were diagnosed between 1990 and 1992. Their hematological findings, i.e. hemoglobin levels, leukocyte and platelet counts, proportions of peripheral blood (PB) blasts and monocytes, and proportion of blasts in bone marrow (BM), were recorded for up to 42 months after diagnosis, when available. BM was examined regularly in only a few patients. Therefore, it was impractical to use the French-American-British Cooperative Group criteria for subtype classification during the disease course. Thus, we used the percentage of PB blasts as the only indicator of stage evolution. We classified the disease into four stages: stage 1, less than 1% PB blasts; stage 2, 1-5% PB blasts; stage 3, 5-30% PB blasts; and stage 4, 30% or more PB blasts. There were 171 patients initially in stage 1, 37 initially in stage 2, and 17 initially in stage 3. Less than half (45%) of the patients initially in stage 1 progressed to stage 2, while 91% of the patients initially in stage 2 and all of the patients initially in stage 3 showed stage evolution. Eight variables, i.e. BM blasts 5% or more, male sex, karyotypic abnormalities, micromegakaryocytes, mononuclear large megakaryocytes, platelet counts 50 x 10(9)/l or higher, abnormal nucleus of granulocytes, and abnormal granules of granulocytes, were found to be significant risk factors for evolution from stage 1 to 2. Evolution from stage 1 to a higher stage within 15 months of diagnosis was associated with impending poor prognosis in most patients. However, of the 67 patients initially in stage 1 who died, 30 did not show stage evolution. Evolution from stage 2 to a higher stage and from stage 3 to stage 4 was also associated with impending poor prognosis. Higher levels of cytopenia were not associated with poorer prognosis in the stage 1 patients. In conclusion, our grading system proved to be useful in evaluating the chronological changes in MDS patients.

Stable human T-lymphotropic virus type I carrier rates for 7 years among a teenaged blood donor cohort of 1986 in Kumamoto, Japan.

The human T-lymphotropic virus type I (HTLV-I) carrier rates for blood donors in Kumamoto, Kyushu, Japan for 8 years, 1986-1993, are currently available. The data show that 16-19-year-olds in 1986 and 20-29-year-olds in 1993 represent nearly the same cohort, because the median age in both groups is 24.5 years in 1993. Therefore, comparison of the HTLV-I positive rate for the two groups gives an estimate of the change in the rate over 7 years within the cohort. In males, 265 of 22,143 donors (1.20%) were seropositive for HTLV-I among 16-19-year-olds in 1986, and 214 were seropositive among 20,076 (1.07%) donors in 20-29-year-olds in 1993. In females, 203 were seropositive among 20,677 (0.98%) donors in 16-19-year-olds in 1986, and there 154 were seropositive among 18,660 (0.83%) donors in 20-29-year-olds in 1993. Thus, the seropositive rates declined in both sexes. However, the average annual rate of immigration to Kumamoto Prefecture was 2.37%. If seropositive rates for 20-29-year-olds in 1993 are adjusted for the dilution effect due to immigration (under the assumption that all immigrants were HTLV-I negative), the adjusted carrier rate for males is 1.26% and that for females is 0.98%. The adjusted carrier rates for both sexes are almost the same as those for 16-19-year-olds in 1986. This indicates that horizontal transmission was negligible for those in the cohort who were in their early reproductive period. Using all 8 year carrier rates for 16-19-year-olds and 20-29-year-olds, chronological changes of 20-29-year-olds, in the near future was estimated. The best goodness of fit model indicated that the HTLV-I carrier rate will decline exponentially, and that the rate will decrease by 50% approximately every 10 years for both sexes. It is probable that in recent years south-west Japan has lost the conditions that are favorable for HTLV-I endemicity and the virus will be virtually non-endemic within a few generations.

Clinical characteristics of Japanese patients with primary myelodysplastic syndromes: a co-operative study based on 838 cases. Anemia Study Group of the Ministry of Health and Welfare.

The characteristics of Japanese (JPN) patients with myelodysplastic syndromes (MDS) were investigated in 838 retrospectively collected cases. The median age of the JPN patients was 60 years, about 10 years younger than that in most of the reports based on Western patients. Median survivals were 65 months for refractory anemia (RA), 58 months for RA with ring sideroblasts (RARS), 16 months for RA with an excess of blasts (RAEB), 10 months for RAEB in transformation (RAEBT), and 20 months for chronic myelomonocytic leukemia (CMML). Cumulative leukemia-free rates at final observation were 73% for RA, 79% for RARS, 24% for RAEB, 20% for RAEBT, and 53% for CMML. When low-risk (RA and RARS) patients were divided into two groups, those 40 years of age and older, and those under 40, the cumulative leukemia-free rate was 94% for the younger patients (n = 101), compared with 66% for the older patients (n = 318). The prognostic factors for survival were different from those in Western reports, i.e., variables representing quantitative abnormalities (hemoglobin levels, granulocyte, and platelet counts) were not major prognostic factors, while variables representing qualitative abnormalities (morphological abnormalities in granulocytic and megakaryocytic series cells) were highly significant. Two scoring systems for overall survival and for leukemic transformation were developed, based on multivariate prognostic factor analysis. Neither system included variables representing the degree of cytopenia. Whatever the reason for the different prognostic factors in JPN and Western MDS patients, the use of a scoring system based on Western patients for clinical decision-making in a JPN patient could be misleading, and vice versa.

Hair dye use and occupational exposure to organic solvents as risk factors for myelodysplastic syndrome.

To investigate the relationships of personal hair dye use and environmental factors to myelodysplastic syndromes (MDS), we conducted a case-control study in Japan. A total of 111 MDS cases and 830 controls randomly selected from the residents in the same prefecture of cases using telephone directories responded to a health questionnaire. The odds ratio (OR) for ever having used hair dye was 1.99 (95% confidence interval (CI) 1.17-3.38) and there were statistically significant trends in risk with increasing duration and number of hair dye use. Occupational exposure to organic solvents was marginally associated with the risk of MDS (OR = 1.99; 95% CI 0.97-4.10).

Refractory myelodysplastic anaemias with hypocellular bone marrow.

Thirty three patients with refractory myelodysplastic anaemias (RMDA) with marrow hypocellularity were reviewed to see whether they differed from those with normocellular or hypercellular marrows. The median age was 65 years with a male:female ratio of 26:7. There were 11 cases of refractory anaemia (RA), four of refractory anaemia with ringed sideroblasts (RARS), and 18 of refractory anaemia with excess of blasts (RAEB). All presented with peripheral cytopenias, mostly pancytopenia or bicytopenia dysplasia in one or more cell lineages, and a marrow biopsy specimen with less than normal numbers of nucleated cells for the age. Twenty four patients died, including 14 of the 16 who developed acute non-lymphocytic leukaemia (ANLL). The results suggest that patients with hypocellular RMDA have a similar prognosis to those with normocellular or hypercellular marrows at presentation.

Infection in myelodysplastic syndromes before evolution into acute non-lymphoblastic leukemia.

The frequencies, kinds, pathogens, and risk factors of infections in the myelodysplastic syndromes (MDS) were analysed in 430 cases. The overall tendency was for one infectious episode per 1023.5 patient days. The frequency of infectious episodes was highest just after diagnosis of MDS when more than 4 episodes per 1000 patient days occurred. Thereafter, the rate declined rapidly to about 0.3 episodes per 1000 patient days within 4 years. The most frequent infection was that of the respiratory tract followed by sepsis and fever of unknown origin (FUO). Among the types of infection resulting in death, sepsis and FUO comprised the highest proportion (40%) followed by respiratory tract infections (39%). The most frequent pathogen observed was Staphylococcus bacteria. The significant multivariate risk factors for fatal infections were subtype, hemoglobin, dependence on red blood cell transfusion, age, and sex. A staging system was created using these five simple variables at diagnosis.

Re-analysis of prognosis in refractory anemia alone, with ring sideroblasts, and with excess of blasts.

Based on 473 primary cases of refractory anemia (RA), RA with ring sideroblasts (RARS), or with an excess of blasts (RAEB), new staging systems for overall survival, leukemic transformation, and nonleukemic death were developed. The reproducibility of these new staging systems, our former staging systems for leukemic transformation and nonleukemic death, and that for overall survival provided by Sanz et al. (Blood 1989;74:395-408), were estimated using a total of 132 patients with RA, RARS, or RAEB (test sample). The correlation of risk ratios of the test sample from our system and that of Sanz et al. was poor (tau = 0.24; Kendall rank correlation). Our risk ratio was a significant (p = 0.0012) continuous covariate of the Cox model life-table analysis in the test sample but that of Sanz et al. was not. The new and previous staging systems for leukemic transformation were highly similar (tau = 0.7) and risk ratios of both systems were significant in the test sample (p = 0.00046 and 0.0017, respectively). Based upon the new system, patients at high risk for leukemic transformation RA or RARS were identified as males, with bone marrow myeloblasts higher than 2.5%, abnormal granules in the granulocytes, and circulating erythroblasts. Their cumulative leukemic transformation rate exceeded 50% within 2 years from presentation. The new and previous systems for nonleukemic death were moderately correlated (tau = 0.47). The risk ratios of both systems were significant in the test sample (p = 0.00012 and 0.000024, respectively) but failed to stratify test sample patients into three distinct risk groups. In conclusion, our new staging systems for overall survival and leukemic transformation were reproducible in RA, RARS, or RAEB patients and will be useful especially in identifying high-risk patients with RA or RARS, who are considered to be at lower risk by the FAB classification.

Successful bone marrow transplantation with rabbit anti-human thymocyte globulin in aplastic anemia. Report of a case previously treated with equine anti-human lymphocyte globulin.

Bone marrow transplantation is widely accepted as the first line therapy for patients with severe aplastic anemia. Patients with less severe forms of aplastic anemia are treated with immunosuppressive agents, hematopoietic growth factors or androgenic steroids. The use of rabbit anti-human thymocyte globulin allowed us to successfully transplant in a patient with a moderately severe form who once failed to respond to all conservative treatment including equine anti-human lymphocyte globulin. We propose that, given the availability of rabbit anti-human thymocyte globulin, marrow transplantation should be considered in non-severe aplastic anemia patients who are refractory to equine anti-human lymphocyte globulin.

Geographical aspects of bcl-2 gene involvement in Japanese patients with non-Hodgkin's B-cell lymphomas.

Using three separate bcl-2 probes, we examined involvement of the bcl-2 gene in Japanese patients with non-Hodgkin's B-cell lymphomas. Of 52 patients with follicular lymphoma (FL), 24 had rearrangements. In a group of 50 patients with diffuse lymphoma, three of 32 patients with diffuse large cell lymphoma had rearrangements. The frequency of rearrangements in each of these groups, as detected by both major and minor breakpoint cluster region probes, was compatible with that found in other Far Eastern studies. However, the difference in frequency between the groups studied in the Far East and the West was significant, and these two geographically distinct populations also displayed a difference in the breakpoint distribution. In the immunophenotype study of 33 patients with FL, the expression of CD10 antigen correlated with bcl-2 involvement, whereas none of the other B markers emerged as parameters to distinguish between the two lymphoma groups; those with, and without, the rearrangements.

Diagnostic and biological significance of sideroblastic erythropoiesis in the myelodysplastic syndromes.

We retrospectively reviewed clinical and hematologic features of nine patients with acquired idiopathic sideroblastic anemia (AISA). Seven of them had ringed sideroblasts (RS) more than 15% of marrow nucleated cells. RS persisted in the marrow even in the remaining two patients who had a relatively low marrow erythroblasts despite RS ranging from 1/4 to half of the marrow erythroid series. However, RS declined in proportion in another two patients of the nine whose disease progressed to refractory anemia with excess of blasts (RAEB), although a high proportion of RS reappeared in one patient at the time of relapse following allogeneic marrow transplantation. A similar decline of RS concomitant with disease progression was also seen in seven additional patients with RAEB or RAEB in transformation (RAEB-t) with sideroblastic erythropoiesis. Cytogenetic abnormalities, although rare initially, became detectable either at the time of disease progression or at the worsening of anemia in AISA. These observations suggest that the majority of AISA fall in the category of myelodysplasia, and that a progressive decline in RS is part of the natural history of myelodysplasia. Closer follow-up of the proportion of RS in patients with AISA is warranted to better understand its biologic significance.

Useful antiglobulin crossmatch test for DST-sensitized patients.

The AG-CDC tests were performed in parallel with C-CDC tests for studying sensitization of DST patients. Fourteen of 56 DST patients were positive by the AG-CDC tests after DST. Ten of 14 were also positive by both tests after DST. In 8 of 14 patients AG-CDC antibodies continued to be detectable even after C-CDC antibodies became undetectable as time passed and with plasmapheresis. Thus, AG-CDC tests are more sensitive compared to C-CDC tests and can extend the detection rate of DST-sensitized patients. Except for two DST patients (highly sensitized), 12 of 14 DST-sensitized patients were given transplants from specific blood donors at the time when their C-CDC tests became negative. One graft failed, another one had impaired function, and ten of them functioned. It should be noted that DST patients were transplanted successfully with or without plasmapheresis across a positive AG-CDC test if the titer was less than 1:4 at the time of transplant. All four DST recipients who developed antibodies detected only by AG-CDC tests after DST experienced severe accelerated rejections. In contrast, two of eight patients who were positive by both tests had "severe" accelerated rejections. The incidence of severe accelerated rejections was shown to be highly associated with the presence of AG-CDC antibodies. These facts suggest that AG-CDC antibodies may damage kidney grafts and result in severe accelerated rejections; and that AG-CDC tests are useful for predicting occurrence of severe accelerated rejections in DST recipients.

A randomized study of alfacalcidol in the refractory myelodysplastic anaemias. A Japanese cooperative study.

A multi-institutional randomized trial of alfacalcidol (1 alpha hydroxyvitamin D3) was performed to determine the therapeutic effect of alfacalcidol in patients with refractory myelodysplastic anaemias. Twenty-three evaluable patients were randomized to receive either a single daily oral dose of 6 micrograms of alfacalcidol or only supportive care as a control. Treatment was continued, whenever possible, for a period of 6 months. Response was assessed by weekly blood counts, clinical course and repeated marrow examinations. No significant difference was noted between the alfacalcidol and control groups. Three of the 13 patients in the alfacalcidol group, and two of the 10 patients in the control group, suffered a progression of their disease. One patient with refractory anaemia showed a good response to alfacalcidol in all three haematopoietic cell lineages; the response, however, could not be maintained, because discontinuation of the drug resulted in a worsening of pancytopenia which was refractory to a second course of alfacalcidol therapy. Hypercalcaemia was the major toxic side-effect of alfacalcidol therapy. The results indicate that alfacalcidol therapy, when used alone, does not induce a beneficial effect in patients with refractory myelodysplastic anaemias.

[Prognostic factors in aplastic anemia. A statistical analysis of 105 cases].

We analyzed 105 cases of aplastic anemia diagnosed between 1958 and 1985 to clarify the variables that are related to prognosis. The most significant variable at diagnosis was reticulocyte count, followed in order by percent bone marrow lymphocyte, red cell turnover rate, T-score severity grade, iron utilization and aplastic anemia study group (AASG) severity grade. Reticulocyte count was the single significant variable in multivariate analysis. Three months after diagnosis, the most significant variable was still the reticulocyte count, followed by AASG severity grade. Changes of variables during the 3 months were not correlated to prognosis. Our result reconfirmed that reticulocyte count was the most important variable related to prognosis.

[Preleukemic disorders].

Certain hematopoietic disorders and immunodeficiency states are known to carry a risk of developing acute nonlymphocytic leukemia. In the past some of them have been classified by a variety of terms ranging from refractory anemia to preleukemia, but are currently grouped into a new concept of the myelodysplastic syndromes (MDS). The purpose of this article is to briefly review the updated knowledge of the MDS with emphasis on the clonal origin, natural history and mechanisms of leukemogenesis.