Real-world status of treatment for lymphoid neoplasms developed during the course of myeloproliferative neoplasms in Japan.

OBJECTIVES: Patients with myeloproliferative neoplasms (MPNs) are at higher risk of developing secondary malignancies. In this study, we focused on patients with MPNs that complicated lymphoid neoplasms. To analyze the real-world status of lymphoid neoplasm treatment in patients with pre-existing MPNs in Japan, we conducted a multicenter retrospective study. METHODS: Questionnaires were sent to collect the data on patients who were first diagnosed with either polycythemia vera, essential thrombocythemia or myelofibrosis and who later were complicated with lymphoid neoplasms defined as malignant lymphoma, multiple myeloma, or chronic lymphocytic leukemia/small cell lymphoma. RESULTS: Twenty-four patients with MPNs complicated by lymphoid neoplasms were enrolled (polycythemia vera, n = 8; essential thrombocythemia, n = 14; and primary myelofibrosis, n = 2). Among these, diffuse large B-cell lymphoma (DLBCL) was the most frequently observed (n = 13, 54.1%). Twelve (92.3%) of the patients with DLBCL received conventional chemotherapy. Among these 12 patients, regarding cytoreductive therapy for MPNs, 8 patients stopped treatment, one continued treatment, and two received a reduced dose. Consequently, most patients were able to receive conventional chemotherapy for DLBCL with a slightly higher dose of granulocyte colony-stimulating factor support than usual without worse outcomes. All 3 patients with multiple myeloma received a standard dose of chemotherapy. CONCLUSION: Our data indicate that if aggressive lymphoid neoplasms develop during the course of treatment in patients with MPNs, it is acceptable to prioritize chemotherapy for lymphoma.

Prognostic Impact of a Body Mass Index Decrease during First Chemotherapy in Patients with Advanced Follicular Lymphoma.

Objective Follicular lymphoma (FL) is an indolent B-cell malignancy, usually treated by immunochemotherapy in advanced-stage and high-tumor-burden cases. Although some reports have shown no significant relationship between the pre-treatment body mass index (BMI) and the overall survival (OS) in FL, little is known regarding BMI changes during chemotherapy. We analyzed the impact of a BMI decrease during chemotherapy on the OS in FL patients. Methods We retrospectively analyzed 56 patients with untreated advanced FL who underwent chemotherapy at our institute between July 2009 and December 2020. The BMI change was defined based on the BMI before and at three months after the first chemotherapy session. The cut-off for a BMI decrease was set at 1.42 kg/m2 according to the receiver operating characteristics curve for the OS. We compared the survival outcome between two BMI groups based on this cut-off. Results A BMI decrease was significantly associated with a worse OS (5-year OS: 86.7% vs. 60.5%, p=0.019), although the pre-treatment BMI showed no significant relationship with the survival. The adverse impact of a BMI decrease remained in a multivariate analysis for the OS (hazard ratio, 3.972; p=0.045). The decreased-BMI group tended to show a higher cumulative incidence of early-onset histological transformation (HT) than the non-decreased-BMI group (20% vs. 0.0%). A BMI decrease during chemotherapy in previously untreated FL patients might reflect the hyperactivation of tumor-induced metabolism related to HT. Conclusion A BMI decrease during chemotherapy might be an independent adverse prognostic factor in FL patients. BMI changes in addition to the condition of FL patients should be monitored during chemotherapy.

Nivolumab Effective for Gastric and Lung Cancers but Not for Multiple Myeloma in a Multiple Primary Cancer Patient.

The case of a 76-year-old man with multiple primary cancers that were treated with nivolumab is presented. Six years earlier, he was diagnosed with multiple myeloma (MM) and was treated with several chemotherapies. He was also diagnosed with gastric cancer with liver metastasis and primary lung cancer by upper gastrointestinal endoscopy and computed tomography (CT). Nivolumab treatment was given as third-line therapy, and it was effective for gastric and lung cancers. But MM worsened, and the patient died. There is no standard treatment for multiple primary cancers, and the development of effective treatments for multiple primary cancers is important.

[A rare synchronous occurrence of multiple myeloma and pulmonary adenocarcinoma with multiple solitary extramedullary plasmacytomas of the liver].

We report the case of a 62-year-old woman with multiple liver tumors. She was diagnosed with synchronous occurrence of multiple myeloma (MM) and primary pulmonary adenocarcinoma 4 years ago. She was treated with bortezomib and dexamethasone for MM, and then she underwent thoracoscopic lobectomy. After the surgery, she received autologous peripheral blood stem cell transplantation. However, recurrence of MM was observed 9 months later. She received multiple chemotherapies for MM, but the effect was limited. Meanwhile, brain metastasis of pulmonary adenocarcinoma was observed; therefore, she underwent surgical resection and received radiation therapy. Furthermore, she had elevated levels of liver enzymes, and ultrasonography revealed multiple liver tumors. Because of thrombocytopenia, liver biopsy could not be performed, and chemotherapies for MM did not improve the tumors. Therefore, we clinically determined that the liver tumors were metastatic pulmonary adenocarcinomas. The epidermal growth factor receptor mutation was present in the pulmonary adenocarcinoma, so gefitinib was administered. However, the tumors were uncontrollable and the patient died within 1 month. From autopsy, the liver lesion was confirmed to be MM. Synchronous occurrence of MM and other primary cancers is very rare, and no standard treatment has yet been established. Thus, it is crucial to accumulate synchronous cases and develop treatment methods in the future.

Expression of programmed cell death ligand-1 by immune cells in the microenvironment is a favorable prognostic factor for primary diffuse large B-cell lymphoma of the central nervous system.

Primary diffuse large B-cell lymphoma (DLBCL) of the central nervous system (PCNS-DLBCL) is rare. Thirty-nine patients consecutively diagnosed as having PCNS-DLBCL were analyzed to highlight the prognostic value of the expression of programmed cell death ligand-1 (PD-L1) by neoplastic cells and immune cells in the microenvironment. They were positive for CD20 in all (100%), CD5 in two (5%), CD10 in nine (23%), BCL-2 in 27 (69%), BCL-6 in 34 (87%), and MUM-1 in 37 (95%). Only one case was positive for neoplastic PD-L1, with an unexpectedly long clinical course of 92 months. The remaining 38 cases were further divided into three groups based on the percentage of PD-L1+ cells among microenvironmental immune cells. Cutoffs of < 5%, 5-40%, and ≥ 40% successfully stratified mean prognoses with three-year overall survival (OS) of 21%, 63%, and 100% (P = 0.009), respectively. Progression-free survival (PFS) and OS were different between the groups with and without methotrexate (MTX)-containing chemotherapy (P = 0.007 and P < 0.001, respectively). Multivariate analysis identified three independent adverse factors of OS: PD-L1 negativity (< 5%) on microenvironmental immune cells (P = 0.027), deep structure involvement (P = 0.034), and performance status (PS) 2-4 (P = 0.009). The study showed that PD-L1 expression on immune cells in the microenvironment was associated with prognosis among patients with PCNS-DLBCL.

[Experience with Secondary Pulmonary Lymphoma Diagnosed by Surgical Biopsy].

Pulmonary malignant lymphoma presents diverse imaging findings, thus making an imaging-based diagnosis difficult. Furthermore, because of the low histological diagnostic rate of approximately 30% based on transbronchial lung biopsy, there are difficulties in the early diagnosis of pulmonary malignant lymphoma. We report a case of pulmonary malignant lymphoma that was difficult to diagnose until a surgical biopsy was performed. A 72-year-old female was referred to our hospital with an abnormal chest shadow on a medical examination. Chest computed tomography(CT) scan demonstrated groundglass opacity and consolidation in both lung fields. Bronchoscopy was performed but a histological definitive diagnosis could not be obtained. We suspected organized pneumonia and initiated steroid therapy that resulted in improvement in the chest shadow. However, new multiple lung nodules and mediastinal lymphadenopathy were noticed on CT scan performed 9 months after the initiation of steroid therapy, and a lung biopsy and mediastinal lymph node biopsy were performed. Finally, the diagnosis was malignant lymphoma with pulmonary infiltrates.

Composite Lymphoma Comprising Extranodal NK/T-Cell Lymphoma and Diffuse Large B-Cell Lymphoma.

We report a rare case of composite lymphoma comprising extranodal NK/T-cell lymphoma, nasal type, (ENKL) and diffuse large B-cell lymphoma (DLBCL) in a 70-year-old man complaining of fatigue. Computed tomography showed multiple consolidations in both lungs, and ENKL was diagnosed from transbronchial lung biopsy. Positron emission tomography also detected abnormal uptake in the stomach, and DLBCL was diagnosed from subsequent gastroscopy. Two courses of chemotherapy including rituximab achieved reduction in DLBCL, but ENKL proved resistant to this treatment and progressed. Concomitant ENKL and DLBCL have not been previously described among reports of composite lymphomas.

A low birth weight infant with no malformations delivered by a primary immune thrombocytopenia patient treated with eltrombopag.

Primary immune thrombocytopenia (ITP) is defined by a low platelet count secondary to antibody-mediated platelet destruction or reductions in platelet production. Although eltrombopag is a thrombopoietin receptor agonist that increases platelet production in refractory or relapsed ITP, the influence on pregnancy is limited. We present the case of a pregnant 25-year-old ITP patient referred to our hospital with a history of two induced abortions. After eradication of Helicobacter pylori and with oral prednisolone at 8 mg/day, platelet count remained below 10,000/µl. Because she declined splenectomy, eltrombopag was initiated at 12.5 mg/day. Afterward, platelet count was maintained at over 50,000/µl. Twenty-one months later, pregnancy became apparent. She continued treatment, and cesarean section was performed at 37 weeks of gestation after administration of intravenous immunoglobulin, platelet transfusions, and steroids. The baby weighed only 1670 g but showed no malformations, and platelet count at birth was 416,000/µl. Studies of eltrombopag in pregnancy have not been reported. A case with administration of eltrombopag from the last trimester of pregnancy that resulted in low birth weight has been reported. Embryo lethality and reduced fetal weights have been reported from animal experiments. Further investigation about the relationship between low birth weight deliveries and eltrombopag is necessary.

EBV-positive Diffuse Large B-cell Lymphoma as a Secondary Malignancy Arising in a Myelodysplastic Syndrome Patient who Was Treated with Azacitidine.

We report a case of secondary diffuse large B-cell lymphoma (DLBCL) after azacitidine (AZA) treatment in a 63-years-old man with myelodysplastic syndrome. The patient suffered from febrile neutropenia after 10 cycles of AZA treatment. Despite the performance of a whole-body CT scan, which showed a multifocal low-density area in the liver and a multifocal nodular shadow in the lung, no malignant neoplasms could be detected. An autopsy was performed 6 months later, and a histopathological examination of the lesions of the liver and lung revealed the infiltration of large round-shaped tumor cells with necrotizing lesions. Immunohistochemically, the tumor cells were positive for CD20 and EBER, indicating EBV-positive DLBCL as a secondary malignancy.

Interdigitating dendritic cell sarcoma successfully treated with ABVD therapy in which serum CEA levels correlated with disease activity.

Interdigitating dendritic cell sarcoma (IDCS) is an extremely rare neoplasm of spindle to ovoid cells with phenotypic features similar to those of interdigitating dendritic cells. No standard therapy for advanced IDCS has yet been established. According to past reports, CHOP-like regimens are often chosen as primary therapy. Herein, we report a case with advanced IDCS, for which ABVD achieved remarkable clinical improvement and serial CEA levels correlated with disease status. A 76-year-old man presented with general fatigue and pancytopenia with CEA elevation. Colonoscopy showed erosion and polyps in the colon. FDG-PET showed marked abnormal accumulation throughout the bone marrow. Pathologically, polyps of the colon and IDCS of the bone marrow were diagnosed. Although the patient received CHOP as initial therapy, clinical improvement was not significant. Subsequently, six cycles of ABVD resulted in remarkable regression of both the colonic polyps and the bone marrow infiltration. Moreover, the patient was transfusion-free after ABVD. In addition to these clinical responses, serial CEA levels normalized. Our case highlights the efficacy of ABVD for IDCS and serial CEA measurements might reflect treatment efficacy.

[A case of secondary pulmonary malignant lymphoma with multiple pulmonary nodules and spiculation].

A 72-year-old man presented to our hospital with fatigue and anemia. Chest CT showed multiple nodular shadows. We first suspected lung cancer and multiple metastatic lesions because some nodules had spiculation. However, PET-CT revealed the small intestine, thyroid and rib as well as these nodules to be positive for FDG uptake, suggesting malignant lymphoma and lung involvement. For diagnosis, lung biopsy by video-assisted thoracic surgery (VATS) was performed. Pathologic examination of the lung biopsy specimen showed diffuse large B-cell lymphoma. We diagnosed secondary pulmonary malignant lymphoma.

Escape mechanisms from antibody therapy to lymphoma cells: downregulation of CD20 mRNA by recruitment of the HDAC complex and not by DNA methylation.

Although rituximab is a critical monoclonal antibody therapy for CD20-positive B-cell lymphomas, rituximab resistance showing a CD20-negative phenotypic change has been a considerable clinical problem. Here we demonstrate that CD20 mRNA and protein expression is repressed by recruitment of a histone deacetylase protein complex to the MS4A1 (CD20) gene promoter in CD20-negative transformed cells after treatment with rituximab. CD20 mRNA and protein expression were stimulated by decitabine (5-Aza-dC) in CD20-negative transformed cells, and was enhanced by trichostation A (TSA). Immunoblotting indicated that DNMT1 expression was first downregulated 1 day after treatment with 5-Aza-dC, but IRF4 and Pu.1, the transcriptional regulators of MS4A1, were still expressed with or without 5-Aza-dC. Interestingly, CpG methylation of the MS4A1 promoter was not observed in CD20-negative transformed cells without 5-Aza-dC. A chromatin immunoprecipitation (ChIP) assay indicated that the Sin3A-HDAC1 co-repressor complex was recruited to the promoter and dissociated from the promoter with 5-Aza-dC and TSA, resulting in histone acetylation. Under these conditions, IRF4 and Pu.1 were continually recruited to the promoter with or without 5-Aza-dC and TSA. These results suggest that recruitment of the Sin3A-HDAC1 complex is related to downregulation of CD20 expression in CD20-negative B-cells after treatment with rituximab.

Down-regulation of CD20 expression in B-cell lymphoma cells after treatment with rituximab-containing combination chemotherapies: its prevalence and clinical significance.

Although rituximab is a key molecular targeting drug for CD20-positive B-cell lymphomas, resistance to rituximab has recently been recognized as a considerable problem. Here, we report that a CD20-negative phenotypic change after chemotherapies with rituximab occurs in a certain number of CD20-positive B-cell lymphoma patients. For 5 years, 124 patients with B-cell malignancies were treated with rituximab-containing chemotherapies in Nagoya University Hospital. Relapse or progression was confirmed in 36 patients (29.0%), and a rebiopsy was performed in 19 patients. Of those 19, 5 (26.3%; diffuse large B-cell lymphoma [DLBCL], 3 cases; DLBCL transformed from follicular lymphoma, 2 cases) indicated CD20 protein-negative transformation. Despite salvage chemotherapies without rituximab, all 5 patients died within 1 year of the CD20-negative transformation. Quantitative reverse-transcription-polymerase chain reaction (RT-PCR) showed that CD20 mRNA expression was significantly lower in CD20-negative cells than in CD20-positive cells obtained from the same patient. Interestingly, when CD20-negative cells were treated with 5-aza-2'-deoxycytidine in vitro, the expression of CD20 mRNA was stimulated within 3 days, resulting in the restoration of both cell surface expression of the CD20 protein and rituximab sensitivity. These findings suggest that some epigenetic mechanisms may be partly related to the down-regulation of CD20 expression after rituximab treatment.

Clinical significance of nuclear non-phosphorylated beta-catenin in acute myeloid leukaemia and myelodysplastic syndrome.

Wnt signaling activates the canonical pathway and induces the accumulation of non-phosphorylated beta-catenin (NPBC) in the nucleus. Although this pathway plays an important role in the maintenance of haematopoietic stem cells as well as in oncogenesis, the significance of nuclear NPBC remains unclear in malignant haematopoiesis. This study examined the expression of nuclear NPBC in bone marrow specimens from 54 and 44 patients with de novo acute myeloid leukaemia (AML) and myelodysplastic syndrome (MDS), respectively. On immunohistochemistry with an anti-NPBC antibody, the nuclei were positively stained in 22 and 18 of AML and MDS specimens, respectively. Staining of nuclear NPBC was associated with AML subtypes (M6 and M7), low complete remission (CR) rate, and poor prognosis. Nuclear NPBC was also associated with a high score when using the International Prognostic Scoring System (IPSS) for MDS and with -7/-7q and complex karyotypes. These findings suggest that in situ detection of nuclear NPBC by immunohistochemistry could provide new insights into the pathogenesis and prognosis of AML and MDS.

Epigenetic regulation of CD20 protein expression in a novel B-cell lymphoma cell line, RRBL1, established from a patient treated repeatedly with rituximab-containing chemotherapy.

Rituximab is a chimeric monoclonal antibody to the surface antigen CD20 and has provided better outcomes against CD20+ B-cell lymphomas than chemotherapy with conventional antitumor drugs alone. Treatment with rituximab poses a considerable problem, however, because of CD20- tumor transformation and subsequent disease progression. We have established a CD20- lymphoma cell line, RRBL1, from a diffuse large B-cell lymphoma with CD20- transformation from CD20+ follicular lymphoma after treatment with rituximab. RRBL1 was CD10+, CD19+, and CD20- by flow cytometry. CD20 expression was not detected by immunohistochemistry. Immunoblotting with whole RRBL1 cell lysate showed a very faint CD20 band only with longer exposures. The level of CD20 messenger RNA (mRNA) expression detected by quantitative reverse transcriptase-polymerase chain reaction analysis was almost 100 times lower than that in CD20+ lymphoma cells. When we treated RRBL1 cells with trichostatin A, an epigenetic drug that modulates histone-acetylation status, we detected dramatically increased CD20 mRNA and protein expression, suggesting that epigenetic mechanisms may explain the CD20- phenotype in RRBL1 cells. Thus, RRBL1 may be useful not only for analyses of mechanisms for the absence of CD20 expression in vitro but also for exploration of therapies against CD20- B-cell malignancies in vivo.

Promoter hypermethylation of the DNA-repair gene O6-methylguanine-DNA methyltransferase and p53 mutation in diffuse large B-cell lymphoma.

The gene for the DNA-repair enzyme O6-methylguanine-DNA methyltransferase (MGMT), which is closely related with cellular sensitivity to alkylating agents, is inactivated by promoter hypermethylation in several human cancers, including malignant lymphoma. Promoter hypermethylation of the MGMT gene is a favorable prognostic factor in diffuse large B-cell lymphoma (DLBCL). Although inactivation of the MGMT gene is closely related to p53 gene mutations in several cancers, the relationship between p53 gene mutation and MGMT inactivation in malignant lymphoma has not been thoroughly examined. We studied the correlation between MGMT hypermethylation and p53 mutation in DLBCL and their impacts on patient prognosis. In a retrospective cohort study, we used a methylation-specific polymerase chain reaction technique to analyze the methylation status of the promoter region of the MGMT gene in 116 DLBCL patients who received cyclophosphamide as part of multidrug combination chemotherapies. Denaturing high-performance liquid chromatography and direct sequencing were used to search for p53 gene mutations in exons 5 through 9 in 96 of the 116 samples. Disease-free survival and overall survival were estimated by the Kaplan-Meier method. Multivariate survival analyses were performed with the Cox proportional hazards model. Forty-five (38.8%) of 116 DLBCL patients showed MGMT promoter hypermethylation. The presence of MGMT hypermethylation was associated with better overall survival (P = .036). MGMT promoter hypermethylation was a prognostic factor that was independent of established prognostic factors, such as age, disease stage, serum lactic dehydrogenase level, and the number of extranodal disease sites (hazard ratio, 2.43; 95% confidence interval, 1.28-4.61; P = .007). p53 mutations were detected in 19 (19.8%) of 96 patients and were identified as a risk factor in the complete remission rate and overall survival (P = .0040, and P = .027, respectively). A correlation between MGMT hypermethylation and p53 mutation or p53 G:C-to-A:T mutation was not observed (P = .88, and P = .31, respectively). MGMT promoter hypermethylation and p53 mutation are useful prognostic markers in DLBCL. The impact of MGMT inactivation on p53 mutation in DLBCL is unclear.