Reduced-intensity stem-cell transplantation for adult acute lymphoblastic leukemia: a retrospective study of 33 patients.

Efficacy of reduced-intensity stem-cell transplantation (RIST) for acute lymphoblastic leukemia (ALL) was investigated in 33 patients (median age, 55 years). RIST sources comprised 20 HLA-identical related donors, five HLA-mismatched related, and eight unrelated donors. Six patients had undergone previous transplantation. Disease status at RIST was first remission (n=13), second remission (n=6), and induction failure or relapse (n=14). All patients tolerated preparatory regimens and achieved neutrophil engraftment (median, day 12.5). Acute and chronic graft-versus-host disease (GVHD) developed in 45 and 64%, respectively. Six patients received donor lymphocyte infusion (DLI), for prophylaxis (n=1) or treatment of recurrent ALL (n=5). Nine patients died of transplant-related mortality, with six deaths due to GVHD. The median follow-up of surviving patients was 11.6 months (range, 3.5-37.3 months). The 1-year relapse-free and overall survival rates were 29.8 and 39.6%, respectively. Of the 14 patients transplanted in relapse, five remained relapse free for longer than 6 months. Cumulative rates of progression and progression-free mortality at 3 years were 50.9 and 30.4%, respectively. These findings suggest the presence of a graft-versus-leukemia effect for ALL. RIST for ALL is worth considering for further evaluation.

Acute respiratory failure caused by vinorelbine tartrate in a patient with non-small cell lung cancer.

We describe a case of vinorelbine tartrate (VNR) associated acute respiratory failure. A 65-year-old man with non-small cell lung cancer developed acute respiratory failure 50 minutes after his first infusion with VNR in combination with mitomycin-C. The patient was treated with furosemide, dopamine and high-dose methylprednisolone, and recovered with no discernible sequelae. Although clinical trials have shown that respiratory symptoms associated with VNR treatment have only rarely been observed and the putative mechanism remains to be elucidated, patients receiving VNR should be monitored carefully, particularly in the first few hours after intravenous administration.

Late onset cyclosporine-induced cerebral blindness with abnormal SPECT imagings in a patient undergoing unrelated bone marrow transplantation.

A 23-year-old woman underwent HLA-matched unrelated BMT for CML. She developed cerebral blindness on day 81. Brain magnetic resonance imaging revealed hyperintensity on a T2-weighted image in the white and gray matter of the right frontal and both occipital lobes. Single-photon emission computed tomography (SPECT) was consistent with a decrease in radionuclide uptake in these areas, suggesting a vasoconstrictive mechanism. A diagnosis of CsA-induced encephalopathy was made and CsA was discontinued. Her vision recovered completely after 24 h and abnormal imaging resolved within 2 weeks. This case demonstrates late onset CsA-induced cerebral blindness with the previously unreported abnormalities on SPECT.

Serum levels of soluble IL-2 receptor, IL-12, IL-18, and IFN-gamma in patients with acute graft-versus-host disease after allogeneic bone marrow transplantation.

BACKGROUND: Acute graft-versus-host disease still represents the major factor that limits successful allogeneic bone marrow transplantation. Cytokines released by type 1 T-helper cells are thought to play a pivotal role in acute graft-versus-host disease. OBJECTIVE: This study was performed to investigate whether the serum levels of soluble IL-2 receptor, IL-12, IL-18, and IFN-gamma were associated with the manifestation of acute graft-versus-host disease. METHODS: Serum cytokine levels were measured by sandwich ELISA in 18 patients who underwent allogeneic bone marrow transplantation. RESULTS: Serum levels of soluble IL-2 receptor, IL-12, IL-18, and IFN-gamma were increased in patients in whom acute graft-versus-host disease developed. However, only serum soluble IL-2 receptor levels were significantly related to disease severity. Serum levels of IL-12 and IL-18, both of which are mainly produced by activated macrophages, were increased in different phases of acute graft-versus-host disease, especially grade I. Serum levels of soluble IL-2 receptor and IFN-gamma were significantly elevated in patients with fever. CONCLUSION: Serum levels of soluble IL-2 receptor were more closely related to the severity of acute graft-versus-host disease than those of IL-12, IL-18, and IFN-gamma.

Primary malignant lymphoma of the central nervous system presenting with ascites and pleural effusion.

A 70-year-old woman was admitted to our hospital owing to ascites and pleural effusion. Though malignant cells (B-cell type lymphoma) were detected in both the ascites and pleural effusion, neither lymph node swelling nor a tumor was detected upon chest, abdominal and pelvic computed tomography (CT). After weekly THP-COP therapy for 8 weeks, the ascites and pleural effusion completely disappeared. Two years after the first admission, she was re-admitted because of a disturbance of consciousness, and a brain tumor was detected on CT scan. The immunohistological and genetic data for the brain tumor were identical to those of the malignant cells in the pleural effusion and ascites detected 2 years previously. Whereas the symptoms at onset of a primary lymphoma of the central nervous system (CNS) are usually neurological ones, in this rare case of primary CNS lymphoma, the symptoms at onset were the ascites and pleural effusion without neurological symptoms.

[Development of cyroglobulinemia and polyneuropathy in a chronic myeloid leukemia patient during interferon-alpha treatment].

Neurological side effects and complications of cryoglobulinemia were observed during interferon-alpha (IFN-alpha) therapy in a patient with chronic myeloid leukemia (CML). A 50-year-old man was hospitalized because of leukocytosis and extramedullary tumors in the lumbar spine. In addition, the patient complained of dysesthesia in his feet. A diagnosis of accelerated phase CML was made. Administration of prednisolone, vincristine, hydroxyurea, and Ara-C and irradiation of the lumbar spine were started. Two months later, the patients achieved hematologic response and the size of his tumors decreased. Thereafter, we started IFN-alpha treatment (3-6 x 10(6) units daily) by intramuscular injection. After 8 weeks of this treatment, the patient complained of worsening dysesthesia in his feet. An axonal form of peripheral neuropathy was diagnosed by electrophysiological examination. Immunological studies revealed decreased complement levels and type III mixed cryoglobulinemia. Methylprednisolone pulse therapy alleviated the neurological symptoms and lowered the cryoglobulin levels. The clinical course suggested that mixed cryoglobulinemia was associated with CML and that the increase in cryoglobulin levels was caused by IFN-alpha and played a causative role in the worsening peripheral neuropathy. Therefore, to prevent these side effects, careful clinical assessment is necessary before starting IFN-alpha therapy.

[Anaphylaxis in a myelodysplastic syndrome patient during platelet transfusion with a leukocyte-reduction filter].

A 77-year-old woman with myelodysplastic syndrome required platelet transfusion. However, she complained of facial flushing and dyspnea immediately after the initiation of an infusion of platelet concentrations (PC) utilizing a Pall PL-PXL8H filter with a negatively charged surface. The same symptoms recurred following a transfusion of washed PC with saline. However, an infusion utilizing a Sepacell PLX5A-W with a positively charged surface caused no problems. Furthermore, the patient demonstrated the same adverse reaction after administration of prostaglandin F2 alpha. This case suggested that special caution is warranted when patients who have an allergic history receive PC infusions through leukocyte-reduction filters with negatively charged surfaces.

[DNA and RNA contents of megakaryocytes using acridine orange staining].

We developed a new microfluorometric method to measure the DNA and RNA contents of individual megakaryocytes using acridine orange (AO) staining in human bone marrow smears. Some bone marrow smears were fixed with ethanol and treated with pretreatment solution and then stained with an AO staining solution. The DNA content was assayed by measuring the green fluorescence and the RNA content was assayed by measuring the red fluorescence under B excitation with microfluorometer using peripheral lymphocytes as the control. The ploidy peak was shown to be 16N in all of 5 normal controls, but it was 8N in the patient with refractory anemia with excess of blasts in transformation (RAEB-T). There was not difference in the RNA content/DNA content ratios (RI) between each ploidy in the normal controls. The RI of the patient with RAEB-T was lower than that of the normal controls. The measurement of the DNA-RNA contents may be useful as a new megakaryocytic parameter.

Comparison of the DNA content of megakaryocytes identified immunologically with that identified morphologically.

We devised a new microfluorometric method for determining the ploidy of megakaryocytes identified immunologically in bone marrow smears. The smears were immunostained by incubation with mouse monoclonal anti-glycoproteins (GP) IIb antibodies, followed by fluorescein isothiocyanate-conjugated goat antimouse IgG antibodies. They were then stained with 4',6-diamidino-2-phenylindole (DAPI). Megakaryocytes were identified by their GPIIb immunofluorescence using a microfluorometer and, after the filters were changed, their DNA content was assayed by measuring the intensity of DAPI fluorescence. This intensity was shown to be proportional to the DNA content when the aperture of the objective lens was reduced. We compared these results with those obtained when megakaryocytes were identified morphologically, using DAPI staining after Wright-Giemsa destaining. In all 12 normal controls, the ploidy peaks were shown to be 16N by both methods, and the mean ploidy detected by the immunological method was only reduced 0.961 times relative to the estimate from the morphological method. In contrast, in eight myelodysplastic syndrome (MDS) patients, the ploidy peaks were either 8N or 4N and the mean was reduced by 0.906 times (P = 0.018). Thus we could immunologically identify small megakaryocytes which we could not identify morphologically. Therefore, this method is useful for measuring megakaryocytic ploidy, especially in the pathological megakaryocytes of MDS patients.

[Epstein-Barr virus-infected T-cell malignancy in an adult patient with Behçet's disease-like symptoms].

A 20-year-old woman was hospitalized on November 11, 1994 with Behçet's disease-like symptoms (fever, genital ulcer and aphtha in the oral cavity). Bilateral cervical lymph node swelling was also noted and diagnosed as lymphadenitis on biopsy. Chronic active Epstein-Barr virus infection (CAEBV) was diagnosed based on the high titer of antibodies to the EBV capsid antigen, early antigen, and nuclear antigen. She was treated with prednisolone and acyclovir and all symptoms improved. However, ten months after onset of symptoms, T-cell malignancy was diagnosed on bone marrow aspiration, which revealed 34.9% blast cells that had rearrangement of TCR-beta. She died on May 8, 1995, despite anticancer therapy. In analyzing the blast cells, the monoclonal junctional DNA structure of the EBV terminal repeat was analyzed by Southern blotting and provided definitive evidence for the monoclonality of EBV-infected T cells. These findings strongly suggest that EBV plays a pathogenic role in T-cell malignancy. EBV-infected T-cell malignancy, such as this case, is very rare in Japan, especially in adult.

Determination of interferon-alpha2 allele composition in the genomic DNA from healthy volunteers and leukemic patients in Japan.

The three interferon-alpha2 (IFN-alpha2) sequences identified to date differ from each other in just two nucleotide positions, both of which result in changes in amino acids. Thus, the mature IFN-alpha2a protein product is characterized by a lysine residue at position 23 (AAA) and a histidine at position 34 (CAA), IFN-alpha2b has an arginine at position 23 (AGA) and histidine at position 34 (CAT), and IFN-alpha2c has arginine residues at both positions 23 (AGA) and 34 (CGT). These nucleotide variations in the DNA sequence can be distinguished by selective restriction enzyme analysis. We studied the distributions of the three IFN-alpha2 variants by analyzing chromosomal DNA from 103 Japanese volunteers and 33 patients with hematologic disorders. Fragments of 238 bp and 617 bp of the IFN-alpha2 gene containing codons 23 and 34 were amplified by PCR using specific primers, and the PCR products were analyzed with specific restriction nucleases to identify the IFN-alpha2 variant sequences. Only IFN-alpha2b gene was detected in normal volunteers, and no IFN-alpha2a gene was detected in Japanese subjects. However, IFN-alpha2c was detected in 4 of 33 (12.1%) patients with leukemia.

[Infections mononucleosis with pleural effusion].

A 24-year-old man was admitted to our hospital for further examination of pleural effusion. On physical examination, he had a temperature of 39 degrees C, the pharynx was painful and liver and spleen were enlarged. The leukocyte count was 5,700/microliters (atypical lymphocyte 6%). The serum LDH, GOT, GPT, ALP and gamma-GTP levels were elevated, and antibodies to Epstein-Barr viral capsid, early, and nuclear antigens were diagnostic of a primary Epstein-Barr virus infection. The CD4/CD8 ratio of peripheral blood lymphocyte was decreased to 0.2. The pleural effusion was exudate, and infiltration of mononuclear cells was noted. The CD4/CD8 ratio of lymphocytes in the effusion also was decreased to 1.1. The result of pleural biopsy showed a perivascular infiltration of mononuclear cells and immunological stain showed that the infiltrated cells were dominantly T-lymphocytes (about 90%). These findings suggested that the pathogenesis of pleural effusion in infectious mononucleosis was a pleulitis due to the infiltration of T-lymphocytes. Pleural effusion is known as a rare complication of infectious mononucleosis.

Changes in c-Kit expression and effects of SCF during differentiation of human erythroid progenitor cells.

We analysed c-Kit expression during erythroid differentiation using immunocytochemical staining and flow cytometric analysis. Burst-forming units-erythroid (BFU-E)-derived cell aggregates were identified in methylcellulose cultures containing human umbilical cord blood CD34+ cells and were stained by the indirect immunoalkaline phosphatase method. To investigate the changes in levels of cell-surface c-Kit expression, we subjected progenitor cells in liquid culture to flow cytometric analysis. In addition, the effects of stem cell factor (SCF) on cell-surface c-Kit expression were analysed in these two culture systems and the effects of SCF on erythroid colony formation were studied in a methylcellulose culture. c-Kit was expressed on the cell surface from BFU-E to erythroid precursors recognized morphologically as basophilic erythroblasts. Flow cytometric analysis showed that c-Kit expression increased until 6 d in liquid culture, and that decreased expression of c-Kit was associated with the increased expression of glycophorin A. Moreover, SCF increased the size of erythroid colonies when added at days 0, 4 and 8 in methylcellulose cultures. These results indicate that the c-Kit/SCF system still plays in proliferation of erythroid progenitor cells at the colony-forming units-erythroid stage. Finally, expression of c-Kit in erythroid progenitor cells cultured without SCF showed a diffuse pattern on the cell surface, whereas we observed positive c-Kit immunoreactivity in the region of the Golgi apparatus of these cells cultured with SCF. Flow cytometric analysis also showed that the levels of cell-surface c-Kit expression decreased in the presence of SCF. These results suggest that SCF induced down-modulation of cell-surface c-Kit expression, despite continuous synthesis of c-Kit protein.

Relationship between morphological classification of the degree of maturation and the ploidy of micromegakaryocytes in myelodysplastic syndrome patients.

To clarify the biological behavior of micromegakaryocytes in myelodysplastic syndrome (MDS), the relationship between the morphological classification and the ploidy of megakaryocytes was studied in bone marrow aspirates obtained from patients with MDS and from normal controls. The morphology was determined according to Feinendegen's classification, which is considered to reflect megakaryocytic maturation, and the ploidy was determined by microcytofluorometry, using 4',6-diamidino-2-phenylindole (DAPI) staining after the removal of Wright-Giemsa stain. Most micromegakaryocytes (i.e., megakaryocytes < 20 microns in diameter) in MDS were morphologically mature, as were those in the normal controls. The peak micromegakaryocytic ploidy was 4N or 8N, whereas that of the megakaryocytes in normal controls was 16N. These findings indicated that the micromegakaryocytes in MDS were morphologically mature but had impaired polyploidization.