The Prospective Natural History Study of Patients with Intractable Venous Malformation and Klippel-Trenaunay Syndrome to Guide Designing a Proof-of-Concept Clinical Trial for Novel Therapeutic Intervention.

Background: The natural history of venous malformation (VM) and Klippel-Trenaunay Syndrome (KTS) has not been quantitatively studied. To obtain benchmarks to guide designing clinical trials to assess safety and efficacy of novel drug candidates, the clinical course of the patients was followed for 6 months. Methods and Results: This is a multicenter prospective observational study evaluating the change rate in lesion volume from baseline with magnetic resonance images, as the primary endpoint. In addition, disease severities, performance status (PS), pain visual analog scale (VAS) score, quality of life (QoL), infections, and coagulation markers were also evaluated. Thirty-four patients (VM = 17, KTS = 17, 1-53 of age; median 15.9 years) with measurable lesion volume were analyzed. There was no statistically significant difference in the lesion volume between baseline and day 180, and the mean change rate (standard deviation) was 1.06 (0.28). There were no baseline characteristics that affected the change in lesion volume over 6 months. However, there were patients who showed more than 20% volume change and it was suggested that the lesion volume was largely impacted by local infection. There were no statistically significant changes in pain VAS score, severity, PS, QoL score, D-dimer, and platelet count over 6 months within all patients analyzed. Conclusion: The results showed the representative natural course of VM and KTS for a 6-month period with objective change of lesion volume and other factors, suggesting that it is scientifically reasonable to conduct a Phase 2 proof-of-concept study without a placebo arm, using the results of this study as the control. Clinical Trial Registration: NCT04285723, NCT04589650.

Comprehensive targeted next-generation sequencing in patients with slow-flow vascular malformations.

Recent studies have shown that the PI3K signaling pathway plays an important role in the pathogenesis of slow-flow vascular malformations (SFVMs). Analysis of genetic mutations has advanced our understanding of the mechanisms involved in SFVM pathogenesis and may identify new therapeutic targets. We screened for somatic variants in a cohort of patients with SFVMs using targeted next-generation sequencing. Targeted next-generation sequencing of 29 candidate genes associated with vascular anomalies or with the PI3K signaling pathway was performed on affected tissues from patients with SFVMs. Fifty-nine patients with SFVMs (venous malformations n = 21, lymphatic malformations n = 27, lymphatic venous malformations n = 1, and Klippel-Trenaunay syndrome n = 10) were included in the study. TEK and PIK3CA were the most commonly mutated genes in the study. We detected eight TEK pathogenic variants in 10 samples (16.9%) and three PIK3CA pathogenic variants in 28 samples (47.5%). In total, 37 of 59 patients (62.7%) with SFVMs harbored pathogenic variants in these three genes involved in the PI3K signaling pathway. Inhibitors of this pathway may prove useful as molecular targeted therapies for SFVMs.

Allogeneic stem cell transplantation for trisomy 8-positive myelodysplastic syndrome or myelodysplastic/myeloproliferative disease with refractory Behçet's disease: Case report and the review of literature.

We had two cases of trisomy 8-positive myelodysplastic syndrome (MDS) with incomplete Behçet's disease (BD) in which the remissions of both diseases were maintained by allogeneic stem cell transplantation (allo-SCT). Among MDS with BD patients, sometimes it is difficult to control the symptoms of BD with standard therapies such as corticosteroids and tumor necrosis factor (TNF) inhibitors. Although there should be careful consideration regarding indications for transplantation, our two cases, in which refractory BD was completely controlled by allo-SCT, suggest that allo-SCT can be one of the treatment options for higher-risk MDS with BD patients.

CXCR3high CD8+ T cells with naïve phenotype and high capacity for IFN-γ production are generated during homeostatic T-cell proliferation.

Naïve phenotype (NP) T cells spontaneously initiate homeostatic proliferation (HP) as T-cell output is reduced because of physiologic thymic involution with age. However, the effects of sustained HP on overall immune function are poorly understood. We demonstrated that the NP CD8+ T cell population in adult thymectomized mice showing accelerated HP has an increased capacity for TCR-mediated interferon-γ and tumor necrosis factor α production, which is attributed to an increase in CXCR3+ cells in the NP CD8+ T cell population. The CXCR3+ NP CD8+ T cells developed during persistent HP with a slow cell division rate, but rarely during robust antigen-driven proliferation with a fast cell division rate. In ontogeny, the proportions of CXCR3+ cells in the NP CD8+ T cell population showed a biphasic profile, which was high at the newborn and aged stages. Upon transfer, CXCR3+ NP CD8+ T cells, but not CXCR3- NP CD8+ T cells, potently enhanced Th17-mediated inflammatory tissue reactions in vivo. Furthermore, CXCR3high NP CD8+ T cells with similar features were also detected at variable levels in healthy human blood. These results suggest that CXCR3+ NP CD8+ T cells generated during physiological HP significantly impact overall immunity at the immunologically vulnerable neonatal and aged stages.

Physiologic Thymic Involution Underlies Age-Dependent Accumulation of Senescence-Associated CD4+ T Cells.

Immune aging may underlie various aging-related disorders, including diminished resistance to infection, chronic inflammatory disorders, and autoimmunity. PD-1+ and CD153+ CD44high CD4+ T cells with features of cellular senescence, termed senescence-associated T (SA-T) cells, increasingly accumulate with age and may play a role in the immune aging phenotype. In this article, we demonstrate that, compared with young mice, the aged mouse environment is highly permissive for spontaneous proliferation of transferred naive CD4+ T cells, and it drives their transition to PD-1+ and CD153+ CD44high CD4+ T cells after extensive cell divisions. CD4+ T cells with essentially the same features as SA-T cells in aged mice are also generated from naive CD4+ T cells after extensive cell divisions under severe T-lymphopenic conditions by gamma irradiation or in developmental T cell defect, often in association with spontaneous germinal centers, as seen in aged mice. The increase in SA-T cells is significantly enhanced after thymectomy at the young adult stage, along with accelerated T cell homeostatic proliferation, whereas embryonic thymus implantation in the late adult stage markedly restricts the homeostatic proliferation of naive CD4+ T cells in the host and delays the increase in SA-T cells. Our results suggest that reduced T cell output due to physiologic thymic involution underlies the age-dependent accumulation of SA-T cells as a result of increasing homeostatic proliferation of naive CD4+ T cells. SA-T cells may provide a suitable biomarker of immune aging, as well as a potential target for controlling aging-related disorders.

Artepillin C, a Typical Brazilian Propolis-Derived Component, Induces Brown-Like Adipocyte Formation in C3H10T1/2 Cells, Primary Inguinal White Adipose Tissue-Derived Adipocytes, and Mice.

Induction of brown-like adipocytes (beige/brite cells) in white adipose tissue (WAT) suggests a new approach for preventing and treating obesity via induction of thermogenesis associated with uncoupling protein 1 (UCP1). However, whether diet-derived factors can directly induce browning of white adipocytes has not been well established. In addition, the underlying mechanism of induction of brown-like adipocytes by diet-derived factors has been unclear. Here, we demonstrate that artepillin C (ArtC), which is a typical Brazilian propolis-derived component, significantly induces brown-like adipocytes in murine C3H10T1/2 cells and primary inguinal WAT (iWAT)-derived adipocytes. This significant induction is due to activation of peroxisome proliferator-activated receptor γ and stabilization of PRD1-BF-1-RIZ1 homologous domain-containing protein-16 (PRDM16). Furthermore, the oral administration of ArtC (10 mg/kg) for 4 weeks significantly induced brown-like adipocytes accompanied by significant expression of UCP1 and PRDM16 proteins in iWAT of mice, and was independent of the ß3-adrenergic signaling pathway via the sympathetic nervous system. These findings may provide insight into browning of white adipocytes including the molecular mechanism mediated by dietary factors and demonstrate that ArtC has a novel biological function with regard to increasing energy expenditure by browning of white adipocytes.

Identification of fibronectin binding sites in dermatopontin and their biological function.

BACKGROUND: Dermatopontin (DP) is a 22kDa acidic extracellular matrix (ECM) protein that plays a critical role in both ECM structure and wound healing. Previously, we demonstrated that DP interacts with fibronectin (Fn) and promotes formation of insoluble Fn fibrils that are called activated Fn (Kato et al., J Biol Chem 2011;286:14861-9). OBJECTIVE: Details of the interaction between DP and Fn are investigated to further examine the biological functions of DP. METHODS: Interactive sites between Fn and DP were examined by a solid-phase assay using Fn, DP, and their respective recombinant proteins and synthetic peptides. The effect of the DP peptides on insoluble Fn fibril formation was examined by both electrophoresis and electron microscopy. RESULTS: A binding site in DP for Fn was identified as the DP-4 (PHGQVVVAVRS) peptide, and the major binding site in Fn for DP was the 14th type III repeat (III14) domain. Further, the major DP binding site in the III14 domain was located around the B- and C-strands and their connecting loop region. A synthetic cyclic peptide mimicking the Fn loop structure enhanced DP binding activity. The DP-4 peptide induced Fn polymerization but the morphology was different from that of Fn fibrils formed by full length DP. The Fn fibrils with DP-4 enhanced integrin α5ß1-mediated cell adhesion and spreading. CONCLUSION: Interactive sites between Fn and DP were identified. The DP-4 peptide activated Fn and enhanced cell adhesion activity. DP-4 has the potential to be used for therapeutic applications, such as a wound treatment.

Functional peptide of dermatopontin produces fibrinogen fibrils and modifies its biological activity.

BACKGROUND: Dermatopontin (DP), a small extracellular matrix protein, interacts with both fibrinogen and fibrin. DP accelerates fibrin fibril formation and enhances cell adhesion to fibrin fibrils but DP does not influence fibrinogen fibril formation. We have previously demonstrated that DP-4 (PHGQVVVAVRS) is a functional dermatopontin peptide (Wu et al., 2014). OBJECTIVE: Identification of biological functions of DP-4. METHODS: Protein-protein interactions were examined by solid-phase assay. The kinetics of fibrinogen/fibrin polymer formation was monitored by turbidity change, SDS-PAGE, and electron microscopy. A cell adhesion assay was performed using human umbilical vein endothelial cells. RESULTS: Although DP promoted fibrin formation, the DP-4 peptide promoted fibrinogen polymerization but did not apparently affect fibrin formation. The polymerized fibrinogen formed straight solid fibrils comparable to the normally formed fibrin fibrils. A minimum functional sequence of the DP-4 peptide was determined to be VVVAVRS. An αC domain in fibrinogen was involved in the fibril formation. Fibrinogen fibrils made by DP-4 enhanced endothelial cell adhesion and spreading in a dose-dependent manner. This cell adhesion was inhibited by heparin and by anti-αvß3 and ß1 integrin antibodies. CONCLUSION: DP-4 did not reproduce the full functional biological activities of DP with fibrin but DP-4 did promote fibrinogen fibril formation. The fibrinogen fibrils produced by DP-4 are useful as a novel synthetic biomaterial for therapeutic applications.

HIV-related NK/T-cell lymphoma in the brain relapsed during intensive chemotherapy but regressed after chemotherapy discontinuation: the importance of maintaining cellular immunity.

This study reports a case of human immunodeficiency virus (HIV)-related natural killer/T-cell lymphoma with an unexpected clinical course. The lymphoma cells were positive for Epstein-Barr virus and the primary nodal lesions regressed after chemotherapy and combined antiretroviral therapy (c-ART); however, brain metastasis progressed along with a reduction in the CD8+ T-cell count. Chemotherapy was discontinued and the patient was treated with c-ART alone, resulting in regression of the brain lesions and recovery of the CD8+ T-cell count. This case highlights the importance of maintaining anti-tumor immunity in patients with HIV-related lymphoma.

Serum IgA level, monocyte count, and international prognostic index are independently associated with overall survival in patients with HTLV-I-negative nodal peripheral T cell lymphoma.

Peripheral T cell lymphomas (PTCL) account for 10-15 % of non-Hodgkin's lymphomas and are associated with poor prognosis. Although many prognostic factors for PTCL have been proposed, the heterogeneity of PTCL seems to be an obstacle in the establishment of clinically useful prognostic system, such as the International Prognostic Index (IPI) in diffuse large B cell lymphoma. PTCL with nodal manifestation include the HTLV-I-negative histologic subtypes of PTCL not otherwise specified (PTCL-NOS), angioimmunoblastic T cell lymphoma (AITL), and anaplastic large cell lymphoma (ALCL). As PTCL-NOS encompasses a group of similar tumors and mostly shares their clinical pictures, we retrospectively analyzed clinical data from 77 patients diagnosed with ALCL, AITL, and PTCL-NOS at Kobe City Medical Center General Hospital from May 1994 to February 2012 to identify the prognostic factor for nodal PTCL. The median age of patients was 64 years, ranging from 23 to 83 years. With a median follow-up of 50 months, 5-year overall survival (OS) was 43 %. Multivariate analysis identified high-risk IPI (hazard ratio (HR), 4.04; P = 0.015), absolute monocyte count > 0.8 × 10(9)/L (HR, 3.44; P = 0.001), and serum concentration of IgA > 410 mg/dL (HR, 2.31; P = 0.013) as poor prognostic factors for OS. Thus, we have identified novel prognostic factors of monocyte count and serum IgA level for nodal PTCL. Although conventional prognostic models mainly reflect both tumor characteristics and host factors, the present model indicates the importance of host immune response as the unfavorable prognosis.

Dermatopontin regulates fibrin formation and its biological activity.

Dermatopontin (DP) is a small extracellular matrix component in the dermis. Fibrin is a major component of a provisional matrix that is formed just after wounding. Previously, we found that DP was present in the provisional matrix, and it interacted with fibrin. Here, we examined the role of DP on fibrin function. DP interacted with both the fibrin monomer and fibrils, and was incorporated into the fibrils during fibrin formation. A DP sequence, PHGQVVVAVRS, was identified as a fibrin-binding site, and a globular D domain of fibrin was the binding site for DP. DP accelerated fibrin fibril formation into structurally modified fibrils. Fibrin fibrils formed in the presence of DP enhanced both endothelial cell attachment and cell spreading. The attached cells developed a more organized cytoskeleton when compared with those that attached to fibrin fibrils only. The main receptor for cell adhesion was identified as αvß3 integrin, and a cooperating receptor was a ß1-containing integrin species, probably α5ß1 integrin. These results indicate that DP can modify certain biological functions of fibrin, and thus a another function of this extracellular matrix protein was revealed. In addition, the fibrin-DP complex might become useful for developing an improved artificial matrix for improving wound healing.

Algorithm for reconstruction of composite cranial defects using the fascial component of free anterolateral thigh flaps.

BACKGROUND: In case of composite cranial defect including the dura mater, the cranial bone, and the scalp, the fascial component of the anterolateral thigh flap can be used for dural reconstruction. However, the advantages and applications of the fascial component depending on the type of defect have not been thoroughly discussed. We made the algorithm for reconstruction of composite cranial defects using the fascial component of free anterolateral thigh flaps. PATIENTS AND METHODS: Six cases of composite cranial defects were reconstructed using free anterolateral thigh flaps with the fascial component. The type of method used was classified into 3 types. Type 1 involves separating the fascia from the flap completely and using it as a nonvascularized component. In type 2, the fascia is not separated from the flap and is instead used as a vascularized component. Type 3 involves separating the vascularized adipofascial component from the skin paddle and using it as a chimeric pattern flap. The algorithm for determining the type of fascial component is applied depending on the condition of the defect. RESULTS: All flaps were transferred successfully in every case. In 4 cases, the type 1 method was used. The type 2 and 3 methods were used in 1 case each. Cranial bone reconstruction was performed in 3 cases. There were no major complications after the procedures. CONCLUSIONS: The fascial component is useful for dural reconstruction. The type of fascial component used is selected depending on the condition of the defect.

The need for continuing chemotherapy for leukemic cell lysis pneumopathy in patients with acute myelomonocytic/monocytic leukemia.

Although fatal pulmonary complications frequently occur during the course of acute leukemia, a minor proportion of the complications are due to leukemia itself. Infections, drug reactions and concomitant medical conditions are the major causes of respiratory distress in leukemic patients. We treated four patients with acute myeloid leukemia complicated by leukemic cell lysis pneumopathy (LCLP). All of the patients had leukemia of monocytoid origin and their respiratory function deteriorated soon after chemotherapy initiation. Although two of the patients required mechanical ventilation, all four improved after continued chemotherapy. Our experience indicates that, in cases of LCLP, chemotherapy should be continued with maximal respiratory support.

Therapeutic effects of lenalidomide on hemorrhagic intestinal myeloma-associated AL amyloidosis.

A 74-year-old woman with refractory IgG-κ multiple myeloma developed massive melena caused by hemorrhagic submucosal tumors in the duodenum and middle jejunum. A biopsy revealed the tumor to be marked AL amyloid deposition. Treatment with bortezomib did not improve the melena or the underlying disease. The patient also developed multiple amyloidomas in the bilateral femoral heads, which caused a fracture in the left femoral head. Treatment with lenalidomide, as the final therapeutic option, resolved the intractable melena and improved both the intestinal lesions and myeloma. This case shows that successful treatment of multiple myeloma leads to marked improvement of accompanying AL amyloidosis.

[Fatal hepatic failure due to AL amyloidosis in a patient with multiple myeloma].

Although about 10 to 15% of patients with multiple myeloma (MM) develop AL amyloidosis, liver-restricted fatal amyloidosis is rare. We encountered such an MM patient. A 73-year-old female without a history of carpal tunnel syndrome was diagnosed with IgG-κ MM (Stage I by Durie & Salmon) in January, 2005. Because MM was exacerbated to Stage III in May, 2007, VAD (vincristine, adriamycin, dexamethasone) chemotherapy was performed with minor response, despite 3 courses of this regimen. Three courses of salvage chemotherapy (cyclophosphamide+melphalan; CM) were then performed with near partial response. In March, 2008, just before the 4th cycle of CM chemotherapy, she was slightly icteric with elevated biliary tract enzymes; therefore, treatment was switched to oral cyclophosphamide and prednisolone. At this time, she did not have macroglossia, skin eruption, gastrointestinal dysfunction, or bleeding. Echocardiography was also non-specific. One month later, she developed a marked bleeding tendency and leg edema. Laboratory tests showed a severe deterioration in liver function. In the middle of May, 2008, she progressed to hepatic coma and died of intracranial hemorrhage several days later. Autopsy showed that the liver was almost substituted by AL amyloid substance.

Leukemic manifestation of blastic plasmacytoid dendritic cell neoplasm lacking skin lesion : a borderline case between acute monocytic leukemia.

Blastic plasmacytoid dendritic cell neoplasm (BPDCN) is a rare hematologic malignancy with a poor prognosis. We encountered a unique case of BPDCN that was leukemic at presentation without skin lesion and expressed CD33 antigen. A 74-year-old man was admitted because of dyspnea. Physically, hepatosplenomegaly, but not skin lesions and superficial lymph node swelling, was noted. The white blood count was 33.6 × 10(9)/L with 19% giant abnormal cells. These cells were positive for CD4, CD86, CD123 (bright), BDCA-2, and HLA-DR, but negative for CD1a, CD3, CD11b, CD11c, CD13, CD14, CD19, CD64, and CD68. From these findings, a diagnosis of BPDCN was made. In terms of unusual expression, these tumor cells were positive for CD33 but negative for CD56. The karyotype was 47, XY, t(6;8) (p21;q24), + r. We performed combination chemotherapy (Ara-C + VP-16 + MIT), which resulted in a marked reduction of tumor cells and improvement of the dyspnea. On day 16, however, he died of sepsis due to Bacillus cereus. The clinical picture of this patient is unusual and may provide new information on the clinicopathology of BPDCN.

A novel form of antihelix deformity.

This report describes a novel form of congenital antihelix deformity. A 2-month-old female presented with an antihelix deformity. Her inferior crus of the antihelix had the third crus, which was smoothly divided from the inferior crus, orienting forward. This type of deformity is not included in the current classification of a third crus deformity; therefore, this is the first report of a novel type of deformity.