Novel Detection of CALR-Mutated Cells in Myeloproliferative Neoplasm-Related Glomerulopathy With Interstitial Extramedullary Hematopoiesis: A Case Report.

Myeloproliferative neoplasms (MPNs) are associated with somatic mutations of genes including JAK2, CALR, or MPL in hematopoietic stem cells. Various glomerular lesions are known to be involved in MPN-related glomerulopathy, including mesangial hypercellularity, segmental sclerosis, features of chronic thrombotic microangiopathy, and intracapillary hematopoietic cell infiltration. Renal extramedullary hematopoiesis (EMH) is uncommon, but it is reported to occur in the setting of MPN; however, to our knowledge, there have been no reports of renal EMH with pathologically verified mutations. We report the case of a 65-year-old woman with MPN who had a CALR mutation and developed nephrotic syndrome. Kidney biopsy showed the typical findings of MPN-related glomerulopathy. CALR mutation-specific immunostaining of the kidney revealed immunopositive cells in the EMH lesion of the interstitium, indicating that renal EMH was caused by CALR-mutated cells. Based on these findings, we diagnosed nephrotic syndrome caused by MPN-related glomerulopathy. After initiation of steroid therapy, the patient's proteinuria gradually decreased and she achieved an incomplete remission. Additionally, the patient was prescribed the JAK inhibitor ruxolitinib and maintained incomplete remission. There is no established treatment for MPN-related glomerulopathy; therefore, further studies are needed to elucidate its pathophysiology.

Myelodysplastic syndrome treated effectively with testosterone enanthate.

We report a case of myelodysplastic syndrome (MDS) treated effectively with testosterone enanthate. A 70-year-old man was diagnosed with low-risk MDS in 1998, and he was first given methenolone acetate orally because of gradual progression of anemia and thrombocytopenia. However, this treatment was not effective, so we changed the treatment to testosterone enanthate because of his symptoms with late-onset hypogonadism. Three months after testosterone replacement therapy (TRT), anemia and thrombocytopenia had improved, and mean platelet count and hemoglobin had significant increases from 2.36 ± 0.45 × 10(4) to 3.83 ± 0.78 × 10(4) /µL, and from 11.7 ± 0.81 to 15.2 ± 1.00 g/dL, respectively, which contributed to a decrease in platelet transfusion requirement. Since then, the patient has been on a good clinical course. The present case suggests that testosterone enanthate administration could be an alternative treatment for men with MDS, even in the case where treatment with anabolic-androgenic steroids is not successful, and suggests another interesting effect of TRT on platelets.

Androgen therapy in combination with granulocyte colony-stimulating factor and erythropoietin in a patient with refractory anemia.

Initial treatment with androgen (metenolone acetate) alone for 19 weeks had no effect in a 45-year-old Japanese female with refractory anemia (RA). The patient achieved trilineage hematologic recovery after addition of recombinant human granulocyte colony-stimulating factor (G-CSF) and recombinant human erythropoietin (Epo) to the androgen therapy. Anemia progressed after the cessation of metanolone acetate, but was effectively treated by the readministration of metenolone acetate. Thus, the androgen therapy in combination with hematopoietic growth factors such as G-CSF and/or Epo may be effective in patients with RA.

[Myelodysplastic syndrome with CREST syndrome successfully treated with metenolone--A case report].

A 54-year-old woman was diagnosed as having refractory anemia (RA) with CREST syndrome (incomplete type). She showed Raynaud's phenomenon, sclerodactyly and telangiectasia, but not calcinosis and esophageal dysmotility. Laboratory findings revealed anemia and thrombocytopenia, and myelodysplasia, abnormal karyotype of 47, XX, +8 in bone marrow cells. Antinuclear and centromere antibody was positive. Treatment with prednisolone was not successful. After prednisolone was tapered, she was given 20 mg/body metenolone orally, which led to hematological improvement, and after 6 months of therapy, abnormal karyotype of 47, XX, +8 disappeared.

Myelodysplastic syndrome associated with myelofibrosis, a report of 3 cases.

Three cases of primary myelodysplastic syndrome (MDS) associated with myelofibrosis were initially diagnosed as refractory anemia by the presence of bicytopenia or pancytopenia and having normo- or hypercellular marrow with dysplastic features. The bone marrow aspiration of these patients showed dry tap a few months after admission, or on admission. Their bone marrow biopsy specimens revealed various grades of increased formation of reticulin fibers. One patient entered into complete remission in response to metenolone, while the other two patients died of cerebral hemorrhage several months after admission. These results indicate that this disease should be classified as a distinct subgroup of MDS.

Fatal outcome of a patient with severe aplastic anemia after treatment with metenolone acetate.

A 75-year-old man suffering from severe aplastic anemia was treated first with cyclosporin A, then with steroid pulse therapy, and subsequently with metenolone acetate. Marked elevation of transaminases was detected following initiation of treatment with metenolone acetate. This was followed by hepatic failure and death. Histopathological findings in autopsy specimens were compatible with the diagnosis of drug-induced liver impairment, for which metenolone acetate was considered the most likely causative agent. Liver impairment as a side effect of the use of this drug has been thought to be mild, reversible and rather infrequent. However, as demonstrated in the case described here, it is apparent that extreme caution should be exercised when using this drug in debilitated patients.

Effects of treatments by calcium and sex hormones on vertebral fracturing in osteoporosis.

Lateral radiographs of the thoracic and lumbar spine were taken periodically in 49 patients with osteoporosis. Thirty patients were postmenopausal, and 19 nonmenopausal with osteoporosis due to steroids, male hypogonadism, alcoholism, thyrotoxicosis or unknown cause. Patients were studied before, during and after treatment with high calcium alone, or with combined calcium and sex steroids. Calcium was given as effervescent calcium lactate gluconate, and sex hormones as oestradiol valerate, testosterone oenanthate, or methenolone oenanthate. A total of 964 films covering 409 patient-years were available for measurement. On each vertebra, deformity due to loss of anterior height was measured and assigned to one of four grades. For the time interval between each consecutive pair of films, a patient's vertebral fracture rate score was calculated and expressed per thousand patient-years. In comparison with the corresponding pretreatment fracture rate score, both the postmenopausal and the nonmenopausal groups who had not received sex hormones previously, failed to show significant changes (p = 0.144; p = 0.017) on high calcium alone during mean periods of 4.3 and 2.8 years respectively. If the first 2 years on high calcium were excluded for the postmenopausal group, they still failed to show a reduction in fracture rate score (observed for a mean period of 5.0 years; p = 0.04). When treated with combined calcium and sex hormones, both postmenopausal and nonmenopausal groups showed a lower fracture rate score of 20 and 207 respectively when compared with the pretreatment levels of 1500 and 1697 (in mean treatment periods of 3.2 and 4.4 years; p less than 0.001 in each case). When given high-dose calcium alone, but after treatment with sex hormones as well, the postmenopausal group showed no change in fracture rate score from pretreatment (in a mean of 3.1 years; p = 0.069); however the nonmenopausal group still showed a significant reduction in fracture rate score from 1697 to 42 over a mean period of 2.3 years (p = 0.001). The postmenopausal group, after stopping all treatment, showed a higher fracture rate score of 1286 (in a mean of 2.6 years) than did those on combined calcium and sex hormones, in whom the fracture rate score was 20 (in a mean of 3.2 years; p = 0.008). A subgroup of 11 patients with osteoporosis of both the menopausal and nonmenopausal types, had data both before (in a mean of 5.5 years) and during (for a mean of 2.5 years) treatment with calcium alone; the fracture rate scores were 1473 and 918 (p = 0.247).(ABSTRACT TRUNCATED AT 400 WORDS)

Androgen in the treatment of refractory anemia.

We retrospectively evaluated the efficacy of androgen in the treatment of refractory anemia (RA) and compared patient characteristics and the probability of survival in androgen-responder and nonresponder groups. Forty patients with RA were treated in our hospital between 1975-1989, and 27 were treated with various derivatives of androgen. Eleven of the latter responded effectively to androgen therapy, representing an efficacy rate of 40.7%, higher than that of any other treatments thus far reported. The probability of 10-year survival estimated by the Kaplan-Meier method was 75.0% for the responder group and 41.3% for nonresponders, with a median follow-up of 1202 and 1272 days, respectively. In addition, the percent probability of transformation-free survival was higher among androgen-responders than among nonresponders, though the difference was not significant. Transformation from RA to RAEB or overt leukemia was seen in only one case among the former group, but in six among the latter. With respect to patient characteristics, only the percentage of marrow myeloblasts differed significantly between the groups.

Experimental treatment of thioacetamide-induced liver cirrhosis by metenolone acetate. A morphological and biochemical study.

The influence of metenolone acetate (1 mg/kg b.m. orally) on intact and chronically thioacetamide-injured rat liver (experimental liver cirrhosis) was investigated over 14 d. Histological examination revealed nodular transformation of liver structure according to cirrhosis like lesions with hepatocellular and cholangiocellular proliferations. These structural alterations were more serious in the group treated with metenolone compared with the group without metenolone. Metanolone administration to animals with thioacetamide-induced experimental liver cirrhosis led to an increase in liver injury. This treatment seems to promote hepatic preneoplastic lesions induced by thioacetamide reflected by histology and induction of gamma-glutamyltranspeptidase and 7-ethoxycoumarin O-deethylase in injured livers. Metenolone did not interfere directly with the processes of connective tissue synthesis and degradation after thioacetamide pretreatment. Only little changes of the investigated biochemical parameters were seen after metenolone administration to animals with intact liver function: increases in serum cholinesterase and tissue N-acetyl-beta-D-glucosaminidase activity; decreases in N-acetyl-beta-D-glucosaminidase in serum, liver hydroxyproline content and hepatic gamma-glutamyltranspeptidase activity. The observed changes reflect hepatic adaption processes under the influence of metenolone. The results of this study indicate that the risk of anabolic steroids in adjuvant therapy of liver cirrhosis cannot be calculated at present.

[Severe aplastic anemia successfully treated with cyclosporin A and prednisolone].

A 7-year-old boy was admitted to our department complaining pale face and subcutaneous bleeding in August, 1987. Peripheral blood analysis showed pancytopenia of WBC 2,600/microliter, RBC 148 x 10(4)/microliter and platelets 5,000/microliter. Bone marrow biopsy revealed hypocellularity. Granulocytes 104/microliter, reticulocytes 4,290/microliter and platelets 5,000/microliter were compatible with the diagnosis of severe aplastic anemia based on the criteria of the Ministry of Public Welfare in Japan. Prednisolone (PDN) was initially indicated and bolus methylprednisolone, metenolone and ALG therapy followed with no hematological improvement. Fifteen months after admission, in addition to 0.5-1 mg/kg/day of metenolone, Cyclosporin A (CyA) was started at a dose of 12 mg/kg/day for a week and 6 mg/kg/day thereafter. After a week from administration of CyA, 1 mg/kg/day of PDN was given because his bleeding tendency became worse. But this combination was complicated with liver damage and hyperglycemia to discontinue both drugs. These adverse effects were subsided within 7 days by cessation of the drugs. CyA was started again at a dose of 6 mg/kg/day without any response for 4 weeks. Then PDN was added together at a reduced dose of 0.5-1 mg/kg/day. Hematological response was obtained promptly. Granulocytes reached 1,500/microliter, hemoglobin 10.2 g/dl and platelets 26,000/microliter after 3 months of therapy. Afterward the patient became transfusion independent. The most effective method of CyA administration for aplastic anemia is still controversial. Alternative use of CyA, considering combination of steroids or anabolic steroids, in patients who failed to respond to conventional immunosuppressive treatments should be further investigated.

[Anabolic therapy in metastatic breast cancer]. / Anabole Therapie bei metastasierendem Mamma-Karzinom.

The medical records of 66 women treated with metenolone for metastasized breast carcinomas were analysed. In 26 patients a remission developed with a mean duration of 8.2 (3-29) months. Patients whose treatment started in the first year after the menopause as well as patients with a beneficial effect of a therapeutic ovariectomy in the past were more often improved by metenolone than average. Metenolone had a better effect against osseous metastases than against visceral metastases. In most cases the treatment was well tolerated. In four patients, however, the treatment had to be interrupted because of cholestasis, pulmonary embolism and hypercalcaemia.

[Pathophysiology of aplastic anemia and its treatment with methenolone enanthate]. / Beitrag zur Pathophysiologie der aplastischen Anämie und deren Behandlung mit Metenolonenanthat.

For the development of an aplastic anaemia a large number of causes is taken into consideration. In our own clinical material of 26 patients in 15 patients none of the up to now known noxae could be established. Recently in the clarification of the picture of the disease important pathophysiological realizations were got. In these cases disturbances of the stem cell compartments, effects through the matrix of the haematopoietic cells and immunological processes have been recognized as significant. --Own investigations concerning the therapy with the anabolic metenolonenanthat (Primobolan-S) yielded approximately the same large number of therapeutic failures and patients with a good result of the treatment or a partial remission in 15 idiopathic and 11 toxically conditioned anaemias. In the partial remissions in most cases a thrombocytopenia continued existing. A therapy lasting at least two months is necessary in order to estimate the result of the therapy. At the present time cannot yet be predicted on which conditions the use of anabolics will be successful.

Prognostic factors in acquired aplastic anemia. A study of 352 cases.

The prognostic factors of short- and long-term survival have been studied in 352 patients with aplastic anemia of all grades of severity. This group was homogeneous with regard to the clinical and laboratory survey, and the treatment used [high-dose androgen therapy]. The "hierarchy" of the individual prognostic parameters has been established: current severe infection, granulocyte count, percentage of the nonmyeloid cells on the bone marrow slides, platelet count, reticulocyte count, 59Fe utilization, and stromal disorganization on the bone marrow biopsy specimen. As these parameters are interrelated, a multiparametric analysis enables us to define groups of patients with different short-term evolution and to derive a prognostic index from these data. The use of such an index, however, allows a correct prediction in only 73 per cent of the cases, better in the milder than in the more severe cases. It is possible that the short-term evolutive tendency (improvement or worsening during the first six weeks of therapy) may contribute supplementary information useful for prognosis and the choice of treatment. After the first three months critical period, the mortality rate no longer depends on the initial severity of the disease but exclusively on the clinical and hematologic improvement. Thus, comparing the hematologic data obtained initially and after three months of androgen therapy allows us to correctly predict the long-term evolution.

Androgen therapy of aplastic anaemia--a prospective study of 352 cases.

A prospective study of 352 patients with aplastic anaemia on androgen therapy has been performed. The following main observations have been obtained: The actuarial mortality rate at the 20th month is 52%, half the deaths being observed during the first 3 months; these figures are similar to those previously published, from smaller series of androgen-treated patients, and lower than those of non-androgen-treated cases. Differences in survival and improvement were observed between groups of patients treated for more than 3 months with either alkylated or non-alkylated drugs. Signs of liver damage were observed no matter which was the drug used. Continous improvement can be observed even in the 2nd year of treatment indicating that full-dose androgen therapy should be continued up to 20 months in not fully improved patients. The degree of initial disease activity is a clear prognostic parameter for the mortality in the first quarter of the course. In case of survival of severe cases, improvement can be obtained to the same extent as in milder cases. This stress the need for adequate maintenance therapy in all types of patients. Addition of glucocorticoids harms the prognosis, mainly in most granulocytopenic patients. Glucocorticoids have no effect upon the liver damage induced by androgens.