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We describe here a unique case of therapy-related myelodysplastic syndrome (t-MDS) with inv(16)(p13q22) after autologous stem cell transplantation for lymphoma. The rare and smallest I type CBFbeta/MYH11 fusion transcript with a breakpoint at nucleotide 399 of CBFbeta and at nucleotide 2134 of MYH11 was detected in the bone marrow cells by reverse transcription polymerase chain reaction analysis. However, the fusion transcript was undetectable in the pretransplant peripheral blood stem cells. These results suggest that the stem cell damage leading to t-MDS may be induced mainly by the conditioning regimen for transplantation. Taken together with previous reports, the I type fusion transcript is preferentially induced with chemotherapy.

Here, we show a functional role of casein kinase I (CKI) epsilon in hematopoietic cell survival through the modification of phosphatidylinositol 3-kinase (PI3K)/Akt signaling. Introduction of wild-type (WT)-CKIepsilon into interleukin-3 (IL-3)-dependent 32D cells increased the sensitivity to genotoxic stresses, such as gamma-irradiation, etoposide, and IL-3 deprivation, whereas kinase-negative (KN)-CKIepsilon suppressed it. Contrary to KN-CKIepsilon, WT-CKIepsilon attenuated the IL-3-induced activation of Akt with the increase of PTEN activity. Similarly, the increase of Akt activation, as well as PTEN inactivation, was accompanied both by a decrease of CKIepsilon expression induced by all-trans retinoic acid and by the addition of a specific inhibitor for CKIepsilon in HL-60 cells. CKIepsilon seems to activate PTEN by physical interaction. These results suggest that the CKIepsilon-induced down-regulation of PI3K/Akt signaling through PTEN lead to amplified sensitivity to apoptosis. Thus, the suppression of CKIepsilon in many human leukemia cell lines may play a role in the cell immortalization.

The TRAP220 subunit of the thyroid hormone receptor-associated polypeptide transcription coactivator complex (TRAP/Mediator complex), mammalian counterpart of the yeast Mediator complex, is proposed to act on a variety of major and specific biological events through physical interactions with nuclear receptors. The vitamin D receptor (VDR) and retinoic acid receptor (RAR), coupled with retinoid X receptor (RXR), are nuclear receptors which have important roles for monopoiesis and granulopoiesis, respectively. In this study, we present the functional role of TRAP220 in nuclear receptor-mediated monopoiesis and granulopoiesis. The mouse Trap220−/– yolk sac hematopoietic progenitor cells were resistant to 1,25-dihydroxyvitamin D3-stimulated differentiation into monocytes/macrophages. Furthermore, flow cytometric analyses showed that HL-60 cells, human promyelocytic leukemia cell line, wherein TRAP220 was down-regulated, did not differentiate efficiently into monocytes and granulocytes by stimulation with 1,25-dihydroxyvitamin D3 and all-trans retinoic acid, correspondingly. The expression of direct target genes of VDR or RAR, as well as the differentiation marker genes, was low in the knockdown cells. These results indicated a crucial role of TRAP220 in the optimal VDR- and RAR-mediated myelomonocytic differentiation processes in mammalian hematopoiesis.

Deletions or translocations of chromosome band 13q14, the locus of the retinoblastoma gene (RB1), have been observed in a variety of hematological malignancies including myelodysplastic syndrome (MDS). We describe here a novel unbalanced translocation der(13)t(7;13)(p13;q14) involving 13q14 in a patient with MDS. A 66-year-old woman was diagnosed as having MDS, refractory anemia with excess of blasts (RAEB-1) because of 7.4% blasts and trilineage dysplasia in the bone marrow cells. G-banding and spectral karyotyping analyses showed complex karyotypes as follows: 46,XX,der(6)t(6;7)(q11;?),der(7)del(7)(?p13)t(6;7)(q?;q11)t(6;13)(q?;q?),der(13)t(7;13)(p13;q14). Fluorescence in situ hybridization (FISH) analyses demonstrated that one allele of the RB1 gene and the microsatellite locus D13S319, located at 13q14 and telomeric to the RB1 gene, was deleted. Considering other reported cases, our results indicate that submicroscopic deletions accompanying 13q14 translocations are recurrent cytogenetic aberrations in MDS. The RB1 gene or another tumor suppressor gene in the vicinity of D13S319, or both, may be involved in the pathogenesis of MDS with 13q14 translocations by monoallelic deletion.

Tolvaptan is an oral vasopressin V2-receptor antagonist recognized as effective for fluid retention associated with congestive heart failure and liver cirrhosis. However, there have been no reports concerning clinical experience with tolvaptan for sinusoidal obstruction syndrome (SOS). A 42-year-old male with primarily refractory T-lymphoblastic lymphoma underwent allogeneic peripheral blood stem cell transplantation from an HLA-matched sibling donor. The myeloablative conditioning regimen consisted of busulfan and cyclophosphamide. On day 20, the total bilirubin level was elevated to 2.0 mg/dL, and body weight increased from 76 to 85 kg, allowing a diagnosis of SOS to be made. Treatments with thrombomodulin, furosemide, carperitide, and low-dose dopamine were ineffective. By day 27, the patient's body weight had increased to 90 kg, and he subsequently developed cardiopulmonary failure. Therefore, we administered low-dose tolvaptan for 2 days (3.75 mg on day 27 and 7.5 mg on day 28). Consequently, his ascites and edema were significantly reduced, and body weight returned to 77 kg by day 34. However, he died of lymphoma progression on day 55. Tolvaptan may be an alternative and promising treatment for refractory fluid retention associated with SOS, although it is unclear whether tolvaptan administration leads to improvement in clinical outcome.

Cytogenetic abnormalities are observed in approximately one half of cases of myelodysplastic syndrome (MDS). Partial or complete chromosome losses and chromosome gains are frequently found, but there is a relatively high incidence of unbalanced translocations in MDS. We describe here two cases of MDS with an unbalanced translocation, der(11)t(11;12)(q23;q13). Both patients were 69 years of age and diagnosed with refractory anemia with excess of blasts in transformation (RAEB-t) according to the high percentage of blasts in the peripheral blood. Cytoplasmic hypogranulation of neutrophils was evident as a dysplastic change. The blasts were positive for CD4 and CD41a as well as CD13, CD33, CD34 and HLA-DR in both cases. Chromosome analysis showed complex karyotypes including a der(11)t(1;11)(q11;p15)t(11;12)(q23;q13) in case 1 and der(11)t(11;12)(q23;q13) in case 2 plus several marker chromosomes. Spectral karyotyping confirmed the der(11)t(11; 12)(q23;q13) and clarified the origin of marker chromosomes, resulting in del(5q) and del(7q). Fluorescence in situ hybridization (FISH) analyses with a probe for the MLL gene demonstrated that the breakpoints at 11q23 were telomeric to the MLL gene in both cases. FISH also showed that the breakpoint at 11p15 of the case 1 was telomeric to the NUP98 gene. Considering another reported case, our results indicate that the der(11)t(11;12)(q23;q13) is a recurrent cytogenetic abnormality and may be involved in the pathogenesis of advanced-stage MDS.

Follicular lymphoma is characterized genetically by t(14;18)(q32;q21), whereas t(18;22)(q21;q11), a rare variant form of t(14;18), has been preferentially observed in chronic lymphocytic leukemia (CLL). We describe here an unusual case of follicular lymphoma with a t(18;22)(q21;q11), that progressed to diffuse large cell lymphoma with a novel t(2;6)(p12;q23). Spectral karyotyping revealed that add(2)(p12) and add(6)(q23) were derived from a t(2;6)(p12;q23). Fluorescence in situ hybridization analysis confirmed rearrangements of the BCL2 gene at 18q21 and the BCL6 gene at 3q27. Our results indicate that a reciprocal translocation involving 6q23 could be implicated in the progression of follicular lymphoma and that t(18;22) may have a specific role in the pathogenesis of follicular lymphoma as well as CLL.

A member of the largest family of receptor protein kinases, EphB6, lacks its intrinsic kinase activity, but it is expressed in normal human tissues. To investigate the physiological function of EphB6, we generated EphB6 deficient mice. EphB6(-/-) mice developed normally, revealed no abnormality in general appearance, and were fertile. Although a developmental increase of EphB6 in the fetal thymus was confirmed, T-cell development in various lymphoid organs of EphB6(-/-) mice was comparable to those of EphB6(+/+). Even in fetal thymus organ cultures, any developmental differences of EphB6(-/-) and EphB6(+/+) thymocytes were undetectable. The different binding characteristics to ephrin-Fc proteins between EphB6(-/-) and EphB6(+/+) thymocytes demonstrated that ephrin-B2 is the unique ligand for EphB6 among eight known ephrins. While EphB6 was a dominant receptor that binds to ephrin-B2 in adult thymocytes, fetal ones also expressed another EphB that binds to ephrin-B2. Overlapping expression of the EphB subfamily in the fetal thymus might compensate for the loss of EphB6 during the thymic development.

Background D-index which combines the intensity and duration of neutropenia is reported as a tool for evaluating the dynamics of neutropenia. This study aimed to analyze the relationship between D-index and oral complications (i.e., oral mucositis [OM] and odontogenic infection [OI]) during chemotherapies for hematological malignancies. Methods A total of 421 chemotherapeutic courses in 104 patients were analyzed. Chemotherapeutic courses in patients who finished all of the prophylactic dental treatments were defined as “treatment Finish”. Chemotherapeutic courses in patients who did not finish prophylactic dental treatments were defined as “treatment not-Finish”. OM was evaluated according to the Common Terminology Criteria for Adverse Events, version 4.0. D-index was compared between chemotherapeutic courses with versus without oral complications. Results D-index was significantly higher in chemotherapeutic courses with grade 1 or 2 OM (p < 0.001) than courses without OM. In contrast, higher D-index did not relate to the development of OI (p = 0.18). The occurrence of OI (p < 0.001) but not OM (p = 0.56) during chemotherapy was significantly higher in chemotherapeutic courses without the completion of dental intervention. Conclusions Higher D-index relates to the development of OM. In contrast, OI occurs due to untreated odontogenic foci, and its occurrence does not relate to higher D-index.

Dear Editor, Intravascular large B cell lymphoma (IVLBCL) is a rare subtype of diffuse large B cell lymphoma (DLBCL) characterized by the selective growth of lymphoma cells within the lumina of vessels [1]. Cytogenetically, the majority of IVLBCL cases demonstrated complex karyotypes with multiple numerical and structural changes, and the most frequent duplicated regions were shown to be the 11q13→qter region and all of chromosome 18 [2, 3]. On the other hand, triplications of chromosome segments other than 1q have been rarely found in hematological malignancies [4–8]. Here, we describe an unusual case of IVLBCL with a tandem triplication of the BCL2 gene at 18q21. An 82 year-old female was admitted because of fever. Computed tomography scans revealed hepatosplenomegaly without lymphadenopathy. Peripheral blood (PB) examination showed hemoglobin 105 g/L, platelets 52×10/L, and leukocytes 10.1× 10/Lwith 15% abnormal lymphocytes. Serum levels of lactate dehydrogenase (LDH) and soluble interleukin-2 receptor were 6,382 IU/L (normal range, 115~217) and 8,429 U/mL (124~ 466), respectively. Bone marrow (BM) was normocellular with 42.4 % abnormal lymphocytes positive for CD5, CD19, CD20, and HLA-DR (Fig. 1a). Pathological examination of the BM revealed a focal and sinusoidal growth pattern of large lymphoid cells, indicating a diagnosis of IVLBCL (Fig. 1b). Immunohistochemistry demonstrated that they were positive for CD5, CD20, BCL2, and MUM1, but negative for CD10 and BCL6 (Fig. 1c, d). The patient received R-CHOP therapy and achieved hematological complete remission. However, 12 months later, she relapsed and died of progressive disease. G banding and spectral karyotyping of BM cells showed 47,XX,del (2)(q?),+del(3)(p?),der(10)t(10;20)(q24;?), dup(17)(q21q23),dup(18)(q11.2q23) [20] (Fig. 1e). Unexpectedly, fluorescence in situ hybridization (FISH) detected three BCL2 signals on the dup(18)(q11.2q23), indicating a tandem triplication of BCL2 (Fig. 1f). Namely, the short 18q fragment containing BCL2 attached to the dup(18). FISH on interphase nuclei confirmed four BCL2 signals. According to the Mitelman Database, nine cases of hematological malignancies with duplication/triplication of 18q (duplication, eight; triplication, one) in the stem-lines have been described [4, 9, 10]. All cases were diagnosed with B lymphoid malignancies. The duplicated regions in two cases of acute lymphoblastic leukemia did not contain 18q21, whereas those in seven cases of B cell lymphomas (DLBCL, four; IVLBCL, one; Burkitt lymphoma, one; mantle cell lymphoma, one) retained 18q21. Thus, duplication/triplication of 18q including 18q21 seems to be specifically associated with B cell lymphomas and suggests the significance of BCL2 in their pathogenesis. Among these, one case with trp(18)(?q21q23) exhibited a tandem triplication of BCL2 [2]. This 62-year-old male was diagnosed as having IVLBCL with BM/PB involvement, thrombocytopenia (34×10/L), and high LDH (2,266 U/L). Lymphoma cells were positive for K. Yamamoto (*) :A. Okamura :K. Yakushijin :H. Matsuoka : H. Minami Division of Medical Oncology/Hematology, Department of Medicine, Graduate School of Medicine, Kobe University, 7-5-1 Kusunoki-cho, Chuo-ku, Kobe 650-0017, Japan e-mail: kyamamo@med.kobe-u.ac.jp

A 40-year-old woman with no past medical history was diagnosed with B lymphoblastic leukemia (ALL), and received induction chemotherapy with L-asparaginase (Lasp), cyclophosphamide, doxorubicin, vincristine, and prednisolone. On day 20 of treatment, 2 days after the fifth administration of L-asp at a dose of 3000 KU/m/day, laboratory tests showed deranged liver function with elevated total bilirubin (2.2 mg/dL, normal 0.3–1.0), AST (70 U/L, normal 8–34), and ALT (43 U/L, normal 13–31). A computed tomography (CT) scan on day 26 revealed severely diffuse low-density of the liver (Fig. 1b), which was not observed at the onset of ALL (Fig. 1a). Furthermore, total bilirubin, AST, and ALT increased to 4.1 mg/ dL, 640 U/L, and 693 U/L, respectively. Because L-asp was suspected to have induced the fulminating liver dysfunction, the next dose of L-asp was discontinued, and ursodeoxycholic acid was administered for liver protection. While CT on day 40 showed similar results (Fig. 1c), on day 100 liver density had nearly recovered to its pre-chemotherapy state, followed by normalization of laboratory findings (Fig. 1d). Thereafter, she achieved and maintained a complete remission after the post-remission therapy, which included allogeneic hematopoietic stem cell transplantation. Although liver injury due to L-asp seems to be a wellknown adverse effect, impressive CT images such as in this case, possibly due to severe fatty liver, have rarely been reported. The mechanism of liver steatosis remains to be elucidated, but asparaginase may cause abnormalities in lipid metabolism by inhibiting protein synthesis. Such liver dysfunction may occasionally develop into fatal liver failure. This case suggests the importance of evaluating periodic CT scans for liver dysfunction after treatment with L-asp. CT images may be useful not only for early

The t(9;11)(p22;p15) is a very rare but recurrent translocation in acute myeloid leukemia (AML) and chronic myeloid leukemia (CML) blast crisis. The translocation results in a fusion gene between NUP98 at 11p15 and PSIP1 encoding two transcriptional coactivators, p52 and p75, at 9p22. Here, we describe the first case of myelodysplastic syndrome (MDS) with t(9;11)(p22;p15).A 64-yr-old woman presented pancytopenia, trilineage dysplasia, and 9.2% blasts in the bone marrow, indicating the diagnosis of MDS.G-banding and spectral karyotyping showed 46,XX,t(9;11)(p22;p15)[20]. Reverse transcription-polymerase chain reaction (RT-PCR) and nucleotide sequencing detected four types of NUP98/PSIP1-p52 and two types of NUP98/PSIP1-p75 fusion transcripts. Essentially, the NUP98 exon 12 or exon 11 by alternative splicing was fused in-frame with the PSIP1 exon 8. Real-time quantitative (RQ) PCR for NUP98/PSIP1/GAPDH demonstrated a 4-log decrease after cord blood transplantation and a 2-log increase at relapse.The fusion genes combining NUP98 exon 11/12 with PSIP1 exon 8, which have never been detected in other AML/CML cases, may be implicated in the pathogenesis of MDS. Furthermore, RQ-PCR for NUP98/PSIP1 could be useful to monitor minimal residual disease.

Chromosomal translocations involving MYC at 8q24 are found in Burkitt lymphoma (BL), diffuse large B-cell lymphoma (DLBCL), and B-cell lymphoma, unclassifiable, with features intermediate between DLBCL and BL (BCLU). Here, we describe a novel five-way translocation, t(3;9;13;8;14)(q27;p13;q32;q24;q32), involving MYC , BCL6 , and the immunoglobulin heavy locus ( IGH@ ) in a 73-year-old man with BCLU. The bone marrow was massively infiltrated with 95.6% abnormal medium- to large-sized lymphoid cells without vacuoles. Flow cytometric analyses indicated that the infiltrating cells were positive for CD10, CD19, CD20, CD25, HLA-DR, and κ chain. Immunohistochemistry revealed that they were also positive for BCL2 and CD10, and weakly positive for BCL6. The MIB1 index was approximately 99%. G-banding and spectral karyotyping demonstrated the presence of a t(3;9;13;8;14)(q27;p13;q32;q24;q32). Fluorescence in situ hybridization detected an IGH/MYC fusion signal on the der(14)t(8;14)(q24;q32). In addition, 5′ and 3′ BCL6 signals were separated onto the der(9)t(3;9)(q27;p13) and the der(3)t(3;14)(q27;q32), respectively. Unexpectedly, no BCL6 signal was found on the non-translocated chromosome 3. Finally, the revised karyotype was as follows: 49,XY,del(3)(q27q27),t(3;9;13;8;14)(q27;p13;q32;q24;q32), +der(6)t(6;13)(q13;q32)t(9;13)(p13;q32),+7,+12,i(18)(q10)[2]/50,sl,+7[2]/50,sl,+2[1]. These results suggest that this five-way translocation could bring about the deregulated expression of MYC on the der(14)t(8;14) and BCL6 on the der(3)t(3;14) by the IGH@ enhancer/promoter in a single event and may have contributed to the development of this BCLU.

In allogeneic hematopoietic stem cell transplantation (allo-SCT), most physicians in Japan utilize granulocyte colony-stimulating factor (G-CSF) at a high dose (HD) of 300 μg/m(2) per day for filgrastim to promote faster neutrophil engraftment. However, the necessity of the HD has not been validated under graft-versus-host disease (GVHD) prophylaxis by mycophenolate mofetil (MMF), which can also be expected to facilitate engraftment. In a total of 51 patients, we compared the clinical outcomes between a standard dose (SD) fixed at 300 μg per day and a HD of G-CSF. While time to neutrophil engraftment was not different in the HD and SD groups in patients receiving cord blood transplantation (CBT, 20 vs. 17.5 days, P = 0.243) or bone marrow transplantation (BMT, 11 vs. 10 days, P = 0.227), there seemed to be an increased risk of developing acute GVHD in the HD group with CBT (20 vs. 0%, P = 0.073) and BMT (57 vs. 24%, P = 0.165). Progression-free survival of patients in the HD group was likely to be worse compared with that of the SD group with CBT (P = 0.099). In this study, the clinical benefits of a HD of G-CSF could not be documented, and we find that the use of G-CSF at a SD after allo-SCT with MMF should be prospectively evaluated.

Diffuse normolipemic plane xanthoma (DNPX) is a rare xanthoma variant characterized by xanthelasma, diffuse plane xanthomas on the neck, upper trunk and extremities and normal plasma lipid levels [1-3]. DNPX has been associated with hematologic disorders, particularly multiple myeloma and monoclonal gammopathy [3]; however, leukemia, lymphoma and Castleman's disease have also been associated with the condition [3]. Here, we describe a patient with DNPX associated with chronic myelomonocytic leukemia [...]

A 26-year-old woman, who successfully underwent umbilical cord blood transplantation for aplastic anemia 4 years previously, had suffered from hepatosplenic microabscesses caused by unidentifiable grocott stain-positive spores from immediately after the transplantation. At 51 months post-transplant, we attempted bone marrow biopsy from her posterior iliac crest, but failed to penetrate the cortical bone. X-ray of her spine and pelvis showed marked and diffuse osteosclerosis. Retrospective analysis of computed tomography revealed the gradual replacement of sternal, vertebral, and pelvic bone marrow with calcified tissues in addition to the dispersed calcification of the liver, spleen, and kidneys over the last 2 years. The bone mineral density of the lumbar spine had increased but not that of the femoral neck. Biomedical parameters for bone remodeling demonstrated enhanced bone formation as well as bone resorption and secondary hyperparathyroidism. Based on the past reports, we suggest that chronic fungal infection, which caused visceral calcification, induced the production of humoral factors for osteoblastic activation.

Sinusoidal obstruction syndrome (SOS) is one of the life-threatening complications caused by endothelial damage to the hepatic sinusoids after hematopoietic stem cell transplantation. However, a satisfactory treatment for SOS has not yet been established. Defibrotide has anti-thrombotic, anti-ischemic, anti-inflammatory, and thrombolytic properties without systemic anticoagulant effects. We treated eight post-transplant SOS patients with defibrotide. Three patients responded to the therapy and the initial response was observed within a week. In addition to the improvement of liver function, rapid recovery of response to diuretic drugs followed by the improvement of renal function was observed. All of the five patients with respiratory dysfunction died despite administration of defibrotide, suggesting that early treatment might lead to better outcomes. There were no severe adverse effects directly due to defibrotide administration. Defibrotide seems to be a promising treatment for SOS, and the initiation of a clinical study in Japan would be important.

To prevent acute graft-versus-host disease (GVHD), mycophenolate mofetil (MMF) combined with calcineurin inhibitors have been used in allogeneic hematopoietic stem cell transplantation (allo-SCT). Previous studies commonly utilize MMF treatment until day 30 after allo-SCT. However, the feasibility of continuous administration after day 30 has not been well evaluated. We retrospectively assessed the safety and efficacy of extended drug administration. Twenty-five patients ceased MMF at day 30 (group A); whereas, 16 patients (group B) received extended regimens depending on individual risk factors for GVHD. No severe adverse events were observed in either group. Although the cumulative incidence (CI) of grade I to IV GVHD at day 100 was comparable between the 2 groups, the CI of grade II to IV GVHD was less among group B (12.5%) compared with group A (42.3%). Extended MMF administration may be safe and beneficial as preemptive therapy to reduce the development of moderate-to-severe acute GVHD.

A 66-year-old female was referred to our hospital with bone pain and progressive pancytopenia with granular lymphocyte infiltration only in the bone marrow (BM). Flow cytometric and histological analyses revealed that these cells were positive for CD3, TCRalphabeta, granzyme B, and the diagnosis of T-cell granular lymphocyte leukemia (T-GLL) with myelofibrosis was made. These BM granular lymphocytes were greatly ruffled and showed the CD3/CD20 double positive phenotype, which was not detected in the peripheral blood. The patient was treated with a single course of fludarabine followed by a favorable clinical course for 3 months. Many of the BM lymphocytes displayed almost normal appearance after treatment, however, the number of lymphocytes in the BM did not decrease and these were still CD3/CD20 double positive. This is an overlap case of T-GLL and peripheral T-cell lymphoma, unspecified (PTCLu).

We describe here the first case of 8p11 myeloproliferative syndrome (EMS) with t(8;9)(p11;q33), who unusually demonstrated B-lymphoblastic/monoblastic biphenotypic transformation. A 57-year-old woman was admitted because of leukocytosis and diagnosed as EMS. Bone marrow was infiltrated with myeloperoxidase (MPO)-, CD10+, CD19+, CD20+, CD34+, HLA-DR+ small lymphoblasts and MPO+, CD2+, CD4+, CD13+, CD14+, CD33+, HLA-DR+ large monoblasts. The karyotype was 46,XX,t(8;9)(p11;q33)[20] and the CEP1/FGFR1 fusion transcript between CEP1 exon 38 and FGFR1 exon 9 was detected. This case clearly indicates that the blastic transformation in EMS with t(8;9) could arise in the stem cells, which differentiate into not only myelomonocytic but also B-lymphocytic lineages.

Sinusoidal obstruction syndrome (SOS) (formerly known as hepatic veno-occlusive disease (VOD)) is a life-threatening complication subsequent to hematopoietic stem cell transplantation. However, no completely satisfactory strategies for the treatment of SOS have been established yet. Defibrotide is a single-stranded polydeoxyribonucleotide with anti-thrombotic, anti-ischemic, anti-inflammatory and thrombolytic properties, but without systemic anticoagulant effects, and some encouraging results have been reported in western countries. We treated four patients with defibrotide for SOS, since there seemed to be no possibility to cure the patients with conventionally available treatments in Japan. All patients showed evidence of multiple organ failure at the start of the treatment. Defibrotide was administered intravenously in normal saline in four divided doses for 14 to 27 days. Three patients (75%) responded to the therapy, while one died of SOS and cytomegalovirus infection despite intensive therapy. None of the patients suffered from significant adverse effects such as severe hemorrhage. This is the first report dealing with the treatment with defibrotide of Japanese patients with SOS. Because defibrotide is considered to be promising for the treatment of SOS, it is important to start a phase II study as soon as possible.

The TRAP220 subunit of the thyroid hormone receptor-associated polypeptide transcription coactivator complex (TRAP/Mediator complex), mammalian counterpart of the yeast Mediator complex, is proposed to act on a variety of major and specific biological events through physical interactions with nuclear receptors. The vitamin D receptor (VDR) and retinoic acid receptor (RAR), coupled with retinoid X receptor (RXR), are nuclear receptors which have important roles for monopoiesis and granulopoiesis, respectively. In this study, we present the functional role of TRAP220 in nuclear receptor-mediated monopoiesis and granulopoiesis. The mouse Trap220(-/-) yolk sac hematopoietic progenitor cells were resistant to 1,25-dihydroxyvitamin D(3)-stimulated differentiation into monocytes/macrophages. Furthermore, flow cytometric analyses showed that HL-60 cells, human promyelocytic leukemia cell line, wherein TRAP220 was down-regulated, did not differentiate efficiently into monocytes and granulocytes by stimulation with 1,25-dihydroxyvitamin D(3) and all-trans retinoic acid, correspondingly. The expression of direct target genes of VDR or RAR, as well as the differentiation marker genes, was low in the knockdown cells. These results indicated a crucial role of TRAP220 in the optimal VDR- and RAR-mediated myelomonocytic differentiation processes in mammalian hematopoiesis.

Two closely related casein kinase I (CKI) isoforms, CKIdelta and CKIepsilon, are ubiquitously expressed in many human tissues, but their specific biologic function remains to be clarified. Here, we provide the first evidence that CKIepsilon is involved in hematopoietic cell differentiation. CKIepsilon, but not CKIdelta, was down-regulated along with human granulocytic differentiation. The specific down-regulation was observed in granulocyte colony-stimulating factor (G-CSF)-induced cell differentiation of murine interleukin-3 (IL-3)-dependent myeloid progenitor 32D cells. Introduction of wild-type (WT)-CKIepsilon into 32D cells inhibited the G-CSF-induced cell differentiation, whereas kinase-negative (KN)-CKIepsilon promoted the differentiation. Neither WT- nor KN-CKIepsilon affected IL-3-dependent cell growth. Moreover, introduction of WT- or KN-CKIdelta did not affect the cytokine-induced cell growth and differentiation. While G-CSF-induced activation of signal transducers and activators of transcription 3 (STAT3) was sustained by KN-CKIepsilon, STAT3 activation was attenuated by WT-CKIepsilon. This may be explained by the fact that the suppressor of cytokine signaling 3 (SOCS3) was stabilized by its physical association with CKIepsilon. Such stabilization by CKIepsilon was also seen in IL-3-induced beta-catenin. The stabilization of downstream components of cytokine and Wnt signaling by CKIepsilon might be critical for integration of several intracellular signaling pathways to a cell-specific biologic response in hematopoietic cell self-renewal.

Flow cytometric immunophenotypic analysis (FC) and cytogenetic analysis are essential techniques for the diagnosis and classification of many hematologic disorders. The roles of these analyses in B-cell lymphoma to detect bone marrow (BM) involvement in clinical staging and to evaluate the effectiveness of treatments have not yet been determined. The aim of this study was to evaluate the usefulness of FC and cytogenetic analysis in the assessment of BM involvement in B-cell lymphoma.We retrospectively analyzed the usefulness of three-color FC and cytogenetic analysis in detecting BM involvement by examining 104 BM specimens from patients with B-cell lymphoma.By morphologic evaluation of BM biopsy (BMB), the BM was involved in 11 specimens (10.6%), not involved in 92 specimens (88.5%) and involvement could not be determined in 1 specimen (0.9%). FC identified a monoclonal B-cell population in 24 samples (23.1%). FC detected BM involvement in all but one BMB positive sample, and showed negative results in a BMB undetermined sample. Conclusively, FC found a monoclonal B-cell population in 14 of 92 BMB negative samples (15.2%). In particular, FC detected smaller amounts of BM involvement than did morphologic evaluation. Cytogenetic analysis revealed clonal abnormalities in only 9 of 104 samples (8.7%). However, 2 of these 9 samples were from patients with aggressive lymphoma with complex structural chromosomal abnormalities detectable only by cytogenetic analysis.Although morphologic evaluation of adequate amounts of BMB specimens remains essential for the evaluation of BM involvement, three-color FC is more sensitive in detecting BM disease than morphologic or cytogenetic analysis. Cytogenetic analysis seems to have low sensitivity and specificity, but this method may improve the detection of BM involvement in a small number of aggressive lymphomas that have many mitotic cells.

Delayed neutrophil engraftment in cord blood transplantation with intensive administration of mycophenolate mofetil for GVHD prophylaxis

Background Odontogenic diseases can be a risk factor for life-threatening infection in patients with hematologic malignancies during chemotherapy that induces myelosuppression of variable severity. Previous studies noted the necessity of the elimination of all odontogenic foci before hematopoietic stem cell transplantation. To enable planning for the adequate dental intervention, the oral medicine team must understand the general status of patient and the intensity of the chemotherapy, which is sometimes difficult to be fully appreciated by dental staff. Therefore, a simplified grading would facilitate the sharing of information between hematologists, dentists and oral hygienists. This study aimed to introduce our myelosuppression grading of chemotherapies for hematologic malignancies and analyze the timing of occurrence of severe odontogenic infection. Methods 37 patients having received various chemotherapies for hematologic malignancies were enrolled. The chemotherapy regimens were classified into four grades based on the persistency of myelosuppression induced by chemotherapy. Mild myelosuppressive chemotherapies were classified as grade A, moderate ones as grade B, severe ones as grade C, and chemotherapies that caused severe myelosuppression and persistent immunodeficiency (known as conditioning regimens for transplant) as grade D. The timing of occurrence of severe odontogenic infection was retrospectively investigated. Results Two patients (5.4%) had severe odontogenic infections after grade B or C chemotherapy. One occurred after extraction of non-salvageable teeth; the other resulted from advanced periodontitis in a tooth that could not be extracted because of thrombocytopenia. Both were de novo hematologic malignancy patients. During grade D chemotherapy, no patients had severe odontogenic infections. Conclusions The simplified grading introduced in this study is considered a useful tool for understanding the myelosuppressive state caused by chemotherapy and facilitating communication between medical and dental staff. During the period around the primary chemotherapy, especially for de novo hematologic malignancy patients who often received grade B to C myelosuppression chemotherapy, caution should be exercised for severe odontogenic infection by the oral medicine team, irrespective of whether invasive treatment is to be performed.

Background Complete resection has been the only potentially curative treatment of patients with neuroendocrine tumors (NETs). Forunresectable NET, however, clinical benefit can be obtained through the molecular-targeted agent everolimus and several cytotoxic agents such as dacarbazine (DTIC), doxorubicin, and 5-fluorouracil. In a phase II trial of DTIC for advanced pancreatic NET, DTIC at 850 mg/m2 i.v. on day 1, repeated every 4 weeks, achieved a response rate of 33% (14/42), but was several severe toxicities, including sepsis. Here, we evaluated the efficacy and safety of DTIC in Japanese patients with unresectable NET. Patients and methods We retrospectively analyzed consecutive NET patients who received chemotherapy with DTIC at 200 mg/m2 i.v. on days 1–5 or 250 mg/m2 on days 1–4, repeated every 4 weeks at our institution between October 2007 and January 2012. Results Five men and one woman with a median age of 59.5 years (range, 38–66) were treated with DTIC. All cases were pathologically classified as NET G2 (WHO2010). Primary sites of tumors were the pancreas in five patients and thymus in one. Three patients were administered octoreotide concurrently, and one patient had previous chemotherapy with etoposide and cisplatin. Median number of treatment cycles was 5.5 (range, 5–24). One complete response and one partial response were achieved, resulting in an overall response rate of 33% (2/6). Another patient had long-term stable disease for nearly 2 years. Median time to treatment failure was 300 days (range, 133–718). Compared with the previous phase II trial, toxicity was mild, and no serious adverse events were observed. Conclusion Treatment with DTIC was safe and feasible, and may be an option for Japanese patients with unresectable NET G2.

Background The prognosis of gastric cancer with peritoneal metastasis is extremely poor. Neither systemic chemotherapy nor surgery alone prolongs survival of patients significantly. Methods Patients diagnosed with advanced gastric cancer underwent staging laparoscopy and received chemotherapy when peritoneal dissemination and/or cancer cells on peritoneal cytology were confirmed. The chemotherapy regimen consisted of S-1, weekly intravenous and intraperitoneal paclitaxel, which was verified in our phase II trial (Ann Oncol 2009). S-1 was administered at 80 mg/m2/day for 14 consecutive days, followed by 7 days rest. Paclitaxel was administered intravenously at 50 mg/m2 and intraperitoneally at 20 mg/m2 on days 1 and 8. Clinical response of chemotherapy was assessed by computed tomography, gastroendoscopy, peritoneal cytology and second-look laparoscopy. Radical gastrectomy was carried out when macroscopic curative resection was made achievable by chemotherapy. Chemotherapy was restarted after operation as soon as possible. Overall survival, relapse free survival, morbidity and mortality of gastrectomy were evaluated. Results Out of 100 patients with peritoneal metastasis who received chemotherapy, 60 patients underwent gastrectomy after response to chemotherapy, including 54 with macroscopic metastasis and 6 with positive peritoneal cytology only. A median of three courses were administered preoperatively (range 1–16). Total or distal gastrectomy with lymphnode dissection was carried out in 54 or 6 patients, respectively. The median survival time was 34.5 months. The median relapse-free survival was 16.7 months. The first site of relapse was the peritoneum in 24 patients and the other organ site in 17 patients. Postoperative complications included anastomotic leakage and pancreatic fistula in two patients each, which were healed conservatively. There were no treatment-related deaths. Conclusions Gastrectomy combined with S-1, intravenous and intraperitoneal paclitaxel is safe and active for gastric cancer patients with peritoneal metastasis.

Background Cancer-induced cachexia is the most common paraneoplastic syndrome and is recognized as an indicator of poor prognosis. Cachexia often occurs in advanced pancreatic cancer, but its mechanism has not been fully elucidated. A number of hormones and cytokines are associated with cachexia. We investigated the role of fasting hormones and pro-inflammatory cytokines in cachexia patients with pancreatic cancer. Methods We enrolled patients with advanced pancreatic cancer in two groups, those with or without cachexia. Eligibility criteria for the cachexia group were >10% weight loss in 6 months, grade 1–4 anorexia, and PS 1-4. Eligibility criteria for the non-cachexia group were 3.5 mg/dl, grade 0-1 anorexia and PS 0-2. We compared patient characteristics and clinical data of the two groups, and measured the plasma level of IL-6, TNF-a and leptin. Results From December 2009 to July 2011, 21 patients (median age, 65 years; range, 36–77 years) were enrolled. In all, 16 (76.2%) patients were male, and 10 (47.6%) patients had stage IVA disease, and the rest had stage IVB disease. In the cachexia group (n = 9), median body weight loss was greater (15.5% versus 2.5%), PS (0, 1, 2, 3) was poorer (n = 0, 5, 3, 1 versus 4, 8, 0, 0) and anorexia (Grade 0, 1, 2, 3) was more severe (n = 0, 8, 0, 1 versus 5, 7, 0, 0) than in the non-cachexia group (n = 12). The median IL-6 level and TNF-a levels appeared higher and leptin concentration appeared lower in the cachexia group albeit without statistical significance (13.8 versus 6.8 pg/ml, P = 0.34; 7.1 versus 3.3 pg/ml, P = 0.27; 2.4 versus 4.0 ng/ml, P = 0.27). Conclusions In our study, the plasma level of IL-6, TNF-a and leptin appeared to be associated with cachexia in patients with advanced pancreatic cancer. Metabolomic analyses are underway.

SRPX2 (Sushi repeat-containing protein, X-linked 2) has recently emerged as a multifunctional protein that is involved in seizure disorders, angiogenesis and cellular adhesion. Here, we analyzed this protein biochemically. SRPX2 protein was secreted with a highly post-translational modification. Chondroitinase ABC treatment completely decreased the molecular mass of purified SRPX2 protein to its predicted size, whereas heparitinase, keratanase and hyaluroinidase did not. Secreted SRPX2 protein was also detected using an anti-chondroitin sulfate antibody. These results indicate that SRPX2 is a novel chondroitin sulfate proteoglycan (CSPG). Furthermore, a binding assay revealed that hepatocyte growth factor dose-dependently binds to SRPX2 protein, and a ligand–glycosaminoglycans interaction was speculated to be likely in proteoglycans. Regarding its molecular architecture, SRPX2 has sushi repeat modules similar to four other CSPGs/lecticans; however, the molecular architecture of SRPX2 seems to be quite different from that of the lecticans. Taken together, we found that SRPX2 is a novel CSPG that is overexpressed in gastrointestinal cancer cells. Our findings provide key glycobiological insight into SRPX2 in cancer cells and demonstrate that SRPX2 is a new member of the cancer-related proteoglycan family.

Objective To evaluate the incidence and clinical characteristics of venous thromboembolism (VTE) in Japanese patients (pts) with solid malignancy at a single institution. Patients and methods Pts with solid malignancy who were treated in our department from July 2007 to December 2011 were retrospectively reviewed from medical records. Results 750 pts with solid malignancy were analyzed. A total of 18 cases (2.4%) were complicated with VTE. Median age at the diagnosis of VTE was 63 years (range: 31–76), and 12 pts were women and 6 pts were men. Eleven cases were complicated with deep vein thrombosis (DVT) and 7 with both pulmonary embolism (PE) and DVT. Symptoms at the initial diagnosis of VTE were swelling of extremities (15/18: 83%), pain in extremities (3/18: 17%), dyspnea (1/18: 7%), and incidental detection of VTE on follow-up imaging study without symptoms (3/18: 17%). Diagnostic procedures of VTE were contrast-enhanced CT in 11 pts (67%) and venous ultrasonography in 16 (89%). The location of the involved veins was the upper limb in 5 pts, lower limb in 12, and inferior vena cava (IVC) in 1. PE was bilateral in six of seven pts. Primary sites of cancer included colorectum (six), pancreas (five), breast (three), lung (one), mediastinum (one), ovary (one) and stomach (one). A total of 13 pts (72%) had metastatic disease. Fifteen pts (83%) had been diagnosed with VTE during chemotherapy, with a median time from the initiation of chemotherapy to diagnosis of VTE of 169 days (range: 3–1636). Central venous port (C-V port) systems were inserted in 6 of 18 pts (33%). Among the 5 pts with DVT in the upper limb, 4 received C-V port insertion. Regarding treatment of VTE, 17 of 18 pts received anti-coagulation therapy with heparin and/or warfarin and 3 of 18 received IVC filter placement. Conclusion The incidence and clinical characteristics of cancer-related VTE at our institution are closely similar to those previously reported from western countries. Consideration of cancer-related VTE is also required in Japanese populations.

e17020 Background: For hematologic malignancy patients receiving allogeneic hematopoietic stem cell transplantation (allo-SCT), the maintenance and/or increase of physical activity (PA) after allo-SCT possibly lead to favorable outcomes. However, it remains to be clarified how much intensity of daily rehabilitation should be prescribed. The aim of this study was to evaluate target PA according to daily performance status (PS) in these patients. Methods: Twenty-seven allo-SCT patients were enrolled in this study (13 males, 14 females, the median age; 47 years). Written informed consent was obtained from all patients. Donor types were bone marrow (n = 12), peripheral blood stem cell (n = 6), and single-unit cord blood (n = 9). All patients received our established exercise program supervised by physical therapists just after neutrophil engraftment in a bioclean room. As an alternative value of PA, daily steps (DS) were measured by using a uniaxial pedometer (Lifecorder EX, Suzuken Co. Ltd., Nagoya, Japan), and Eastern Cooperative Oncology Group PS after allo-SCT were also assessed daily for each individual. The data were statistically analyzed by using ANOVA and Scheff 's tests. Results: A correlation between DS and PS was observed. After the early physical intervention, the mean DS of patients with PS 1, 2, or 3 in a bioclean room were 2,411 ± 1,068, 1,205 ± 572, and 597 ± 216 steps/day, respectively. DS significantly declined by about 50% according to one grade deterioration of PS. Conclusions: As the target PA correlated with PS seems to be existence, we should plan daily activity in a bioclean room to keep more than above-mentioned mean DS according to daily PS for allo-SCT patients.

To prevent acute graft-versus-host disease (GVHD) and graft failure, mycophenolate mofetil (MMF) has been employed as a substitute of methotrexate in allogeneic hematopoietic stem cell transplantation (all-SCT). However, the dosing strategy of MMF after all-SCT remains to be established. In this study, we investigated the optimal MMF dosing until day 30 based on pharmacokinetic studies in 28 Japanese allo-SCT patients. For better clinical outcomes of MMF, higher mycophenolic acid (MPA) plasma levels are proposed to be desirable. Therefore, the first 11 patients (group A) received MMF orally every 12 hours at an escalated dose from 15 mg/kg to 25 mg/kg (maximum total daily dose 3000 mg), according to real-time pharmacokinetic monitoring of the total MPA area under the curve (AUC). However, the dose escalation in each individual did not always increase the AUC. Then, MMF was given orally at a fixed dose of 1000 mg every 8 hours in the subsequent 17 patients (group B). The pharmacokinetic data revealed that the increase of dosing frequency could statistically keep higher MPA plasma levels, as reflected in concentration at steady state (Css: group A vs. group B; 1.12 vs. 2.18 μg/ml on day 16, P = 0.003) or trough value (Ctrough: 0.18 vs. 0.56 μg/ml on day 16, P = 0.019). These results indicate that MMF administration of every 8 hours would be better than that of every 12 hours even in the same total daily dose until day 30. We further assessed the safety and efficacy of extended MMF administration beyond day 30 retrospectively. Twenty-five patients ceased MMF at day 30, whereas 16 patients were subjected to extended regimen depending on the individual risk factors for GVHD (median dosing period 64.5 days, 50–94 days). No severe adverse events were observed in both groups. While the cumulative incidence (CI) of more than grade I acute GVHD at day 100 was comparable between the two groups (72.1 % vs. 62.5 %, P = 0.63, Figure 1A), the CI of grade II to IV acute GVHD was lesser in the latter group (42.3 % vs. 12.5 %, P = 0.045, Figure 1B). These results suggest that MMF should be administered every 8 hours until day 30 after allo-SCT, followed by extending MMF administration at least until day 60 as a preemptive therapy for moderate- to severe-acute GVHD. This strategy might be very useful for double UCB transplantation under non-myeloablative conditioning especially, because the transplantation is reported to develop severe acute GVHD frequently. Figure Figure