Search

The outcome of elderly patients with acute myeloid leukemia (AML) has not been improved for these three decades, although the incidence is getting increased with the aging of the population in Japan. In the JALSG GML200 study, we prospectively registered all elderly patients with AML during this study irrespective of the eligible criteria,. Since elderly patients are less able to tolerate to intensive cyottoxic intensive chemotherapy, we conducted a randomized study to assess an individualized induction treatment. After consolidation chemotherapy, we evaluated the adjuvant effect of ubenimex (UBX), an anti-leukemia immunomodulator. Method: From April 2000 to August 2005, the JALSG GML200 study registered all newly diagnosed AML patients aged 65 years and over. Patients who satisfied the eligibility criteria were randomized to receive either the individualized therapy (arm B) or non-individualized therapy (arm A). Patients who were not eligible were classified in arm C. Induction therapy of Arm A: enocitabine (BH-AC) 200 mg/m2 on days 1–8, 3 h infusion + daunorubicin (DNR) 40 mg/m2 on days 1–3, 30 min infusion. Arm B: BH-AC 200 mg/m2 on days 1–8, with extension to day 12 according to the results of bone marrow examination on days 7 and 10, + DNR 40 mg/m2 on days 1–3, with extension on day 12 depending on the results of bone marrow examination on days 7 and 10. Patients who achieved a complete response (CR) were randomized again to receive immuno-therapy with ubenimex (group UY) or without ubenimex (group UN). Consolidation therapy consisted of three courses: BH-AC 200 mg/m2 on days 1–5 + Mitoxantrone (MIT) 7 mg/m2 on days 1–3, BH-AC 200 mg/m2 on days 1–5 + DNR 30 mg/m2 on days 1–2, ETP 100 mg/m2 on days 1–3, BH-AC 200 mg/m2 on days 1–5 + ACR 14 mg/m2 on days 1–5. Result: Of the 374 patients registered, 244 patients were eligible for randomization to arms A and B, and 235 patients were evaluable. The median patients’ age of arms A, B and C were 70 (range, 65–79), 71 (range, 65–79), and 74 years (range, 65–92), respectively. CR rate of arm A was 63.2% and that of arm B was 65.3% (p = 0.75). CR rates of male and female patients significantly differed in each arm (arm A: male 55.4% vs. female 76.3%, p=0.053, arm B: male 53.1% vs. female 80.0%, p=0.008). Overall survival rates at 3 years of arms A and B were 25.5% and 21.5% (p = 0.56), respectively. With reference to survival with or without ubenimex in patients who achieved CR, the overall survival rate at 3 years was 43.1% for arm UY and 26.9% for arm UN (p=0.073). The number of patients in arm C was 130, and most patients in this arm received similar induction chemotherapy using DNR and BH-AC. The survival rate of this group at 3 years was unexpectedly high at 29.4%. Conclusion: Induction chemotherapy using DNR and BH-AC is one of the superior methods to achieve CR in elderly AML patients. However, individualized treatment has little advantage over non-individualized therapy. The remission rate of the female patients is higher than male patients, and it may have relations with a long life span of the Japanese female. Long-term survival rate is still unfavorable and search for a better post-remission therapy is warranted. Immunomodulator therapy using ubenimex provides a possible benefit for longer survival in elderly AML patients at CR.

Acute myeloid leukemia (AML) is a heterogeneous disorder of hematopoietic progenitor cells. The World Health Organization (WHO) classification of the myeloid neoplasm incorporates genetic, immunophenotypic, biologic and clinical features. Although the WHO classification recognizes several chromosomal translocations they are frequently seen in AML patients, for categorizing the AML with recurrent genetic abnormalities, a number of other genetic alterations such as point mutations and gene rearrangements have not been included. To date, several genetic alterations, which are involved in the pathogenesis of AML and associated with prognosis of patients, have been documented. Therefore, it is required to establish the detailed classification of AML according to the genetic status. In this study, we comprehensively analyzed the genetic alterations and in de nove AML patients and investigated the association with mutational status, cytogenetic status and clinical features in comparison with the WHO classification. The study population included 144 newly diagnosed de nove AML patients consisting of 38 recurrent genetic abnormalities (RGA), 34 multilineage dysplasia (MLD) and 72 not otherwise categorized (NOC) according to WHO subcategories. Bone marrow samples were obtained from the patients after obtaining informed consent for banking and molecular analyses. Mutations in FLT3, cKIT, NPM1, N-RAS, TP53, C/EBPA, AML1, WT1 and MLL/PTD were analyzed as previously described. In consistent with previous reports, FLT3 (24%), cKIT (5%), NPM1 (20%), N-RAS (8%), C/EBPA (12%), AML1 (2%), MLL-PTD (9%), WT1 (3%) and TP53 (8%) mutations were frequently observed. No significantly different distribution was found in the prevalence of FLT3, N-RAS, C/EBPA, AML1 and MLL-PTD mutations among the WHO categories. However, the skewed prevalence was found in cKIT, NPM1 and TP53 mutations: cKIT mutation was frequently found in AML-RGA, NPM1 mutation was not found in AML-RGA, and TP53 mutation was preferentially found in AML-MLD. N-RAS, C/EBPA, AML1 and WT1 mutations were not identified in AML-RGA, though their distributions were not statistically significant among the WHO categories. It is notable that 9 of 12 (75%) patients who have TP53 mutation are categorized in AML with MLD and 8 of the 9 have complex-karyotype. Importantly, 8 of 9 (88.9%) showed complex karyotype, and 5 of them deleted chromosome 17. In this study, we found 2 additional patients harboring TP53 mutation in the other categories, while they did not show the complex karyotype and chromosome 17 abnormality. Furthermore, complex karyotype was found in 14 of the 144 entire AML patients, while 10 of them were categorized in AML-MLD. The remaining 4 patients were categorized in AML-NOC. Three of them showed del(17) or del(17p), though TP53 mutation was not identified. The genotype consisting of complex karyotype and TP53 mutation was, therefore, specifically found in AML-MLD. Thus TP53 mutation and complex-karyotype AML are significantly correlated and associated with the presence of multi-lineage dysplasia (P= .000 and P= .000, respectively). Moreover, these patients have significantly inferior induction rate and overall survival in AML with MLD. These results suggest that TP53 mutation and complex-karyotype AML distinguish a disease entity in AML with MLD.

We conducted a randomized study to determine whether the intensified daunorubicin (DNR) induction chemotherapy would be as effective as idarubicin (IDR) in adult acute myeloid leukemia (AML). From December 2001 to December 2005, 1064 newly diagnosed patients with de novo AML were registered and 1057 were eligible. Median age was 47 years old (range 15 to 64). The patients with AML excluding FAB-M3 were randomized to receive either increased dose of DNR (50 mg/m2 daily for 5 days) or standard dose of IDR (12 mg/m2 daily for 3 days), with cytarabine 100 mg/m2 daily for 7 days by continuous intravenous infusion for induction chemotherapy. Complete remission (CR) was achieved in 407 patients (77.5%; 95% CI, 73.9% – 81.1%) in DNR group and 416 patients (78.2%; 74.7% – 81.7%) in IDR group (p = 0.79). After a median follow up of 48 months there was also no significant difference between the groups in the longer-time measures of efficacy: estimated overall survival at 5 years was 48.0% (95% CI: 43.3% – 52.8%) for DNR and 47.6% (42.8% – 52.4%) for IDR (p = 0.54); estimated relapse free survival at 5 years from CR was 40.7% (35.4% – 45.4%) for DNR and 40.6% (35.6% – 45.6%) for IDR (p = 0.97). The second purpose of this study was to evaluate the efficacy of allogeneic hematopoietic stem cell transplantation (allo-SCT) during the first CR in patients with intermediate or poor risk. If the patients other than CBF leukemia were in CR and had an HLA identical related donor, we recommended them to receive allo-SCT. Of the 823 patients that achieved CR, 132 (16.0%, madeian age, 37 years old; range, 15 – 61) received allo-SCT during the first CR: 72 patients, allo-SCT from a related donor and 60, from an unrelated donor. We examined the efficacy of SCT by comparing these patients with those who did not receive SCT using a matched-pair analysis method. We were able to select 95 pairs of patients by matching karyotype (MRC category), prognostic category established by JALSG, number and type (DNR or IDR) of induction therapy, post-remission therapy and age, that received (SCT pts) and did not receive SCT (non-SCT pts) during the first CR. Variables such as initial WBC count, diagnosis by FAB classification and myeloperoxidase positivity of blasts were comparable between the two groups. Estimated relapse free survival at 5 years from CR was 62.9% (52.5% – 73.3%) for SCT pts and 28.2% (20.6% – 35.8%) for non-SCT pts (p < 0.0001), and estimated overall survival at 5 years was 62.7% (51.5% – 73.8%) for SCT pts and 49.3% (40.6% – 58.1%) for non-SCT pts (p = 0.016). Estimated overall survival at 5 years was 47.0% (39.5% – 54.5%) in patients that received their first allo-SCT after relapse. It is noteworthy that many patients who suffered from relapse were also rescued by allo-SCT. We conclude that the long-term efficacy of the induction chemotherapy with increased dose of DNR and that with standard dose of IDR were comparable demonstrating high remission rate and fair overall survival. They are equally effective for the treatment of AML patients up to 64 years old. It is suggested that SCT during the first CR is recommended for patients that are categorized into the intermediate or poor risk group if a suitable donor is available.

Background The gain-of-function point mutation in Janus kinase 2 exon 14 gene (JAK2-V617F) influences the diagnosis of bcr/abl-negative chronic myeloproliferative disorders (CMPDs). We previously reported that analyzing platelets is advantageous in detecting the JAK2-V617F mutation, particularly in essential thrombocythemia (ET), when compared to granulocytes. However, there have been few reports analyzing the JAK2-V617F mutation in erythroid lineage cells, and comparing the mutation status in all three lineages. Method Study protocols were approved by the Institutional Review Board of Gunma University Hospital, and written informed consent was obtained from all the patients. Heparinized peripheral blood was obtained from 113 patients with CMPDs (82 with ET, 25 with polycythemia vera (PV), and 6 with primary myelofibrosis (PMF). After centrifugation, platelets were collected from the upper plasma layer. Remaining blood was mixed with Hank’s Balanced Salt Solution and was subjected to Ficoll-Hypaque density gradient centrifugation. Granulocytes were obtained from the pellet. Mononuclear cells were resuspended in RPMI 1640 medium; 5 × 105 cells were plated in duplicate in 1 ml of methylcellulose medium and cultured in a humidified atmosphere of 5 % of carbon dioxide at 37°C for 14 days in the presence of erythropoietin to obtain erythroid colonies (BFU-E). T-cells were obtained from the remaining mononuclear cells using anti-CD3 immunoconjugated magnetic beads. After extraction of DNA from granulocytes, T-cells and BFU-E, and RNA extraction from granulocytes and platelets, PCR amplification and sequencing of exon 14 of the Jak2 gene was performed to confirm the presence of JAK2-V617F mutations. To confirm the mutation status of granulocytes, T-cells and BFU-E, allele-specific PCR (AS-PCR) was performed. Results For ET, 57 out of 82 patients (69.5%) had the JAK2-V617F mutation. In the 57 patients with the JAK2-V617F mutation, 38 (67%) had the mutation in all three lineages, 5 had the mutation in granulocytes and platelets, 2 had the mutation in platelets and BFU-E, 10 patients had the mutation only in platelets and 2 patients had the mutation only in BFU-E. In contrast, for PV, 22/25 patients (88%) had the JAK2-V617F mutation. Of note, in 22 patients having JAK2-V617F mutation, 20 (91%) were JAK2-V617F mutation-positive in all three lineages; the remaining two patients had the mutation in either platelets or BFU-E. The frequency of JAK2-V617F in all three lineages was significantly higher in PV than in ET (p < 0.05). For PMF, 5 of 6 patients had the mutation in granulocytes, and 3 of these had it in all three lineages. Conclusion Among JAK2-V617F mutation-positive CMPDs, most PV patients had the JAK2-V617F mutation in all three lineages, thus suggesting that the JAK2-V617F mutation occurs in progenitor cell(s) common to granulocytes, platelets and erythrocytes. In contrast, only 67% of ET patients had the JAK2-V617F mutation in three lineages; in the remaining cases, not all of the three lineages have the mutation. This difference in lineages showing the JAK2-V617F mutation between the ET and PV may be related to the pathophysiological differences in ET and PV. Furthermore, the heterogeneous mutation status in ET may be related to its heterogeneous clinical manifestation.

A 31-year-old man with chronic myelogenous leukemia in a chronic phase complicated with reversible ischemic cerebrovascular disease is described. Before therapy, the WBC count was 530.0 x 10(9)/l. Four days after initiation of busulfan, he rapidly developed disturbance of consciousness and right hemiplegia. Computerized tomography demonstrated the presence of multiple low density areas in the cerebrum. The symptoms were, however, completely relieved in accordance with the decrease in the WBC counts in 8 days. Repeated CT studies showed no abnormal findings after one month. The intracranial change was considered to be one of the manifestations of hyperleukocytic syndrome.

Imatinib-combined chemotherapy is highly effective for newly diagnosed Philadelphia chromosome-positive acute lymphoblastic leukemia (Ph+ ALL); however, a substantial proportion of patients experience relapse. Here, we evaluated 80 patients enrolled in the phase II study by the Japan Adult Leukemia Study Group (JALSG) with extended follow-up with the aim of identifying factors associated with relapse-free survival (RFS). For remission induction therapy, imatinib was administered from day 8 to day 63 in combination with daunorubicin, cyclophosphamide, vincristine (VCR) and prednisolone (PSL). Consolidation therapy consisted of an odd course (C1) comprising high-dose methotrexate (MTX), high-dose cytarabine (Ara-C) and methylprednisolone, and an even course (C2) with single-agent imatinib for 28 days. C1 and C2 were alternated for 4 cycles each. After completion of the consolidation therapy, patients received maintenance therapy consisting of VCR, PSL and imatinib up to 2 years from the date they had attained complete remission (CR). The daily dose of imatinib used in this study was 600 mg. The protocol was reviewed and approved by the institutional review board of each of the participating centers and was conducted in accordance with the Declaration of Helsinki. A total of 80 patients aged between 15 and 63 years were recruited between September 2002 and January 2005. For a median follow-up of 26.7 months (maximum, 52.5 months), 28 of the 77 CR patients showed relapse. Of the 17 relapses observed during the consolidation therapy, 13 occurred during the imatinib course. The probability of RFS was 50.5% at 2 years. Allogeneic transplantation was performed for 60 patients, including 44 in first CR, 12 in second CR, and 12 in non-CR. Neither transcript types nor copy numbers at diagnosis were associated with RFS (p=0.763 and 0.912). Furthermore, RFS for those with an undetectable BCR-ABL level at the end of induction therapy was similar to that for the other CR patients (p=0.707). In contrast, the presence of secondary chromosome aberrations in addition to t(9;22) or variant translocations detected at diagnosis, particularly +der(22)t(9;22) and abn(9p), was significantly associated with inferior RFS (p=0.003). Multivariate analysis revealed that the presence of additional chromosome aberrations was the only significant prognostic factor for RFS (HR, 2.84; 95% CI, 1.12–7.19; p=0.027). Even after allogeneic HSCT, patients with additional aberrations appeared to have a trend for shorter RFS than those without (p=0.080), but this might reflect a larger proportion of transplantation beyond first CR in the former (31% vs 17%). Although these results need to be validated in the context of the ABL kinase domain mutations, our findings may be of clinical importance for the future treatment of Ph+ ALL.

Background: The treatment for acute myeloid leukemia patients with relapse after stem cell transplantation is limited to dose reduction of immunosuppressive agents, donor leukocyte infusion (DLI), and a second transplantation. The prognosis of such patient is very poor if these therapies cannot be tolerated or are unsuccessful. Gentuzumab ozogamicin(GO) is an antibody targeted chemotherapy consisting of a humanized anti-CD33 monoclonal antibody linked to calicheamycin. The CD33 antigen is expressed on most AML cells and myeloid progenitor cells, but is not expressed on lymphocytes which play an important role in GVL effect. Therefore, GO can potentially eradicate AML cells without harming these lymphocytes. Patients: We retrospectively studied 9 patients with AML, who relapsed following allogeneic stem cell transplantation (SCT) and had difficulty tolerating DLI. Their donor sources included one 6/6 HLA-matched sibling bone marrow cells, four 6/6 HLA-matched unrelated bone marrow stem cells, and four 4/6 HLA-matched unrelated cord blood. The status of leukemia at SCT was 1st complete remission (CR) in one patient, 2nd CR in one patient, and active disease in seven patients. Treatment protocol: GO was administered at 6 mg/m2 for 2 doses separated by 2 weeks. Treatment was initially performed at morphological relapse but after April 2006 patients received treatment at molecular relapse. The molecular relapse was diagnosed by the quantitative expression of WT1 (Wilms tumor gene). (Blood.2003;101:1698–1704) Results: Five patients were treated at morphological relapse (group A) and four patients were treated at molecular relapse (group B). Eight received both doses of GO. The period from SCT to relapse ranged from 36 days to 193 days (median: 85 days). The period from SCT to GO administration ranged from 54 days to 229 days (median: 98 days). Seven of 9 patients achieved a remission (3/5 in group A, 4/4 in group B). Three CR patients in group A relapsed (day 48, 95, and 106, respectively). All of the patients in group A died within 447 days. (at 42 days, 131 days, 158 days, 173 days and 447 days, respectively, after GO). Two of the 4 patients in group B relapsed, one on day 300 and one on day 350. One patient died in CR from multiple organ failure following CMV infection; the fourth patient is still in CR. Three patients in group B are alive at 276 days, 410 days, and 443 days. Three patients developed infusion-related fever, one patients nausea. All patients developed grade 4 neutropenia and thrombocytopenia. Febrile neutropenia was observed in four patients. Five patients developed elevation of ALT, grade 3 in 1 patient and grade 1 in 4 patients. Three patients developed grade 1 hyperbilirubinemia. Only one patient developed reversible VOD. VOD occurred on thirteenth day after the administration of GO. The period between SCT and GO administration was 77 days. Conclusion: The administration of GO is effective in inducing remission in relapsed AML patients after SCT. The ability of GO therapy to induce durable response may possibly be enhanced by early therapeutic intervention before the onset of hematologic relapse. This approach is feasible and well tolerated with minimal toxicity. Additional studies in a large group of patients will be required to adequately assess the safety and efficacy of this approach.

Dasatinib (SPRYCEL®, formerly BMS-354825) is a potent, orally active, multi-targeted kinase inhibitor active against BCR-ABL and SRC family kinases. Studies outside Japan have demonstrated that dasatinib is highly effective in overcoming resistance and intolerance to imatinib (im), inducing durable cytogenetic and hematologic responses in this CML patient population. In establishing the dose for non-Japanese patients, the maximum tolerated dose failed to be reached and the 70-mg-twice-daily (BID) dose was determined to provide the optimal benefit-risk profile. Based on clinical experience to date, dasatinib has the potential to have a major impact on the current treatment paradigm for patients with CML resistant or intolerant to prior therapy, including im. To assess the safety and efficacy of dasatinib in Japanese patients, a phase-I/II study was conducted in patients with all phases of im-resistant or -intolerant CML. In the phase-I portion of this study, dasatinib was administered at one of three escalating dose levels for a period of 4 weeks: 50 mg, 70 mg, or 90 mg BID. As of July 2006, 15 eligible patients have been enrolled and treated. Six evaluable patients (4F, 2M; median age 43 y [range 27–56]; 4 im-resistant, 2 im-intolerant) were treated at the 50 mg BID dose level and one dose-limiting toxicity (DLT) was observed (grade 4 thrombocytopenia). Two patients experienced transient grade 3 ALT elevations but as treatment was uninterrupted, these were not considered DLTs. A further 6 evaluable patients (6M; median age 42 y [range 27–55]; 3 im-resistant, 3 im-intolerant) were treated at the 70 mg BID dose level and one DLT was observed (grade 4 thrombocytopenia). Three patients have recently been enrolled at the 90 mg BID dose level. As the safety of the 70 mg BID dose was established in the phase-I portion of the study, the use of this dose is being expanded into the phase-II element, which plans to evaluate cytogenetic response in chronic phase CML patients at 24 weeks, and hematologic response rate in accelerated- or blast-phase CML and Philadelphia chromosome-positive acute lymphoblastic leukemia (Ph+ ALL) patients at 12 weeks. Accrual to the phase-II portion of this study is ongoing. Updated data including baseline mutational analyses will be presented at the meeting.

We conducted a multicenter prospective randomized study to determine whether the intensified daunorubicin (DNR) induction chemotherapy would be as effective as idarubicin (IDR) in adult acute myeloid leukemia (AML). Newly diagnosed adult patients with AML excluding FAB-M3 were consecutively registered and randomized to receive either increased dose of DNR or standard dose of IDR induction chemotherapy. All patients received cytarabine 100mg/m2 daily for 7 days by continuous intravenous infusion, and either DNR 50mg/m2 daily for 5 days or IDR 12mg/m2 daily for 3 days according to randomization. If the patients did not achieve complete remission (CR) after the first induction therapy, the same induction therapy was given once more. Patients achieving CR were again randomized to receive either 3 courses of high-dose cytarabine or 4 courses of conventional multiagent consolidation therapy. The results of later randomization will be reported another abstract. From December 2001 to December 2005, 1064 newly diagnosed patients with de novo AML were registered and 1057 were eligible. Median age was 47 years old (range 15 to 64). Five hundred twenty five patients were randomized to DNR group, and 532 to IDR group. The two groups were well matched for pretreatment characteristics. CR was achieved in 407 patients (77.5%; 95% CI, 73.9% – 81.1%) with 321 (61.1%) after 1 induction course in DNR group and 418 patients (78.6%; 75.1% – 82.1%) with 341 (64.1%) after 1 course in IDR group (p = 0.68). Patients receiving IDR took slightly but significantly longer to recover from neutropenia and thrombocytopenia. There was a higher rate of sepsis in IDR (8.7%) than DNR (4.9%) (p = 0.02). The early death within 60 days occurred in 25 patients (4.7%) in IDR and 11 (2.1%) in DNR (p = 0.03). Logistic regression analysis revealed that induction regimen was not the independent prognostic factor, but CBF leukemia and the percentage of peroxidase positive leukemic blast were the significant independent factors for achieving remission. There was also no significant difference between the groups in the longer-time measures of efficacy: estimated overall survival at 4 years was 49.1% (42.4% – 55.8%) for DNR and 53.1% (47.6% – 58.6%)for IDR (p = 0.37); estimated relapse free survival at 4 years from CR was 42.2% (36.1% – 48.3%) for DNR and 41.8% (35.9% – 47.7%) for IDR (p = 0.62). The Cox proportional hazards analyses showed that the induction regimen did not affect these outcomes. In conclusion, increased dose of DNR and standard dose of IDR both achieve high remission rate and good long-term efficacy, and are equally effective for the treatment of AML patients up to 64 years, although the final assessment will have to be performed after longer follow up.

BCR/ABL-negative chronic myeloproliferative disorders (CMPDs) are considered to arise in a pluripotent progenitor cell. High prevalence of a point mutation in Janus Kinase 2 (JAK2) exon12 gene (JAK2-V617F) in CMPDs has been observed in many reports. Since most studies, however, are restricted mainly in granulocyte lineage, information about the JAK2 gene status in other cell lineage is limited. Heparinized peripheral blood was obtained from 49 patients with polycythemia vera (PV), 109 with essential thrombocytosis (ET), and 5 with chronic idiopathic myelofibrosis (CIMF). After centrifugation, platelets were collected from the upper plasma layer. The remaining blood layer was subjected to Ficoll-Hypaque density gradient centrifugation. Granulocytes were obtained from the pellet and T-cells recovered from the interface were further positively selected using either anti-CD3 or anti-CD4 immunoconjugated magnetic beads (Miltenyi Biotec, Germany). After DNA and RNA extraction, PCR amplified JAK2 exon 12 gene was sequenced to check the presence of JAK2-V617F mutation. Furthermore, X-chromosome linked clonal analysis using human androgen receptor (HUMARA) gene was carried out in 58 females. Correlation between the mutation status and clinical data was analyzed using statiscal software R (The R Development Core team). In PV, the frequency of JAK2-V617F mutation in granulocytes and platelets was 72.3 % and 74.3%, respectively (p-value 0.844). In ET, this mutation rate was 51.9% in granulocytes and 73% in platelets and the difference was significant (p-value 0.005). In all CMPDs, the cases showing JAK2-V617F mutation in granulocytes always had the mutation in platelets as well, but in one case of PV and 11 cases of ET, the JAK2-V617F mutation was observed only in platelets. T cell fraction was negative for JAK2-V617F mutation in all cases examined. White blood cell count was significantly higher in cases of JAK2-V617F mutation in their platelets compared to that in cases without this mutation (12.6 × 109/l vs. 9.2 × 109/l), but hemoglobin level and platelet count did not differ between the two groups (14.9g/l vs. 14.6 g/l, 81.4 × 109/l vs. 95.2 × 109/l). In addition, cases showing this mutation in platelets were more likely to be associated with thrombosis than cases showing the wild type gene (p-value 0.018). On clonal analyses using the HUMARA gene, 6/8 patients with PV, 15/27 patients with ET, and 1/1 patient with CIMF demonstrated a monoclonal pattern in their granulocytes. Interestingly, in 23 cases showing the JAK2-V617F mutation, 7 patients showed the polyclonal HUMARA pattern; in 13 cases without mutation, 7 showed the monoclonal HUMARA pattern. The discrepancy of JAK2-V617F mutation rate between platelets and granulocytes in ET suggests that analysis of platelet fraction is advantageous for detecting the mutation. This finding also suggests that the JAK2 mutation could be involved only in megakaryocyte lineage in some ET patients. HUMARA analysis confirmed that some ET patients with monoclonal disease lack the JAK2-V617F mutation, which is consistent with previous reports.

Prognostic factors for patients with AML are commonly used to classify patients into different prognostic groups. Karyotype of AML cells is currently most powerful to predict prognosis as a single factor. However, almost half cases are usually categorized into the intermediate risk group, which necessitates further stratification of cases in this group. Internal tandem duplication of FLT3 gene (FLT3-ITD) is one of the most frequent genetic changes found in AML cells that relates to poor response to chemotherapy: FLT3-ITD is expected to be used for the stratification of AML cases. To test the value of FLT3-ITD as prognostic factor, using cases in Japan Adult Leukemia Study Group (JALSG) AML97 trial, we examined the significance of FLT3-ITD to predict the prognosis of patients with AML along with other factors such as karyotype. FLT3-ITD was tested in 263 cases in the AML97 trial, and karyotype of AML cells and the morphological diagnoses were centrally reviewed by committee members of JALSG without any other clinical data. Karyotype of AML cells (modified MRC method) created three distinct risk groups (5-year OS: favorable group, 69.0% [n=57]; intermediate risk group, 42.0% [n=184]; adverse risk group, 0% [n=18], p50% [high MPO group, MPO-H], 51.9% [n=229]; low MPO group [MPO-L], 32.9% [n=92], p=0.0058). These data recapitulated our previous observations in the JALSG-AML92 trial. FLT3-ITD divided cases into two groups showing significantly different prognoses; the 5-year overall survival (0S) was 23.0% (n=52) and 49.5% (n=211) in the FLT3-ITD positive and negative group, respectively (p

Between 2001 and 2005, JALSG conducted a randomized study to assess the optimal post remission therapy for adult AML in the first CR. JALSG AML201 enrolled 1064 previously untreated AML patients (pts) aged 15–64 yrs. The induction therapy consisted of cytarabine (Ara-C 100mg/m2 day1–7) and idarubicin (IDR 12mg/m2 day1– 3) (arm A) or cytarabine (100mg/m2 day1–7) and daunorubicin (DNR 50mg/m2 day1– 5) (arm B). If the patients did not achieve remission after the first induction therapy, then the same therapy was given once more. Pts were categorized into good, intermediate or poor risk groups by risk factors based on the criteria established in previous JALSG AML studies. All CR pts were stratified according to the induction, the number of courses of induction, age and karyotype and were randomly assigned to the high dose Ara-C (HDAC) post remission regimen (arm C) or the conventional JALSG post remission regimen (arm D). Arm C: the three courses of HDAC which consisted of Ara-C 2.0g/m2 q12h day1–5, arm D: the first course consisted of Ara-C 200mg/m2 day1–5+ mitoxantrone (MIT) 7mg/m2 day1–3, 2) Ara-C 200mg/m2 day1–5+ DNR 50mg/m2 day1–3, 3) Ara-C 200mg/m2 day1–5+ aclarubicin (ACR) 20mg/m2 day1–5, 4) Ara-C 200mg/m2 day1–5+ etoposide (ETP) 100mg/m2 day1–5 + vincristine (VCR) 0.8mg/m2 day 8 + vindesine (VDS) 2 mg/m2 day10. Results: Of the 1064 pts registered, 1057 pts (median age: 47 years) were evaluable. 825 pts (78%) achieved CR after one or two courses of induction therapy. Of the 825 pts in CR, 781 pts were assigned to arm C or arm D. The 4-year OS rate of arm C was 61.6% while that of arm D was 62.8% (p=0.58). The 4-year RFS rate of the CR patients was 42.8% in arm C and 40.8% in arm D (p=0.65). Among the good risk group, the 4-year OS rate of arm C was 77.0% while that of arm D was 75.8 % (p=0.40), and the 4-year RFS rate of arm C was 54.6% while that of arm D was 53.1% (p=0.71). Among the intermediate risk group, the 4-year OS rate of arm C was 63.2% while that of arm D was 65.7% (p=0.78), and the 4-year RFS rate of arm C was 38.7% while that of arm D was 42.2% (p=0.63). Among the poor risk group, the 4-year OS rate of arm C was 36.3% while that of arm D was 34.1% (p=0.71), and the 4-year RFS rate of arm C was 25.9% while that of arm D was 6.6% (p=0.17). In the CBF leukemia group, the 4-year OS rate of arm C was 79.4% while that of arm D was 66.5% (p=0.09), and the 4-year RFS rate of arm C was 57.7% while that of arm D was 43.7% (p=0.14). Among the young group (=50 yrs), the 4-year OS rate of arm C was 53.4% while that of arm D was 57.7% (p=0.90), and the 4-year RFS rate of arm C was 39.1% while that of arm D was 33.8% (p=0.67). Conclusion: The conventional post remission therapeutic regimen established by JALSG consisting of 4 courses of consolidation was thus found to be as effective as the three courses of HDAC therapy. To further confirm these results, a longer follow-up is therefore needed.

Background: Approximately 70–80% of all newly diagnosed patients with adult AML achieve a complete remission (CR). However, only about one third of those pts remain free of disease for more than 5 years. It is therefore important to predict which pts are most likely to suffer a relapse and thus perform alternative treatments such as stem cell transplantation in order to improve the prognosis of AML. We evaluated the impact of the detection of Wilms’ tumor gene1 (WT1) mRNA in the peripheral blood on the prognosis of AML pts. Patients and Methods: From June 1, 2001 to October 30, 2003 a study was performed on 191 pts with AML which evaluated the clinical usefulness of a WT1 mRNA assay kit for the early detection of relapse in AML pts (submitted in Rinsho Ketsueki). From these 191 pts, we selected the subjects for this study. All selected subjects achieved a complete remission, and also had their WT1 expression analyzed after consolidation therapy. The pts were excluded if they had received a stem cell transplantation before relapse. The WT1 mRNA levels were determined using the WT1 mRNA assay kit (Otsuka Pharmaceutical Co. Ltd) in accordance with the standard operating procedures using peripheral blood. The lower limit of detection was 50 copy/μgRNA. Therefore, less than 50 copy/μgRNA was judged as negative. All induction, consolidation and maintenance therapies were performed according to institutional standards. Results: Of 118 pts who achieved a complete remission, 50 pts (median age: 56 yrs 22–86) were evaluable. Their median WT1 mRNA levels before induction therapy was 48327 copy/μgRNA (137–329185). The WT1 mRNA levels at diagnosis did not correlate with either the relapse rate, DFS or OS, respectively. After CR, the WT1 mRNA level ranged from Conclusion: This study shows that the detection of the WT1 mRNA in the peripheral blood after treatment closely correlated with the prognosis in AML.

Nucleophosmin (NPM) is a nucleolar protein with multi-functions including centromere duplication, nuclear-cytoplasmic shuttling, ribosomal biogenesis, p53 stability. NPM1 mutations were found in a large number of patients with acute myeloid leukemia (AML) especially with normal karyotype. The mutations lead to the aberrant subcellular localization of NPM protein. However, their impacts on clinical outcome remain controversial. We screened the mutations of NPM1 in 257 AML patients and analyzed the clinical significance. NPM1 mutations were found in 64 of 257 patients (24.9%). Seven types of mutations, including four novel mutations, were identified. NPM1 mutations were associated with normal karyotype, FLT3 mutations (both FLT3-ITD and D835 mutation) but not with other gene alterations such as N-RAS, p53 mutations and partial tandem duplication of the MLL gene. In 190 patients except the M3 subgroup, who were treated according to the protocol of Japan Adult Leukemia Study Group, the multivariate analysis revealed that NPM1 mutation was a favorable factor for achieving complete remission, but significantly associated with relapse. A sequential analysis, using paired samples obtained at diagnosis and relapse in 39 patients, revealed that NPM1 mutations were lost at relapse in 2 of the seventeen patients who had NPM1 mutations at diagnosis and none of the patients, who did not have NPM1 mutations at diagnosis, gained NPM1 mutations at relapse. Our results suggest that NPM-mutated AML should be a distinct subgroup with specific clinical characteristics and outcome. Loss of NPM mutations at relapse implies that NPM mutation is not necessarily a primary genetic alteration and that these leukemic clones could be sensitive to chemotherapy.

In Japan Adult Leukemia Study Group (JALSG) clinical trial, imatinib was used as initial therapy for 171 patients with chronic myelogenous leukemia. We measured levels of BCR-ABL transcripts in the blood of all patients in this trial before and 1, 2, 3, 6 and 12 months after the treatment. Levels of BCR-ABL transcripts were measured by a quantitative real-time polymerase-chain-reaction assay. Results were expressed copy number of BCR-ABL per 1 microgram of RNA. Median number of BCR-ABL transcript was 106,478 at diagnosis and 61328, 24213, 4981, 331 and 98 at 0, 1, 2, 3, 6, 12 months after the treatment, respectively. Three log reductions were obtained 0%, 35.5% and 50.9% of patients at 3, 6 and 12 months of the treatment. Half reduction time between 0 and 1 month (0M–1M) is 1.3 M. In the next month (1M–2M), it is 0.75M and those between 2–3 and 3–4.5 months are 0.44 and 0.51. Thereafter, reduction speed is down because half reduction time is 1.5 between 4.5 and 6 months. After 6 months half time is 4.1months. This reduction curve shows the. Exponential decline value per day are 1.8%, 3.1% and 5.2% during first, second and third month, respectively. Thereafter exponential decline value is decreasing as 4.4% (3M–4.5M), 1.5% (4.5M–6M) and 0.6% (6–12M). In the previous study reported that, successful therapy leads to a biphasic exponential decline of leukemic cells (Nature435:1267–1270, 2005). The first slope is determined by calculating the exponential decline between 0 and 3 months; mean value of 0.05 per day was observed. While the second slope showed 0.008 per day. Our observation suggests that imatinib leads to a triphasic exponential decline of leukemic cells; between 0 and 2 months, much slower declining curve in comparison with between 2–6 months.

Background: Translocation (8;21) is one of the most common structural aberrations found in AMLand good response rates and a better DFS have been described in pts possessing it. Especially, the DFS rate may exceed 60–70% in younger pts given repetitive courses of HDAra-C. However, it was recently reported that a subtype of AML with t(8;21) showed a poor prognosis and this case also had the KIT mutation. As a result, we retrospectively analyzed the prognosis of AML pts with t(8;21) prospectively enrolled in the JALSG AML97 study. Patients and Methods: Between 1997 and 2001, JALSG AML97 enrolled 809 pts previously untreated for AML and pts with M3 were excluded. From the 789 eligible pts, we selected the subjects with t(8;21) for this study. Induction therapy consisted of cytarabine and idarubicin. All CR pts were randomized to receive either four courses of standard dose consolidation therapy without maintenance therapy or three courses of standard dose consolidation with 6 courses of maintenance therapy. HDAra-C was not administered in the JALSG AML97 study. Peripheral blood and bone marrow smears and karyotypes were reevaluated by the central review committees. Any patients who underwent SCT were censored at the date of SCT. The Kaplan-Meier method was used to estimate OS and DFS. For comparisons of OS or DFS, the log rank test was used. Result: Cytogenetic studies were performed in 783 patients (99.2%) and only 15 studies resulted in failure. One hundred forty-two (18.5%) of those pts showed t(8;21). The median age was 43 yrs (15–64). The male: female ratio was 95: 47. The distribution of FAB types was as follows: AMLM2, 130; M4, 6; M1, 5; and M5, 1. A total of 69 (48.6%) pts had a sole t(8;21), 46 (32.4%) had a loss of a sex chromosome, and 27 (19.0%) had other cytogenetic abnormalities. The CR rate was 90.0%. Thirty-two pts underwent two courses of induction therapy. The early death (< one month) rate was 1.4% (2/142). Only a high WBC count (>=10x109/L) was found to be a marginally significant prognostic factor (p=0.0517). The estimated OS rate at 5yrs was 53.6%, and the DFS of the CR pts was 41.2%. We found no relationship between OS or DFS and the following factors: age, gender, karyotypic abnormality, performance status, the percentage of MPO positive blasts, the presence or absence of Auer rods, the platelet count, the number of induction therapies for CR and the type of postremisson therapy. However, two factors, the WBC count and the percentage of blasts in bone marrow were found to be strongly predictive factors for the outcome. For the pts with a WBC count >=10x109/L, the DFS rate at 5yrs was 30.8%, while for the pts with less than 10x109/L, it was 48.8% (p=0.0215). For the pts with blast >=50% and less than 50%, the DFS rates at 5yrs were 32.2% and 56.7% (p=0.0087), respectively. According to these two factors, a poor risk group (N=30, 21.0%) was thus identified. They had a WBC count >=10x109/L and blast >=50%. The DFS rate at 5yrs was only 22.3 % in the poor risk group while that of the other pts was 48.9% (P=0.0003). Conclusion: This study confirmed that all AML pts with t(8;21) shows a high response rate and a good prognosis, thus indicating that this favorable AML group includes a poor risk group which can be identified based on the WBC count and the blast percent in the bone marrow.

Prognosis of patients with AML varies widely reflecting the heterogeneity of AML and the background of each patient. It is important for both physicians and patients to predict the response to chemotherapy to correctly select the therapeutic options. In the JALSG-AML97 study, patients were stratified using JALSG scoring system, and those who were categorized into the intermediate or adverse prognosis group were assigned to allo-HSCT during CR1 if they had an HLA-matched sibling. JALSG scoring contains several factors that have 1 or 2 points: 2 points, age < 50 years, WBC 50%; 1 point, PS Both JALSG scoring and karyotypic grouping divided AML patients into three groups with significantly different prognoses. Five-year OS of each group was 68.1% (Fav-Js, 171 cases), 49.8% (Int-Js, 301 cases) and 22.5% (Adv-Js, 122 cases) in the JALSG scoring system, and 66.7% (Fav-MRC, 134 cases), 42.6% (Int-MRC, 412 cases) and 11.0% (Adv-MRC, 48 cases) in the karyotypic grouping (p

The aim of this study was to investigate the efficacy of allo-SCT as a postremission treatment in patients (pts) with intermediate/poor risk AML in first CR. Previously untreated pts aged15–64 years were eligible. Pts received standard induction therapy consisting of cytarabine (100 mg/m2 d1–7) and idarubicin (12 mg/m2 d1- 3). If the pts did not achieve remission after the first induction therapy, the same induction therapy was given once more. The pts who achieved CR were randomized into an intensified short-course postremission regimen group (arm A) and conventional JALSG postremission regimen group (arm B). Pts were also categorized into good, intermediate or poor risk groups by risk factors based on previous JALSG AML trials using univariate and multivariate analyses. The intermediate or poor risk pts Result: 809 pts were registered between December 1997 and July 2001. 789 pts were evaluable (median age: 45 years). 621 pts achieved CR (78.7%) after one or two courses of induction therapy. Os of 789 evaluable pts at five years and DFS of CR pts at five years were 40.8% and 35.5%, respectively. Of the 75 pts who were assigned to the allo-SCT group, 56 pts underwent allo-SCT (38 during CR1 and 18 after relapse). For the allo-SCT group, OS and DFS at 5 years were 51.8% and 43.1%, respectively. For the non-transplant group (n=95), OS and DSF at 5 years were 32.2% and 18.3%, respectively. DFS was significantly better in the allo-SCT group compared to the non-transplant group (p=0.005). OS was marginally better in the allo-SCT group (p=0.06). In conclusion, our study showed that allo-SCT for pts with intermediate or poor risk is effective as a postremission treatment in adult AML.

Background: HLA-DR antigen is present on hematopoietic progenitors and granulocyte/monocyte, erythrocyte and megakaryocytic precursors but absent at the promyelocytic stage during myeloid cell maturation. In accordance with this, majority of promyelocytic leukemia (APL) cells were negative for HLA-DR. Meanwhile, some of non-APL acute myeloid leukemia (AML) cells is found to express HLA-DR. However, the clinical significance of HLA-DR antigen on AML cells is currently unclear. Purpose: We sought to determine the prevalence and clinical characteristics of negativity in HLA-DR expression by retrospectively analyzing 181 consecutive patients with de novo adult AML. Patients and Methods: AML patients examined in the current study (aged 15–86 years) had been diagnosed between August 1995 and July 2004, and categorized to M0 (8 patients), M1 (35), M2 (74), M3 (20), M4 (25), M5 (15), and M6 (4), based on the FAB classification. Median follow-up time was 19.3 months. Phenotypic analyses of leukemic cells were performed using CD45 gating methods. HLA-DR-negative AML was defined as HLA-DR expression less than 20% of cells in the CD45 leukemic cell gate. Results: Among 181 patients, HLA-DR antigens were not detected on AML cells from 46 patients; 20 with APL and 26 with non-APL (non-APL/DR(−)), the latter of which included M0 (2 patients), M1 (15), M2 (7), M4 (2). Leukemic cells from other non-APL patients were HLA-DR-positive (non-APL/DR(+)). None of non-APL/DR(−) patients had t(15;17) nor PML/RARa rearrangement on cytogenetic analysis. Twenty out of 26 patients with non-APL/DR(−) had normal chromosome, and 6 had abnormal karyotypes. In the non-APL/DR(−) group, various degrees of nuclear folding, convolution, or lobulation were observed in 9 patients. Although treatment response and overall survival rate were similar in the three groups (APL, non-APL/DR(−), and non-APL/DR(+)), both FDP levels at diagnosis (57.3 vs 13.2, p 40 mg/ml. Conclusion: Our study suggests that AML with negative HLA-DR antigen tend to be associated with abnormality in coagulation and fibrinolysis even if they are genetically non-APL. We propose that more attention should be paied for HLA-DR expression to avoid a devastating coagulopathy which carries a high risk of mortality unless specifically addressed.

Between 1997 and 2001, JALSG conducted a randomized study to assess the optimal post remission therapy for adult AML in the first CR. The JALSG AML97 enrolled 809 previously untreated AML patients (pts) aged 15–64 yrs. Induction therapy consisted of cytarabine (100mg/m2 day1–7) and idarubicin (IDR 12mg/m2 day1– 3). If the patients did not achieve remission after the first induction therapy, the same therapy was given once more. Pts were categorized into good, intermediate or poor risk groups by risk factors based on the previous JALSG AML studies. All CR pts were randomized to receive either the intensified short course post remission regimen (arm A) or the conventional JALSG’s post remission regimen for AML including maintenance therapy (arm B). Arm A: 1) AraC 200mg/m2 day1–5+ Mitoxantrone (MTZ) 7mg/m2 day1–3, 2) AraC 200mg/m2 day1–5+Daunorubicin (DNR) 50mg/m2 day1–3, 3) AraC 200mg/ m2 day1–5+ Aclacinomycin (ACR) 20mg/m2 day1–5, 4) AraC 200mg/m2 day1–5+ Etoposide (ETP) 100mg/m2 day1–5 + Vincristine (VCR) 0.8mg/m2 day 8 + Vindesine (VDS) 2 mg/m2 day10. Arm B: 1) AraC 200mg/m2 day1–5 + MTZ 7mg/m2 day1–3, 2) Behenoyl AraC (BHAC) 200mg/m2 day1–7 + ETP 100mg/m2 day1–5 + DNR 50mg/m2 day1–3 + 6 mercptopurine (6MP) day1–7, 3) BHAC 200mg/m2 day1–7 + ACR 14mg/m2 day1–7, and then 6 courses maintenance therapy: 1) BHAC 170mg/m2 day1–5 + DNR 50mg/m2 day1,4+6MP day1–7, 2) BHAC 170mg/m2 day1–5 + MTZ 5mg/m2 day1–3, 3) BHAC 170mg/m2day1–5 + ETP 80mg/m2 day1,5,7 + VDS 2mg/m2 day1,8, 4) BHAC 170mg/m2 day1–5 + ACR 14mg/m2 day1–4 + 6MP day1–7, 5) BHAC 170mg/m2 day1–5 + DNR 50mg/m2 day1–4 + 6MP day1–7, 6) BHAC 170mg/m2 day1–5 + ETP 80mg/m2 day1,5,7 + VDS 2mg/m2 day1,8. Result: Of the 809 pts registered, 789 pts (median age: 45 years) were evaluable. 621 pts (78.7%) achieved CR after one or two courses of induction therapy. The 5-year OS rate of arm A was 45.6% and of arm B 53.2% (p=0.3259). The 5-year DFS rate of CR patients was 34.8% in arm A and 28.9% in arm B (p=0.4978). Among the good risk group, the 5-year OS rate of arm A was 62.1% and of arm B 70.2% (p=0.5068), and the 5-year DFS rate of arm A was 53.4% and of arm B 42.0% (p=0.3719). Among the intermediate risk group, the 5-year OS rate of arm A was 35.6% and of arm B 45.5% (p=0.4776), and the 5-year DFS rate of arm A was 26.0% and of arm B 26.1% (p=0.9653). Among the poor risk group, the 5-year OS rate of arm A was 29.7% and of arm B was 33.4% (p=0.6523), and the 5-year DFS rate of arm A was 20.4% and of arm B was 13.5% (p=0.6339). In conclusion: JALSG’s conventional post remission therapy consisting of 3 courses of consolidation and 6 courses of maintenance therapy could be replaced by a shorter duration of intensified consolidation therapy.

In a part of the prospective multicenter study of the Japan Adult Leukemia Study Group (JALSG-ALL97), we studied the amount and function of three important multidrug resistant (MDR) proteins: P-glycoprotein (P-gp), multidrug resistance associated protein (MRP) and lung resistance related protein (LRP), in the leukemia cells of adult acute lymphobastic leukemia (ALL) at the diagnosis. We related the results with patients’ biological and clinical features and their treatment outcome. From May 1997 to December 2001, newly diagnosed patients with de novo ALL except B-ALL were registered and received an induction therapy including cyclophosphamide (1200 mg/m2, d1), daunorubicin (45 mg/m2, d1-3), vincristine (1.3 mg/m2, d1, 8, 15, 22), L-asparaginase (3000 U/m2, d1, 9, 11, 13, 16, 18, 20) and predonisolone (60mg/m2, d1-14). Patients achieving complete remission (CR) received 8 courses of consolidation/intensification therapy followed by maintenance therapy. Median age was 38 years old. Out of 175 patients tested, 169 were evaluable. The amount and function of the MDR proteins were analyzed in CD45-gated leukemia cells by flow cytometry. After incubating with biotinylated MRK16 (IgG2a (Fab’)), anti-MRP or anti-LRP antibodies, cells were post-stained with SA-RED670. The function of P-gp and MRP was determined by Rhodamin-123 (Rh-123) accumulation with PSC833 and carcein-AM efflux with probenecid, respectively. Factors to predict CR were age, performance status (PS), chromosome, pretreatment WBC count, CD25 expression and the function of P-gp in univariative analyses. Logistic regression analysis shows that favorable prognostic factors for the achievement of CR were PS (Ps=0) and the lower ( The clinical importance of MDR proteins has been discussed in the treatment acute leukemias. We prospectively analyzed them in patients receiving the same treatment. Our study demonstrates that the function of P-gp in de novo ALL is one of the independent unfavorable factors for CR. However, it did not change the survival rates in the treatment of ALL with combination chemotherapy. Other MDR proteins relate to neither CR rate nor survival. We have also investigated these proteins in AML (Blood 102, 605a). The MDR proteins in the treatment of ALL are possibly less important as compared to those of AML.

The Japan Adult Leukemia Study Group conducted the ALL-87 study to determine whether response-oriented induction therapy and intensive consolidation and maintenance/intensification therapies could increase complete remission (CR) rate and survival in adult acute lymphoblastic leukemia (ALL). Of 121 patients registered, 116 were evaluated. Patients' ages ranged from 15 to 72 years (median, 38 years). Induction therapy, which consisted of doxorubicin, vincristine, cyclophosphamide, L-asparaginase and prednisolone, was given in a response-oriented individualized fashion. Patients were randomly allocated either to receive or not, intrathecal chemotherapy on day 8 of the induction therapy. Complete remission (CR) was obtained in 97 (83.6%) patients (90.2%) in patients of less than 50 years of age and 67.6% in patients 50 years of age or older). At a median follow-up period of 65 months, the predicted 6-year overall survival and event free survival (EFS) rates of 116 patients were 23.4 and 20.0%, respectively. Predicted 6-year survival and disease-free survival (DFS) rates of 97 CR patients were 28.2 and 24.5%, respectively. By multivariate analysis, patients under 40 years of age (P = 0.002) or those with a platelet count of more than 100,000/microliters (P = 0.004) were significant favorable prognostic factors for obtaining CR, and days to CR less than 50 (P = 0.003), patients under 50 years of age (P = 0.005) were significant favorable factors for longer DFS. There was no significant difference in CR rates and DFS between the two randomized groups according to the intrathecal chemotherapy on day 8. Response-oriented induction therapy produced a high CR rate, but fairly intensive consolidation and maintenance/intensification chemotherapies resulted in only a marginal effect on DFS in adult ALL. Although age is one of the most important prognostic factors in ALL, the outcome was unsatisfactory even in younger adult patients using chemotherapeutic regimen employed in this study.

Adult patients with acute lymphoblastic leukemia (ALL) were treated according to the ALL90 study, the second prospective study for ALL of the Japan Adult Leukemia Study Group (JALSG). Its characteristics included response-oriented individualized induction therapy with six drugs (doxorubicin, mitoxantrone, vincristine, prednisolone, [corrected] cyclophosphamide and L-asparaginase), and a prospective comparison between allogeneic bone marrow transplantation (allo-BMT) and chemotherapy alone in patients below 45 years of age. The protocol consisted of one or two courses of induction, four courses of consolidation, and three courses of intensification including 12 month maintenance and six times of central nervous system (CNS) prophylaxis. Of 180 evaluable patients (median age, 43), 125 (69%) achieved complete remission (CR). Predicted overall survival (OAS), event-free survival and disease-free survival (DFS) were 15, 10 and 14%, respectively at the median follow-up period of 62 months. No specific toxicities were observed. Leukocytes < 30,000/microliter, normal karyotype, and blasts < 10% in bone marrow at day 15 of induction therapy were significantly favorable prognostic factors for the achievement of CR, DFS and OAS by univariate analysis. Multivariate analysis showed leukocytes < 30,000/microliter and blasts < 10% on day 15 was a significant factor for the achievement of CR, DFS and OAS. Ph-chromosome was found in 28% (36/130) of patients examined and was one of the worst prognostic factors. All Ph positive patients were predicted to die within 600 days. Allo-BMT was not significantly superior to chemotherapy with respect to DFS (P = 0.226). The overall results were inferior to those of the former ALL87 protocol. As reasons, the older median age of 43 years old (vs. 38 years old) and lower dose intensity, especially of l-asparaginase, etc. were suggested. However, patients with good prognostic factors (leukocyte < 30,000/microliter and age < 30 years old) showed better survival than others (P < 0.0001), and the result was similar to that of older children, the high risk group of childhood ALL, suggesting that ALL could be a disease of single entity, showing higher resistance to chemotherapy as patients become older.

Four patients with common acute lymphoblastic leukemia antigen (CALLA)-positive myeloma are presented. The subclasses of monoclonal protein were IgD kappa (1 case), IgA lambda (1 case), and IgA kappa (2 cases). Bence Jones proteinuria was seen in all cases. The clinical stages were determined as IIA (2 cases) and IIIA (2 cases). All patients died with a median survival time after diagnosis of 62 days due to rapid development of renal failure (3 cases), and renal insufficiency and pneumonia (1 case). According to light microscopic evaluation, these myelomas corresponded to plasmablastic (1 case), immature (2 cases), and intermediate (1 case) types. Both CALLA and a cytoplasmic immunoglobulin identical with the serum monoclonal protein were simultaneously detected in single cells from all cases using immunofluorescent double labeling. These findings suggest that CALLA-positive and plasma-blastic myelomas constitute clinically a subgroup characterized by extremely poor survival but they represent cytologically different subcategories.

A 35-year-old male was admitted to the hospital because of massive pleural effusion. Aleukocytosis with marked eosinophilia was present and the pleural effusion contained numerous eosinophils. The diagnosis of paragonimiasis Miyazakii was established by immunological studies. This is the third case of this infection in Gunma prefecture.

A 28-year-old man was admitted on November 8, 1986, because of anemia and petechiae. He was diagnosed as having acute myelogenous leukemia (M2). Complete remission was obtained with a BH-AC·DMP regimen, but relapse occurred August 1987. Shortly thereafter, he received an allogeneic bone marrow transplantation from his HLA-compatible sister following conditioning with high-dose cytosine arabinoside and total body irradiation. No additional chemotherapy was given. A successful engraftment was confirmed by karyotypic conversion of bone marrow cells from male to female type on day 24 after transplantation. He is alive and with normal haematopoiesis and is in excellent clinical condition ten months after BMT.

Mouse leukemia cell (L1210) is sensitive to 6-mercaptopurine (6-MP) and does not usually grow in medium containing 0.1 μg/ml of 6-MP. However, cells which could grow in medium containing 0.3 μ/ml of 6-MP were easily obtained at a rate of about 10-5.There were two types of 6-MP resistant strains thus obtained in 0.3 pig/ml of 6-MP; the one was low-resistant strain which could grow in 1 μg/ml of 6-MP but could not in 3 μg/ml, and the other was high-resistant strain which could grow even in 30 μg/ml of 6-MP. Most (96.1 %) of the resistant cells obtained in medium containing 0.3 μg/ml of 6-MP belong to high resistant strain and 3.9% to low-resistant one.The resistance mechamisms of these two strains were not clarified but might be different from each other by the following results;1) Low-resistant strain could grow in HAT medium but high-resistant strain could not.2) The sensitivity of low-resistant strain to 6-MP was increased by the treatment with Levamisole, whereas no change was found in high-resistant strain.3) Reversion to sensitive cell could be observed in the low-resistant strain but not in high-resistant one.4) Only high-resistant cell could obtained from the revertant cell but no low-resistant cell could be obtained.

Fifteen adult patients (21-60y.) with AML (12 fresh and 3 relapsed) who had achieved complete remission, were treated with AcDAc regimen as an intensive consolidation therapy. Their clinical courses were followed without further chemotherapy (Group A). The results were compared with those obtained in 17 adult patients (26-60y.) who were treated with2 or 3 courses of BH-AC DMP regimen as a standard consolidation therapy and thereafter with 6MP/ara-C as a maintenance therapy following achievement of complete remission (Group B) to determine the efficacy of intensive consolidation therapy in improving the prognosis. Rates of surviving patients and of patients in complete remission were always higher in Group A than Group B, although the differences were not statistically significant. Myelosuppression after consolidation therapy was more severe in Group A than Group B judging from the changes in peripheral blood and bone marrow findings. This was confirmed by the evaluation of changes in CFU-GM of the bone marrow. All consolidation courses in Group A were complicated by severe infection and 3 patients were died of fulminant hepatitis or pneumonia, while only one patient was complicated by infection and all were survived in progress of consolidation therapy in Group B. In Group A, more than 70% of patients had gastrointestinal toxity and eruption. These were mild and well tolerated. It is concluded that intensive consolidation therapy like AcDAc regimen given in aseptic environment seems to be superior to standard consolidation therapy with maintenance therapy for long time in the treatment of adult patients with AML.

Wilms’ tumor 1 (WT1) is a promising target of new immunotherapies for acute myeloid leukemia (AML) as well as for other cancers. OCV-501 is a helper peptide derived from the WT1 protein. OCV-501 induced OCV-501-specific Type 1 T-helper (Th1) responses dose-dependently and stimulated helper activity of the specific Th1 cells in peripheral blood mononuclear cells from healthy donors. OCV-501 also enhanced the increase in WT1-killer peptide-specific cytotoxic T lymphocytes. OCV-501 stimulated the OCV-501-specific Th1 clones in an HLA class-II restricted manner and formed a complex with HLA class-II protein. OCV-501-specific Th1 clones demonstrated significant OCV-501-specific cytolytic activity against OCV-501-pulsed B-lymphoblastoid cell line cells. Based on the pre-clinical results, phase 1 clinical trial was conducted. The result of this trial suggested that the subcutaneous administration of OCV-501 once weekly for 4 weeks at doses of 0.3, 1, and 3 mg in older patients with AML during complete remission was safe and well tolerated. The maximum tolerated dose was considered to be ≥3 mg. Of the nine subjects enrolled, neither relapse nor blast cells were observed during the study. Immunological responses were observed in OCV-501-specific delayed-type hypersensitivity test. This trial was registered at http://www.clinicaltrials.gov as NCT 01440920. Electronic supplementary material The online version of this article (doi:10.1007/s00262-017-1981-3) contains supplementary material, which is available to authorized users.

The ultrastructure of multinucleated giant myeloma cells obtained from an IgA kappa myeloma patient was investigated. The characteristic findings were marked nucleocytoplasmic asynchrony, irregular nuclear indentation, branched mitochondria, and Golgi apparatus surrounded by nuclei. The patient died of renal failure only 6 months after diagnosis.

A case of acute myeloblastic leukemia with bilateral tympanic cavity infiltration with effusion in addition to right facial and bilateral auditory nerve involvement is described. Tympanotomy demonstrated the presence of leukemic cells in the effusion of bilateral tympanic cavities. While repeated examinations of the cerebrospinal fluid using the cytocentrifuge failed to show any leukemic cells, it was suspected that the bilateral tympanic cavity infiltration was associated with meningeal involvement.