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Since the long-term safety profile of tyrosine kinase inhibitors (TKI) in chronic myeloid leukemia (CML) therapy has not been well characterized, we investigated renal impairment in 50 CML patients treated with TKI in our institute. During the median follow up period of 63 months, 29% of patients developed chronic kidney disease (CKD). Although the glomerular filtration rate (GFR) gradually declined, it dropped most markedly in the first 2 years after starting TKI. The CKD incidence was higher in patients older than 40 years or with decreased GFR, hypertension, or dyslipidemia at baseline. These findings highlight the necessity of careful monitoring of renal function in TKI-treated CML patients with these risk factors.

The safety and efficacy of treatment with liposomal amphotericin B (L-AMB) in elderly patients has not been clarified, especially in Japanese patients. Therefore, we retrospectively analyzed 33 elderly patients with hematological diseases of at least 65 years old who received L-AMB between 2009 and 2012. Their clinical outcomes were compared to those of 21 patients who were younger than 65 years. L-AMB was administered for empirical therapy (n = 2) or target therapy for possible (n = 14) or probable/proven (n = 17) invasive fungal infection. There was no discontinuation of L-AMB due to adverse events. More than 2-fold increases from the baseline Cre, AST, and ALT values were observed in 21.2%, 39.4%, and 45.5% of the older group and 38.1%, 61.9%, and 52.4% of the younger group, respectively. The concurrent use of nephrotoxic antibiotics was the only risk factor for the development of a 2-fold increase in the serum Cre level. The duration of L-AMB was significantly longer in patients who developed grade III-IV hypokalemia. A partial or complete response was observed in 54.8% and 62.5% of the elderly and younger groups, respectively. In conclusion, L-AMB therapy appeared to be acceptably safe as empirical therapy or treatment for invasive fungal infection.

Bloodstream infection (BSI) is a significant complication following allogeneic hematopoietic stem cell transplantation (allo-SCT). Corticosteroids mask inflammatory responses, delaying the initiation of antibiotics. We reviewed medical records of 69 allo-SCT patients who had been on >0.5 mg/kg prednisolone to investigate the efficacy of weekly surveillance blood cultures. A total of 36 patients (52%) had positive cultures, 25 definitive BSI and 11 probable BSI. Pathogens in definitive BSI were Staphylococcus epidermidis (n=7), S. aureus (n=4), Entrococcus faecalis (n=3), Pseudomonas aeruginosa (n=5), Acenitobacter lwoffii (n=4), and others (n=10). The median interval from the initiation of corticosteroids to the first positive cultures was 24 days (range, 1–70). At the first positive cultures, 15 patients with definitive BSI were afebrile. Four of them remained afebrile throughout the period of positive surveillance cultures. Patients with afebrile BSI tended to be older (P=0.063), and had in-dwelling central venous catheters less frequently than febrile patients (P

BACKGROUND: TRALI is one of the most serious, life-threatening complications after blood transfusion. Antibodies against neutrophils or HLA molecules from the donor are thought to be the primary causative agents. Rarely, antibodies in the recipient may react with transfused neutrophils and initiate the same events, which raises the possibility that TRALI may also occur in an allogeneic PBPC transplantation setting. CASE REPORT: A 30-year-old Japanese man with acute lymphoblastic leukemia developed TRALI immediately after the infusion of marrow cells from an unrelated donor. The infusion was suspended, and he gradually improved after receiving steroids and oxygen support. The next day, the remaining cells, which were separated to MNCs, were infused with no reactions. He then recovered over 5 days without the use of mechanical ventilation. RESULTS: Laboratory evaluation disclosed the presence of antibodies to neutrophils in his sera sampled after transplantation, but not in the donor's marrow graft. Hence, antibodies to neutrophils in the recipient may have reacted with neutrophils in the graft and contributed to the development of TRALI. CONCLUSION: This is the first reported case of TRALI after allogeneic BMT. TRALI should be recognized as a rare but serious complication in allogeneic hematopoietic stem cell transplantation.

Summary. We evaluated erythrocyte recovery in 121 allogeneic haematopoietic stem cell transplantation (HSCT) recipients. There were 35 major and minor ABO-incompatible transplants, respectively, including 10 bi-directionally ABO-incompatible transplants. The use of peripheral blood stem cells facilitated erythrocyte recovery, regardless of the presence or absence of major ABO-incompatibility, and was associated with a frequent detection of anti-host isohaemagglutin early after minor ABO-incompatible transplantation, which was not associated with clinically relevant haemolysis. The use of a reduced-intensity regimen combining a purine analogue and busulphan did not delay erythrocyte recovery after major ABO-incompatible transplantation, suggesting this regimen had a strong activity against host plasma cell.

Flow cytometry (FC) is widely utilized in the diagnosis of lymphoma and the light chain ratio (LCR) is especially useful in the diagnosis of B-cell malignancy. In this study we analysed, retrospectively, the predictive value of the LCR in the diagnosis of B-cell lymphoma in 105 consecutive patients with persistent lymph node enlargement or extranodal masses who underwent biopsy. We used a receiver-operating characteristic curve to establish a LCR threshold value of 2.0. The specificity, sensitivity, positive and negative predictive values were 92.3%, 73.1%, 90% and 77%, respectively. We concluded that determination of LCR is a useful adjunct to pathological diagnosis.

A reduced-intensity hematopoietic stem cell transplantation (RIST) regimen was developed to induce immunosuppression to facilitate the engraftment of donor cells. However, there have been concerns that the incidence of opportunistic infection may increase after this procedure. To address this problem, we retrospectively analyzed the medical records of 24 RIST recipients who were treated over a recent 16-month period for comparison with 31 recipients of conventional allogeneic transplantation (CST). The RIST regimen consisted of cladribine (0.66 mg/kg), busulfan (8 mg/kg), and rabbit anti-thymocyte globulin (ATG; 5-10 mg/kg). All of the patients received allogeneic peripheral blood stem cells from an HLA-identical or one-locus mismatched related donor. Although the incidence of positive CMV antigenemia was comparable between the two groups (58% vs 68%), RIST patients developed positive antigenemia significantly sooner than did CST patients (P = 0.01) and showed higher initial and maximum antigenemia values (P = 0.026 and P = 0.003, respectively). These findings may suggest that immune recovery against CMV was delayed after our RIST procedure, but this did not directly translate into an increase in clinically significant CMV disease. Early therapeutic intervention with ganciclovir might play a role in preventing the progression of early CMV infection to CMV disease.

We report a 37-year-old pregnant woman with paroxysmal nocturnal hemoglobinuria (PNH) treated with eculizumab. She had been diagnosed with PNH-aplastic anemia at age 19 years, and started to receive eculizumab at age 35 years. Thereafter, she had no hemolytic attacks. She became pregnant 2 years later, and treatment with eculizumab was continued. During her pregnancy, she showed no exacerbation of hemolysis. She delivered a girl by Caesarean section at 37 weeks and 3 days of gestation. Postpartum, anticoagulant therapy was started. Although mild hemolysis and a rise in FDP/Ddimer were seen, she had no symptoms of thrombosis. Ten days after delivery, she and her baby were discharged. Eculizumab was present in the first breast milk and cord blood but was below detectable levels. The cord blood showed blockage of hemolysis.

A 72-year-old man visited our hospital in July 2009 with a major complaint of lightheadedness. Based on bone marrow aspiration, myelodysplastic syndrome (MDS), refractory anemia with excessive blast-2 was diagnosed. Complete remission (CR) was achieved after low-dose cytarabine and aclarubicin therapy. After two courses of low-dose cytarabine therapy, at the first CR, cord blood transplantation (CBT) was performed after reduced-intensity conditioning in January 2010. However, recurrence was found in September 2011. Azacitidine (AZA) was administered subcutaneously daily for either 7 or 5 days and repeated every 4 weeks at doses of 100 mg/day. During nine cycles of AZA treatment, no graft-versus-host disease was observed and no transfusions of red cells/platelet concentrate were required. As of 1 year after the relapse was detected, the patient remains alive with stable disease. As there are few reports on AZA treatment for patients with MDS who experience relapse after CBT, the efficacy of this approach remains unclear. Further clinical trials including dose, duration, and number of cycles of AZA for MDS patients who relapse after transplantation are required.

Soluble interleukin-2 receptor (sIL-2R) is produced by activated T and B cells, and the level of this receptor is elevated in patients with non-Hodgkin's lymphoma (NHL). The present study demonstrated that the sIL-2R level was high in the following groups of patients with aggressive NHL; those aged > or = 60 yr, those with a poor PS, those in Ann Arbor stage III or IV, and those in the high intermediate or high risk group according to the International Prognostic Index (IPI). Overall survival was significantly poorer when the sIL-2R level was 2000 U/ml or more. In addition, the overall survival of patients in the low (L) and low-intermediate (L-I) risk groups with an sIL-2R level of 3000 U/ml or more was significantly poorer, suggesting that the sIL-2R level could be particularly useful for identifying patients with a poor prognosis among the L and L-I risk groups. Univariate analysis identified some significant prognostic factors, and multivariate analysis of these factors plus the five IPI prognostic factors showed that the sIL-2R level was an independent prognostic indicator. In conclusion, the present findings established that the sIL-2R level is a significant independent prognostic factor in patients with aggressive NHL.

C-reactive protein (CRP) is an acute phase reactant of inflammation. We evaluated the clinical value of serial measurement of CRP in neutropenic patients. CRP was shown to be useful to monitor the response to therapy for febrile episodes in neutropenia. However, we failed to show statistically significant differences in CRP levels between febrile episodes with or without clinically documented infection (p = 0.10) and with or without bacteremia (p = 0.55). Also, we could not predict febrile episodes within three days by the elevation of CRP value. The area under receiver-operating characteristic curve depicting the relationship between CRP levels and forthcoming febrile episodes was only 0.60. In conclusion, serial measurement of CRP was considered to be not useful to predict fever within three days, or to differentiate the types of infection.

BACKGROUND Fluconazole is used widely for fungal prophylaxis. Although studies with bone marrow transplantation (BMT) recipients clearly showed the usefulness of oral fluconazole, results of the studies in neutropenic patients other than BMT recipients have been inconsistent. Therefore, the authors performed a meta–analysis to evaluate the efficacy of fluconazole prophylaxis during chemotherapy-induced neutropenia. METHODS The authors identified reports that were not restricted to those in English and not restricted to published trials through MEDLINE, CANCERLIT, or the data base of the Pfizer company. The authors included prospective, randomized studies comparing oral fluconazole with placebo, no treatment, or oral polyenes as prophylaxis for fungal infections in neutropenic patients. Two independent authors extracted data from 16 trials with 3734 patients enrolled. The outcome measures were the development of fungal-related death, systemic and superficial fungal infections, the use of empiric intravenous amphotericin-B, and infections or colonization with fluconazole-resistant fungi. The summarized odds ratios (ORs) were calculated using the Mantel–Haenszel method and the DerSimonian–Laird method. RESULTS Prophylactic fluconazole was not effective in reducing fungal-related death or in reducing proven, systemic fungal infections in non-BMT patients (OR, 0.91; 95% confidence interval [CI], 0.30–2.82 and OR, 0.85; 95% CI, 0.47–1.55, respectively). However, fluconazole was very effective in reducing superficial fungal infections (OR, 0.44; 95% CI, 0.24–0.80), even when it was given in lower doses (50–200 mg per day). There was no increase in proven, systemic infection of fluconazole-resistant fungi, although colonization of those fungi increased. When the results were combined in studies in which the incidence of systemic fungal infections was > 15%, fluconazole was effective in reducing such infections (OR, 0.23; 95% CI, 0.15–0.36). CONCLUSIONS The current analyses failed to find an effect of fluconazole on both fatal fungal infection and systemic fungal infection in non-BMT patients. Further studies on severely neutropenic patients are warranted because prophylactic fluconazole seemed to be effective when the incidence of systemic fungal infection was expected to be > 15%. Cancer 2000;89:1611–25. © 2000 American Cancer Society.

BACKGROUND Although many studies have been performed to evaluate the prognostic significance of CD34 expression in acute myeloid leukemia (AML), the findings have been inconsistent. In this study, the authors reviewed such previous studies to establish a definite conclusion. METHODS Using MEDLINE, the authors identified studies that evaluated the prognostic significance of CD34 expression in AML. The outcome measure was the complete remission rate. They used the random-effect method to combine the results. Results were presented as odds ratios (ORs) with 95% confidence intervals (CIs). The ORs were less than 1 if the complete remission occurred more frequently in the CD34 negative group. RESULTS Twenty-two studies including 2483 patients were reviewed. The combined OR was 0.38 (95% CI, 0.26–0.57), which suggested that CD34 expression was associated with a poor remission rate. However, the authors found statistical evidence of marked heterogeneity among trials (P < 0.001), especially according to time of publication. The combined OR in studies published in or after 1994 was 0.70 (95% CI, 0.47–1.09). The authors divided the studies into several subgroups, but they could not determine the reason for the heterogeneity. CONCLUSIONS At present, CD34 expression should not be considered a marker of poor prognosis because it is not supported by the combined data from recent studies. Further studies should be conducted to investigate the intensity of CD34 expression in specific populations of patients, such as those with t(8;21) or t(15;17) translocations or the AML-M0 subtype. Cancer 2000;88:2529–33. © 2000 American Cancer Society.

Interleukin 2 receptor is expressed not only on the surface of activated T or B lymphocytes, but also on certain lymphoid malignancies. The receptor is released from the cell membrane as soluble form (sIL-2R). Serum sIL-2R level is a sensitive and quantitative marker of circulating peripheral blood mononuclear cell activation or specific tumor cell growth including non-Hodgkin's lymphoma (NHL). However, the relevance of serum sIL-2R levels relating to clinical outcome in adult patients with NHL remains uncertain. Therefore, we investigated the serial serum sIL-2R levels in 28 untreated patients with NHL to evaluate its correlation with clinical characteristics. High serum sIL-2R level (>1000 U/ml) at diagnosis was associated with a high incidence of treatment failure (p=0.03) and poor overall survival (p=0.057). The serum sIL-2R levels decreased significantly after achieving complete remission (p=0.003). Further larger studies are required to evaluate whether serum sIL-2R level is an independent prognostic factor or not. However, adding this parameter to those already employed in the International Prognostic Index would perhaps provide a better prognostic index for adult patients with NHL.

We evaluated possible prognostic factors just before salvage therapy with vincristine, doxorubicin, and dexamethasone (VAD) for 36 patients with refractory multiple myeloma. The median duration from diagnosis to the first VAD salvage was 14 months (range 2-76 months). Among parameters that have been shown to be associated with poor survival, a high serum lactate dehydrogenase (LDH) level was the sole significant predictor of survival. The median survival of patients with high LDH levels was 4 months, whereas that of patients with low LDH levels was 20 months. A multivariate analysis identified high LDH and high age as independent prognostic factors. More aggressive therapies might be indicated for high-LDH patients with refractory myeloma.

Guillain–Barre syndrome associated with rapid immune reconstitution following allogeneic hematopoietic stem cell transplantation

Objective: Polycythemia Vera (PV) and Essential Thrombocythemia (ET) are chronic myeloproliferative neoplasms (MPN) characterized by frequent thrombotic complication. Thus, the important goal of therapy is to prevent thrombosis. However, there are some JAK2V617F mutation-positive patients who show bone marrow features characteristic for PV but do not meet the World Health Organization (WHO) diagnostic criteria of PV. Recently, a new definition of masked PV is proposed; which is hypothesized as the initial manifestation of MPN. Masked PV is believed to have thrombosis more frequently than PV and ET. Here, we evaluated the outcome of patients who corresponded to masked PV. Design: We reviewed our patients retrospectively who were diagnosed as PV or ET in our institute. From medical records, we evaluated the incidence of thrombosis of patients who corresponded to masked PV. Patients: Eligible patients were JAK2V617F mutated PV or ET patients who were diagnosed in our hospital according to WHO criteria. They were classified as overt PV if hemoglobin level was >18.5g/dl in males and >16.5g/dl in females. When hemoglobin level of 16.018.4g/dl in males and 15.0-16.4 g/dl in females, they were classified as masked PV. The remaining patients with>45 10/mL of platelets were diagnosed as ET. Main Outcomes Measure: The incidence of thrombosis was 17% in masked PV and this was less frequently than in overt PV or ET. Results: Among 56 JAK2V617F-mutated patients, 6 patients (11%) were classified as masked PV and all of them were males. Their leucocyte counts was lower (11300 vs 10950/mL) and platelets counts was higher (51.6 vs 61.4 10/mL) than overt PV. Median age was 60 in overt PV, 68 in ET and 47.5 in masked PV. The incidence of thrombosis was 36%, 28% and 17%, respectively. In masked PV patients of our hospital, the incidence of thrombosis was less frequently. A possible reason for that is the treatment which maintained the Hematocrit (Hct) level below 50% in masked PV patients. Conclusion: In our patients the masked PV did not show high incidence of thrombosis, possibly because of the treatment that maintained the Hct level below 50%.

Little information is available on the clinical characteristics of infectious complications that occur in the early period after reduced-intensity stem cell transplantation (RIST). We retrospectively investigated the clinical features of neutropenic fever and infectious episodes within 30 days after RIST in 76 patients who had received fluoroquinolones as part of their antibacterial prophylaxis. Preparative regimens included cladribine 0.66 mg/kg or fludarabine 180 mg/m2 plus busulfan 8 mg/kg. All but 1 patient survived 30 days after transplantation, and 75 patients (99%) became neutropenic within a median duration of 9 days. Neutropenic fever was observed in 29 patients (38%), and bacterial infection was confirmed in 15 (20%) of these, including bacteremia (n = 13), bacteremia plus pneumonia (n = 1), and urinary tract infection (n = 1). The causative organisms were gram-positive (n = 9) and gram-negative organisms (n = 7), with a mortality rate of 6%. Neither viral nor fungal infection was documented. Multivariate analysis showed that the presence of neutropenia at the initiation of preparative regimens was an independent risk factor for subsequent documented bacterial infections (P = .026; 95% confidence interval, 1.25–35.1). We conclude that neutropenic fever and bacteremia remain common complications in RIST.

TRALI is one of the most serious, life-threatening complications after blood transfusion. Antibodies against neutrophils or HLA molecules from the donor are thought to be the primary causative agents. Rarely, antibodies in the recipient may react with transfused neutrophils and initiate the same events, which raises the possibility that TRALI may also occur in an allogeneic PBPC transplantation setting.A 30-year-old Japanese man with acute lymphoblastic leukemia developed TRALI immediately after the infusion of marrow cells from an unrelated donor. The infusion was suspended, and he gradually improved after receiving steroids and oxygen support. The next day, the remaining cells, which were separated to MNCs, were infused with no reactions. He then recovered over 5 days without the use of mechanical ventilation.Laboratory evaluation disclosed the presence of antibodies to neutrophils in his sera sampled after transplantation, but not in the donor's marrow graft. Hence, antibodies to neutrophils in the recipient may have reacted with neutrophils in the graft and contributed to the development of TRALI.This is the first reported case of TRALI after allogeneic BMT. TRALI should be recognized as a rare but serious complication in allogeneic hematopoietic stem cell transplantation.

We retrospectively analyzed data of 47 patients aged 60 years or older, hospitalized in our institution with the diagnosis of acute myelogenous leukemia (AML), and searched for prognostic factors. Induction with anthracyclines significantly correlated with better complete remission (CR) rate (P = 0.0016) and overall survival (OS) (P0.001). Another factor significantly affecting CR rate was higher age (70 years) (P = 0.042). Therapy-non-related factors predictive for shorter OS in univariate analyses were age older than 70 years (P = 0.003), percentage of blasts in bone marrow more than 80% (P = 0.048), serum lactate dehydrogenase level higher than 250 U l(-1) (P = 0.032). In stepwise cox proportional hazard regression model, all the four factors predictive for poor OS remained to be independently and significantly prognostic for shorter OS. Only two patients receiving anthracyclines died within 30 days and the frequency was not different from that in patients not receiving anthracyclines. The use of anthracyclines as induction therapy is recommended even in the elderly patients.

Background. Preemptive therapy against cytomegalovirus (CMV) disease has succeeded in reducing the incidence of CMV disease, but the toxicity of ganciclovir remains problematic. Methods. We prospectively evaluated the efficacy and toxicity of a preemptive protocol with ganciclovir at a reduced initial dose in 40 patients who achieved engraftment after allogeneic hematopoietic stem cell transplantation. Results. Twenty-three (58%) patients had high-risk features, including transplant from an HLA-mismatched or unrelated donor, or associated acute graft-versus-host disease. CMV antigenemia assay was performed weekly, and ganciclovir was started in a risk-adapted manner, in which the initial dose of ganciclovir was fixed at 5 mg/kg/d and then adjusted based on the results of a weekly CMV antigenemia assay. In this protocol, 23 (58%) patients demonstrated positive antigenemia, and 19 (48%) received a preemptive administration of ganciclovir. Only one patient had CMV disease in the gastrointestinal system, which was successfully treated with a regular therapeutic dose of ganciclovir. Consequently, the total dose of ganciclovir was significantly less than that in a previous protocol using the conventional double dose (5 mg/kg twice daily) of ganciclovir (134 mg/kg vs. 190 mg/kg on average, P=0.046). There were no significant toxicities attributed to ganciclovir, except for neutropenia

A 19-year-old woman with myelodysplastic syndrome underwent reduced-intensity stem cell transplantation [RIST: (cladribine 0.11 mg/kg for 6 days, busulfan 4 mg/kg for 2 days, and rabbit antithymocyte globulin)] from her one HLA-mismatched mother. Prophylaxis against graft-versus-host disease (GVHD) was performed with cyclosporine A (CSA) alone. Severe acute GVHD in the skin, gut, and liver developed concurrently with stable engraftment, and methylprednisolone was administered (1-2 mg/kg per day, then pulse therapy with 1 g/day for 3 days) until day 40 of transplant, when a necrotic lesion of 10 mm in diameter appeared on the right cheek. The initial skin biopsy of the affected area showed a nonspecific inflammatory change. Routine X-ray and computed tomography examinations of the sinuses, chest, and abdomen disclosed no particular abnormalities. Despite intensive antibiotic therapy, the lesion rapidly extended to form an ulcer. A second biopsy specimen obtained from the lesion showed massive septa hyphae, suggesting mold infection. Although we immediately started amphotericin B, she died of multiorgan failure on day 68. Postmortem DNA sequence analysis of the specimen using the polymerase chain reaction identified Aspergillus ustus. Although this is an extremely rare complication after transplantation, this case highlights that we should pay more attention to primary cutaneous aspergillosis in severely immunosuppressed patients.

We studied clinical features and pathologic findings in 52 consecutively autopsied patients with multiple myeloma in our center between 1979 and 1998. Distant extraosseous involvement was found in 33 patients (63.5%). Thirty-one patients (59.6%) were proven to have infection at autopsy, among which pneumonia was most common site of infection. Amyloidosis was shown in 8 patients. Second malignancies were observed in 4 cases. The three major causes of death were hemorrhage, infection, and renal failure, which accounted for death in approximately 70% of the patients. Advances in the anticancer and antimicrobial chemotherapies might have decreased deaths due to myeloma itself or infection.

The range of survival duration in myeloma patients is wide and several percent of patients live longer than 10 years. Therefore, a precise prediction of survival for the individual patient is required to decide treatment. We evaluated possible prognostic factors at diagnosis for 116 Japanese patients with multiple myeloma. Twelve parameters reported to affect survival were analyzed using a log rank test and stepwise Cox proportional hazards regression. Factors identified as adversely affecting survival were age over 60 years, male sex, blood hemoglobin less than 8.5 g/dl, platelets less than 100 x 10(9)/l, serum creatinine level more than 2.0 mg/dl, serum C-reactive protein (CRP) level more than 6.0 mg/l, and serum beta2-microglobulin level more than 6.0 mg/l. Among them, only high age and high serum CRP level were independently prognostic for poor survival. In conclusion, we have established a simple prognostic model for Japanese myeloma patients only, using factors that can be determined in routine examinations without the need of subjective information.

Cyclophosphamide (CPA) is widely used for peripheral blood stem cell mobilization, and a dose adjustment of CPA in the presence of renal failure has not been suggested. However, we describe a myeloma patient with renal failure (serum creatinine 4.2 mg/dl, creatinine clearance 11.2 ml/min) receiving CPA 2 g/m2 for 2 days, who developed unexpectedly severe toxicity, including myopericarditis and prolonged myelosuppression. The serial serum concentrations of CPA metabolites were persistently much higher than those in a myeloma patient with normal renal function. We consider, therefore, that the dose of CPA should be reduced in the presence of severe renal failure when used as high-dose therapy or to mobilize peripheral blood stem cells.

Oral complications occur frequently after bone marrow transplantation (BMT). Some of them are caused by regimen-related toxicity of the preparative regimen, and others by infections. In addition, oral tissues are targets of graft-versus-host disease (GVHD). Oral granulomatous lesions are not a common complication after BMT, and are especially rare on the tongue. Such rare lesions reported in the literature, developed late after BMT with oral chronic GVHD. We present here a patient who developed pyogenic granuloma of the tongue early after allogeneic BMT done for multiple myeloma. Regimen-related mucositis, oral acute GVHD, the administration of cyclosporine A, and the preexisting macroglossia might be responsible for the formation of granuloma.

Abstract 4495 Incidence of myeloid malignancies such as myelodysplastic syndrome (MDS) and acute myeloid leukemia (AML) is higher in elderly population. However, standard chemotherapy has not been established and the potential role of RICBT has remained unclear. This study reports the results of RICBT for elderly patients with myeloid malignancies. To investigate the feasibility of RICBT. Primary endpoints were engraftment and overall survival (OS). 2nd endpoints were transplant-related mortality (TRM) and relapse rate. Between Mar.2009 and Jul.2011, 21 patients (median age 70 years, range 65–74) received RICBT for myeloid malignancies (de novo AML; n=7, MDS related; n=14). Primary diseases were divided into 2 groups; advanced (high risk; n=11) or standard (CR1 & 2; n=10). Median follow up 9.5 months (0.3–29).Conditioning regimen was fludarabine 200mg/m2, busulfan, and TBI 2Gy(n=9) or ATG 7.5mg/kg (n=12).Immunosuppresants were tacrolimus± MTX (n=13) or cyclosporine ± MTX (n=8). Median total nucleated cells (TNC): 2.6 × 10^7 cells (2.0–4.8); Median CD34+: 0.4 × 10^5 cells (0.2–2.9); HLA match: 5/6 (n=1), 4/6 (n=20). Time to event curves were plotted by using the actuarial method of Kaplan-Meier, and differences between curves were analyzed by log-rank tests. Neutrophile (>500/μ L) and platelet recovery (>20,000/μ L) were observed in 86% (95% CI; 82–87) at day 60 (median; 17 day, range; 12–27), 62% (95% CI; 41–83) at day 100 (median; 32 day, range; 41–83), respectively. Neutrophile engraftment was 100% in TBI regimen (median; 16 days, range; 13–20), 79% in ATG regimen (median; 19 days, range; 12–27) (P=0.09). Platelet engraftment was 86% (95% CI; 60–100) in TBI regimen, 42% (95% CI; 14–70) in ATG regimen, respectively (p=0.02). Cumulative incidence of acute GVHD (II-IV) was 33% (95% CI; 13–53) at day 100 (median; 24days, range; 10–82), 73% (95% CI; 17–82, median; 25 days, range; 17–82) in TBI regimen and 14% (95% CI; 0–33, median; 11.5 days, range; 10–13) in ATG regimen, respectively (P=0.02). The 1-year OS was 64% (95% CI; 46–86) in all cases, 71% (95% CI; 38–100) in TBI regimen, 63% (95% CI; 37–89) in ATG regimen, respectively (P=0.55,Figure1). According to the age, OS was 81% (95% CI; 57–100) in 60’s, 45% (95% CI; 14–76) in 70’s, respectively (P=0.04). Causes of TRM included infections (n=2) and late graft failure (n=1), all cases in 70’s and received ATG. Relapse rate was 19% (95% CI; 2–36) in all cases, 43% (95% CI; 6–80) in TBI regimen, and 7% (95% CI; 3–68) in ATG regimen at 500 days, respectively (P=0.06). RICBT with ATG regimen is associated with a high TRM in over 70 year-old high risk patients. However, ATG regimen may conduct low incidence of acute GVHD and relapse rate. Eligibility of RICBT needs to be investigated, especially in over 70 patients, and further studies are warranted to clarify the safety in elderly patients. Disclosures: No relevant conflicts of interest to declare.

Abstract 2349 Introduction: Incidence of hematological malignancies is higher in elderly population. However, standard chemotherapy has not been established and the potential role of RICBT has remained unclear. This study reports the results of RICBT for elderly patients with hematological malignancies, retrospectively. Objective: To investigate the feasibility of RICBT. Primary endpoints were engraftment and overall survival (OS). secondary endpoint was transplant-related mortality (TRM). Patients and Methods: Between Feb.2009 and Jun.2010, 29 patients (median age 70 years, range 58–76) received RICBT for hematological malignancies. Primary diseases were divided into 2 groups; advanced (intermediate and high risk; n=21) or standard (n=8). All cases in 70's were included in the high risk. Median follow up time was 238 days (range 8–464).Conditioning regimen and GVHD prophylaxis consisted of fludarabine, busulfan or cyclophosphamide, and TBI 2Gy with tacrolimus± MTX for 70 years (n=11) and Results: Neutrophile (>500/μL) and platelet engraftment (>20,000/μL) were observed in 89.6% (95% CI; 79–100) at day 60 (median; 18.0 days, range; 13–28), and 62.1% at day 100 (median; 36.5 days, range; 17–60), respectively. Neutrophile engraftment was 100% in TBI regimen (median; 18 days, range; 13–28), 75% in ATG regimen (95% CI; 51–100, median; 19 days, range; 16–27)(p=0.04). Platelet engraftment was 77% in TBI regimen, 42% in ATG regimen, respectively (p=0.06). Primary graft failure occurred in 3% of all cases. Cumulative incidence of acute GVHD (II-IV) was 58% (95% CI; 39–78) at day 100 (median; 27.5 days, range; 13–82), 81% (95% CI; 62–100, median; 28 days, range; 17–82) in TBI regimen and 12.5% (95% CI; 0–35, median; 13 days, range; 13) in ATG regimen, respectively (p=0.01). The 1-year estimated OS was 51% (95% CI: 25–77) in all cases, 51% (95% CI: 13–90) in TBI, and 48% (95% CI: 18–77) in ATG, respectively (p=0.08). According to the age, OS was 80% (95% CI: 45–80) in 50's, 53% (95% CI: 20–86) in 60's, and 38% (95% CI: 0–77) in 70's (P=0.0765). Causes of TRM included infections (n=5 including 3 cases in 70's), TMA (n=2). Incidence of TRM at day 100 was 20% (95% CI; 4–35, median; 47 days, range; 8–79), 7% in TBI regimen (95% CI; 0–21, median; 79days), 41% in ATG regimen (95% CI; 9–72, median; 30 days, range; 9–72). Incidence of TRM, according to the age, was 40%,0%, and 52% in 50's,60's, 70's, respectively. Discussion and Conclusion: Because of the high incidence of high risk disease and TRM, despite low incidence of GVHD, RICBT is associated with a low OS in patients over 70 years compared with those who are under 70 years. Eligibility of RICBT needs to be investigated, especially in 70's patients, and further studies are warranted to clarify the safety in elderly patients. Disclosures: No relevant conflicts of interest to declare.

Recent introduction of molecular targeted drugs such as bortezomib and IMIDs in the clinical settings has achieved the improved treatment outcome of multiple myeloma (MM). However, MM is still an incurable disease and these drugs also possess serious adverse reactions, therefore, safe and more effective therapy should be established. Artesunate (ART) is a semi-synthetic derivative of artemisinin and is widely used for the treatment of malaria as a salvage therapy. Recent in vitro studies showed that ART also has an anti-tumor activity against several cancer cell lines. We thus investigated whether ART could possess anti-myeloma activity and demonstrated that apoptosis of myeloma cells is strongly induced by ART. Interestingly, we also found that this activity is mediated through heat shock protein (Hsp) 27-dependent pathway. Several MM cell lines (IM9, OPM2, RPMI8226, U266) were treated with various concentrations of ART for 48 hours, and MTT assays were performed to assess the anti-myeloma activity. IM9, OPM2, RPMI8226 cells showed the striking reduction of viability (up to 40% at 1μM and up to 90% at 10μM) in a dose- and time-dependent manner, whereas ART has less inhibitory effect on U266 cell line. ART induced G1 arrest of IM9 cells, and apoptosis was confirmed by decreased mitochondrial membrane potential, and flow cytometric analysis using AnnexinV/PI staining. Colony assay showed that ART has no growth inhibitory effect on normal CD34-positive bone marrow cells even at a concentration of 10μM. Immunoblot analyses demonstrated the activation of caspases-3 and -9, and the decreased expression of pro-apoptotic protein Bid. Interestingly, heat shock protein (Hsp) 27 was downregulated in myeloma cell lines (IM9, RPMI8226) which are sensitive to the ART treatment. In contrast, downregulation of Hsp 27 was not observed in U266 cells which are resistant to ART. Other anti-apoptotic Hsps (Hsp70, 90), as well as Bcl-2 family proteins (Bcl-2, Bax, Bad, Bcl-xL), Akt, MDM2, p53 and MAPKs (SAPK/JNK, p38, ERK1/2) were not affected by ART. Quantitative RT-PCR analysis showed that ART did not influence the mRNA expression of Hsp27, suggesting that ART could downregulate the Hsp27 protein at a posttranscriptional or posttranslational levels. Overexpression of Hsp27 cDNA by transfection method in ART-sensitive myeloma cell lines demonstrated that these cell lines acquired resistance to ART and apoptosis was not induced at a concentration which ART is effective to the parental cells. Our preliminary data using knockdown procedure of Hsp27 mRNA by RNAi-expressing lentivirus showed the growth suppression of myeloma cells, which apparently suggested that Hsp27 could confer a critical function in the proliferation of myeloma cells and that downregulation of Hsp27 could result in induction of apoptosis in MM. Hsp27 has an important role in anti-apoptotic effect against various stresses to the cells. Our data implies a novel mechanism that downregulation of Hsp27 by ART could induce misfolding of several client proteins indispensable for the cell growth, which results in the induction of apoptosis in MM cells. In conclusion, ART could become a candidate of safe and effective therapeutic drug for MM, and Hsp 27 might be a potential molecular target for the treatment of MM.

CD47 belongs to the immunoglobulin superfamily, and is expressed as a 50 kDa cell surface antigen in a wide variety of tissues. CD47 is associated with integrins of β1, β2, and β3, and serves as both a receptor for thrombospondin (TSP) and a ligand for the transmembrane signal regulatory protein SIRP-α . CD47 has a number of different functions, including platelet activation, cell motility, leukocyte adhesion, migration and phagocytosis. Recently, it was reported that the ligation of CD47 rapidly induces cell death in T-cells and chronic lymphocytic leukemic B cells (B-CLL) in a caspase-independent manner (Nat Med, 1999;5:1277–1284). These findings indicate that CD47 ligation may have potential as a new therapeutic approach for lymphoid malignancies. B-CLL is the most common hematological malignancy in Western countries. Although new therapeutic agents such as fludarabine and 2-chlorodeoxyadenosine have been introduced in the clinic, B-CLL is not considered curable, and thus there is an immediate need for new, effective drugs. In an attempt to establish a novel therapeutic agent for B-CLL, we first generated a murine monoclonal antibody against an extracellular domain of human CD47 (designated MABL). Soluble MABL (10μg/ml) with goat anti-mouse IgG (GAM) induced apoptosis of CD47-positive CCRF-CEM and MOLT-4 cells. However, because MABL caused hemoagglutination, we created a disulfide-stabilized dimer of a single-chain antibody fragment of MABL (S-S diabody) to get rid of this adverse effect. The S-S diabody did not cause hemoagglutination. Treatment with the S-S diabody (0–0.1 μg/ml for 0–24 hours) alone was fully active in inducing apoptosis of primary samples from patients with B-CLL and CD47-positive lymphoid cells (MOLT-4 and JOK-1) in a dose- and time-dependent manner. In addition, administration of the S-S diabody (30 mg/kg for 5 days) significantly prolonged the survival of SCID mice inoculated with JOK-1 cells compared with that of the control mice (median survival 21 days vs. more than 30 days, p

Although the analysis of chimerism induction has become an important diagnostic tool for providing better clinical management of patients undergoing allogeneic HSCT, the techniques have not been fully standardized. Moreover, it is currently unknown whether the onset of graft-versus-host disease (GVHD) is related to the status of mixed chimerism (MC) or complete donor-type chimerism (CDC). First, to validate our chimerism analysis system, we performed experiments with artificially mixed cell samples from healthy volunteers to examine the reliability of short tandem repeat (STR) determination by quantitative polymerase chain reaction (PCR). We confirmed a linear correlation between the proportion of mixed cells and the calculated ratio, with a correlation coefficient of 0.99, which enables the detection of target cells at 3% (median standard deviation, 1.6%). Next, using this validated system, we prospectively evaluated the kinetics of chimerism in CD3+, CD19+, and peripheral blood mononuclear cells (PBMC), for correlation with the occurrence of GVHD in 19 patients with various hematological diseases (median age, 53y) who had received allogeneic HSCT from an HLA-identical sibling donor between July 2003 and February 2004. The preparative regimen was fludarabine/busulfan (BU) (n=12) or cladribine/BU (n=7). GVHD prophylaxis consisted of cyclosporin alone (n=8), cyclosporin plus short-term methotrexate (n=7), or tacrolimus (n=4). Chimerism analysis was repeated weekly after transplantation. We evaluated 405 consecutive blood samples from these 19 recipients, 12 of whom developed acute GVHD. Six of these 12 patients showed MC, i.e. 91% (83–94%; MC) donor cells in the CD3+ fraction at the onset of GVHD, but all except one subsequently achieved CDC within a median of 15 (7–33) days without additional DLI. The remaining patient showed persistent MC and relapsed 158 days after transplantation. We found that the presence of MC in the CD3+ fraction is rather common at the onset of acute GVHD, but GVHD subsequently eradicates residual host hematopoietic cells. Alternatively, GVHD is part of a clinical manifestation of an immune reaction that is related to the induction of CDC.

Background. Reactivation of chronic hepatitis B virus (HBV) infection is a major complication when HBV carriers receive immunosuppressive therapy. Recipients of allogeneic hematopoietic stem cell transplantation (HSCT) carry the highest risk of fatal HBV disease (up to 12%). Methods. In an attempt to identify a suitable procedure for the prevention and management of HBV reactivation, the administration of lamivudine over the course was tested in two patients. Results. Generally, the patients transplant courses were successfully managed despite their difficult clinical situations: a high HBV load before transplant in one patient and intense steroid therapy for complicated acute graft-versus-host disease (GVHD) in the other patient. However, one patient showed a reactivation of HBV after discontinuing lamivudine and the other showed persistently high DNA polymerase activity despite prolonged administration of lamivudine. Conclusions. We concluded that lamivudine could have a place in the management of patients who suffer from chronic HBV infection and who are undergoing allogeneic HSCT. However, the efficacy of lamivudine seemed to be limited compared with other settings, including solid organ transplantation and autologous HSCT.