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A 78-year-old man with prostate squamous cell carcinoma recurrence in his pelvis was admitted to our hospital. Rectal obstruction led to creation of an artificial anus on the transverse colon. Then, docetaxel and radiation therapies were started. A week later, severe hematuria and melena occurred. Activated partial thromboplastin time (APTT) and prothrombin time (PT) were extremely prolonged. Cross-mixing test for APTT and PT revealed an inhibitor pattern, which was diagnosed as acquired factor V inhibitor. Fresh frozen plasma and vitamin K infusions were ineffective, but platelet transfusion successfully stopped the bleeding. Platelet factor V derived from megakaryocytes may affect local hemostasis. The patient received prednisolone (PSL), and the inhibitor disappeared on day 70 and was in remission. PSL could be stopped on day 100. Later, we demonstrated APTT and PT shortening of factor V deficient plasma by the supernatant of activated platelets with collagen.

This study aimed to clarify the clinical utility of oral management to prevent bloodstream infections by oral bacteria microbiologically in patients undergoing allogeneic hematopoietic stem cell transplantation (ASCT). Ten consecutive patients with hematological malignancies undergoing ASCT were enrolled in this study. We implemented dental treatments before transplantation, if required, and carried out oral hygiene instructions and oral management every other day after transplantation. Molecular analysis of bacterial DNA for seven oral species using a polymerase chain reaction (PCR) assay was performed for oral samples and peripheral blood once a week for 3 weeks after transplantation. Periodontitis was found in all 10 patients (mild grade in 3 and middle grade in 7) for whom basic periodontal therapy was conducted. Necessary dental procedures, including tooth extraction were performed in 5 patients. After transplantation, oral mucositis occurred in 10 patients (grade 1 in 3, grade 2 in 2, and grade 3 in 5) for whom oral hygiene instruction and oral care were continued every other day. PCR-identified three to six bacterial species in oral samples from nine patients, but none in peripheral blood from any patient during the observation period. Our study suggests that oral management could prevent bloodstream infections by oral bacteria in ASCT recipients despite the existence of periodontitis or oral mucositis. Its utility was confirmed by microbiological evidence based on molecular data.

Monomorphic epitheliotropic intestinal T-cell lymphoma (MEITL) is a rare subtype of intestinal T-cell lymphoma that occurs mostly in Asia. CHOP-like therapy is usually selected, but the prognosis is very poor. This report concerns a 43-year-old woman with newly diagnosed stage IVA MEITL. The patient obtained a partial response after 4 cycles of GDP (gemcitabine, dexamethasone, cisplatin) and achieved a complete response (CR) after cord blood transplantation (CBT) conditioned with total body irradiation, cyclophosphamide, and cytarabine. Seven months after transplantation, the patient experienced cognitive impairment. Magnetic resonance imaging of the brain showed a high-intensity lesion in the right cerebral peduncle and internal capsule. A cerebrospinal fluid examination confirmed central nervous system (CNS) relapse of MEITL. After 3 cycles of MPV (methotrexate, procarbazine, vincristine) followed by whole-brain radiotherapy, her cognitive impairment improved. Due to disease progression, she died 6 months after CNS relapse. Given the CNS relapse after achieving a CR with GDP and CBT in this patient, CNS prophylaxis during first-line therapy may be beneficial in the treatment of MEITL.

Almost comparable transplantation outcomes have been reported with HLA-matched unrelated donor transplantation (UDT) and cord blood transplantation (CBT). We conducted a prospective phase 2 study to assess the efficacy and safety of single-unit myeloablative CBT in adult leukemia and myelodysplastic syndrome. Because the day 180 survival of UDT was approximately 80%, we determined the alternative hypothesis of expected day 180 survival with a successful engraftment rate of 80% and set the null hypothesis of threshold rate at 65%. Sixty-two patients (median age, 37 years) were registered, including 28 with acute myelogenous leukemia, 25 with acute lymphoblastic leukemia, and 9 with myelodysplastic syndrome. Of 61 eligible patients, 52 were successfully engrafted and survived at day 180 (85%; 95% confidence interval, 74% to 93%). Single-unit CBT was judged to be effective because the null hypothesis was rejected (P.001). Furthermore, neutrophil engraftment was observed in 57 patients (92%); the incidences of grade II-IV acute and chronic graft-versus-host disease were 30% and 32%, respectively; and the cumulative incidences of nonrelapse mortality and relapse at 2 years were 18% and 13%, respectively. The present study showed favorable survival outcomes with single-unit CBT. Therefore, this method may be considered if a well-HLA-matched UDT cannot be obtained.

Blood stream infections (BSIs) are a serious problem in patients with hematologic malignancies receiving allogeneic hematopoietic stem cell transplantation (ASCT). We evaluated the clinical utility of molecular diagnosis for the management of BSIs in such patients. We prospectively performed a polymerase chain reaction (PCR) analysis of microbial DNA in blood samples from 10 consecutive patients with hematological malignancies at least once a week for one month after ASCT. In total, 51 and 54 samples were analyzed by bacterial and fungal PCR assays, respectively. Bacteria were detected in 24 samples from 8 patients by PCR, but in only 2 samples from one patient by blood culture. Notably, the bacteria detected in at least half of the 24 samples were considered to have originated from the oral cavity. Fungi were detected in 5 samples from 3 patients by PCR, but not by blood culture. Most cases with positive PCR results were manageable with empirical antimicrobial therapy without disclosure of DNA data. Our DNA analyses did not directly contribute to management of BSIs, but did provide valuable microbiological evidence for the patients. Additionally, oral management appears to require a critical re-evaluation to reduce the occurrence of BSIs in ASCT recipients.

Purpose: This study aimed to clarify the clinical utility of oral management to prevent bloodstream infections by oral bacteria microbiologically in patients undergoing allogeneic hematopoietic stem cell transplantation (ASCT). Methods: Ten consecutive patients with hematological malignancies undergoing ASCT were enrolled in this study. We implemented dental treatments before transplantation, if required, and carried out oral hygiene instructions and oral management every other day after transplantation. Molecular analysis of bacterial DNA for seven oral species using a polymerase chain reaction (PCR) assay was performed for oral samples and peripheral blood once a week for 3 weeks after transplantation. Results: Periodontitis was found in all 10 patients (mild grade in 3 and middle grade in 7) for whom basic periodontal therapy was conducted. Necessary dental procedures, including tooth extraction of the tooth were performed in 5 patients. After transplantation, oral mucositis occurred in 10 patients (grade 1 in 3, grade 2 in 2, and grade 3 in 5) for whom oral hygiene instruction and oral care were continued every other day. PCR-identified three to six bacterial species in oral samples from nine patients, but none in peripheral blood from any patient during the observation period. Conclusions: Oral management prevented blood stream infections by oral bacteria in ASCT recipients despite the existence of periodontitis or oral mucositis. Its utility was confirmed by microbiological evidence based on molecular data.

Monomorphic epitheliotropic intestinal T-cell lymphoma (MEITL) is a rare subtype of intestinal T-cell lymphoma that occurs mostly in Asia. CHOP-like therapy is usually selected, but the prognosis is very poor. This report concerns a 43-year-old woman with newly diagnosed stage IVA MEITL. The patient obtained a partial response after 4 cycles of GDP (gemcitabine, dexamethasone, cisplatin) and achieved a complete response (CR) after cord blood transplantation (CBT) conditioned with total body irradiation, cyclophosphamide, and cytarabine. Seven months after transplantation, the patient experienced cognitive impairment. Magnetic resonance imaging of the brain showed a high-intensity lesion in the right cerebral peduncle and internal capsule. A cerebrospinal fluid examination confirmed central nervous system (CNS) relapse of MEITL. After 3 cycles of MPV (methotrexate, procarbazine, vincristine) followed by whole-brain radiotherapy, her cognitive impairment improved. Due to disease progression, she died 6 months after CNS relapse. Given the CNS relapse after achieving a CR with GDP and CBT in this patient, CNS prophylaxis during first-line therapy may be beneficial in the treatment of MEITL.

A 56-year-old man diagnosed with multiple myeloma was treated with CBD (cyclophosphamide, bortezomib, and dexamethasone; DEX), which was discontinued because of bortezomib-associated adverse events. Thereafter, he was treated with Ld (lenalidomide; LEN+DEX) followed by high-dose chemotherapy with autologous stem cell rescue, resulting in a complete response. Ld as maintenance therapy was discontinued because of immune thrombocytopenia, resulting in disease progression. Although treatment was switched to Pd (pomalidomide+DEX), DLd (daratumumab+LEN+DEX), and IRd (ixazomib+LEN+DEX); the patient's M protein level continued to increase and the extramedullary disease expanded despite radiotherapy. He was treated with E-Ld (elotuzumab+LEN+DEX) after 3 cycles of short VAD (vincristine, doxorubicin, and DEX). The extramedullary disease disappeared after 8 cycles of E-Ld. To the best of our knowledge, this is the first report showing the effectiveness of E-Ld treatment for extramedullary disease of a heavily treated patient for multiple myeloma. We believe that the clinical course of this patient provides useful insights about the antimyeloma mechanism of elotuzumab.

Recent studies have described various impacts of obesity and being overweight on acute myeloid leukemia (AML) outcomes in adult patients, but little is known about the impact of being underweight. We compared the outcomes of underweight patients to those of normal weight and overweight patients. Adult patients with AML who registered in the JALSG AML201 study (n = 1057) were classified into three groups: underweight (body mass index [BMI]

Pulmonary mucormycosis (PM) is a life-threatening fungal infection in patients with hematologic malignancies, and early and accurate diagnostic modalities are urgently needed. We conducted a polymerase chain reaction (PCR) assay targeting these fungi in peripheral blood from four patients with hematologic malignancies who were strongly suspected of having PM. In these four patients, the Rhizopus species was identified in two patients, and the Cunninghamella and Absidia species in one each. Based on these molecular findings, all of the patients were successfully treated via targeted therapy with liposomal amphotericin B. In this report, a PCR analysis proved very useful for managing PM in patients with hematologic malignancies.

Antifungal prophylaxis is crucial for successful hematopoietic stem cell transplantation (HSCT). Maintenance therapy with fluconazole (FLCZ) is generally prescribed as secondary prophylaxis in patients with human immunodeficiency virus infection and non-immunocompromised hosts. However, previous reports have revealed that FLCZ is insufficient as a secondary prophylaxis for cryptococcal infection in HSCT cases. There is no well-established evidence of effective secondary prophylaxis against cryptococcal infection in conditions of severe immunosuppression, such as in HSCT. Herein, we report a case of atypical chronic myeloid leukemia (aCML) presenting with cryptococcal meningitis. A 58-year-old man with progressive leukocytosis and headache was referred to our hospital. Bone marrow biopsy revealed aCML. Because the estimated overall survival was limited, HSCT was indicated. Furthermore, enhanced magnetic resonance imaging and lumbar puncture aided in diagnosing cryptococcal meningitis, which was treated with a combination therapy comprising liposomal amphotericin B and 5-fluorocystine for 28 days. Given the high recurrence rate of cryptococcal meningitis, voriconazole (VRCZ) dose was calculated using the trough concentration of VRCZ in the cerebrospinal fluid. Eventually, HSCT was successfully performed at an appropriate therapeutic range of VRCZ. To the best of our knowledge, there is no case report on HSCT with secondary prophylaxis against cryptococcal meningitis. Our report thus emphasizes the efficacy of VRCZ maintenance therapy as secondary prophylaxis for cryptococcal infection.

Leuconostocspecies are vancomycin-resistant Gram-positive cocci. Infections due toLeuconostocspecies have been reported in various immunocompromised patients, but little is known about such infection in patients with hematologic malignancies. We report a case ofLeuconostocinfection in a 44-year-old woman with acute lymphoblastic leukemia. The patient developed a high fever despite antimicrobial therapy with doripenem after induction chemotherapy. After an isolate from blood cultures was identified asL. pseudomesenteroides, we changed the antibiotics to piperacillin-tazobactam and gentamicin, after which the patient recovered from the infection. Physicians should be aware ofLeuconostocspecies as causative pathogen if they encounter Gram-positive cocci bacteremia resistant to standard antibiotics such as vancomycin and teicoplanin, especially in patients with hematologic malignancies.

A 23-year-old man from Mie Prefecture, Japan, with past and family history of hematuria was diagnosed with influenza A and admitted to our hospital on the following day because of hemoglobinuria. He was diagnosed with thrombotic microangiopathy and was suspected of having atypical hemolytic uremic syndrome (aHUS). C3 p.I1157T missense mutation, which we had previously reported in eight aHUS patients from six families in Mie Prefecture, was identified. The laboratory findings and symptoms of our patient promptly improved after administering eculizumab. Little information is available on abnormalities of the complement system in aHUS or on mutation-specific outcomes of eculizumab therapy. Eculizumab was effective for treating our aHUS patient with C3 p.I1157T missense mutation.

BACKGROUND Blood tacrolimus (TAC) concentration delivered via intravenous administration is known to be influenced by genetic polymorphism of CYP3A5 and interaction with triazole antifungal agents. However, interindividual variability of blood TAC concentration is as of yet still difficult to predict during the early stages of hematopoietic stem cell transplantation (HSCT). This study was conducted to assess the wide variability of blood TAC concentrations because of the hepatic metabolic activities of CYP3A and CYP2C19 in HSCT recipients. METHODS This study is a single-institute prospective study that includes 21 adult patients who underwent HSCT and received 24 hours continuous intravenous administration of TAC at the Mie University Hospital between January 2009 and March 2014. After HSCT, the changes in blood TAC concentration/dose (C/D) ratio and TAC dose reduction from initial dose were investigated. RESULTS Significant differences between HSCT recipients with CYP3A5*1 allele and CYP3A5*3/*3 genotype were observed with respect to the median TAC C/D ratio on day 14 (563 versus 742 ng/mL per mg/kg, P < 0.01) and day 21 (672 versus 777 ng/mL per mg/kg, P < 0.05) after HSCT. Concomitant administration of voriconazole (VRCZ), but not of lansoprazole, was found to significantly increase the median TAC C/D ratio on day 14 (557 versus 723 ng/mL per mg/kg, P < 0.01). Possession of the CYP3A5*3/*3 genotype (day 14: odds ratio, 32.2; day 21: odds ratio, 33.0; P < 0.05) and concomitant administration of VRCZ (day 14: odds ratio, 37.8; P < 0.05) were found to be independent risk factors, which significantly contributed to an increased TAC C/D ratio. In HSCT recipients with CYP3A5*3/*3 genotype (78.0%), the median TAC dose ratio (day 21/day -1) was significantly lower compared with HSCT recipients with the CYP3A5*1 allele (94.1%), whereas VRCZ administration itself had no significant influence. Interestingly, in HSCT recipients with CYP2C19*1/*1, we found that the influence of VRCZ on the TAC dose ratio (85.7%) was relatively mild, even in a recipient with CYP3A5*3/*3. CONCLUSIONS In HSCT recipients, the variability of intravenous TAC concentration in the blood could be explained in part by the genetic variation of CYP3A5. The study results also strongly imply that the magnitude of hepatic interaction between TAC and VRCZ is affected by the genetic polymorphism of both CYP3A5 and CYP2C19 genes.

Exophiala dermatitidis is a dematiaceous fungus that is increasingly being identified as a cause of fungal infection especially in patients with immunodeficiency. To date, however, the factors predisposing E. dermatitidis and its optimal treatments have not been fully addressed. Here, we report the first patient with untreated multiple myeloma who developed E. dermatitidis pulmonary infection. We also review recent clinical reports describing the features of E. dermatitidis infection.

Background: A drug interaction between oral tacrolimus (TAC) and lansoprazole (LAN) has been reported in patients with CYP2C19 homozygous mutations and the CYP3A5 *3/*3 genotype. A Pubmed search (date of implementation, March 16, 2011) using search terms drug interaction, tacrolimus, and lansoprazole, failed to identify the drug interactions in CYP3A5 extensive metabolizers , and parenterally administrated TAC.Objective: To report a case of drug interaction between intravenous TAC and LAN in a patient being treated with voriconazole (VCZ) and harboring CYP2C19 and CYP3A5 heterozygous mutations.Case Summary: An 18-year-old Japanese man weighing 53 kg with an anaplastic large cell lymphoma received continuous intravenous administration of TAC as post-transplantation prophylaxis against graft-versus-host disease (GVHD) after an allogeneic bone marrow transplantation (BMT). He began receiving intravenous LAN 60 mg/day and VCZ 400 mg/day initiated the day before BMT. His blood TAC concentrations were within the range of 9 -16 ng/ml from post BMT day 5 to 26. The engraftment of the donor’s hematopoietic cells was observed on day 17. The LAN dose was reduced to 15 mg/day orally on day 26, and the blood TAC concentration subsequently decreased to 6.6 ng/ml, with GVHD related symptoms emerging on day 28. Consequently, the plasma VCZ concentration also decreased from 5.0 ng/ml to 2.5 ng/ml after reducing the LAN dose. VCZ was switched to liposomal amphotericin B on day 48. Thereafter, the blood TAC concentration decreased to 4.4 ng/ml on day 51. Ultimately, the patient died on day 77 because of the recurrence and progression of lymphoma. Other drugs taken were acyclovir, ursodeoxycholic acid, cefepime, meropenem, vancomycin, lenograstim and dopamine hydrochloride. The genotyping analyses using the pre-BMT and post-engraftment (day 33) samples indicated that both were CYP2C19 *1/*2 and CYP3A5*1/*3. The calculated Horn drug interaction probability scales between TAC and LAN is 6, indicating a probable interaction. TAC and VCZ concentrations were measured by an affinity column-mediated immunometric assay and high performance liquid chromatography, respectively. Mutant alleles were examined using the multiplex extension of unlabeled oligonucleotide primers with fluorescently labeled dideoxynucleotide triphosphates.Conclusions: Blood TAC concentration decreased after reducing the LAN dose, which was likely caused by a reduction in plasma VCZ concentration, in a BMT patient with CYP2C19 and CYP3A5 heterozygous mutations.

We conducted a prospective randomized study to assess the optimal postremission therapy for adult acute myeloid leukemia in patients younger than 65 years in the first complete remission. A total of 781 patients in complete remission were randomly assigned to receive consolidation chemotherapy of either 3 courses of high-dose cytarabine (HiDAC, 2 g/m2 twice daily for 5 days) alone or 4 courses of conventional standard-dose multiagent chemotherapy (CT) established in the previous JALSG AML97 study. Five-year disease-free survival was 43% for the HiDAC group and 39% for the multiagent CT group (P = .724), and 5-year overall survival was 58% and 56%, respectively (P = .954). Among the favorable cytogenetic risk group (n = 218), 5-year disease-free survival was 57% for HiDAC and 39% for multiagent CT (P = .050), and 5-year overall survival was 75% and 66%, respectively (P = .174). In the HiDAC group, the nadir of leukocyte counts was lower, and the duration of leukocyte less than 1.0 × 109/L longer, and the frequency of documented infections higher. The present study demonstrated that the multiagent CT regimen is as effective as our HiDAC regimen for consolidation. Our HiDAC regimen resulted in a beneficial effect on disease-free survival only in the favorable cytogenetic leukemia group. This trial was registered at www.umin.ac.jp/ctr/ as #C000000157.

Background Allogeneic hematopoietic stem cell transplantation (allo-HSCT) is a potentially curative therapy for acute myeloid leukemia (AML), but non-relapse mortality (NRM) remains obstacles to this treatments. Therefore, precise comorbidity evaluation before transplantation is crucial for better outcomes. One of the most frequently used tools for assessing the risk profile of transplant recipients is the hematopoietic cell transplantation comorbidity index (HCT-CI), which only incorporates information of the antibiotics use on day 0 as an infection-related factor, however, some important components, such as the number and severity of infectious episodes, are not included. Methods From December 2001 to December 2005, 1,057 newly diagnosed adult AML patients were registered to JALSG AML201 (Blood 2011; 117: 2358-65, 2366-72). Of them, the 121 evaluable patients who underwent allo-HSCT in the first hematological complete remission were analyzed. We have checked the above mentioned components, in addition to the interval from the last chemotherapy to transplantation, in these 121 patients and analyzed whether these factors might affect the subsequent transplant outcome. Results The median age was 37 years (range, 15-61). Regarding cytogenetic risk, 7 (6%), 92 (76%), and 15 (12%) patients were categorized as favorable, intermediate and high risk, respectively. The median follow-up period after transplantation was 939 days (range 19-2204). At 2 years after allo-HSCT, overall survival, leukemia free survival, cumulative incidence of relapse (CIR), and NRM for all patients were 73.2%, 65.4%, 19.4%, and 15.8%, respectively. A total of 106 (88%) patients developed at least one infectious episode as 102 (84%) patients faced to febrile neutropenia (FN), 45 (37%) patients experienced severe infection (≥ grade 3), and 27 (22%) patients eventually developed sepsis. Regarding the episode of FN, 52 (43%) patients experienced more than 2 times during chemotherapy. The median cycles of chemotherapy before transplantation was 4 (range, 1-6) and the median interval from the first day of last chemotherapy to transplantation was 77 days. The ROC curve indicated mild correlations between NRM and the interval with an area under the curve of 52% and the cutoff value at 113 days. The number of infectious episodes or severity of infection did not carry a significant impact on NRM at 2 years as 19.2% in FN with ≥3 episodes vs. 13.2% in FN with 0-2 episodes; p=0.18, 18.0% in patients with severe infection vs. 14.5% in patients without severe infection; p=0.49. However, in view of bone marrow transplant (BMT) recipients (n=76), multiple FN episodes was significantly associated with higher NRM (23.5% vs. 7.2% at 2 years, p=0.029) (Fig 1A). While, the relative shorter interval ( Conclusion Combining the number of infectious episodes and interval of chemotherapy to transplantation may predict a transplant outcome in AML patients. Providing an adequate interval from the last chemotherapy to transplantation may reduce NRM especially in BMT recipients who developed multiple FN episodes during induction or consolidation chemotherapy. Figure 1. Figure 1. Disclosures Kiyoi: Astellas Pharma Inc.: Research Funding; Novartis Pharma K.K.: Research Funding; Kyowa Hakko Kirin Co., Ltd.: Research Funding; Zenyaku Kogyo Co., Ltd.: Research Funding; Otsuka Pharmaceutical Co., Ltd.: Research Funding; Takeda Pharmaceutical Co., Ltd.: Research Funding; Nippon Shinyaku Co., Ltd.: Research Funding; Eisai Co., Ltd.: Research Funding; Chugai Pharmaceutical Co., Ltd.: Research Funding; Sanofi K.K.: Research Funding; Celgene Corporation: Research Funding; FUJIFILM Corporation: Research Funding; Phizer Japan Inc.: Research Funding; Sumitomo Dainippon Pharma Co., Ltd.: Research Funding; Bristol-Myers Squibb: Honoraria. Naoe:Nippon Shinyaku Co., Ltd.: Research Funding; Astellas Pharma Inc.: Research Funding; Otsuka Pharmaceutical Co., Ltd.: Research Funding; Fujifilm Corporation: Patents & Royalties, Research Funding; Pfizer Japan Inc.: Research Funding; Toyama Chemical Co., Ltd.: Research Funding.

Study Objective. To investigate whether a drug interaction exists between bortezomib and the cytochrome P450 (CYP) 3A4 inhibitor itraconazole and/or the CYP2C19 inhibitor lansoprazole that results in increased severity of bortezomib-induced peripheral neuropathy and thrombocytopenia. Design. Retrospective medical record review. Setting. Hematology-oncology ward of a university-affiliated hospital in Japan. Patients. Six adults with relapsed multiple myeloma who received intravenous bortezomib plus oral dexamethasone as the first course of a 21–day cycle between July 2007 and December 2008. Four of the six patients were treated concomitantly with itraconazole or lansoprazole: two with itraconazole, one with lansoprazole, and one with both itraconazole and lansoprazole. Measurements and Main Results. Using the National Cancer Institute's Common Terminology Criteria for Adverse Events, we identified the presence and graded the severity of peripheral neuropathy and thrombocytopenia before and during each patient's first 21–day course of bortezomib plus dexamethasone therapy. All three patients who received itraconazole experienced new or worsening peripheral neuropathy; they also experienced grade 4 thrombocytopenia. The patient who received lansoprazole alone, as well as the two patients who did not receive itraconazole or lansoprazole, had no changes in either adverse effect. We also evaluated the relationship between peripheral neuropathy and bortezomib plus dexamethasone therapy by using the Naranjo adverse drug reaction probability scale, and a probable relationship was found. We further assessed whether a drug interaction between bortezomib and itraconazole and/or lansoprazole had occurred involving the CYP3A4 and/or the CYP2C19 pathways, respectively—resulting in increased severity of the bortezomib-induced peripheral neuropathy and thrombocytopenia—by using the Horn drug interaction probability scale. We found that the occurrence of this drug interaction was strongly supported. Conclusions. Itraconazole appears to exacerbate peripheral neuropathy and thrombocytopenia induced by bortezomib; however, the mechanism of this drug interaction is unknown. Clinicians should closely monitor for bortezomib-induced adverse effects when itraconazole, or any other potent CYP3A4 inhibitor, is administered concomitantly with bortezomib.

Intra-bone marrow injection is a novel strategy for hematopoietic stem cell transplantation. Here, we investigated whether ex vivo culture of cord blood hematopoietic stem/progenitor cells influences their reconstitution in bone marrow after intra-bone marrow transplantation. Freshly isolated AC133+ cells or cells derived from AC133+ cells cultured with cytokines (stem cell factor, flt-3 ligand, and thrombopoietin) for 5 days were injected into the bone marrow of the left tibia in irradiated NOD/SCID mice. In the bone marrow of the injected left tibia, the engraftment levels of human CD45+ cells at 6 weeks after transplantation did not differ considerably between transplantation of noncultured and cytokine-cultured cells. However, the migration and distribution of transplanted cells to the bone marrow of other, noninjected bones were extremely reduced for cytokine-treated cells compared with noncultured cells. Similar findings were observed for engraftment of CD34+ cells. Administration of granulocyte colony-stimulating factor to mice after transplantation induced the migration of cytokine-cultured cells to the bone marrow of previously aspirated bone but not to other intact bones. These data suggest that ex vivo manipulation of hematopoietic progenitor/stem cells significantly affects their migration properties to other bone marrow compartments after intra-bone marrow transplantation. Our data raise a caution for future clinical applications of the intra-bone marrow transplantation method using ex vivo-manipulated hematopoietic stem cells. Disclosure of potential conflicts of interest is found at the end of this article.

Bing-Neel syndrome is known as Waldenström's macroglobulinemia with central nervous system infiltration by neoplastic lymphoplasmacytoid and plasma cells. A 74-year-old man was admitted because of progressive cognitive impairment. Serum immunoelectrophoresis showed a monoclonal IgM-kappa component. Bone marrow aspiration revealed 59% small lymphocytes showing plasmacytoid differentiation. Bone marrow flow cytometry disclosed a population of kappa light-chain positive lymphoid cells expressing CD19, CD20, CD38, and CD138. Magnetic resonance imaging of the brain demonstrated gadolinium-enhancement in the right temporo-parieto-occipital meninges with sulcal enhancement. Cerebrospinal fluid cytology showed a population of lymphoplasmacytoid cells, positive for CD19, CD20, CD25, and kappa light-chain. Based on these findings, Bing-Neel syndrome was diagnosed. Although combination chemotherapy consisting of intrathecal methotrexate and oral cyclophosphamide was started, his symptoms continued to worsen. Then, we initiated treatment with a regimen consisting of fludarabine/rituximab (FR). After 6 courses of this FR regimen, a complete remission was achieved. Our case suggests the FR regimen to potentially be an effective treatment option for Bing-Neel syndrome of the scattered type.

Summary Histone acetylation and deacetylation play fundamental roles in transcriptional regulation. We investigated the role of histone deacetylases (HDACs) in human adult haematopoiesis, using the structurally distinct HDAC inhibitors FK228 (depsipeptide) and Trichostatin A. When CD34 + cells were cultured with interleukin (IL)-3 or stem cell factor (SCF) + IL-3, FK228 (0AE5 ng/ml) specifically enhanced the generation of immature erythroid cells with a CD36 + glycophorin A (GPA) low phenotype. In semisolid cultures, FK228 promoted the formation of erythroid colonies by CD34 + cells with IL-3 and SCF + IL-3. Furthermore, upon exposure to FK228, CD34 + cell-derived CD36 + GPA ) cells were induced to form erythroid colonies with IL-3 alone. Conversely, FK228 inhibited the generation of CD36 + GPA high relatively mature erythroid cells from CD34 + cells in the presence of erythropoietin (EPO) and SCF + EPO. FK228 suppressed the EPO-mediated survival of CD36 + GPA low/- and CD36 + GPA high cells and induced their apoptosis. Similar effects were observed for trichostatin A in the generation of erythroid cells in IL-3- and EPO-containing cultures. These data suggest that HDACs negatively regulate the IL-3-mediated growth of early erythroid precursors by suppressing their responsiveness to IL-3, while playing an important role in EPO-mediated differentiation and survival of erythroid precursors. Our data revealed that HDACs have diverse functions in human adult erythropoiesis.

我々は, 複数の不規則抗体の存在により, 適合血確保に難渋した鎌状赤血球症 (以下SCD) の18歳ブラジル人女性症例を経験したので報告する. ブラジル在住の2歳時にSCDと診断され, 以来, 輸血を繰り返し受けてきた. 来日4日前, ブラジルにて急性アルコール中毒のため入院し, 点滴と輸血を受けた. 来日翌日, 両側大腿部痛を主訴に当院内科へ緊急入院した. 著明な溶血のため輸血が必要であった. 不規則抗体検査で抗E, 抗M, 抗S抗体が検出されたので, E, M, S抗原陰性MAPを用いて交差適合試験を行ったが, 数単位しか適合MAPが得られなかった. 患者の血液サンプルを東京都中央血液センターに送り, 詳細な血液型検査と, 不規則抗体の同定を依頼した. Percoll-Urografin 比重遠沈法により分離した患者網状赤血球と低張食塩液により分離した患者赤血球を用いて詳細な血液型が検査された. その結果, 患者の血液型は, CcDee, Le (a-b-), NNss, Fy (a+b+), Jk (a+b+), Di (a-b+) であった. さらにIgG型抗 Yka 抗体が同定された. 我々は, 全国調整により出来る限り患者の詳細な血液型と一致したMAPを得ることができた. SCD患者への赤血球輸血に際しては, 不規則抗体産生を予防するために患者の詳細な血液型に一致したMAPを確保することと白血球除去が重要であると思われる.

It is generally recognized that postmitotic neutrophils give rise to polymorphonuclear neutrophils alone. We obtained evidence for a lineage switch of human postmitotic neutrophils into macrophages in culture. When the CD15+CD14- cell population, which predominantly consists of band neutrophils, was cultured with granulocyte macrophage–colony-stimulating factor, tumor necrosis factor-α, interferon-γ, and interleukin-4, and subsequently with macrophage colony-stimulating factor alone, the resultant cells had morphologic, cytochemical, and phenotypic features of macrophages. In contrast to the starting population, they were negative for myeloperoxidase, specific esterase, and lactoferrin, and they up-regulated nonspecific esterase activity and the expression of macrophage colony-stimulating factor receptor, mannose receptor, and HLA-DR. CD15+CD14- cells proceeded to macrophages through the CD15-CD14- cell population. Microarray analysis of gene expression also disclosed the lineage conversion from neutrophils to macrophages. Macrophages derived from CD15+CD14- neutrophils had phagocytic function. Data obtained using 3 different techniques, including Ki-67 staining, bromodeoxyuridine incorporation, and cytoplasmic dye labeling, together with the yield of cells, indicated that the generation of macrophages from CD15+CD14- neutrophils did not result from a contamination of progenitors for macrophages. Our data show that in response to cytokines, postmitotic neutrophils can become macrophages. This may represent another differentiation pathway toward macrophages in human postnatal hematopoiesis. (Blood. 2004;103:2973-2980)

We examined the actions of granulocyte-macrophage colony-stimulating factor (GM-CSF) and interleukin-3 (IL-3) on human monocytes, using a serum-free culture system. GM-CSF and IL-3 did not promote the differentiation of monocytes into macrophages but rather into cells with a phenotype compatible with that of immature dendritic cells (DCs). The addition of fetal bovine serum to serum-free cultures with GM-CSF or IL-3 restored the differentiation of monocytes into macrophages. Cells generated with GM-CSF or IL-3 elicited phagocytic activity. Cells generated in the presence of GM-CSF or IL-3, followed by the addition of tumor necrosis factor-alpha, displayed a phenotype of mature DCs, and primed and stimulated immunogenic peptide-specific T lymphocytes. Surprisingly, GM-CSF and IL-3 inhibited macrophage colony-stimulating factor (M-CSF)-dependent differentiation of monocytes into macrophages and induced differentiation into immature DCs. We asked if the inhibition of M-CSF-dependent differentiation into macrophages by GM-CSF or IL-3 was associated with the expression of M-CSF receptors (M-CSFR). GM-CSF or IL-3 down-regulated the expression of M-CSFR. These data demonstrate that GM-CSF and IL-3 primarily support the differentiation of monocytes into DCs and inhibit M-CSF-dependent differentiation into macrophages by suppressing the expression of M-CSFR, thereby promoting differentiation into DCs.

We conducted a multi-institutional randomized study to determine whether high-dose daunorubicin would be as effective as standard-dose idarubicin in remission-induction therapy for newly diagnosed adult patients younger than 65 years of age with acute myeloid leukemia. Of 1064 patients registered, 1057 were evaluable. They were randomly assigned to receive either daunorubicin (50 mg/m2 daily for 5 days) or idarubicin (12 mg/m2 daily for 3 days) in combination with 100 mg/m2 of cytarabine by continuous infusion daily for 7 days as induction therapy. Complete remission was achieved in 407 (77.5%) of 525 patients in the daunorubicin group and 416 (78.2%) of 532 in the idarubicin group (P = .79). Patients achieving complete remission received intensive postremission therapy that consisted of either 3 courses of high-dose cytarabine or 4 courses of standard-dose therapy. Overall survival rates at 5 years were 48% for the daunorubicin group and 48% for the idarubicin group (P = .54), and relapse-free survival rates at 5 years were 41% and 41% (P = .97), respectively. Thus, high-dose daunorubicin and standard-dose idarubicin were equally effective for the treatment of adult acute myeloid leukemia, achieving a high rate of complete remission and good long-term efficacy. This study is registered at http://www.umin.ac.jp/ctrj/ as C000000157.

This study aimed to assess the clinical utility of PCR for the analysis of bacteria and fungi from blood for the management of febrile neutropenic patients with hematologic malignancies. Using a PCR system able to detect a broad range of bacteria and fungi, we conducted a prospective pilot study of periodic analyses of blood from patients following intensive chemotherapy. When fever occurred, it was treated with empirical antibiotic therapy, basically without knowledge of the PCR results. In 23 febrile episodes during the neutropenic period, bacteria were detected by PCR in 11 cases, while the same species were identified by blood culture in 3 cases. In 10 out of 11 PCR-positive cases, fever could be managed by empirical therapy. In the empirical-therapy-resistant case, the identification of Stenotrophomonas maltophilia by PCR led to improvement of fever. No fungi were detected by PCR in febrile cases, while Aspergillus fumigatus was detected in one afebrile patient, several days before a clinical diagnosis was made. In subsequent sporadic PCR analyses in 15 cases of febrile neutropenia, bacteria were detected by both PCR and blood culture in 7 cases and by PCR alone in 6. Fungi were not detected. While fever was improved by empirical therapy in 12 out of the 13 PCR-positive cases, the identification of Pseudomonas aeruginosa by PCR in one therapy-resistant case contributed to the successful treatment of persistent fever. Our results indicate that PCR analysis of bacteria from blood provides essential information for managing empirical-therapy-resistant febrile neutropenia.

Autologous peripheral blood stem cell transplantation (auto-PBSCT) is considered the standard therapy for younger patients with multiple myeloma, however, survival curve doesn't reach plateau. On the other hand, allogeneic reduced-intensity stem cell transplantation (RIST) with graft-versus-myeloma (GVM) effects is expected to be the curable therapy. We had three cases received RIST (one case as a salvage therapy for relapse after tandem auto-PBSCT, and two cases as an intentional RIST after achieving partial response by auto-PBSCT). All of three cases relapsing or progressing after RIST showed disease type of plasmacytoma without plasma cells in the bone marrow. That may be because conditioning regimen doesn't include total body irradiation, or GVM is ineffective in plasmacytoma, but effective in bone marrow. Here, we report clinical course of these three cases with some consideration.

Deletion of the long arm of chromosome 15 is known as a rare but recurrent chromosomal abnormality in myeloid malignancies. We report a novel case of minimally differentiated hypoplastic acute myeloid leukemia (AML M0) in a patient who initially had a normal karyotype, but clonal interstitial deletion of chromosome 15, del(15)(q11.2q22), coincided with increment of leukemic cells a year later. We also summarize 18 published cases with myeloid malignancies and this chromosomal abnormality.

Receptors for granulocyte-macrophage colony-stimulating factor (GM-CSF) and interleukin-3 (IL-3) share a common beta subunit. We recently reported that GM-CSF acts in concert with transforming growth factor-beta1 (TGF-beta1) and Notch ligand Delta-1 (Delta-1) to promote the differentiation of human blood monocytes into Langerhans cells. In the present study, we examined whether IL-3, in place of GM-CSF, can induce the development of Langerhans cells from blood monocytes in the presence of TGF-beta1 and Delta-1, because the IL-3 receptor alpha chain was substantially expressed on monocytes. However, the generation of Langerhans cells was not obtained by the combination of IL-3, TGF-beta1 and Delta-1, even though GM-CSF and IL-3 exhibited a similar effect with respect to the differentiation of monocytes into macrophages and dendritic cells. The addition of GM-CSF to the culture supplemented with IL-3, TGF-beta1 and Delta-1 restored the differentiation of monocytes toward Langerhans cells. A microarray analysis revealed that a number of genes including Langerhans cell markers, E-cadherin and Langerin, were specifically expressed in cells from GM-CSF-containing cultures but not in those from IL-3-containing cultures. These data suggest that IL-3 can not replace GM-CSF to induce the differentiation of human monocytes into Langerhans cells in culture.

Granulocytic sarcoma (GS) is a rare extra-medullary tumor and usually involves the skin, soft tissue, and lymph nodes. GS is found in 8% of acute myeloid leukemia (AML) patients, especially patients with t(8;21)AML. It has been suggested that GS is a poor prognostic factor in t(8;21)AML. Compared to t(8;21)AML, GS is rare in cases of inv(16)AML. Thus, the characteristics of inv(16) with GS are not well understood. Here, we describe a patient with AML and mesentery GS. The chromosomal analysis was normal, but molecular analysis detected the CBFB/MYH11 fusion gene in the blasts. A complete remission was achieved with standard induction therapy followed by high-dose cytarabine consolidation. We have also summarized 12 reported cases of inv(16)AML with GS and found that GS was commonly found in abdominal lesions. These observations suggest that when abdominal GS is diagnosed, an analysis of the CBFB/MYH11 fusion gene is necessary to make an appropriate decision regarding treatment options, even if no chromosomal abnormalities are found.

Histone acetylation controls the expression of specific genes in eukaryotic cells. We investigated the role of histone deacetylases (HDACs) in the differentiation of human erythroid cells, using pharmacological approaches. When CD36+ erythroid precursor cells, generated from CD34+ cells with stem cell factor, flt-3 ligand, thrombopoietin, interleukin-3, interleukin-6, and erythropoietin, were cultured with an HDAC inhibitor FK228 (depsipeptide) at a specified dose in the presence of erythropoietin, their differentiation was inhibited, as determined by the expression of CD45 and glycophorin A. Addition of the same dose of FK228 to cultures did not affect the growth of CD36+ cells. Regardless of the presence or absence of FK228, cultured CD36+ cells displayed similar proliferation kinetics. Analysis of acetylated histones revealed that FK228 upregulated the acetylation status of histones H3 and H4 in CD36+ cells. The inhibition of CD36+ cell differentiation was restored by removal of FK228 from the culture, indicating that the modification of CD36+ cell differentiation by FK228 is reversible. Furthermore, interference with histone deacetylation by FK228 inhibited the generation of CD36+ erythroid cells from CD34+ hematopoietic progenitor cells. Our results indicate the possible involvement of HDACs in human erythropoiesis, especially the regulation of erythroid cell differentiation.

Interleukin (IL)-4 and IL-10 have a wide variety of activities in the immune system. We re-evaluated the action of IL-4 and IL-10 on human blood monocytes, myeloid dendritic cell (DC1) precursors, using a serum-free culture system. Both IL-4 and IL-10 inhibited the survival of CD14 + monocytes supported by granulocyte-macrophage colony-stimulating factor in a dose-dependent manner. When IL-4 and IL-10 were combined, they had synergistic effects at low doses and induced a profound suppression of CD14 + monocyte survival. When the optimal timing was determined, the exposure to IL-4 and IL-10 for the initial 2 days was essential for suppression of survival of CD14 + monocytes. Annexin V/propidium iodide staining indicates that the suppression of CD14 + monocyte survival induced by IL-4 and IL-10 results from apoptosis. Tumor necrosis factor-a and lipopolysaccharide abrogated the effects of IL-4 and IL-10 on CD14 + monocytes, albeit incompletely. Thus, IL-4 in synergy with IL-10 negatively regulates the survival of DC1 precursor monocytes by inducing their apoptosis, which is modulated by factors such as tumor necrosis factor-a and lipopolysaccharide. Our data suggest the primary activities of IL-4 and IL-10 in DC1-mediated immune responses.

This report describes a patient with Philadelphia chromosome-negative (Ph-) but bcr/abl fusion gene-positive chronic myeloid leukemia (CML) and a molecular analysis of the mechanisms behind the Ph- status. Spectral karyotyping-fluorescent in situ hybridization (SKY-FISH) analysis showed no abnormal translocation; however, a bcr/abl fusion gene was detected by reverse transcriptase-polymerase chain reaction analysis. FISH analysis showed that signals from the 9q and 22q subtelomere probes were detected on the der(9) and der(22) chromosomes, respectively. On the other hand, FISH analysis of the abl and bcr genes with dual fusion probes, which can detect the bcr/abl fusion gene on both the der(9) and der(22) chromosomes, showed the signal for bcr/abl fusion on the der(22) chromosome but not on the der(9) chromosome.These results indicate that insertion of the abl gene into the bcr region on the der(22) chromosome or retranslocation between the der(9) chromosome and the der(22) chromosome may have caused the Ph- CML in this case.

Abstract 1963 Purpose: Management of febrile neutropenia in patients receiving allogeneic hematopoietic stem cell transplantation (HCT) is crucial for successful treatment, but precise pathogen identification is difficult because the sensitivity of blood culture remains low, making the antimicrobial therapy empiric. This study aimed to detect and identify bacterial and fungal pathogens from peripheral blood samples during early phase of HCT, using highly sensitive PCR method which is able to detect and identify a broad range of bacteria and fungi (J Clin Microbiol. 48(6):2030-6, 2010) and to assess the clinical usefulness of PCR analysis in managing febrile neutropenia after HCT. Patients and Methods: Ten consecutive patients who underwent HCT in our institute between June 2007 and December 2009 were enrolled. Eight patients received TBI-based conventional and two received reduced-intensity preparative regimens. All patients received antibacterial prophylaxis with fluoroquinolone and antifungal prophylaxis by mold-active azole with temporary use of micafungin. We prospectively performed PCR analysis and blood culture of blood samples at least once a week for the first 30 days of HCT. For species identification, positive PCR products were sequenced. Results: In a total of 56 analyses, bacteria were detected in 23 cases with PCR but in only one case with blood culture. In the febrile patients, 18 cases out of 37 PCR analyses were positive for bacteria, while, in afebrile cases, 5 cases out of 19 PCR analyses were positive for bacteria. In 17 pathogen identified cases, 14 were gram positive cocci and 3 were gram negative rods. Most of the identified pathogens were oral and intestinal bacteria reflecting grade 3 severe mucositis. Fever was manageable in most cases with empiric use of antibiotics, but several series of antibiotic change was required in 2 cases, in which bacteria susceptible to specific antibiotics such as Stenotrophomonas maltophilia were detected. In several cases suffering from severe diarrhea, pathogen could not be identified because PCR products formed multiple peaks. Fungi were detected in only 4 cases, of which 2 cases were provable Aspergillus infection and another 2 cases possessed no other evidence of fungal infection. Conclusion: Bacterial pathogens mostly associated with oral and intestinal mucositis were detected with PCR in approximately half cases of febrile neutropenia, but fever was manageable in most cases with empiric antibiotic therapy by experienced physicians. PCR analysis was considered to be useful in febrile neutropenia due to bacteria susceptible to specific antibiotics such as Stenotrophomonas maltophilia. More rapid and simplified approach which targets clinically important pathogens such as Stenotrophomonas maltophilia that requires specific use of antibiotics may be useful and reasonable to provide support for the choice of antibiotics in clinical practice. Disclosures: No relevant conflicts of interest to declare.

Abstract 3090 Poster Board III-27 The outcome of Philadelphia chromosome-positive acute lymphoblastic leukemia (Ph+ALL) has dramatically improved since the start of treatment with imatinib. The Japan Adult Leukemia Study Group (JALSG) has reported a high complete remission (CR) rate for Ph+ALL treated with imatinib-combined chemotherapy (Yanada et al, J Clin Oncol 2006). Here we report a follow-up analysis of the results of the JALSG imatinib-combined chemotherapy. In the study, remission was induced by administering imatinib from day 8 to day 62 in combination with cyclophosphamide, daunorubicin, vincristine (VCR), and prednisolone (PSL). Consolidation regimen consisted of an odd course comprising high-dose methotrexate and high-dose cytarabine and an even course with 28 days administration of single-agent imatinib. The consolidation regimens were alternated for four courses each. Maintenance consisting of VCR, PSL, and imatinib was continued for two years after a CR. Allogeneic hematopoietic stem cell transplantation (allo-HSCT) was recommended if HLA identical sibling donor was available and was allowed from an alternative donor. A total of 103 newly diagnosed Ph+ALL patients were enrolled in the study between August 2002 and August 2004. Median age of the patients was 45 years (range, 15-64 years), and there were 57 males and 46 females. Median follow-up period was 2.6 years (range, 0.1-5.1 years). A CR was achieved in 100 (97.1%) of the 103 patients and not achieved in a patient in whom imatinib was discontinued because of ileus. There were two early deaths during induction. The probability of overall survival (OS) rate for the entire group at three years was 56.8%. No severe adverse effects were observed. Allo-HSCT was performed in the 1st CR (CR1) in 54 of the 74 CR patients under 55 years of age. Relapse occurred in 18 of 20 patients (90.0%) in whom allo-HSCT was not performed in CR1, but in only seven of the 54 patients (13.0%) who underwent allo-HSCT. At three years, the probability of OS rate for patients under 55 years of age was 75.0% in the transplanted group and 36.4% in the non-transplanted group. Allo-HSCT was performed in CR1 in eight of the 25 patients over 55 years of age. Two were myeloablative and six reduced intensity conditionings. Seven of eight patients who underwent HSCT are still alive in a CR. However, the probability of OS rate at three years in the non-transplanted group was 43.2%. In the group that did not receive allo-HSCT in CR1, age (55< years or 55> years), WBC count, bcr/abl transcript level, bcr/abl transcript type (major or minor), co-expression of myeloid antigens (CD13 and/or CD33), and additional chromosomal abnormalities at diagnosis were not associated with OS. The results demonstrated that the imatinib-combined chemotherapy regimen was effective and feasible. The regimen provided a better chance to receive allo-HSCT which resulted in an excellent outcome. However, relapse still remains a problem, especially in patients who are not candidates for allo-HSCT. Disclosures No relevant conflicts of interest to declare.

Abstract 1058 Poster Board I-80 High-dose ara-C is a basic regimen for the treatment of either relapsed or refractory AML. To improve the outcome of salvage therapy, various combinations of high-dose ara-C have being studied. We herein report the outcome of a phase 2 study of FLAGM. Between 2004 and 2008, JALSG conducted a phase 2 study of FLAGM for relapsed or refractory AML to evaluate its efficacy and toxicity. We thereafter further attempted to predict the response to FLAGM by determining the capability of blast cells to yield the intracellular active metabolite of ara-C: ara-C triphosphate (ara-CTP) in vitro before the start of treatment. JALSG FLAGM enrolled 41 relapsed or refractory AML patients (pts) aged 15-64 yrs (median 52 yrs). The patients were treated with fludarabine 15 mg/m2 twice daily (bid)(d1-4), as well as with ara-C 2g/m2, bid (d1-4), G-CSF 300 μg/m2 (d1-4), and mitoxantrone 10 mg/m2 (d3-5). Six pts showed primary refractory AML. 21 pts relapsed within 12 months after the 1st complete remission (CR), whereas 11 pts suffered their 1st relapse later than 12 months thereafter. Only 1 pt with a 2nd relapse was enrolled. Two pts showed refractory AML after relapse. The diagnoses according to the FAB criteria were as follows: M0 - 3 pts, M1 - 7 pts, M2 – 21 pts, M4 - 8 pts, M5 - 2 pts. Performance status: ECOG 0, 1 and 2 in 76%, 22% and 2% of the pts, respectively. Eight pts had good-risk cytogenetics, 26 pts had intermediate-risk cytogenetics, 2 pts poor-risk cytogenetics, no metaphases were obtained and no cytogenetics were performed in 5 pts. Twenty-one blast samples were evaluated for the production of ara-CTP. The blasts were incubated in vitro either with or without 10 μM fludarabine nucleoside (F-ara-A) for 3 h, followed by washing in fresh media and then subsequent incubation with 10 μM ara-C for 3 h. The nucleotide pool was extracted from each sample and applied to HPLC to measure the ara-CTP production. Following FLAGM, 28 pts (68%) achieved a CR and 1 pt (2%) a CR with an incomplete platelet count recovery (CRp), thus resulting in an overall response rate of 70%. The CR rate of pts in primary refractory and that of pts in 1st relapse were 50% and 79%, respectively. 83% of the pts with a late relapse (duration of 1st CR >=12 months) and 77% of the pts with an early relapse (duration of 1st CR Disclosures: No relevant conflicts of interest to declare.

[Purpose] To compare the incidence, onset and severity of hepatic toxicities and their ultimate impact on survival after reduced-intensity HCT (RIST) and conventional HCT (CST). [Patients and methods] We retrospectively reviewed the data of 151 patients with AML (n=86), MDS (32) and overt AML (33) who underwent allogeneic HCT after either RIST (n=78) or CST (73) between Jan, 2000, and Oct, 2004. Conditioning regimens for RIST included busulfan plus fludarabine or cladribine with or without 2–4 Gy TBI, and those for CST included cyclophosphamide with 12 Gy TBI or busulfan. The median age of the patients was 55 years (range, 15–67) for the RIST group and 37 years (1–57) for the CST group. Patients received marrow (n=64), G-CSF-mobilized PBSC (77) or cord blood (10) from either an HLA-matched relative (59), a mismatched relative (19) or an unrelated volunteer (73). The severity of liver toxicities was assessed by maximal measurements of total bilirubin, ALP, AST and ALT according to CTCAE v.3. Causes of hepatic toxicities were assessed basically by the clinical presentation and, in selected cases, by liver biopsy and autopsy results. The median follow-up of surviving patients was 1,401 days (598–2,317). [Results] The incidences of grade 3–4 hepatic toxicities in the RIST and CST groups were, respectively, 38% vs 38% at day 30, and 60% vs 56% at day 100. The timing of maximum hepatic toxicity was also similar between the two groups. However, the incidence of grade 3–4 hyperbilirubinemia was higher in the RIST group after day 60, probably due to the late onset of acute GVHD after the early tapering of immunosuppression in this group. In contrast, there was a trend for more grade 3–4 abnormal transaminase levels in the CST group than in the RIST group, probably due to the toxicities of drugs including myeloablative conditioning. The causes of grade 3–4 hepatic toxicities were GVHD (n=27), drugs (27), conditioning regimen (7), VOD (3), and others (13). Among the 68 RIST and 66 CST patients who survived more than 100 days after HCT, overall survival (OS) was significantly worse in those who developed grade 3–4 hyperbilirubinemia during the first 100 days after HCT than in those who did not (Figure; 1-year OS, 38% vs 76% after RIST and 33% vs 79% after CST). In a multivariate ananysis, grade 3–4 hyperbilirubinemia (HR 1.8 [95% CI, 1.2–2.7], p=0.02) and non-remission status before HCT (HR 2.5 [95% CI, 1.5–4.4], p=0.0001) were associated with an increased risk of mortality. However, grade 3–4 abnormality in ALP and AST/ALT during the first 100 days after HCT was not a significant risk factor for mortality. [Conclusions] Contrary to our expectations, our data showed a similar incidence of hepatic toxicities between the RIST and CST groups. This may be due to an older age population, the use of busulfan in the conditioning regimen, and the rapid tapering of immunosuppression in the RIST group. The outcome of patients who developed severe grade 3–4 hyperbilirubinemia was poor regardless of the conditioning regimen. Figure Figure

Background: Although acute GVHD (aGVHD) is a significant cause of non-relapse mortality (NRM) after allogeneic hematopoietic stem cell transplantation (HSCT), its impact on outcomes has not been fully evaluated in older patients who receive reduced-intensity HSCT (RIST). Patients and Methods: We retrospectively surveyed the data of 334 patients (median age, 46 years: range, 1–68) with hematological malignancies who underwent allogeneic HSCT between January, 2000, and June, 2005. The diagnoses included AML/MDS (n=164), CML (n=31), ALL (n=39), lymphoma (n=95), and other malignancies (n=5). Sixty-nine patients (21%) had low- and 265 (79%) had high-risk disease. Patients were conditioned with a fludarabine-based reduced-intensity (n=169) or conventional myeloablative regimen (n=165). Patients received bone marrow (n=131), G-CSF-mobilized PBSC (n=173) or cord blood (n=30) from either an HLA-matched relative (n=138), a mismatched relative (n=41) or an unrelated volunteer (n=155). The median follow-up of surviving patients was 1,210 days (range, 346–2,317). Results: Grade II-IV aGVHD occurred in 146 patients (44%; grade II, n=82; grade III, n=43; grade IV, n=21), 73 patients each in the myeloablative and RIST groups, and the timing was before disease progression or relapse in 144 patients. The incidence of NRM in these 144 patients with aGVHD was 41% (59/144), while this was 29% in the overall 334 patients. The causes of NRM included GVHD (n=22), infections with (n=19) or without (n=9) GVHD, and others (n=9). Hence, aGVHD was the primary cause of NRM. Among these 144 patients with grade II-IV aGVHD, 121 (84%) received ≥1 mg/kg/day of methylprednisone as a primary treatment for GVHD, and 19 of the 121 patients (16%) required additional treatment including switching to tacrolimus (n=11), MMF (n=9), or ATG (n=4). Subsequently, 93 patients (65%) developed chronic extensive GVHD (46 progressive and 47 quiescent). The 2-year probability of NRM after the development of aGVHD was higher as the patient age increased; i.e. 29% for Conclusions: Our data suggest that older patient age is a significant risk factor for NRM after the development of aGVHD, regardless of the type of conditioning regimen. The development of a careful management of aGVHD, focusing on older patients should be the subject of intense clinical research. Figure Figure

The commitment and differentiation of hematopoietic progenitors are thought to be associated with the restriction of transcriptional accessibility for genes of unselected cell-lineage. Histone acetylation-mediated remodeling of chromatin structures is known to regulate transcriptional activity of genes, and the acetylation level of histones is controlled by the balance between opposing activities of histone acetyltransferases and histone deacetylases (HDACs). In this study, we investigated the role of HDAC activity in the proliferation and differentiation of erythroid and granulocytic precursors, using a HDAC inhibitor FK228 [depsipeptide]. CD36+ erythroid precursors were generated from cord blood CD34+ cells with SCF, flt-3 ligand, TPO, IL-3, IL-6 [5GF], and EPO. These precursors expressed low or undetectable level of glycophorin A (GPA) but mostly expressed CD45. When these precursors were cultured with EPO alone in the presence of FK228 (0.4~0.5 ng/ml), the resulting cells expressed GPA at a low level in comparison with the cells cultured without FK228, and a large population of the GPA+ cells remained to be CD45+. On the other hand, most of cells in cultures without FK228 expressed a high level of GPA and a majority of the GPA+ cells were negative for CD45. These data suggest that FK228 represses the EPO-dependent differentiation of erythroid precursors. The retardation of differentiation due to FK228 was, however, completely recovered when cells exposed to FK228 were incubated for additional 5 days without FK228. At these concentrations, FK228 did not affect the proliferation of erythroid precursors. Granulocytic precursors were also prepared from CD34+ cells with 5GF and G-CSF. In culture with G-CSF, FK228 did not affect the differentiation of granulocytic precursors but did inhibit their proliferation in a dose-dependent fashion. Histone acetylation induced by FK228 in precursors was confirmed using anti-acetylated histone antibodies. These data demonstrate a distinct and regulatory role for HDAC activity in the proliferation and differentiation of hematopoietic precursors.