Since G-CSF-mobilized blood cells contain much higher numbers of CD34⁺ cells compared with marrow cells, it is a more suitable target population for positive selection with immunological methods. By the use of this purification procedure, the number of tumor cells contaminated in the grafts can be reduced in autologous settings and T cells can be depleted from the grafts in allogeneic settings. Furthermore, the volume of purified cell suspension is quite small, and we can ignore the adverse effects at the time of infusion without loss of the rapid reconstitutional ability of blood components after transplants. The purified blood CD34⁺ cell transplantation could become a revolutionary method in hematopoietic cell transplantation. It has not been clinically confirmed, however, that the use of purified cells has resulted in an improvement of patient survival or in a cure rate in the treatment of various types of diseases. The purified CD34⁺ cell transplantation has just been established as one type of stem cell rescue. To evaluate the advantage of the use of purified CD34⁺ cell transplants in treatment strategy, randomized clinical studies should be organized to compare with other types of transplants with unmanipulated blood cells, bone marrow cells, or cord blood cells.

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We measured the percentage of circulating platelets that were stained supravitally for RNA with thiazole orange (TO), a fluorescent dye, in patients with various thrombocytopenic disorders. In patients with acute idiopathic thrombocytopenic purpura, the percentage values of TO-positive platelets were significantly elevated over those in normal control. However, the percentage values of TO-positive platelets in patients with aplastic anemia remained within the range of normal control. These findings suggest that the elevated percentage of TO-positive platelets reflects the activation of thrombopoiesis in the bone marrow. An apparent elevated percentage of TO-positive platelets was noticed at the recovery phase from chemotherapy-induced thrombocytopenic nadir in patients with leukemia and malignant tumor. Thus we confirmed that TO-positive platelet was one marker of thrombopoietic activity. Serial measurements of TO-positive platelets during recovery from cytopenic nadir with stem cell transplantation, by using a granulocyte colony-stimulating factor, showed that the neutrophile progressively returned to increase before the percentage of TO-positive platelets and reticulocytes elevated. These observations indicate that TO analysis is potentially a reliable method of estimating platelet production.

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Serological observations of patients with IgG2 deficiency have shown frequent occurrence of abnormal patterns of antibodies to Epstein-Barr virus (EBV). To elucidate this mechanism, we studied the immunological functions of seven patients. Four had unusual EBV serological profiles ; three of the seven were two half-brothers and their mother. The lymphocyte subsets, nonspecific killer activity, and lymphocyte proliferative responses were determined by flow cytometry, ⁵¹Cr-release assay, and [³H] thymidine incorporation assay, respectively. The cytotoxic T-cell responses to autologous EBV-infected cells were further analyzed in a ^51Cr-release assay, in combination with cell depletion and cold-target inhibition assays. Although four of the patients with abnormal serological profiles for EBV had low CD4/CD8 ratios (<1.0), their nonspecific killer activity and lymphocyte proliferative responses were normal. The lymphocytes stimulated with autologous EBV-infected cells had a defect in their ability to kill the autologous cells : The percent lysis values (mean±SD) were decreased (5.8%±1.5%) in the four patients, compared with the control values of 20.8%±4.5%. There was no such defect of EBV-specific cytotoxic T cells in the other three patients. Phenotypic and functional analyses of the cytotoxic T cells demonstrated that the decrease in killing ability was, at least in part, caused by a defective generation of the EBV-specific cytotoxic CD8⁺ T cells. The present study indicates that a portion of IgG2 deficiency patients develop atypical EBV infection because of the defective cytotoxic T-cell response to EBV. It would appear that this disorder is, in part, a combined immunodeficiency characterized by IgG2 deficiency and defective cellular immunity against EBV.

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We report on three patients with abdominal malignant lymphoma presented with intussusception. They were a 10-year-old boy with ileocolic tumor (diffuse large cell type), an 8-year-old girl with ileocolic tumor (Burkitt type), and a 3-year-old girl with jejunal tumor (Burkitt type). It took 3 to 4 weeks for the patients to diagnose malignant lymphomas after the appearance of the first symptoms. Including these cases with 25 patients reported in the literature, we noted that it required about 6 weeks (median 4 weeks) from the initial signs and symptoms to the diagnosis of malignant lymphoma. To make such a diagnosis in children with prolonged abdominal pain, we should therefore be careful not to overlook intussusception induced by malignant lymphoma.

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We report on a 14-year-old boy who relapsed as AML (FAB-M2) 9 months after diagnosis of _γδ-type T cell ALL. At the onset, the patient had pleural effusion and mediastinal mass with bone marrow smear showing 43.5% blast cells (FAB-L1). The blast cells were positive for CD2, 3, 5, 7, 8, TCR γδ and were shown to be rearranged on TCR_γ gene analysis. A complete remission was obtained by a combination induction chemotherapy, but 9 months later the disease recurred when his bone marrow smear revealed 70% blast cells (FAB-M2). Because in a TCR_γ gene analysis the leukemic blasts showed the same rearrangement pattern, we assumed that leukemic blasts at the onset and relapse were derived from the same origin. Reports on a lineage switch being referred to the clonal origin at the onset and relapse in ALL are rare in which most of their phenotypes have been described as T-cell types. We think that T-ALL tends to relapse as AML, compared with other types of ALL.

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This report is on the development of acute myelogenous leukemia (AML) in a 21-year-old Japanese female with systemic lupus erythematosus (SLE). She had previously received immunosuppressive agents, including corticosteroid and azathioprine to treat SLE. After about 11 years of medical care, she developed AML. She aggressively underwent induction chemotherapy with antileukemic drugs. In spite of these treatments at induction, a complete remission was not achieved. A postmortem examination was performed and leukemic infiltrates were found in almost all organs, including bone marrow, liver, spleen, kidneys, colon, and lymphnodes. Although the occurrence of autoimmune disease and lymphoproliferative disorders is shown, it is rare that AML developed during the course of SLE. The occurrence of this malignancy might have been coincidental or caused by other factors; however, the likelihood that it developed as a result of the administration of azathioprine is of great concern. Physicians should remain alert to an occurrence in patients with SLE treated with such a drug.

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We report a case of myeloid surface antigen-negative acute myelocytic leukemia (AML). Peroxidase (POX) -positive leukemia was determined by light microscopy to be AML according to French-American-British classification. In general, POX-positive blasts show positive for myeloid surface antigen. In our case, leukemic blasts occupied 88.2% of total nuclear cells in the bone marrow, and 15% of the blasts showed positive for POX staining as defined by both light and electron microscopy. Flow cytometric analysis also revealed the blasts' positivity for myeloperoxidase. Surface antigen analysis of the blasts indicated them to be positive for CD 10, 19, 20, Sm-IgM, Sm-λ, and TdT and negative for myeloid antigens CD 13 and 33. The chromosomal analysis was t (1;19) (q31;p13) in 9 of 20 cells. There were rearrangements at the Ig (H) JH, Cμ, and Ig (L) CL loci. The patient's leukemia is considered to be of a rare type showing POX-positivity but, otherwise manifesting the characteristics of the lymphoid series. Only 5 adult cases of the same phenotype as our case have been reported in the literature. This report represents the first description of a childhood case.

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We report the case of a 11-year-old boy with Philadelphia chromosome-positive refractory ALL who underwent transplantation with unmanipulated bone marrow from his HLA 2-locus mismatched father. The conditioning regimen consisted of total body irradiation, high-dose cytosine arabinoside, and busulfan. PCR analysis revealed positive results for minor BCR-ABL before BMT and on the 40th day after BMT ; the results were negative on days 96 and 180 after BMT. The patient suffered from chronic GVHD and severe visual impairment caused by cytomegalovirus retinitis. The patient remains in complete clinical remission 750 days after transplantation. The GVL effect was thought to be important for the prevention of leukemic relapse.

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We report a 15-month-old girl who developed hemophagocytic syndrome (HPS) 2 months before the diagnosis of acute lymphoblastic leukemia (ALL) with the 4 ; 11 translocation. She was admitted for persistent fever, pallor, hepatosplenomegaly, and severe pancytopenia and was diagnosed to have HPS. The clinical and laboratory findings were normalized by supportive care, including G-CSF administration. Two months after the onset of HPS, she was readmitted for an evaluation of fever, leukocytosis, and thrombocytopenia. The bone marrow specimen revealed a massive infiltration of lymphoblasts (L2 by FAB classification) without an increase in hemophagocytic cells. She was diagnosed by surface marker analysis as having B-precursor ALL and was successfully induced to complete remission. Because the blasts had the 4 ; 11 translocation and the MLL gene rearrangement, which predict poor prognosis of the disease, she received an allogeneic bone marrow transplantation from an HLA-identical sibling. At 2 years posttransplantation, she shows no recurrence of HPS or of ALL. The etiological relationship between HPS and ALL was discussed.

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We performed HLA one haploidentical cord blood stem cell transplantation (CBSCT) from a sex-mismatched sibling for a case of infantile ALL. This case developed hematological and meningeal relapse after receiving an autologous bone marrow transplantation and could not find an HLA-matched donor. The CBSCT was done on 16 February 1996. He received 2.5 × 10⁷ mononuclear cells/kg (5 × 10⁴ CD34-positive cells/kg) after conditioning with craniospinal irradiation (6 Gy), TBI (12 Gy), thio-TEPA (600 mg/m²) and cyclophosphamide (120 mg/kg). Cyclosporine was used for GVHD prophylaxis. Ganciclovir (GCV) was administered from day -9 to day -2 because the patient was CMV-seropositive. G-CSF was given from day 3. Neutrophil counts rose to 0.5 × 10⁹/l on day 17. Complete chimerism was confirmed by the detection of XX chromosome in peripheral blood nuclear cells by FISH on day 28. He developed grade III acute GVHD with resolution by repeated pulse therapy (high-dose methylprednisolone) and tacrolimus. Chronic GVHD (skin and gut) subsequently developed and was controlled well with prednisolone alone. He suffered from CMV enteritis on day 152, which was successfully treated by GCV. This case is doing well two years after CBSCT. It is suggestive that haploidentical CBSCT from a sibling is feasible under the sufficient GVHD prophylaxis and proper supportive therapy.

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In two cases of Philadelphia-positive childhood acute lymphoblastic leukemia (Ph¹ ALL), we performed allogeneic bone marrow transplantation (AlloBMT) with preconditioning regimen, including hyperfractionated high-dose total body irradiation (TBI) (13.5 Gy, in 9 fractions). Their disease statuses at BMT were hematological relapse in case 1 and molecular relapse in case 2. Bone marrow donors were unrelated in case 1, and HLA was a partially mismatched mother in case 2. Regimen-related toxicity was tolerable in both cases. Hematological recovery was rapid, and engraftment was obtained on day 14 in case 1 and on day 12 in case 2. BCR/ABL message in bone marrow disappeared on day 89 in case 1 and on day 19 in case 2 and throughout their subsequent clinical courses. Although short-term MTX and Cy-A continuous infusion were used for GVHD prophylaxis, grade IV GVHD was observed in case 1 and grade III in case 2. Both cases experienced hemorrhagic cystitis because of adenovirus type 11 infection. Although case 1 died of interstitial pneumonitis on day 442, case 2 has been free of disease through day 231. AlloBMT for Ph¹ ALL with preconditioning regimen including hyperfractionated high-dose TBI is considered to be worth further investigation.

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