Effects of antileukemic agents of nucleic acid metabolism of human leukemic leukocytes were studied by chemical determination of incorporation of radioactive nucleic acid precursors into nucleic acids of the cells and by radioautography using thymidine-³H in vitro in relation with hematological effects of the agents.
Leukocyte suspension was prepared from venous blood of patients with various types of leukemias using the method of Skoog and Beck. Nucleic acid biosynthesis in the leukemic leukocytes was determined by adenine-¹⁴C or hypoxanthine-¹⁴C incorporation into DNA and RNA of the cells during a 3 hour incubation. Inhibition of the nucleic acid biosynthesis by antileukemic agents was observed by measuring the reduction of the incorporation in the presence of the agents. Antileukemic agents such as cytosine arabinoside (CA), 6 mercaptopurine (6 MP) and prednisolone were shown to have a good correlation between the rate of inhibition and hematological effects of the agents. When an agent produced a high rate of inhibition in the majority of cases of a certain type of leukemia, it was found that the agent was effective for that type of leukemia. In the same way, CA was suggested to be effective for a large portion of cases of acute leukemia, but only for a small number of chronic myelocytic leukemia. In the clinical course of patients with acute leukemia treated with CA or 6 MP, the rate of the inhibition was in a good correlation with the hematological effects of the agents. These findings suggest that determination of the rate of inhibition of nucleic acid biosynthesis by the antileukemic agent is valuable for predicting hematological effects of the agent in the chemotherapy of leukemia.
In the clinical course of acute leukemias, the ratio of dividing compartment to non-dividing compartment in leukemic blast cells was shown to be variable according to the chemical determination of DNA biosynthesis or observation of labeling index in the radioautography. The ratio was high in relapse, especially when the leukocyte count was rapidly increasing. DNA inhibitors were effective in this period. On the other hand, the ratio was low in remission. Steroid was effective for small blast cells which had low DNA synthesis or low labeling index in radioautography with thymidine-³H and were suspected to be cells belonging to non-dividing compartment.
Haematological effects of 6 MP were in a good correlation with the ratio of hypoxanthine-¹⁴C/adenine-¹⁴C incorporation. From the results, a possibility that low activity of inosinic and guanylic pyrophosphorylase resulted in deficiency of 6 MP-ribotide formation was suggested as a mechanism of resistance against 6 MP. Rapid conversion of 6 MP to thiouric acid by xanthine oxidase was also suggested to be one of other possible mechanisms of 6 MP resistance in a case of chronic myelocytic leukemia in which a combination of hydroxypyrazolopyrimidine, xanthine oxidase inhibitor, and 6 MP was effective for the resistance.

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This report concerns a response to chemotherapy of erythroleukemia in cases treated in The 2nd Department of Internal Medicine, Kumamoto University School of Medicine. Thirty-four cases of acute and 3 of subacute erythroleukemias have been treated up to the present. Out of the 34 acute cases, 31 were complicated with myelogenous leukemia and the remaining 3 were complicated with monocytic leukemia.
Out of 27 cases receivng chemotherapy, subjective symptoms in 52% of the cases, objective ones in 15%, the blood picture in 59% and the bone marrow picture in 11% were improved. Some cases of erythroleukemia have no symptoms except those due to anemia. Excluding these cases, the rates of effectiveness indicated 61% on subjective symptoms and 21% on objective ones.
All the cases receiving adrenocorticosteroids alone were aleukemic. Out of 7 cases, 3 were effective and the remaining were ineffective. The appearance rate of immature cells in the peripheral blood in aleukemic cases is generally low compared with that in leukemic cases. The averages of the rate indicated 26.7% in effective cases and 10.5% in ineffective ones. This shows that, the treatment using adrenocorticosteroids alone is not always ineffective in the cases with high percentage of immature cells in peripheral blood. Morphological aspects of leukemic cells were more important than the quantity of these cells, that is, the cases with high percentage of promyelocytes were not improved by adrenocorticosteroids alone. The averages of the rate of promyelocytes to the total number of immature cells in peripheral blood were 8.0% in effective cases and 78.6% in ineffective cases. On the other hand, this therapy is effective on the cases with a considerable percentage of paramyeloblasts. The nucleated cell count in the bone morrow was relatively low in the most of the cases belonging to this group. The averages of leukemic cells were 30.9% in effective cases. Adrenocorticosteroids alone were ineffective in most of the cases with lower than 10% of leukemic cells in the bone marrow. The cases with a high ratio of promyelocytes to myeloblasts in both the bone marrow and the peripheral blood, were not improved by adrenocorticosteroids alone. There was no significant difference between effective and ineffective cases concerning erythroblasts in the bone marrow. The influence of adrenocorticosteroids on the erythremic picture was not obvious.

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On the bases of the clinical statistics from 23 collected cases of chronic myelocytic leukemia (CML) with terminal blastic crisis and the related literature 1) effectiveness of early diagnosis and therapy upon elongation of the duration of life, 2) therapy of the blastic crisis and 3) its prophylaxis were investigated.
1. Early diagnosis and therapy on blastic crisis were proved to elongate the duration of life after blastic crisis. As a clue for its early diagnosis the prodromal or initial manifestations or laboratory findings were neuralgic pains in extremities, fever, sudden enlargement of splenic tumor, hemorrhagic diathesis, developments of anemia and thrombocytopenia due to unknown causes, combination of splenomegaly and relatively low value of leukocyte count, CRP (++), and increase in myeloblasts in both peripheral blood and bone marrow. It should be emphasized, however, that in half of cases bone marrow aspiration showed dry-tap.
2. Therapy of choice of blastic crisis might be almost the same as that of acute leukemia, but quick switch over to other drugs should be needed because of the short life span. Steroid hormones, 6 mercaptopurine, Methotrexate, Vinblastin, Vincristin, Daunomycin, and blood transfusions should be used in either single, combined, or cyclic form under a careful consideration to the general physical condition of the patient.
3. As far as prophylaxis is concerned, it would be wise not to completely depress the bone marrow by alkylating agents. Thus, leukocyte count between 10,000 and 20,000 would be most proper during maintenance of remission of CML.

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The Survey on the survivals of 1820 Cases with malignant lymphoma which were collected from all over Japan, shows that the evolution pattern of the lymphnode involvement and the initial site are the largest factors influencing the survivals among over 40 factors. From these results we made new clinical classification. For the accurate evaluation of the survival prolongation effects of the therapy on malignant lymphoma, it is necessary to classify the cases into our new classification.
1. localized type; lymphnode involvement localizes in the initial lymphnode region for more than five month. (for reticulum cell sarcoma, excludes the cases which are classified as naso-pharyngeal sublocalized type)
2. generalized type; lymphnode involvement generalizes beyond the range of the initial region within less than five months.
3. gastro-intestinal type; initial region is in gastro-intestinal tracts. (for reticulum cell sarcoma and lympho-sarcoma)
4. naso-pharyngeal sublocalized type; initial site is in the naso-pharyngeal lymph apparatus, and lymphnode involvement spreads beyond the area of the primary region within three to five months. (for reticulum cell sarcoma)
Fifty % survival of all cases of reticulum cell sarcoma, lymphosarcoma and Hodgkin's disease is 12.6, 10.4, 16.7 months respectively, and that of localized type, generalized type, gastro-intestinal type and naso-pharyngeal sublocalized type is 30.0, 6.9, 26.9, 13.5 months for reticulum cell sarcoma respectively, that of localized type, generalized type and gastro-intestinal type is 57.9, 6.0, 10.0 months for lymphosarcoma respectively, and that of localized type and generalized type is 48.0, 10.1 months for Hodgkin's disease respectively.
We treated 131 cases with malignant lymphoma using various chemotherapeutic agents. We compared the tumor regression effects and remission rates using scoring method. The length of remissions were caliculated and the side effects of those drugs were checked up.
Vincristine alone and combination therapy with Vincristine, cyclophosphamide, 6 MP and prednisolone showed the highest regression rates, remission rates and the longest durations of remission. The cases which were treated with Vinca alkaloids showed the remarkable prolongation of the survivals comparing to the cases which treated with other drugs.
Bleomycin, a new antibiotic, showed complete remissions in two of four cases, premises to be a useful drug for malignant lymphoma.

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(1) Treatment and prognosis of polycythemia vera among Japanese.
With the purpose of knowing the present states of therapy and prognosis of polycythemia vera in Japan, we asked to the doctors in about 600 hospitals concerning the details of the polycythemia vera patients they had treated since 1950. Analysis of the data of 153 cases (male 87, female 66) we have thus collected, revealed that the survival rate of the patients was apparently reduced as compared to normal Japnese, and that this reduction was mainly caused by the low survival rate among the patients who have been treated by chemotherapy. The patients treated with radioactive phosphorus showed a similar survival rate to the normal people. In 22 cases, death was confirmed. Main cause of death was cerebral vascular lesion (6 cases) and gastrointestinal bleeding (6 cases). Acute leukemia was observed in a case who had received ³²P therapy 8 years prior to his death.
(2) Clinical effect of vercyte.
A derivative of the piperazine (vercyte), which has been tried in the treatment of polycythemia vera in the United State, has been administered to 4 patients with polycythemia vera. The drug was effective in all patients, and no side effect was observed.
(3) Mechanism of action of vercyte.
To study the mechanism of action of vercyte, spleen cells from phenylhydrazine-injected mouse was incubated in vitro with vercyte to observe the effect of the drug on RNA, DNA and protein synthesis. It was found that the DNA synthesis was most strongly affected by the drug. Incorporation of the thymidine, deoxyuridine, and orotic acid into DNA were similarly inhibited. Activities of thymidine-kinase and DNA-polymerase of cell-sup from phenylhydrazine mouse spleen was not inhibited by the vercyte. When the calf-thymus DNA was preincubated with the vercyte, however, its template activity with DNA-polymerase was markedly decreased by the drug. Template activity with DNA-dependent RNA polymerase of the calf-thymus DNA or chromatin from the mouse spleen cells was also significantly reduced by the vercyte. It was suggested, therefore, that the vercyte inhibited the template activity by binding with DNA. Changes in the karyotype of the bone marrow cells obtained from vercyte injected mouse also support the above suggestions on the binding of the vercyte with DNA.
(4) Sensitivity to vercyte of various hematopoietic cells.
When the sensitivity to the vercyte was compared among colony-forming cells (Till & McCulloch), erythropoietin-responsive cells, and erythroblasts, the undifferentiated colony forming cells, which have been considered as the multipotential stem cells, were most resistant to the vercyte. There was no difference among erythroblasts, granulocytes, and lymphocytes in their sensitivities to the vercyte which were measured by the reduction in DNA-synthesis.
(5) Effect of vercyte on human hematopoietic cells.
DNA synthesis in the normal human bone marrow cells in vitro was inhibited by adding vercyte. The degree of the inhibition was identical to the one observed in mouse bone marrow cells. The leukemic leukocytes from a patient with chronic myelogenus leukemia who became resistant to vercyte treatment were less sensitive to the vercyte than normal bone marrow cells.

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Thrombocytopenic effect of the ITP patient's serum on rabbits was investigated, in comparison with the serum from normal adult and patients with secondary thrombocytopenia.
The decrease of rabbit platelets after infusion of patient's serum was most remarkable and continued more than 24 hours since the beginning of injection.
The number of megakaryocytes in the bone marrow of rabbits rapidly decreased and their platelet production also depressed 4 and 24 hour after injection.
There was a definite correlation between the thrombocytopenic effect of patient's serum and their clinical course.
From the results mentioned above, it was concluded that the demonstration of thrombocytopenic factor in the patient's serum was useful method for the diagnosis of ITP.

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Two cases of them had complications; one aortic regurgitation, and the other diabetes mellitus and a bladder tumor. The diagnosis of myeloma was given by the serum protein fractionation and immunoelectrophoresis.
X-ray examination revealed punched-out areas and thin cortices of the skull and, in addition, osteoporosis of ribs in one of them. In all cases a compression fracture, spondylitis ancylopoietica or osteoporosis of the lumber vertebra was found.
In myelogram an increase of plasma cell was found, but no plasma cell in the blood. There were moderate anemias. Serum showed elevated levels of B.U.N., uric acid and total protein, but no cryoglobulin. All the serum electrophoretic patterns showed a high, sharp peak in γ region. Urine of two cases with Bence Jones proteinuria showed similar electrophoretic pattern to the serum. The other case had neither a sharp peak in γ region on electrophoresis nor Bence Jones protein.
In immunoelectrophoresis every case presented a larage, diffuse IgG bow, and disappearance or decrease of IgA and IgM was observed. Lastly in the immunoelectrophoresis using anti-K and anti-L rabbit serum, a deposit line strongly reacting with anti-K serum was found.
From these facts, these three caces were concluded as IgG myeloma of K-type.

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There are a number of reports of myelofibrosis in Europe and America, but few in Japan since G. Heuck first reported two cases in 1879.
A case of primary myelofibrosis, for which steroid hormone was effective, was reported.
The patient was a fifty-four-year-old woman. On admission chief complaints were paplpitation, dizziness, general fatigue and hepatosplenomegaly
Family history and past history were noncontributory.
Blood studies revealed remarkable anemia and leukopenia. Examination of blood smears showed immature neutrophils, erythroblasts and tear drop cells. The bone marrow was found to be in the condition of so-called dry tap.
Fibrotic change of bones was disclosed by bone marrow biopsy.
Extramedullary erythropoiesis was recognized by liver biopsy.
Ferrokinetics and organ scanning for lokalization of radioactive iron was performed and results were typical for myelofibrosis, and a diagnosis of primary myelofibrosis was made because the cause of it was unknown.
At first the treatment with androgen was ineffective. Next he was treated by steroid hormone with marked improvement.

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The clinical course of a case of early diagnosed chronic myeloid leukemia was reported. The patient was a 41-year-old male, who had been working as X-ray technician for 15 years.
In 1963, his leukocyte count was normal. On July, 1966, Slight leukocytosis was accidentally found although he had neither complaints nor clinical signs at that time. Bone marrow aspiration and chromosomal analysis were carried out on September, 1966 and the diagnosis of CML was established by confirming Ph¹ chromosome. Clinical manifestations of the disease (marked leukocytosis, anemia, splenomegaly etc.) became completed on March, 1968. Assuming that the onset was between 1963 and 1966, asymptomatic period of this case was roughly estimated 3.5 years.
Ferrokinetic studies revealed that the bone marrow erythropoietic activity was normal in 1966, but the extramedullary erythropoietic activity overwhelmed the bone marrow in 1966.
From March, 1968, 2 mg of busulfan were administered daily and the remission was successfully induced 3 months later.

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