Thrombolytic enzymes belong to plasminogen activator (PA) in blood fibrinolysis and love been used for the efficient thrombolysis is achieved by the administration of PA which has high affinity for fibrin and induces plasminogen activation on the fibrin surface. PA with lower affinity for fibrin can activate plasminogen in circulating plasma, which causes bleeding tendency. At present, 11 PAs which are available for clinical usage or under investigation, are classified into two types: direct-type PA and indirect-type PA. The former which cleaved plasminogen directly and produces plasmin, includes urokinase-type PA, tissue-type PA, single-chain u-PA, bat PA, mutant PA, hybrid PA, IgG carrying PA and bispecific monoclonal antibody. The latter has no biological function by itself and expresses PA activity after forming a complex with plasminogen. This group includes streptokinase, anisoylated plasminogen streptokinase activator complex and staphylokinase. The PA activity of staphylokinase/plasminogen complex is inhibited by α₂-plasmin inhibitor, but can be expressed on the fibrin surface. Thus, PA activity of this complex is hardly observed in plasma. These feature of staphylokinase resembles to tissue-type PA.

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Among malignant disease, the non-Hodgkin's lymphomas (NHL) are a diverse group of lymphoid neoplasms that display a wide spectrum of clinical, morphologic, immunologic, and molecular features. Currently the NHL are divided into three groups based on their clinical behavior: 1) indolent, 2) aggressive, and 3) highly aggressive. Among the groups, many patients with aggressive NHL is curable with current combination chemotherapy, however fractions of patients will relapse, and resistant disease remains a problem. It would be valuable to identify those patients with a particularly poor prognosis when treated with a standard regimen so that alternative therapies could be tested. A number of risk factors distinguish patients with a distinct natural history and probability of response to therapy. Recently, international index indentifies subsets of patients who are likely to do well or unlikely to benefit from standard regimens and younger high risk patients are candidates for more intensive experimental therapy. A major idea that is guiding the development of new treatment programs is augmenting the dose intensity of the treatment. The development of colony-stimulating factors allow us to increase intensity of chemotherapy. However, it must be confirmed that such therapy really improve the survival of the patients with high risk NHL. Formerly a universally fatal disease, relapsed aggressive lymphoma now appears to be responsive to combinations of non-cross resistant antineoplastic drugs or to high-dose chemotherapy with or without rediation therapy followed by autologous or allogeneic bone marrow or peripheral blood stem cell transplantation. The capacity of non-cross resistant or high-dose chemotherapy to cure a fraction of these patients, who are resistant to conventional-dose chemotherapy, suggests that addition of such regimen as an alternative or consolidation therapy in primary therapy would improved the outcome of high risk NHL. There are many new approaches to treatment of NHL emerging as a result of improvements in our understanding of biology of lymphomas and the host response to lymphoma. At this time, none of these new approaches are sufficiently improve upon standard combination chemotherapy in the management of patients with high risk NHL.

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Recently transfusion-transmitted infections (TTI) have been decreased remarkably. Especially nonA, nonB posttranfusion hapatitis (PTH) has reduced to one third by introducing anti-HCV (C100-3) antibody screening. HCV-PTH will be lowered more with screening by the 2nd generation reagent of HCV. None of cases with HIV infection by transfusion has been reported since introduction of anti-HIV antibody screening, but we have to watch out it, due to rapid increase of hetrosexual infection of HIV during this one year in Japan. Voluntary blood donors should warrant blood safety by their own responsibility. We have no cases with malaria by transfusion for these several years. There are no reported cases with Chagas' disease in Japan, but increase of international immigrations will be potential to introduce these infections by transfusion into Japan. Recently TTI by bacteriacontaminated blood have been very rare owing to technical improvement of blood-drawing. However, platelet concentrates stored at 22°C for 3∼5 days and red cell products stored at 4°C for 35∼42 days have presented new problems concerning bacterial contamination. We have to consider thses problems concerning bacterial contamination.

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The mechanism of human multiple myeloma cell growth was studied utilizing eleven myeloma cell lines established in vitro or in vivo (Scid mouse). Four bone marrow derived cell lines grew dependently on IL-6 or bone marrow stromal cells. Seven extramedullary lesion derived cell lines grew spontaneously and additively proliferated in response to IL-6. All cell lines expressed the IL-6 receptor (IL-6R) and IL-6RmRNA, but none expressed IL-6mRNA. No IL-6 activity was detected in the myeloma cell culture supernatant. Both the anti-IL-6 antibody and anti-IL-6R antibody neutralized IL-6-induced proliferation, but did not inhibit spontaneous proliferation of extramedullary lesion derived cell lines. While establishing cell lines, it was found that the proliferating fraction was primarily included in a fraction which was non-adherent to stromal cells and composed of undifferentiated plasmablasts. Undifferentiated plasmablasts proliferated in response to IL-6, in contrast to the adherent, mature form of myeloma cells which did not proliferate in response to IL-6. Innoculation of myeloma cells into Scid mice induced subcutaneous tumor formation. These tumors were composed of undifferentiated plasmablasts, which also proliferated in response to IL-6. These results imply that the growth of bone marrow derived myeloma cell lines are dependent on the IL-6 paracrine mechanism and that the growth of extramedullary lesion derived cell lines primarily autonomous and additively dependent on the IL-6 paracrine mechanism.

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It remains to be clarified whether IL-6 acts on the growth of human myeloma cells by an autocrine or paracrine mechanism. Even in established myeloma cell lines, the autocrine growth by IL-6 appears unusual. In the present study, we deviced a model of IL-6 autocrine growth in vitro by transfecting IL-6 cDNA into a human myeloma cell line that had a proliferative response to IL-6 but did not produce IL-6. After IL-6 transfection, the cells (S6B45) proliferated in culture media without IL-6. IL-6 production by S6B45 was demonstrated both at protein and mRNA level. The growth of S6B45 was definitely inhibited by anti-IL-6 (MH166) or anti-IL-6 receptor (PM1) monoclonal antibodies. Furthermore, S6B45 was succesfully transplanted to nude mice. The transplanted tumor growth was clearly inhibited by the administration of MH166 or PM1 to the mice. The in vivo antitumor activity of these antibodies suggest a new therapeutic strategy against tumors that proliferate by an autocrine mechanism through a cytokine such as IL-6.

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The physiological role of fibronectin (FN) on the human plasma cells were examined using three PC cell lines, FR4ds, OPM1 and OPM1ds. FR4ds was reactive with anti-VLA-α4 and anti-α5. In contrast, OPM1 and OPM1ds were not reactive with anti-VLA-α5. FN induced spreading in FR4ds and OPM1ds. Albumin blocked these spreadings. FR4ds with mature plasma cell phenotype of α4+ and α5+ was more sensitive for FN than OPM1 and OPM1ds with immature phenotype of α4+ and α5-. Spreading cells proliferated more than floating cells. All these cell lines showed chemotaxis toward FN. α5+ FR4ds was more sensitive for FN than OPM1 and OPM1ds with α5- phenotype. These new abilities of PC of spreading and chemotaxis we found are summarized to be an affinity to organs. It is likely that α4+ and α5- PC with low affinity to organs are stored in peripheral blood as a result. We examined the chemotaxtic activity of myeloma cells in bone marrow and these in pleural effusions in a patient with multiple myeloma. These cells in pleural effusions showed more chemotaxic activity than these in bone marrow. FN induced growth, production of Ig, and motility of PC, which resulted in the augumentation of humoral immunity.

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Heterogenous biological character of myeloma cells was associated with different expression of adhesion molecules. Myeloma cells could be phenotypically divided into two subpopulations: CD38⁺⁺/VLA5⁺/MPC-1⁺ (VLA-5⁺) cells and CD38⁺⁺/VLA5^-/MPC-1^- (VLA-5^-) cells. VLA-5^- myeloma cells were morphologically immature and proliferated markedly with response to IL-6 in vitro, while VLA-5⁺ cells showed very low uptakes of ³H-TdR but secreted higher amounts of M-protein in vitro. These results suggest VLA-5^- cells are proliferative precursor in myeloma. With respect to VLA-5 and MPC-1 expression, myeloma precursor cells (CD38⁺⁺/VLA-5^-/MPC-1^-/CD10^-/CD24^-) showed similar phenotype to germinal center B cells (CD38⁺/VLA-5^-/MPC-1^-/CD10⁺/CD24^-), rather than that of pre-B cells in the bone marrow (CD38⁺/VLA-5⁺/MPC-1^-/CD10⁺/CD24⁺). Identification of precursor cells and characterization of their growth is important for the understanding of pathophysiology of myeloma and the therapeutic strategy.

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The clinical course of multiple myeloma (MM), ranging from relatively asymptomatic form to frankly aggressive neoplasia, is more variable than that of other hematologic malignancies. The nature of tumor cells and/or the secondary effects of malignancy as anemia, hypercalcemia, and renal failure have shown to correlate with clinical behavior of MM. Prognostic variables include age, degree of anemia, morphologic subtypes, serum creatinine and calcium levels, Bence Jones proteinuria, plasma cell LI%, β2MG level, nucleolus-associated J chains and other laboratory prognostic factors. The plasma cell LI% is the most reliable predictor of survival. Analysis of the presenting features and the clinical characteristics indicates that there are several variants of MM with a poor prognosis, including jevenile myeloma, plasma cell leukemia, aggressive myeloma, high LDH myeloma, J chain myeloma, and amylase-producing myeloma. Four relapsing patterns have been pointed out. The appearance of an additional M-component (mutation escape) suggests the terminal or advanced stage of illness. A new lambda-type M-component can be found in patients with kappa-type myeloma. The prognostic significance of Bence Jones escape varies for different stage of illness. Bence Jones escape is an important predictor of the development of overt MM in patients with smoldering MM. The need for clearly established prognostic criteria is imperative for the choice of correct therapeutic strategies.

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Quantitation of peripheral circulating myeloma cell precursors, problems on serum β2—microglobulin value which is a prognostic factor in myeloma, and prognostic factors associated with long-term survival in our Japanese myeloma patients are described.
Peripheral blood mononuclear cells were cultured in vitro in the presence of various recombinant cytokines and differentiated to plasma cells to quantify peripheral circulating myeloma cell precursors. It has speculated that the variation in the number of myeloma cell precursors in peripheral blood could be used as a parameter of the efficacy of chemotherapy in patients with myeloma.
Serum β2-miciroglobulin value increased with age and under α-interferon therapy in myeloma, even if M protein decreased, suggesting that its value should be carefully monitored when evaluating the response to α-interferon and other chemotherapeutic agents.
Of 1,119 Japanese patients with symptomatic myeloma who were newly diagnosed at 16 institutions of the Japan Myeloma Study Group between 1965 and 1981, 38 (3.4%) patients survived for more than 10 years. In comparison with 121 patients who died within 10 years in our institution, younger age, low and intermediate tumor mass, lower plasmacytosis, higher percentages of granulocytes and erythroblasts in bone marrow, and subtype classified as mature or intermediate were strongly correlated with long-term survival.

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There are only 3.3% of patients with multiple myeloma in Japan Myeloma Study Group who have lived longer than ten years. Features associated with long survival include responded well to simple treatment such as melphalan or cyclophosphamide and prednisone, short duration of treated time with long activity and prolonged unmaintained remissions. High-dose melphalan therapy, VAD chemotherapy and MCNU-VP16-melphalan combination were tried for patients relapsed with alkylating agents and the result were reported. Bone marrow transplantation and cytokine therapy for myeloma will be discussed.

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In two consecutive studies of a pilot study and a multicenter trial 16 patients and 61 patients, respectively, with multiple myeloma were treated with the combination chemotherapy (CMVM regimen; the same intermittent high dose dexamethasone as in VAD regimen, MCNU bolus injection of 1.2mg/m² on day 1, melphalan 12mg/day on days 1-6) plus IFNα (HLBI 300MU every day or two) to assess the efficacy and the toxicity of this protocol. Both studies were achieved in the same regimen except for initial 12 days administration of IFNα in the multicenter trial. The treatment was repeated 3 times every 6∼8 weeks. Complete remission (CR) in which serum and urine M protein disappeared and myeloma cells in bone marrow were eradicated was obtained in 6 in 16 patients (37.5%) in the pilot study and 16 in 61 patients (26.2%) in the multicenter trial. CR plus PR was 68.8% and 68.9% in two studies. The achivement of CR in such high proportion of patients may exhibit a significant advance in the myeloma therapy.

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We report a therapeutic protocol for elderly patients with chronic idiopathic thrombocytopenic purpura (ITP) and related conditions. Twelve chronic ITP patients over 60 years of age (elderly group), and 40, 59 years old or less (young group) were evaluated in this study. The therapeutic protocol for ITP, proposed by the Japanese Idiopathic Disease of Hematopoietic Organ Research Committee, was modified for the elderly (group) as follows: the initial dosage of prednisolone was reduced by half and danazol therapy was selected in cases in which splenectomy was impossible. Platelet counts and PAIgG showed no significant difference between the two groups. All 12 elderly patients were initially treated with prednisolone, and five patients responded to it. Among the seven non-responders, four patients underwent splenectomy, and the three three others (non splenectomized patients) were treated with danazol. Platelet counts were maintained over 150×10³/μl in eleven patients except one splenectomized patient. The outcome in the elderly ITP group was better than in the young group.

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Serum erythropoietin (EP) concentration was measured by the recombinant EP-based radioimmunoassay and was examined to standardize the hemoglobin (Hb) related level of 144 normal control and 56 patients with iron deficiency anemia and hemolytic anemia excluding paroxysmal nocturnal hemoglobinuria. The standardization was achieved by logarithmic regression of the EP titier on Hb either by the two-phase linear form or by the third degree sigmoid form at a 95% confidence limit for each regression. The third degree regression was found to be preferable from the view point of both statistics and the negative feedback mechanism. The avarage and scattering of the deviation from the standard level thus determined of the disease groups indicated that the EP level is: (1) 12 fold higher than the standard level in 42 aplastic anemias (the most in excess and a few in standard). (2) three fold higher than that in 27 myelodysplastic syndromes (relatively higher dispersed state). (3) 29% of the standard level in 33 anemias associated with chronic renal failure (deficient state). (4) 105% of the extrapolated standard level in 22 polycythemia veras (standard state). The standardization of Hbrelated Ep titer may provide new pathophysiological approaches in a variety of hematopoietic disorders.

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Two cases fo non-Hodgkin's lymphoma suffered from acute respiratory failure. Both patients were treated with MACOP-B therapy, and received recombinant granulocyte-colony stimulating factor (rG-CSF) during the myelosuppression. They had fever and severe hypoxemia several days after 11 and 12-week's treatment, respectively. The chest X-ray films revealed diffuse fine granular shadows in bilateral lung fields. The number of white blood cells had rapidly increased when the shadows appeared. These cases suggested the possibility that rG-CSF, or the rapid increase of white blood cells, might induce interstitial pneumonia.

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The authors report a de novo AML (M2) patient associated with 5q- as the sole karyotypic abnormality. A 76-year-old woman was referred to our hospital because of anemia and leukocytosis. On examination a neck lymphn node was enlarged, but neither the liver nor the spleen could be palpated. The hemoglobin level was 7.1g/dl, the mean corpuscular volume 102fl and the white-cell count was 256.1×10³/μl with 87% blast cells. The platelet count was 10.9×10⁴/μl. The bone marrow was hypercellular with 79.8% blast cells and showed dysmegakaryocytopoietic features (hypolobulation, multiple separated nuclei and micromegakaryocytes). Blast cells gave a positive reaction for peroxidase and αNB esterase which was not blocked by NaF. The diagnosis of AML (M2) was made but she died before chemotherapy. Autopsy revealed general hemorrhagic tendency and leukemic cell infiltration. Chromosome analysis of the bone marrow showed 46, XX, del(5)(q13q31). Electron micrographs revealed increase of micromegakaryocytes as small as myelocytes and aggregation of demarcation membranes in some megakaryocytes. This may suggest that some molecular changes, instead of karyotypic evolution, contributed to a leukemic transition from the 5q- syndrome to AML with 5q- as the sole abnormality.

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A 35-year-old female was referred to our hospital for fever and anemia. Physical examination was unremarkable. Complete blood count revealed microcytic hypochromic anemia and reticulocytopenia. The bone marrow cellularity was normal. Some giant pronormoblasts were seen but other erythroid cells were absent. No stainable iron was seen. Parvovirus B19 (PVB19) DNA was detectable by polymerase chain reaction. Anti-PVB19 IgM-antibody was also positive in the serum on admission. Antibodies against rubella, measles, mumps, EB virus and HBs were negative and HBs antigen was also negative. Thus the diagnosis of iron deficiency anemia complicated with pure red cell aplasia secondary to PVB19 infection was made. The PVB19 DNA was still positive on days 6 and 11, suggesting that PVB19 virus persists as long as 3 weeks after the onset of PVB19 infection. However, the erythroid cells had recovered by day 6 after admission suggesting that the development of IgM antibody successfully protected the erythroid cells from infection by the residual PVB19. Hence, careful observation for PVB19 DNA and the antibody may be necessary if immunodeficient patients developed anemia of unknown etiology.

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Recently, it has been shown that the thrombocytopenia that complicates some malarial infections is caused by immune mechanisms. We report a case of malaria associated with thrombocytopenia and increased platelet-associated IgG (PAIgG). In this case, anti-malarial therapy reduced the level of PAIgG to normal levels in association with normalization of the platelet count. This case suggests the immunological mechanisms of thrombocytopenia in malaria.

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An elderly man with an intestinal hemorrhage from bowel diverticulosis developed human parvovirus B19-induced aplastic crisis. A 71-year-old man noticed occasional tarry stools and at the same time showed fever, arthralgia and severe anemia. Blood counts revealed Hgb 5.3g/dl, reticulocytes 0%, and WBC 1,900/μl. Bone marrow examination showed hypocellular marrow with rare erythroid precursors (4.8%). A few giant proerythroblasts were found in the bone marrow smears. A diagnosis of parvovirus B19 infection was made because of detection of B19-specific IgM and IgG antibodies. Parvovirus B19 infection should be carefully checked for in patients with hemorrhage as well as those with hemolysis.

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A 47-year-old woman with antiphospholipid syndrome was referred to us for hemostatic control at the time of extraction of teeth. After administration of intravenous gammaglobulin of 0.4g/kg daily for 5 days, lupus anticoagulant activity disappeared and platelet count slightly increased. Furthermore, she had a transfusion of platelet-rich plasma before operation and no hemorrhagic or thrombotic complications occurred. These findings suggest that gammaglobulin infusion therapy is useful in preventing the complications at operation in patients with antiphospholipid syndrome.

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