Azacitidine (AZA) is useful for the treatment of myelodysplastic syndrome; however, there are a few case reports involving patients receiving hemodialysis and no case reports involving patients receiving peritoneal dialysis. We describe a patient with acute myeloid leukemia with myelodysplasia-related changes (AML-MRC) receiving peritoneal dialysis who was treated with AZA. Peritoneal dialysis was initiated for an 85-year-old man with chronic renal failure in April 2014. In February 2015, peripheral blood analysis showed pancytopenia and bone marrow examination revealed excess of myeloblasts and dysplasia of trilineage cells. He was diagnosed with AML-MRC and treated with AZA because of being elderly and suffering from chronic renal failure. He achieved transfusion independence after 1 course and hematological remission after 3 courses of AZA treatment, without severe side effects. This case suggests that AZA is an effective therapeutic option for patients with AML-MRC receiving peritoneal dialysis.
We report three cases of fusariosis that occurred during the treatment of acute leukemia, during the past 5 years at our institution. Case 1: A 70-year-old male with relapsed and refractory acute lymphoblastic leukemia (ALL) developed fever and multiple nodular lesions in both the lungs. Blood culture that was subsequently obtained revealed Fusarium species. Treatment with liposomal-amphotericin B (L-AMB) was ineffective, and the condition of the patient deteriorated rapidly leading to death. Case 2: A 28-year-old male with T-ALL developed echthyma gangrenosum (EG) ulcers on the scrotum during conditioning for transplantation. Antifungal therapy with L-AMB was ineffective, and later, itraconazole and micafungin (MCFG) were introduced. However, the engraftment was not achieved, and the patient died on day 27. Microbiological examination of EG samples collected on day 13 revealed infection by Fusarium species post mortem. Case 3: A 50-year-old male with blast crisis of chronic myeloid leukemia developed EG primarily on the trunk during chemotherapy. The patient died without any response to L-AMB and MCFG. A culture obtained from EG on day 19 yielded Fusarium species, post mortem. The prognosis of fusariosis is extremely poor. However, skin lesions such as EG may assist in the early diagnosis of the disseminated disease.
The prognosis of multiple myeloma (MM) has been improved due to the introduction of novel agents like proteasome inhibitors and immunomodulatory drugs (IMiDs). However, some cases are refractory to the use of novel agents, and the prognosis of such cases is poor. A 53-year-old male was diagnosed with MM and categorized as follows: Bence-Jones protein lambda type MM, Durie-Salmon IIIA, international staging system (ISS) stage II, and revised ISS stage II. Mutations in K-RAS and IGH/FGFR3 translocation were detected at diagnosis. His tumor was refractory to seven therapeutic regimens including bortezomib, IMiDs (lenalidomide, thalidomide, pomalidomide), conventional chemotherapy, and radiation therapy. N-RAS mutations, CKS1B gains, and C-MYC split signals were detected after treatment. We performed high-dose melphalan/autologous stem cell transplantation (HD-MEL/ASCT) as a salvage therapy and achieved very good partial response. The correlation between K-RAS mutations and poor prognosis or between N-RAS mutations and reduced sensitivity to bortezomib is reported. However, RAS mutations are reported as a favorable factor for HD-MEL/ASCT. In general, mutations of both the K-RAS and N-RAS are known to be mutually exclusive. This rare MM case has mutations in both K-RAS and N-RAS, and the possible relevance of these mutations to both the refractoriness to novel therapies and sensitivity to HD-MEL/ASCT is suggested.
Here we report a case of secondary graft failure that was effectively treated with donor lymphocyte infusion (DLI). A 64-year-old female patient with acute myeloid leukemia obtained partial remission with azacitidine therapy and subsequently underwent unrelated allogeneic bone marrow transplantation (BMT). After confirming successful engraftment and achieving complete remission with incomplete blood count recovery, she was subsequently followed up at an outpatient clinic. A routine test performed by day 110 after BMT revealed the presence of pancytopenia. A bone marrow aspirate did not reveal any evidence of disease relapse or hemophagocytic syndrome but demonstrated hematopoietic insufficiency. Donor chimerism also declined over time; thus, the patient was diagnosed with secondary graft failure. Supportive treatment, including granulocyte-colony stimulating factor and blood transfusion, failed to improve the blood parameters. Because the patient refused a second BMT, we performed DLI on day 147 after BMT (CD3+ cells: 1.0×107/kg, single dose). Consequently, the blood cell count improved promptly and dramatically without adverse events. Following this, we discussed the case and analyzed the related literature.
A 39-year-old man with anemia presented at our hospital in November 2011. Peripheral blood analysis revealed lymphocytosis with a large granular lymphocyte (LGL) count of 2,272/µl, with CD3+, CD4−, CD8+, CD56−, TCR-αβ+; Southern blotting analysis revealed clonal TCR Cβ 1 gene rearrangement, leading to the diagnosis of T-LGL leukemia. In June 2012, the patient was administered with cyclophosphamide as an initial treatment because he developed transfusion-dependent anemia. His anemia improved, and the treatment was discontinued in March 2013. However, anemia recurred in March 2014. The administration of cyclophosphamide was resumed; however, it was subsequently replaced with cyclosporine because of the risk of secondary cancer due to the long-term use of cyclophosphamide. However, his anemia did not improve. Further, the patient was administered with prednisone, methotrexate, and pentostatin; however, the transfusion-dependent state persisted with the cumulative transfusion of 186 RBC units until March 2016. After CD52 expression on the surface of LGL cells was confirmed, treatment with alemtuzumab, which is a monoclonal antibody against CD52, was initiated in April 2016 and the dose was gradually increased from 3 mg to 30 mg thrice per week. The patient’s anemia began to improve 1 week after initiating alemtuzumab treatment, and he became transfusion-independent in the second week. Although alemtuzumab treatment was discontinued at the fifth week on the basis of a positive test result for CMV antigenemia, the result consequently became negative after ganciclovir treatment. To date, the patient's hemoglobin level has been maintained at approximately 12 g/dl without any treatment. Herein we reported the case of a patient having LGL leukemia with refractory anemia that was successfully treated using alemtuzumab.
The prognosis for relapsed Hodgkin lymphoma after allogeneic hematopoietic cell transplantation (HSCT) is poor, partly because of limited treatment options. Here we present a case of a Hodgkin lymphoma patient who relapsed after allogeneic HSCT but remains in complete remission (CR) at 38 months from the start of extended brentuximab vedotin (BV) dosing. A 33-year-old man with refractory and relapsed nodular sclerosis classical Hodgkin lymphoma who underwent previous treatments, including adriamycin, bleomycin, vinblastine, and dacarbazine (ABVD) ; seven combination regimens; and autologous HSCT, prior to allogeneic HSCT achieved CR after three cycles of BV. BV was continued for 26 cycles and then discontinued because of a neurogenic bladder. The other adverse effects were mild paresthesia in the fingers, mild dysgeusia, and fatigue. The patient still remains in CR at 38 months from the start of BV. Thus, extended BV dosing may be a treatment option for relapsed and refractory Hodgkin lymphoma after allogeneic HSCT.
A 75-year-old woman suffered a cat bite 10 months after myelodysplastic syndrome (MDS) diagnosis. She visited our hospital because the internal bleeding of the wound did not improve. Although the wound was treated, the bleeding did not stop. She was hospitalized for emergency medical treatment because the bleeding volume exceeded 200 ml. Although her platelet count was normal, the platelet function test showed a decrease in collagen and arachidonic acid aggregation. After platelet transfusion, her bleeding stopped. Patients with MDS may potentially have platelet dysfunction. In the case of bleeding without thrombocytopenia, a platelet function test should be performed and treatment intervention, such as platelet transfusion, should be considered.
A 68-year-old male patient, who was diagnosed with MGUS (IgG-λ) 11 years ago, was referred to our hospital because of a progressing pancytopenia. He was diagnosed with multiple myeloma (MM) and was hospitalized because of fever and pneumonia. Although empiric antibiotic and antifungal therapies were promptly initiated, his pneumonia worsened. Chest CT images revealed diffuse interstitial pneumonia. Although bortezomib/dexamethasone therapy was initiated as a treatment for MM and pneumonia, he showed little response. His pneumonia worsened and progressed to acute respiratory distress syndrome. Using mPSL (500 mg/day), sivelestat, and MM treatment switching to lenalidomide/dexamethasone (Rd), his respiratory status and CT findings rapidly improved. He received Rd therapy as an outpatient; however, after the completion of six cycles of therapy, his MM progressed, with a recurrence of pneumonia and high fever again. The onset of pneumonia was closely associated with MM progression. His pneumonia improved by treatment with mPSL half-pulse and MM treatment switching to carfilzomib/Rd. In the present study, we report the case of a patient with myeloma, who presented with multiple interstitial pneumonia, resulting in respiratory failure twice in concordance with myeloma progression.
An 85-year-old male presented with 1-year history of a right breast mass. Needle biopsy of the mass revealed diffuse proliferation of large lymphoid cells that were positive for CD20, BCL2, BCL6, and MUM1 and negative for CD5, CD10, MYC, and EBER. The patient was diagnosed as having diffuse large B-cell lymphoma, a type of primary breast lymphoma (PBL). Sex hormone imbalance, which causes conditions such as gynecomastia, is associated with PBL development in males. Estramustine is a nitrogen mustard moiety linked to estradiol. For 5 years, the patient underwent estramustine therapy for treating prostate cancer. Our case suggests an important role of estrogen in PBL development.
Human leukocyte antigen (HLA) mismatch increases the risk of severe graft-versus-host disease (GVHD) and transplant-related mortality. However, the variety of stem cell sources such as cord blood units or the improvements in GVHD prophylaxis makes the interpretation of HLA mismatch more complex. In unrelated transplantation, the locus of HLA mismatch has a great impact on the donor candidate selection, whereas in related transplantation, it has an impact on the intensity of GVHD prophylaxis because donor availability is limited. Anti-thymocyte globulin and post-transplant cyclophosphamide are attractive GVHD prophylactic agents to reduce the risk of immune-associated complications in HLA-mismatched transplantations. HLA mismatch has a reduced impact in adult cord blood transplantation. In this review article, the impact of HLA mismatch based on graft sources is discussed.
Reduction of pretransplant conditioning intensity since the late 1990s has resulted in an increased incidence of relapse, although the number of transplantations has dramatically increased. In the 2000s, pretransplant conditioning was intensified again using drugs with less non-hematological toxicity. For myeloid malignancies, intravenous busulfan (ivBu), which has lesser toxicity than its oral formulation, was introduced. Its myeloablative dose can be safely administered to many patients, including the elderly. Fludarabine-ivBu combination is reported to be comparable or even better than conventional myeloablative conditioning regimens, such as Bu-Cy or TBI-Cy, for those 50 years and older. The cumulative incidence of early NRM post-transplant in patients in remission was more or less comparable to those undergoing the Seattle regimen consisting of Flu+TBI 2 Gy. Incorporating novel drugs into conditioning regimens may further reduce toxicity, particularly for patients not in remission.
Genetic association studies are now widely applied to various medical conditions and abnormalities. Unfortunately, it remains challenging to conduct such studies in cases that require hematopoietic stem cell transplantation (HSCT) because candidate patients usually have a complicated clinical background. In this field, a uniform cohort and well-designed protocol are critical to increasing the effectiveness of genetic association analyses, and parameters such as pre-conditioning regimen, donor source, graft versus host disease and its prophylaxis, and disease status need to be considered. Our studies thus far have revealed that focusing on the relationship between drug metabolism-associated genes and drug-induced complications after HSCT could often offset the complicated clinical background. Thus, here we describe a genetic association study focused on complications after HSCT.
Steroid-refractory graft-versus-host disease (SR-GVHD) is one of the most important complication post allogeneic hematopoietic stem cell transplantation. Mesenchymal stem cells (MSCs) possess characteristic immunomodulatory features which are beneficial in the salvage treatment for SR-GVHD. Following the first case report in 2004, numerous clinical trials have shown encouraging results with MSC infusions for treating SR-GVHD. In Japan, two clinical trials have achieved favorable results, and subsequently in September 2015, MSC infusion became the first approved allogeneic cell therapy for SR-GVHD. Currently, MSCs are available at limited institutes, and all patients infused with MSCs have been registered in the post marketing survey. Based on the results of this survey, the establishment of guidelines for the proper use of MSCs is anticipated. Moreover, several groups have reported the efficacy of MSCs for chronic GVHD or GVHD prophylaxis. In the present review, current issues regarding the use of MSCs in the management of GVHD are summarized.
As the number of long-term survivors after allogeneic hematopoietic stem cell transplantation (HSCT) has increased owing to advances in transplantation and supportive care techniques, the health and welfare of these survivors have come into focus. However, they are still at risks for various complications, including chronic graft-versus-host disease, infectious diseases, and secondary cancers even in the late period, which can not only interfere with the patient’s quality of life (QOL) but also lead to death. The importance of long-term follow-up (LTFU) and management have been recently recognized, and nationwide systems to promote LTFU care in patients receiving HSCT, such as medical fee revision, publication of a LTFU guideline unique to Japan, and preparation of patient pocketbook, is under consideration. The number of medical facilities at LTFU outpatient clinic is also increasing; therefore, an optimal comprehensive support system may be established sooner or later. However, self-management by patients is essential to overcome late complications as well as to improve QOL after HSCT. Healthcare professionals should collaborate and continue to make the greatest possible efforts to educate patients regarding the risks of late complications and their prevention.