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Hemoglobinopathies in Taiwan

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					Hemoglobinopathies in Taiwan Jan-Gowth Chang, MD. Departments of Clinical Research and Laboratory Medicine, Kaohsiung Medical University Hospital

Hemoglobinopathies constitute a range of genetic disorders of hemoglobin genes including abnormal hemoglobin or thalassemia, and they are caused by abnormalities of the protein structure, imbalanced globin chain production and a combination of both condition. Due to increase immigration from Southeast Asia, the clinical features of abnormal haemoglobin are changing and different from our previous experience. In this presentation, I am going to focus on the issue about abnormal haemoglobin. There are more than 20 types of abnormal hemoglobin in Taiwan, and they can be subgrouped to stable variant (such as Hb J-Meinung, Hb Kaohsiung, HbG-Taichung), detectable unstable variant (such as Hb Kohn, HbCS), undetectable unstable variant (such as Hb Quong Sze, Hb Perth).The combination of thalassemia or Iron deficiency with haemoglobin variant is not rare in this region, these combinations are great chalange for clinician to make accurate diagnosis. In this report, I will show some representative cases to solve these problems.

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醫師告知義務的相關法律問題
~告知、代理、無過失、守密

台中榮民總醫院 醫學倫理與法律中心 吳俊穎 主任

案例一 – 68 歲男性患者,因白血球過高求診。經檢查證實為 Leukemia,醫師告知需 住院接受化學治療。 – 病患家屬要求醫師隱瞞病情,同時幫患者拒絕了化學治療的建議,決定尋求其他偏 方治療。

案例二 – 78 歲男性罹患肝癌,建議住院接受肝動脈栓塞(TAE)治療。經過主治醫師解 釋病情、治療方針、可能風險、併發症、替代性的治療、以及不治療的結果後,病 患及其家屬同意接受 TAE 治療。 – 病患於接受 TAE 三十分鐘後開始出現意識昏迷現象,經 brain CT 檢查發現 大腦有 lipiodol 造成 infarction – PubMed : 全世界兩篇 case reports 報導過類似個案

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案例三 – 一位 56 歲男性病患罹肺結核,於胸腔科門診治療一段時間後,發燒仍然持 續,胸腔科醫師由於懷疑病患是否同時罹患 AIDS,因此抽血檢查,發現病患罹患 AIDS。 – 檢查結果出來後,胸腔科醫師還沒有機會告訴病患該檢查結果,病患又因為 發燒來到急診部。急診部醫師基於好意,在發現病患罹患 AIDS 後,便將病患罹患 AIDS 的情況,告知其太太。

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低增生性骨髓形成不良症候群面面觀: 從染色體異常, 國際預後計分系統, 遺傳與表觀遺 傳標記等方面來看 Characterization of Primary Hypoplastic Myelodysplastic Syndrome by Chromosome Aberrations, International Prognostic Scoring System, Genetic and Epigenetic Alterations

黃泰中, 柯博升, 許駿, 陳建源, 蔡偉, 唐季祿, 黃聖懿, 姚明, 陳耀昌, 沈銘鏡, 王秋華, 田蕙芬 Tai-Chung Huang, Bo-Sheng Ko, Chiun Hsu, Chien-Yuan Chen, Woei Tsay, Jih-Luh Tang, Sheng-Yi Huang, Ming Yao, Yao-Chang Chen, Ming-Ching Shen, Chiu-Hwa Wang, Hwei-Fang Tien.

台大醫院內科部血液腫瘤科 Division of Hematology-Oncology, Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan Purpose: The distinction between hypoplastic MDS (h-MDS) and normo/hyper-cellular MDS (NH-MDS) remains unsettled. In this study, we sought to characterize the clinical features, chromosomal abnormalities, genetic and epigenetic alterations in h-MDS, and to verify the applicability of International Prognostic Scoring System (IPSS) in this special entity of MDS. Materials & Methods: We retrospectively reviewed medical records and bone marrow findings in 228 patients with primary MDS diagnosed at National Taiwan University between 1984 and 2002. Thirty-seven of them were diagnosed as having h-MDS. Comparison of the clinical and laboratory characteristics, and genetic alterations between the patients with h-MDS and NH-MDS was made. For Kaplan-Meier survival analysis, the closure date was November 30, 2006. Patients receiving hematopoietic stem cell transplant were censored at the time of transplantation. Results: Among the 37 patients diagnosed as having h-MDS, male-to-female ratio is 3.6 to 1. Mean white blood cell count and absolute neutrophil count were significantly lower in h-MDS (p<0.001 and p=0.002 respectively) than in NH-MDS. Likewise, thrombocytopenia is more severe in h-MDS (p=0.014). Based on French-American-British classification, refractory anemia (RA) is the predominant subtype (56.8%) in h-MDS whereas refractory anemia with excess of blast (RAEB) is the most common diagnosis (36.1%) in NH-MDS. Using Kaplan-Meier survival analysis, International Prognostic Scoring System (IPSS) was proved to be an ideal parameter to predict prognosis in h-MDS patients (median survival time 85 months in patients
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with low and Int-1 risk h-MDS vs. 12 months in those with Int-2 and high risk subtypes, p=0.004), similar to NH-MDS patients. Among patients of low and Int-1 risk groups, h-MDS patients have a significantly longer survival than NH-MDS patients (median survival: 85 months vs. 32 months, p<0.001). There was no statistically significant difference in chromosomal abnormalities between the patients with h-MDS and NH-MDS. In an array of genetic markers including mutations of N-RAS, K-RAS, AML1, JAK2, the internal tandem duplication of FLT3, and hypermethylation of SOCS1 and SHP1, N-RAS mutation was associated with acute leukemic transformation and poor prognosis in h-MDS and NH-MDS. But the distribution of these genetic alterations in these two groups of patients was not significantly different. Conclusions: Patients with h-MDS frequently have RA subtype of MDS, compare with RAEB in HN-MDS. IPSS is also applicable to prognostic evaluation in h-MDS as in NH-MDS. In patients with Low and Int-1 risk MDS, h-MDS patients have better prognosis than NH-MDS patients.

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比較骨髓再生不良症候群與慢性骨髓單核球性白血病中,AML1 基因變異之比例與型態 High Frequency of AML1 Mutations in Both De Novo Myelodysplastic Syndrome and Chronic Myelomonocytic Leukemia but With Different Mutation Patterns 蘇勇誠, 施麗雲, 梁德城, 黃千芳, 吳金和, 石昱書, 王博南, 郭明宗, 鄧波, 林棟樑, 湯崇 志, 張鴻 Yung-Cheng Su, Lee-Yung Shih, Der-Cherng Liang, Chein-Fuang Huang, Jin-Hou Wu, Yu-Shu Shih, Po-Nan Wang, Ming-Chung Kuo, Po Dunn, Tung-Liang Lin, Tzung-Chih Tang and Hung Chang 長庚紀念醫院血液腫瘤科 Division of Hematology-Oncology, Chang Gung Memorial Hospital, Taipei, Taiwan Purposes: We sought to determine the frequency and patterns of AML1 mutations in de novo MDS and CMML and to correlate the mutation status with the clinicohematologic features. Methods and materials: Mutation analysis of AML1 was performed on bone marrow samples from 76 patients with MDS (11 RCMD, 31 RAEB1 and 34 RAEB2) and 67 patients with CMML by direct sequencing for all RT-PCR products amplified with 3 overlapping primer pairs which cover the coding sequences of AML1 gene from exon 3 through exon 8. Results: At initial presentation of MDS, 14 of 76 MDS patients (18.4%) had AML1 mutations; 3 mutations were located in Runt homologogy domain (RHD) (exons 3-5) whereas 11 mutations were located in the non-RHD region (exons 6-8). The 14 AML1 mutations included 6 missense mutations, 4 nonsense mutations, 2 frameshift mutations, and 2 silent mutations. AML1 mutations were detected in 27 of 67 CMML patients (40%) at initial diagnosis, 17 patients had 19 mutations located in RHD and 10 patients had mutations located in the non-RHD region; the patterns of 29 mutations consisted of 7 missense mutations, 5 nonsense mutations, 14 frameshift mutations and 3 silent mutations. One CMML patient had two missense mutations in RHD, another patient had two frameshift mutations in RHD. Cloning analysis showed that the two mutations were on different alleles in both patients. The frequency of AML1 mutations was significantly higher in patients with CMML than in MDS (P=0.005). Mutations in RHD occurred more frequently in CMML than in MDS (P=0.020). CMML patients had a higher frequency of frameshift mutations as compared with MDS patients (P=0.045). AML1(+) CMML patients had a significantly lower platelet count than AML1(-) patients (P=0.025). There were no differences in age, sex, hemoglobin level, WBC count, percentages of blasts in bone marrow and peripheral blood, morphologic subtype, and cytogenetic risk group between AML1(+) and AML1(-) patients in CMML or MDS. Eleven of 14 AML1(+) MDS patients (78.6%) progressed to AML compared with 39 of 62 AML1(-) patients (62.9%) (P=0.357). Eleven of 27 AML1(+) CMML patients (40.7%) progressed to AML compared to 13 of 40 AML1(-) patients (32.5%) (P=0.605). Time to AML transformation and overall survival of AML1(+) patients did not differ from AML1(-)
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patients in both MDS and CMML groups. Conclusions: Our study showed that AML1 mutations were frequently detected in de novo MDS and CMML, especially the latter. Patients with CMML were more frequently associated with mutations in RHD and frameshift patterns compared to patients with de novo MDS. 在原發骨髓分化不良症候群患者的 AML1 突變基因特徵 Characterization of AML1 Gene Mutation in Primary Myelodysplastic Syndrome—The Mutation is Always Detected at Diagnosis, Remains Stable During Follow-Up, and is Associated with Poor Outcome. 陳建源 1, 林亮音 2,4, 唐季祿 1, 柯博升 1, 曾美瑄 1, 黃琦斐 1, 林凱信 3, 蔡偉 1, 周文堅 2, 姚明 1, 吳尚儒 1, 邱榮敬 1,

林東燦 3, 田蕙芬 1

Chien-Yuan Chen1, Liang-In Lin2,4, Jih-Luh Tang1, Bo-Sheng Ko1, Woei Tsay1, Wen-Chien Chou1,2, Ming Yao1, Shang-Ju Wu1,5, Rong-Jing Chiou1, Mei-Hsuan Tseng1, Chi-Fei Huang1, Kai-Hsin Lin3, Dong-Tsamn Lin2,3, Hwei-Fang Tien1

台大醫院內科部血液腫瘤科 1, 實驗診斷部 2, 小兒部 3, 台大醫學院醫技系 4, Departments of Internal Medicine1, Laboratory Medicine2, and Pediatrics3, National Taiwan University Hospital; Department of Clinical Laboratory Sciences and Medical Biotechnology4, College of Medicine, National Taiwan University Taipei, Taiwan. Purpose: The AML1 gene encodes a transcriptional factor essential for definitive hematopoiesis. Mutations of AML1 have been detected in patients with myelodysplastic syndrome (MDS), especially that secondary to irradiation or chemotherapy. In this study, we sought to characterize AML1 mutation in primary MDS and to assess the sequential changes of the mutation during the clinical course. Materials & Methods: We analyzed mutations of AML1 exons 3-8 in 132 patients with primary MDS and correlated the results with clinical features. Serial studies were performed during the follow-up period in 52 of them. Results: Eighteen patients (13.6%) had AML1 mutations, including 9 at the N-terminal and 9 at the C-terminal. Seventeen patients had single mutation while the remaining one showed two loci of mutations at different alleles. All AML1 mutations were detected at diagnosis and remained unchanged during the clinical course, except for one mutation that was acquired at leukemic transformation. Patients with AML1 mutations had higher absolute neutrophil counts, lower platelet counts, shorter overall survival, and higher frequency of -7/7q deletion. There was no prognostic implication of the location (N- or C-terminal) or type (missense or non-missense) among patients with AML1 mutations. Conclusions: Most AML1 mutations were detected at diagnosis and might play a role in the development of subsets of primary MDS. The patients with AML1 mutation had poorer prognosis than those without it.
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PML 與 TAp73 作用於核體為與 p53 不相關的 Glevec 誘導 CML 細胞凋亡所必須 PML and TAp73 interacting at nuclear body mediate glevec-induced p53-independent apoptosis of chronic myelogenous leukemia cells

劉俊煌, 劉錦誠, 顏厥全, 楊慕華, 蕭樑材, 高志平, 徐會棋, 陳博明 J-H Liu, C-C Liu, C-C Yen, M-H Yang, L-T Hsiao, J-P Gau, H-C Hsu, P-M Chen

台北榮總 血液腫瘤科 Division of Hwmatology/Oncology, Taipei Veterans General Hospital, Taiwan Purpose: Bcr-Abl signals leukemogenesis of chronic myeloid leukemia (CML) cells and suppresses counteracting replicative senescence or apoptosis. Exposure of CML cells to glevec (STI571), a specific inhibitor of Abl tyrosine kinase, leads to apoptosis. Since p53-nonfunctional CML cells can still be sensitive to STI571, we search for a p53-independent proapoptotic mechanism. Materials & Methods: Using the p53-nonfunctional K562 CML cells, we study the protein expression and the state of phosphorylation by Western blot. Subcellular co-localization of promyelocytic leukemia protein (PML) and TAp73 by confocal microscopy. Functional mediation of PML and TAp73 were studied by short interfering RNA (siRNA) targeting. Results: We found in K562 CML cells that Glevec induced formation of PML-nuclear body (NB), phosphorylation of TAp73 and subnuclear co-localization of TAp73 to PML-NB. Knocking down of PML or TAp73 in K562 cells treated with STI571 by siRNAs targeting led to increased G0/1 cell cycle arrest and hindered apoptosis while interferon -2a (IFN), which induces PML expression and PML-NB formation, enhanced co-localization of TAp73 to PML-NB and subsequent apoptosis. STI571 also upregulated phosphorylation of p38 mitogen-activated protein kinase (MAPK) and Chk2 probably upstream of PML and TAp73 as well as expression of p21Waf1/Cip1 and Bax downstream of TAp73. Conclusions: Taken together, STI571 induced a p53-independent apoptosis through the p38MAPK/Chk2-PML/TAp73 network with recruitment of TAp73 to PML-NB. This new network controlling STI571-induced p53-independent proapoptotic signaling is of potential therapeutic importance.

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SR-T100 對 CML K562 細胞株作用探討 The Cytotoxic Mechanism of SR-T100 to K562 cell.

汪天祥、楊吉雄、林增熙、楊陽生、滕傑林 T-H Wang, J-H Young, T-H Lin, Y-S Yang, C-L Teng

台中榮民總醫院 血液腫瘤科 Division of Hematology-Oncology, Taichung Veterans General Hospital, Taichung, Taiwan Purpose: SR-T100, extracted from Solanum incanum, Agaricus blazei and Astragalus membranaceus, is a compound with excipient. Its major ingredient is solamargine. Previous experiments had shown that solamargine induced apoptosis in lung cancer cells. In our experiment we would survey the cytotoxic mechanism of the SR-T100 in K562 cell line. Materials & Methods: The K562 cell line was kept in RPMI 1640 medium supplemented with 10% fetal calf serum. The SR-T100, provided by Dr. K-W Kuo, was suspended in sterile water. Number of the K562 cell viability was counted by trypan blue staining. The effect of SR-T100 on the inhibition of K562 cell proliferation was assessed by MTT colorimetric assay. Apoptotic features were confirmed by propidium iodide staining and Annexin V staining. Results: The concentration that SR-T100 inhibited K562 cell growth was above 0.05%(W/V). High concentration (0.15%) of the SR-T100 directly led K562 cell to death. The half-inhibitory concentration (IC50) of the cell viability was 0.025%(W/V). The number of K562 in the sub-G1 fraction increased in a dose- and time-dependent manner. In phosphatidylserine externalization, the results revealed that early apoptotic cells slight increased, but late apoptotic/necrosis cells apparently increased. Conclusions: Our findings suggest that both apoptosis and necrosis contribute the cytotoxic effects of SR-T100 to K562 cells.

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急性骨髓性白血病之 NPM 基因突變: 臨床特徵分析及微量殘存疾病偵測之應用 NPM Mutations in de novo Acute Myeloid Leukemia: analysis of clinical features and applications in minimal residual disease detection 吳尚儒, 周文堅*, 唐季祿, 田蕙芬 Shang-Ju Wu, Wen-Chien Chou*, Jih-Luh Tang, Hwei-Fang Tien 臺大醫院 內科部 及 檢驗醫學部* Department of Internal Medicine and Laboratory Medicine*, National Taiwan University Hospital Purpose Nucleophosmin (NPM) mutations exist in a significant proportion of adults with de novo acute myeloid leukemia (AML), especially in those of a normal karyotype. We investigated the incidence and clinical features of this group of patients in our institute. We also explored the validity and prognostic significance of minimal residual disease (MRD) detection by quantification of NPM mutants. Materials & Methods We included 173 de novo AML patients, a population of mixed Chinese adults and children for NPM mutation analysis and correlated the results with clinical features, cytogenetics, immunophenotyping and other genetic alterations. We also performed sequential analyses on some patients during the clinical course to investigate the stability and etiological role of NPM mutations in AML. We quantified mutants in genomic DNA from 40 patients with at 5 BM samples for serial analysis to test our hypothesis that mutant quantification can correlate with disease statuses and be useful in outcome prediction. Results NPM mutations were present in 19.1% of the overall population and 40.3% of those with a normal karyotype. Adults had a significantly higher incidence of NPM mutations than children (32/126, 25.4% vs. 1/47, 2.1%, p<0.001). NPM mutations were closely associated with normal karyotype (p<0.001) and FLT3/ITD (p=0.002), but negatively associated with CEBPA mutations (p=0.032) and expression of CD34 (p<0.001) and HLA-DR (p=0.003). Serial analyses of NPM mutations showed the mutation disappeared at complete remission, but the same mutation reappeared at relapse, except for one who lost the mutation at the second relapse, when new cytogenetic abnormalities emerged. None acquired novel mutations during the follow-up period. Samples taken at clinical relapse contained more mutants than those at morphological complete remission (CR) (p<0.001). Mutants at morphological CR in patients without further relapses were fewer than those with subsequent relapses (p<0.001). Detection of mutants predicted relapse if no further chemotherapy was administered. Failure to achieve 2 logs of reduction after consolidation predicted shorter overall survival (OS) (p=0.01) and relapse-free survival (RFS) (p=0.001). Patients with any rise of mutants during follow-up relapsed more frequently than those with persistently low or undetectable signals (p<0.001). Along follow-up, patients
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obtaining any mutant reduction to < 0.1% of internal control (INC) had longer OS (p=0.002) and RFS (p<0.001). On the other hand, detection of mutants >1.5% of INC in any post-induction sample predicted poorer outcome (p=0.002 for OS and <0.001 for RFS). Conclusions NPM mutations occur in an age-dependent fashion. The mutations have positive association with FLT3/ITD and expression of CD34, but are mutually exclusive with CEBPA mutation and other specific chromosomal translocations. NPM mutant quantity matches well with disease statuses, is useful in MRD monitoring and may be predictive of patients’ outcome.

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Expression of angiopoietins and vascular endothelial growth factors and its clinical significance in acute myeloid leukemia: Ang-2 expression is an independent prognostic factor for overall survival

侯信安 1,周文堅 2,曾美瑄 1,唐季祿 1,姚明 1,黃聖懿 1,陳建源 1,柯博升 1,蔡偉 1, 陳耀昌 2,王秋華 2,沈銘鏡 2,田蕙芬 1 Hsin-An Hou,1 Wen-Chien Chou,2 Mei-Hsuan Tseng, 1 Jih-Luh Tang, 1 Ming Yao, 1 Shang-Yi Huang, 1 Chien-Yuan Chen, 1 Bo-Sheng Ko, 1 Woei Tsay, 1 Yao-Chang Chen, 2 Chiu-Hwa Wang1, Ming-Ching Shen1, Hwei-Fang Tien,1

血液科/內科部 1,檢驗醫學部 2,國立台灣大學醫學院附設醫院 Division of Hematology, Department of Internal Medicine1, Department of Lab Medicine2, National Taiwan University Hospital, College of Medicine, National Taiwan University, Taipei, Taiwan Background and Purpose: Concerted expression of angiopoietins, their receptor Tie2 and vascular endothelial growth factor (VEGF) family, most specific inducers of angiogenesis secreted by leukemia blasts, are known to play an essential role in normal and pathologic angiogenesis. We therefore evaluate the clinical implication of angiogenic factors in patients with acute myeloid leukemia (AML). Method and Patients: We investigated the RNA expression of genes encoding angiopoietin-1 (Ang-1), angiopoietin-2 (Ang-2), the receptor Tie2, VEGF-A and VEGF-C by real-time quantitative polymerase chain reaction (RQ-PCR) in a cohort of 126 patients with newly diagnosed de novo AML at National Taiwan University from June 1995 to Feb 2006. The results were correlated with clinical features and outcome of the patients. Results: 67 were male and 59 were female and the median age was 39.5 years. Distribution within the FAB classification was as follows: M0, 1.5%; M1, 33.3%; M2, 40.5%; M4, 17.5%; M5, 4%; M6, 3.2%. The karyotype analysis showed 25 patients were in good-risk, 83 in intermediate-risk and 14 in poor-risk group. 101 of 126 patients (80%) achieved complete remission and 39 (31%) remained disease free. Expression of Ang-1, Ang-2 and VEGF-A was significantly higher and that of VEGF-C was lower in AML patients than in 22 normal controls. RNA expression level correlated well with the results of immunocytochemical staining in the selected patients studied. Patients with high Ang-1, Ang-2, or Tie2 expression had significantly shorter relapse-free survival than those with low expression (8 months versus 14 months, P=0.029; 9 months versus 14 months, P=0.01; 8.5 months versus 14 months, P=0.01, respectively) by univariate analysis, but the significance disappeared by multivariate analysis. On the other hand, high expression of
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Ang-2 and Tie2, but not other angiogenic factors, was correlated with a shorter overall survival (15.7 months versus 38 months, P=0.005; 14 months versus 26 months, P=0.043, respectively). In multivariate analysis, only karyotype and Ang-2 expression were independent prognostic factors, with a hazard ratio of 2.19 (95%CI, 1.27-3.77, P=0.005) and 2.05 (95%CI, 1.20-3.52, P=0.009), respectively. Furthermore, the prognostic relevance of Ang-2 expression became even more pronounced in the patients with intermediate-risk karyotype (P=0.004). Subgroup analysis showed that the prognostic impact of Ang-2 expression was only evident in the patients with low Ang-1 or low Tie2 levels, but not those with high levels, and in the patients high VEGF-A or high VEGF-C levels, but not those with low levels. Conclusions: These results provide evidence that high pre-treated levels of Ang-2 in the bone marrow indicate an unfavorable prognosis in AML. Further research into interaction of concerted angiogenic factors in AML is warranted. Key words: Angiopoietin, vascular endothelial growth factor, acute myeloid leukemia

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2-Methoxyestradiol 藉由調控白血病細胞內的 c-Myc 穩定性誘發細胞凋亡 2-Methoxyestradiol Induces Apoptosis of Acute Myeloid Leukemia Cells by Targeting Proteasomal Degradation of c-Myc Protein 劉興璟,周志銘,黃明哲 H. Eugene Liu, J-H Chow, M-J Huang 萬芳醫院血液腫瘤科, 馬偕醫院血液腫瘤科 Division of Pediatric Hematology-Oncology, Mackay Memorial Hospital, Taipei, Taiwan

Purpose: 2-Methoxyestradiol (2ME) increases cellular reactive-oxygen species (ROS) by blocking superoxide dismutase. In this study, we intended to further investigate the underlying mechanisms in acute myeloid leukemia. Materials & Methods: AML cells, HL-60, NB4 and U937 and primary AML cells were used for study. Results: We found that 2ME increased cellular ROS and induced apoptosis of AML cells, HL, through mitochondrial pathway, which could be partially abrogated by glutathione replenishment. Further investigation showed that 2ME decreased c-Myc protein but not mRNA level in AML cells. Addition of proteasome inhibitor, MG132 or glutathione restored the c-Myc protein levels, suggesting that 2ME might regulate c-Myc levels through inhibition of proteasomal degradation. To demonstrate the 2ME decreased cellular c-Myc through affecting c-Myc stability, we ectopically expressed wildtype c-Myc or T58A c-Myc mutant in AML cells and found that cells expressing T58A c-Myc mutant was resistant to 2ME. We also found that 2ME inhibited the growth of primary AML cells and downregulated their c-Myc expression. Conclusions: Our results indicate that 2ME inducing apoptosis of AML cells by targeting proteasomal degradation of c-Myc protein.

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Sonic hedgehog 路徑在急性前骨髓性白血病細胞株的表現 The role of Sonic hedgehog pathway in acute promyelocytic leukemia cell line

白禮源、葉士芃、高銘欽、邱昌芳 L-Y Bai, S-P Yeh, M-C Kao, C-F Chiu

中國醫藥大學附設醫院血液腫瘤科,中國醫藥大學附設醫院 Division of Hematology and Oncology, Department of Internal Medicine, China Medical University Hospital, and China Medical University Purpose: Sonic hedgehog (Shh) proteins play an important role in cell-to-cell contact through the Ptc receptors expressed on adjacent cells. Previous reports showed that they are critical in normal cellular expansion and in the patterning of the early embryo of vertebrates and invertebrates. They were also implicated in human cancers, including basal cell carcinoma, medulloblastoma, small cell lung cancer, and cancers of stomach, esophagus, pancreas, biliary tract and prostate gland. Although Shh is shown to be involved in the hematopoiesis and immune system, there is no evidence demonstrates its relation to hematopoietic malignancy. In preliminary study, we have found that there are variable expressions of Shh and Gli-1 in different diseases. These two proteins are demonstrated most in myeloid leukemia, less in multiple myeloma, and least in lymphoid leukemia. Based on the results of immunohistochemical studies, we want to explore the role of hedgehog pathway for acute promyelocytic leukemia in the influence of cell growth, regulation of cell cycles and apoptosis. Materials and Methods: We choose an acute promyelocytic leukemia cell line, HL60, for the following studies. The immunohistochemical staining for Shh and Gli-1 protein were performed. For further confirmation, we tested the presence of Shh pathway in the HL60 cell by RT-PCR of mRNA of Shh, Ptc, Smo and Gli-1. Cyclopamine, an inhibitor of Smo and recombinant Shh-N peptide were used in the cell culture, in the presence of G-CSF or not. Finally, we checked the change of cell cycle by stimulating or inhibiting the Shh pathway. Results: First, we demonstrated the presence of Shh pathway in the HL60 cell by RT-PCR of mRNA of Shh, Ptc, Smo and Gli-1. In the study regarding cell growth, cyclopamine, an inhibitor of Smo, can inhibit the growth of HL60 in dose-dependent manner. However, addition of recombinant Shh-N peptide cannot stimulate the cell growth, even in the presence of G-CSF. To see the implication of Shh pathway in cell cycle, we analyzed the change of cell cycle by flow cytometry. The data will be presented in the meeting.
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Discussions: Sonic hedgehog pathway is expressed in the acute promyelocytic leukemia cell line. Its implication in prognosis needs further studies. 第三號誘餌受體的過度表現會使白血病細胞逃離免疫監控,並對 doxorubicin 產生抗藥性, 且為急性白血病病患的不良預後因子 Decoy receptor 3 (DcR3) increases immune evasion and resistance to doxorubicin-induced apoptosis of leukemia cells and is a poor prognostic factor for acute leukemia patients 王緯書 1, 2, 謝世良 3, 邱宗傑 1, 2, 陳博明 1, 2* W-S Wang 1, 2, S-L Hsieh3, T-J Chiou1, 2, P-M Chen 1, 2* 國立陽明大學醫學系; 2 台北榮總內科部血液腫瘤科; 3 國立陽明大學微免所

1 1

National Yang-Ming University School of Medicine; 2Division of Oncology and Hematology, Department of Medicine, Taipei Veterans General Hospital; 3Department of Microbiology and Immunology, National Yang-Ming University, Taipei, Taiwan Purpose:Decoy receptor 3 (DcR3) is a soluble molecule classified as a member of the TNF receptor superfamily. By neutralizing the cytotoxic effects of several ligands, including fas ligand (FasL), DcR3 may facilitate immune evasion of tumor cells. Since doxorubicin may enhance the expression of FasL, by effectively neutralizing FasL with DcR3, a reduced susceptibility to doxorubicin of tumor cells was proposed. In this study, we first analyze the influence of DcR3 on apoptosis-resistance in leukemia cells and the clinico-pathological features in acute leukemia patients. Materials & Methods:The expression of FasL in RPMI6410 leukemia cells before and after doxorubicin treatment was examined by Western blot. The influence of a recombinant DcR3 protein on apoptosis-resistance to doxorubicin and Jurkat cell (a FasL-bearing immune cell) in RPMI6410 as well as patients’ leukemia cells was examined with MTT assay. In some experiments, a DcR3-neutralizing antibody was added to assure that the apoptosis-resistance was really mediated by DcR3. The levels of DcR3 expression in 77 patients’ leukemia cells were examined by IHC, and the correlations between DcR3 expression and clinico-pathological features and survival were examined by chi-square, log-rank, and multivariate analysis, respectively. Results:The FasL expression in RPMI6410 cells was indeed enhanced by doxorubicin treatment. Interestingly, DcR3 pre-treatment dramatically reduces the susceptibility of patients’ leukemia cells to Jurkat cell- and doxorubicin-induced apoptosis (P<0.05), and a DcR3-neutralizing antibody could successfully reverse this apoptosis resistance (P<0.05). Additionally, there was a trend that patients’ leukemia cells treated with DcR3 having a higher viability (P=0.063). Clinically, acute leukemia patients with a positive DcR3 staining (n=26) in tumor cells survived significantly shorter than those who with a negative staining (n=51) (P<0.05), and the percentage of surviving for more than 3 years was about 40% (DcR3-negative group) and 10% (DcR3-positive group), respectively.
16

Conclusions:These results suggest that overexpression of DcR3 in leukemia cells may result in immune evasion and increased resistance to doxorubicin-based chemotherapy, which may lead to an aggressive clinical behavior and a poor prognosis in acute leukemia patients.

17

The current role of transplantation in lymphoma N. Schmitz Department of Hematology and Stem Cell Transplantation, ASKLEPIOS Klinik St. Georg, Hamburg, Germany

The appearance of new modalities, in particular the monoclonal anti-CD 20 antibody Rituximab to treat patients with a variety of B-cell lymphomas has changed the treatment algorithm for all patients with B-cell neoplasias. Furthermore, the broader applicability of autologous transplantation to elderly patients beyond the age of 60 years and the development of reduced intensity conditioning (RIC) prior to allogeneic transplantation have direct impact on the choice of therapy for patients with lymphoma. In patients with aggressive lymphomas it is still unclear if younger patients with high-risk disease (aaIPI 2,3) may benefit from high-dose therapy (HDT) and autologous stem cell transplantation (ASCT) in first CR. We are currently performing a large randomized trial comparing conventional chemotherapy and ASCT, both supplemented with Rituximab to address this question. For patients with relapsed aggressive lymphoma HDT/ASCT is considered the treatment of choice. However, new studies which integrate Rituximab into the concept need to be performed. An international study (CORAL) is addressing this question: Patients are randomized to either R-DHAP or R-ICE as salvage regimen and continue to HDT/ASCT if a PR or CR is reached. A second randomization after HDT/ASCT will answer the question if rituximab consolidation after transplantation can further improve results. Other areas of ongoing research are the use of radiolabelled antibodies in the conditioning regimen and the role of allogeneic transplantation for patients with relapsed aggressive lymphoma and bad prognostic features. Symptomatic patients with follicular lymphoma are currently treated with a combination of rituximab and chemotherapy. It is obvious that the addition of rituximab to chemotherapy (CHOP, CVP, MCP or other chemotherapy) has improved results substantially. Maintenance treatment with rituximab will improve results further in the future. Therefore, it is completely unclear if HDT in follicular lymphoma patients will play any role. Likewise, there is no consensus if and which patients are candidates for HDT/ASCT at the time of relapse. An EBMT trial (LYM-1 trial) addressing this questions has recently been closed but no data are available. Allogeneic transplantation will have a role in patients with follicular lymphoma after failing an autograft or patients with refractory disease. Recently, a number of European cooperative groups have looked at results of chemotherapy and ASCT for patients with T-cell lymphoma. Resulting from a long discussion at the European level two international studies are about to be launched: The first study will address the role of transplantation in T-cell neoplasias and will randomize younger patients (< 60 yrs) to allogeneic or autologous stem cell transplantation. In elderly patients, conventional chemotherapy (6 courses of CHOP-14) will be compared to the same chemotherapy given together with
18

alemtuzumab. In summary, the therapeutic armamentarium for all lymphoma subtypes is increasing. The most important task for the future will be to select the most promising approaches and to perform prospective studies in order to define the optimum therapy for different disease at different time points during the course of disease.

19

Quantification of Plasma Epstein-Barr Virus DNA in Patients with Non-Hodgkin’s Lymphoma

林增熙 1 林進清 2 楊陽生 1 黃文豊 3 楊吉雄 1

1

台中榮民總醫院血液腫瘤科; 2 放射腫瘤科; 3 血庫

BACKGROUND. Epstein-Barr Virus (EBV) has been associated with the development of a variety of cancers, including Hodgkin’s lymphoma and Non-Hodgkin’s lymphoma (NHL). Cell-free viral DNA may be shed from circulating apoptotic malignant cells. The objective of this study was to investigate the plasma concentrations of EBV DNA in patients with NHL. METHODS. We investigated seventy-five patients with biopsy-proven NHL. Plasma samples from the patients prior to therapy were subjected to a real-time quantitative polymerase-chain-reaction (PCR) assay. RESULTS. Plasma EBV DNA was detectable in 30 of the 75 patients (40%), but no in health controls. In 30 patients of EBV-positive (natural killer [NK] cell, n = 3; T cell, n = 6; B cell, n = 21) lymphoma, the median age was 68 years (range, 17-82), including 24 male and 6 female. Of the 30 patients, 10 had stage I/II and 20 had stage III/IV disease. The median concentration of plasma EBV DNA were 18 copies per milliliter among 10 patients with stage I/II disease, 186 copies per milliliter among 20 patient with stage III/IV disease (P < 0.05). The median concentration of plasma EBV DNA were 17 copies per milliliter among 21 patients with B cell, 646 copies per milliliter among 9 patient with NK/T or T cell (P < 0.01). CONCLUSIONS. The preliminary data show that quantitative PCR assay to detect plasma EBV DNA is feasible. Additional prospective studies are required to further evaluate the clinical significance and usefulness.

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EB virus associated aplastic anemia successfully treated with acyclovir contained regimen

廖優美 張泰琮 邱世欣 林佩瑾 高雄醫學大學附設中和紀念醫院兒科部 小兒血液腫瘤科

Purpose : Aplastic anemia is a hematological disorder characterized by pancytopenia with a hypocellular or aplastic bone marrow .The major identifiable etiologies of aplastic anemia (AA) includes radiation exposure, chemical agents, drugs and certain viruses .The most cases’ etiologies are unknown .Viral associated AA is a common category .The best documented virus is parvovirus B19 .Other viruses such as Hepatitis, HIV, Cytomegalovirus, herpes simplex virus and Epstein –Barr virus are also reported association with bone marrow failure. Virus from different taxonomic families cause hematosuppression by a variety of mechanism and the host’s immune response may also plays a role. Materials &Methods: The Epstein –Barr vial associated AA is rare and the treatment of choice is still in controversial. There were two cases of EBV associated AA successfully treated with acyclovir alone or combined with steroid will be reported. Results: Case 1 was a 18 years old girl who was admitted on Dec 28th ,1998 due to bilateral lymphadenopathy, pancytopenia for 2months and prolonged fever for at least ten days. The EBV serological titers include EB VCA IgG =1:160, EB VCA IgM< 1:10, EBV VCA IgA=1:40,Heterophil antibody negative and diagnosed as acute primary infection .Bone marrow exam showed aplastic anemia after admission .She was treated with acyclovir 30mg/kg/day .The bone marrow recovered 7 days after acyclovir treatment. and the serological results were as follows :EB VCA IgG =1:160, EB VCA IgM< 1:10, EB VCA IgA=1:40,EBNA:positive . Case 2 is a 22 years old girl .The patient was confirmed as primary infection on July 20th, 2001 with the serologic changes as the table1. Conclusions : EB virus reactivation associated marrow hypoplasia with progressed thrombocytopenia and leucopenia were noted. Acyclovir combined with steroid were given immediately. The followed bone marrow aspiration and biopsy

EBV

2001 7/20

2001 8/9

2001 10/11

2002 2/21

2002 8/26

2006 12/15

2006 12/25

2006 1/2

VCA IgG VCA IgM VCA IgA

<1:40

1:1280

1:640

1:160

1:160

1:1280

1:640

>1:12 80 <1:10 1:10

<1:10 <1:10

<1:10 1:40

<1:10 1:10

<1:10 1:10

<1:10 1:10

<1:10 1:10

<1:10 1:10

recovered several days after these two drugs. EB virus associated aplastic anemia may be more Mono + spot common than was as known. Monitoring of EBNA + + + + + + + patient with chronic EB virus infection may lead to early treatment. It is very difficult to make a conclusion for the choice of treatment for this
21

disease. To our knowledge, acyclovir contained regimen may be considered as a feasible treatment modality .

22

The Impact of Oral Candidiasis and Herpes Simplex Virus Infection on Chemotherapy-induced Oral Mucositis Yin-Kai Chen,1 Po-Ren Hsueh2,3, Chuan-Liang Kao,4 Yee-Chun Chen2, , Ming Yao1, Shang-Yi Huang1, Wen-Chien Chou2,3, Bo-Sheng Ko1, Chien-Yuan Chen1, Jih-Luh Tang,1 Woei Tsay,1 Yao-Chang Chen,2 Hwei-Fang Tien1 陳尹愷 1,薛博仁 2,3,高全良 4,陳宜君 2,姚明 1,黃聖懿 1,周文堅 3,柯博升 1,陳建源
1

,唐季祿 1,蔡偉 1,陳耀昌 2,田蕙芬 1

Divisions of Hematology1 and Infection2, Department of Internal Medicine; 3Department of Laboratory Medicine, National Taiwan University Hospital; Department of Clinical Laboratory Sciences and Medical Biotechnology4, College of Medicine, National Taiwan University, Taipei, Taiwan 血液科 1/感染科 2/內科部,檢驗醫學部 3,國立台灣大學醫學院附設醫院 醫學檢驗暨生物技術部 4 ,國立台灣大學醫學院

Background and Purpose: Oral mucositis is an important problem in patients receiving chemotherapy. Multiple factors influence the severity of mucositis. We evaluated the role of oral candidiasis and herpes simplex virus (HSV) infection in chemotherapy induced oral mucositis. Method and Patients: We retrospectively reviewed charts of patients receiving chemotherapy for hematological malignancies at National Taiwan University Hospital from January 2005 to November 2006. 138 episodes (in 82 patients) of chemotherapy-induced oral mucositis that had been evaluated by cultures for both fungus and HSV were analyzed. The results were correlated with associated clinical features. Results: Among the 82 patients, 38 were males and 44 were females and the median age was 47 years. The hematological malignancies these patients had included AML (n=26, including 1APL and 1CML in ABC), NHL (n=24), ALL (n=15), MM (n=11), HD (n=1), acute biphenotypic leukemia (n=1), CML (n=1), CLL (n=1), SAA (n=1) and myelofibrosis (n=1). 76% (n=104) of the mucositis were detected at the time when absolute neutrophil counts were below 1000/μL. Overall, 108 episodes (78%) of the oral mucositis were related to either fungal or HSV-1 infections, including 63 episodes (46%) of fungal infection alone, 24 episodes (17%) of HSV-1 infection alone and 20 episodes (14%) of both fungal and HSV-1 infections. Among the 85 episodes of fungal mucositis, C. albicans was the most common pathogen isolated (70 episodes), followed by C. tropicalis (7 episodes). Thirty-four of the 85 patients (40%) who had received anti-fungal agents before the occurrence of mucositis had HSV-1 infection, compared with 10 of
23

the 53 (19%) who had not (P=0.0141).

Patients receiving anti-fungal agents for ≧7 days were

more susceptible to HSV-1 infection (25/54 versus 17/82, P=0.003). Those patients with HSV-1 infection suffered from grade 3~4 mucositis more frequently (13/44 versus 12/94, P= 0.0317) and tended to depend on longer TPN (P=0.0239) for nutritional support and topical lidocaine for symptomatic relief (17/44 versus 17/94, P=0.0164). Conclusions: These results suggest that Candida albicans and HSV-1 play an important role in oral mucositis. It is essential to perform fungal culture and HSV isolation promptly once mucositis occurs after chemotherapy and to start empirical treatments immediately. HSV infection should be considered in the differential diagnosis of oral mucositis particularly in those patients who have prior antifungal therapy.

24

以 Caspofungin 治療中性球低下發燒之東臺灣三例經驗 Caspofungin in the Treatment of Febrile Neutropenia in Eastern Taiwan: Experiences of Three Cases

姚朝元 李啟誠 黃冠博 朱崧肇 王佐輔 李思錦 吳懿峰 黃威瀚 高瑞和 Chao-Yuan Yao, Chi-Cheng Li, Kuan-Po Huang, Sung-Chao Chu, Tso-Fu Wang, Szu-Chin Li, Yi-Feng Wu, Wei-Han Huang, Ruey-Ho Kao

花蓮佛教慈濟醫院血液腫瘤科 Department of Oncology/Hematology, Buddhist Tzu Chi General Hospital, Hualien, Taiwan Purpose:Invasive fungal infections are important causes of morbidity and mortality after chemotherapy or stem cell transplantation with neutropenic fever for patients with hematological malignancies. Here, we report our experiences by using caspofungin in the treatment of febrile neutropenia in eastern Taiwan. Case Reports: Case 1 is a 62-year-old man with the diagnosis of acute myeloid leukemia (AML) presented with leukocytosis and neutropenic fever. The fever can be controlled initially by Tazocin but fever occurred again after starting chemotherapy. The fever persisted even under broad-spectrum antibiotics coverage including meropenem, vancomycin & fluconazole. Blood culture yielded no micro-organism. Sputum culture grew Candida tropicalis. The fever dramatically subsided after replacing fluconazole by caspofungin 24 hours later. Unfortunately, he died of refractory leukemia with multiple cerebral hemorrhagic infarcts. Case 2 is a 48-year-old man with the diagnosis of AML. After initiating chemotherapy, he got fever with Pseudomonas bacteremia during neutropenic stage. Although fever subsided a little after anti-pseudomonas antibiotics, which peaked to 410C later when repeated blood culture yielded nothing. Empirical liposomal amphotericin-B (AmBisome) was given then fever disappeared. AmBisome was given for a total of 8 days when neutrophils recovered. However, fever occurred again 4 days later. No positive blood culture was found, caspofungin was used this time and fever disappeared. He had received the other two courses of caspofungin during subsequent two times of post-chemothaerpy febrile neutropenia with successful control. He died of refractory AML finally. Case 3 is a 47-year-old man of refractory AML. He was treated with cord blood stem cell transplantation (CBT). A right upper lobar pneumonia developed progressively. Caspofungin was used to in the control of febrile neutropenia before and after CBT. Unfortunately, the fever did not respond to multiple anti-microbial agents and pneumonia progressed. He was found to have multiple embolic cutaneous lesions and biopsy revealed aspergillosis infection. Caspofungin was shifted to AmBisome plus voriconazole. He soon died of multi-organ failure. Autopsy confirmed
25

to be disseminated apsregillosis which involved lung, pleura, pericardium, peritoneum & skin. Conclusions: Caspofungin was effective in the treatment of febrile neutropenia in two of our three patients. Its empirical use as antifungal therapy needs more clinical investigation. 自體周邊血液幹細胞移植治療復發急性骨髓性白血病之臨床困難與未來展望 Autologous Transplantation Using In Vivo-Purged Peripheral Blood Stem Cells For Relapsed AML: Clinical Limitation And Future Implication

廖裕民 1 林嬌玲 2

葉士芃 1,2 林振源 1 邱昌芳 1

黃馨慧 1

白禮源 1

羅偉忠 1

謝清昀 1

羅文吉 2

Yu-Mine Liao, Su-Peng Yeh, Chen-Yun Lin, Hsin-Hui Huang, Li-Yuan Bai, Woei-Chung Lo, Ching-Yun Hsieh, Wen-Jyi Lo, Chiao-Lin Lin, Su-Peng Yeh, Chang-Fang Chiu,

中國醫藥大學附設醫院內科部
a b

血液腫瘤科 1 醫研部幹細胞研究室 2

Division of Hematology and Oncology, Department of Internal Medicine, Stem Cell Research Lab., Department of Medical Research

China Medical University Hospital, Taichung, Taiwan Purpose: For patients of relapsed AML and having no HLA-matched donor, the treatment is limited and the outcome is dismal. This study is to examine the feasibility of myeloablative therapy followed by ―in vivo-purged‖ autologous peripheral blood stem cell transplantation (APBSCT) in this situation. Patients and Methods: Patients of intermediate or high risk AML and had no HLA-matched donors received conventional induction chemotherapy followed by consecutive 2 courses of high dose Ara-C/Mitoxantrone consolidation chemotherapy (in-vivo purging). APBSCs were routinely collected immediately after recovery from nadir phase of the second course consolidation chemotherapy. At relapse, the patients were treated with high dose chemotherapy or chemoradiotherapy followed by ―in vivo-purged‖ APBSCT. For patient with first CR longer than 1 year, another course of salvage chemotherapy with high dose Ara-C will be given to induce 2nd CR. Results: Of the consecutive 26 patients enrolled, sufficient APBSC (≧2 × 106/kg BW) was successfully harvested in 17 (65.4%). Of these 26 patients, 19 relapses were identified. 12 of them had cryopreserved APBSC and 9 patients proceeded to myeloablative conditioning followed by APBSCT. Although there was no transplant-related mortality and 6 achieved second complete remission (CR), the duration of second remission was generally less than 1 year and
26

there was only 1 long-term survivor. Besdies, almost two third (65/105) of all the cryopreserved APBSC units were still maintained in liquid nitrogen without further clinical usage. Conclusion: Our data suggest that APBSCs were not easy to mobilize after consecutive 2 courses of high dose Ara-C chemotherapy and using this strategy to treat relapsed AML is clinically and economically inefficient. Nevertheless, this approach is safe and a significant portion (66%) of patients who received autologous transplantation achieved second CR. This strategy would become viable if the efficacy of APBSC mobilization can be improved and some kind of consolidation therapy (such as target therapy) can be incorporated to decrease the relapse of AML following APBSCT.

27

國人第十二凝血因子活性低於白種人並與一基因多型性有關 The Relatively Lower Activity of Plasma Factor XII in the Population of Taiwan is Related to the 46 C/T Genetic Polymorphism

余垣斌 高志平 李樹中 楊慕華 周永強 徐會棋 陳博明 Y-B Yu, J-P Gau, S-C Lee, M-H Yang, W-K Chau, H-C Hsu, P-M Chen

台北榮民總醫院內科部血液腫瘤科 Division of Hematology and Oncology, Department of Medicine, Taipei Veterans General Hospital, Taiwan Purpose A common genetic polymorphism (46 C to T substitution) in the 5’-untranslated region of coagulation factor XII gene is associated with low translation efficiency and decrease in plasma factor XII activity. We studied the C46T polymorphism and plasma factor XII activity in healthy Chinese people and estimated its impact. Materials & Methods Blood was obtained from 50 healthy Chinese people and DNA from peripheral blood leukocytes was extracted for allele-specific restriction analysis with restriction endonuclease Hga I. Genetic polymorphism was confirmed by subsequent DNA sequencing. Plasma factor XII activity was measured by the aPTT method by using a synthetic substrate specific for thrombin and FXII-deficient plasma. t-test was used to determine the differences in plasma FXII levels between the 3 allele types. Results The distribution of 3 genotypes (C/C:C/T:T/T) in Chinese people was 2%, 40% and 58% respectively and the allele frequency of 46C/T was estimated to be 0.22/0.78. Mean plasma FXII level of 50 donors was 66% and mean plasma FXII level of 3 genotypes was 100.5%, 85.99±9.55% and 52.15±11.56% respectively. Significant lower FXII activity was noted in people with T/T genotype, compared with C/T genotype (p<0.001). Conclusion Factor XII genotype has a significant impact on plasma factor XII activity, which is consistent with the finding of previous studies. However, T/T genotype is predominant among Chinese population and resulted in a lower plasma level of factor XII.

28

抗凝血酶 缺失家族基因變異之研究 Characterization of Genetic Lesion in a Family with Antithrombin Deficiency

高志平

余垣斌

洪英中 徐會棋

陳博明

Jyh-Pyng Gau, Yuan-bin Yu , Yin-Chung Hung , Hui-Chi Hsu, Po-Min Chen

台北榮總內科部血液腫瘤科 Division of Hematology and Oncology, Department of Medicine, Taipei Veterans General Hospital and National Yang-Ming University School of Medicine, Taiwan

Purpose A family in Taiwan with many members suffering from deep vein thrombosis have been found due to antithrombin (AT) deficiency. Characterization of the genetic lesion may be helpful for definite diagnosis of the asymptomatic patients before initiatiation of primary prophylaxis when increased risk of Materials and Methods Genomic DNA was isolated from the family members with informed consents. PCR was performed with primers encompassing all the 7 exons and the intronic sequences near the splicing junctions of the AT gene. Sequencing of the PCR products was performed using the original primers for PCR reactions in the ABI PRISM DNA sequencer. Results Family members with history of deep vein thrombosis and low level of AT activity were noted to be heterozygous for a nonsense mutation (C9819 > T) in exon 5, resulting in the formation of a stop codon TGA. This mutation is absent in the family members without AT deficiency and in normal subjects. Conclusion The family members are widely spread in Taiwan. In Taiwan, patients with AT deficiency probably all come from the same family. Genetic diagnosis may be helpful for identifying asymptomatic carrier in order to give them primary prophylaxis in condition with increased risk of thromboembolism. This mutation also further testifies the vulnerable hotspot of CpG dinucleotide. venous thrombosis is anticipated.

29

在台灣以血液凝固檢查做 B 型血友病的帶因子鑑定 Carrier Detection By Coagulation Tests In Hemophilia B In Taiwan

洪美華 1, 林正修 1, 沈明來 2, 楊永立 1, 沈銘鏡 1 Mei-Hua Hong1, Jen-Shiou Lin1, Ming-Lai Shen2, Yung-Li Yang1, Ming-Ching Shen1

1 1.

台大醫院檢驗醫學部 Department of Laboratory Medicine, National Taiwan University Hospital, Taipei, Taiwan 台灣大學農學院生物統計實驗室

2 2.

Biometry Research Laboratory, College of Agriculture, National Taiwan University, Taipei, Taiwan Purpose: Phenotypic analysis of carrier detection in hemophilia is useful as an adjunct to genetic analysis, and may be the only option when key family members are not available for genetic analysis. Carrier detection of hemophilia B involves the same principles and limitations described for hemophilia A, however, carrier detection based on coagulation assay alone usually is more clear-cut and has higher rate than the case with hemophilia A. Materials & Methods: 1. Subjects 1.1 33 patients with hemophilia B, 27 were severe type, 4 moderate type, 2 mild type 1.2 24 were B- type with no excess of IX:Ag over IX:C 4 were BR type with an excess of IX:Ag over IX:C but below normal values 5 were B+ type with normal level of IX:Ag 1.3 37 normal women without personal and family history of abnormal bleeding 2. Statistical method 2.1 Seven combinations of 1 of 3 variables (IX:C, IX:Ag, IX:C/IX:Ag) were used to derive linear discriminant functions for identification of carriers from normal according to Fisher’s theorem. The data were processed by the computer package of the biomedical computer program which was used at University of California at Los Angeles. Results: Blood samples collected from 37 normal women, 13 definite carriers and 44 possible carriers of hemophilia B were examined for factor IX coagulant activity (IX: C), factor IX -related antigen (IX: Ag) and ratio of IX: C to IX: Ag (C/A) in order to do carrier detection in hemophilia B. The lower 95% confidence limit of IX: C and C/A was 65.5% and 0.61, respectively; the measurement of IX: C alone correctly identified 94.6% of normal women and 100% of definite carriers without a single misclassification, an overall identification success of
30

95.0 to 95.7%. The measurement of C/A alone correctly identified 94.6% of normal women and 100% of definite carriers of BR and B+ without a single misclassification, and as expected misclassified all of 10 definite carriers of hemophilia B-. A comparison of seven linear discriminant functions for carrier detection in hemophilia B derived from data of 37 normal women and 13 definite carriers of hemophilia B, which were processed by the computer package of a biomedical computer program used at University of California at Los Angles, has indicated that the best and simplest is y = 0.24303 IX: C + 0.27699 IX: Ag (cut-off point ỹ = 34.0935). It correctly identified all of the normal women and definite carriers. The measurement of IX: C and C/A alone identified 59.4 to 66.7% and 6.3 to 25% of possible carriers as carriers, respectively. In possible carriers, 56.3 to 66.7% were identified as carriers by linear discriminant function. Conclusions: In conclusion, the lower 95% confidence limit of IX: C and the linear discriminant function are useful for carrier detection in hemophilia B.

31

在台灣所見類血友病(vonWillebrand disease)的臨床,實驗室和基因診斷 Clinical, laboratory and genetic diagnosis of vWD seen in Taiwan

沈銘鏡 1,2 林博淂 2 林炫聿 1 蔡偉 2 徐思淳 1 林正修 3,4 郭夙峰 4 洪美華 4 王瑛琦 4 Ming-Ching Shen1,2, Bodo Lin2 , Hsuan-Yu Lin1, Woei Tsai2, Su-Chuen Hsu1, Jen-Shiou Lin3,4, Su-Fong Kuo4, Mei-Hua Hong4 , and Ying-Chi Wang4.

1 1

彰化基督教醫院內科部 Department of internal Medicine, Changhua Christian Hospital, Taiwan. 台大醫院內科部 Department of intermal Medicine, National Taiwan University Hospital, Taiwan 彰化基督教醫院檢驗醫學部 . Department of Laboratory Medicine, Changhua Christian Hospital, Taiwan 台大醫院檢驗醫學部 Department of Laboratory Medicine, National Taiwan University Hospital, Taiwan

2 2

3 3

4 4

Purpose: vonWillebrand disease(vWD) was first reported in 1926 by Erik vonWillebrand in Finland, and is perhaps the most common hereditary bleeding disorder, its prevalence in the general population in Caucasian is estimated to be 0.82~1.6%. vWD is probably very common in Taiwan, it has not been well studied before. Materials & Methods: A revised classification of vWD described by Sadler JE et al in 1994 and provisional criteria for the diagnosis of vWD type 1 proposed by Sadler JE et al in 2005, as well as defined criteria for significant hemorrhagic symptoms as: 1)bleeding stopped within 5 minutes was considered to be normal, 2)duration of bleeding should be more than 10 minutes to be judged as abnormal, 3) Three or more symptoms when bleeding stopped between 5 and 10 minutes were used for the diagnosis of vWD. Results: We have seen 96 patients in whom vWD has been diagnosed from the year 1990 to 2006. Among them 34 were male, 62 were female, their age ranged from 1 to 67 years with a mean of 27.3 years. Forty-one, 45(17 were index patients) and 10 had type 1, type 2 and type 3 subtypes of vWD, respectively. Bleeding from the wound, postexfraction bleeding, easy bruising, postoperative bleeding, epistaxis and gum bleeding were suffered in 75%, 74.7%, 70.8%, 57.8%, 57.3% and 47.9% of whole patients, respectively. Menorrhagia was present in 60.0% of female
32

patients, which might lead to a higher incidence of female patients in our study. Exons of vWD gene were amplified using polymerase chain reaction(PCR) and sequenced. Eleven different mutations in 12 index patients with type 2 vWD were identified. Five patients with type 2A vWD had mutation each of S1506L, R1597W, R1374H, C1272G and C1272R. A novel mutation of del 1519E was found in a patient with type 2A-like vWD. Two patients with 2B vWD had mutation of V1316M and R1308C, respectively. Both 2 patients with type 2B vWD had mutation of R1306W, parents of one patient were free from mutation. Two patients with type 2M vWD had mutation each of R1315C and R1374C. Conclusions: In conclusion, the hemorrhagic symptoms that were most associated with vWD in out study were bleeding from minor wound and easy bruising, much similar to those found in recent European mulficenter study (MCMDM-1 vWD), the laboratory and genetic characteristics of our patients are not different from those observed in Western countries. R1306W type 2B vWD may be caused by de novo mutation. A novel vWF gene mutation with del GGA(del 1519E) was found in one of our patients who had type 2A-like vWD.

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基隆地區乙型海性貧血貝他血球蛋白基因的突變 -thalassemia globin gene mutations in Keelung area 藍以政 1 劉育志 2 王正旭 1 黃仁聖 1 葉光揚 1 賴建宏 1 闕宗正 1 施麗雲 3

Y-J Lan, Y-C Liu, C-J Wang, J-S Huang, K-Y Yeh, C-H Lai, T-C Chueh, L-Y Shin 長庚大學醫學院
1

基隆長庚醫院 血液腫瘤科 基隆長庚醫院 胸腔科 林口長庚醫院 血液腫瘤科

2

3

Purpose: 乙型海洋性貧血是常見的遺傳性疾病,台灣是高盛行區。乙型海洋性貧血也是血液腫 瘤科門診常見的疾病 乙型海洋性貧血起因於第 11 對染色體短臂上貝他血球蛋白基因群的 。 突變,大部分的突變是一小點或小段的缺損或插入。目前全世界已知有超過 200 多種突變, 其中在華人有 27 種,在台灣可見到約有 18 種。而每一族群都有其常見的突變型,基隆地 區乙型海洋性貧血貝他血球蛋白基因的突變型分佈仍未明。 Material and Methods: We collected peripheral blood of ß-thalassemia cases from Keelung Chang Gung Memorial Hospital with informed consent. The ß-thalassemia is defined as microcytic RBCs with HbA2>3.5%. The entire -globin gene including 470 bp of the promoter region were amplified in four segments by using four pairs of oligonucleotide primers with polymerase chain reaction and sequenced. Results: From July 2005 to Augest 2006, 39 cases of ß-thalassemia were collected. There were 13 male and 26 female. The age at diagnosis ranged from 13 years to 87 years, mean age 43.2 years. Hb ranged from 7.2 gm/dl to 13.8gm/dl (mean 10.5 gm/dl). MCV ranged from 57.7 fl to 78.4 fl (mean 66 fl). RBC ranged from 3.47 x 106/cmm to 6.54 x 106/cmm, mean 5.18 x 106/cmm. A total of 4 different ß-thalassemia mutation were identified. IVS-2 position 654(C→T) is the most frequent mutation in this population (n = 20/39)(51.3%), followed by 4-base pair (-CTTT) deletion at codon 41-42 (n = 13/39)(33.3%). The remaining 2 mutations were codon
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17(A→T) (n = 2/39)(5.1%) and start codon (ATG→AGG) (n = 1/39)(2.6%). No -globin gene mutation was found in 3 cases (n = 3/39)(7.7%). Conclusion: IVS-2 position 654(C→T) is the most frequent ß-thalassemia mutation in this population (n = 20/39)(51.3%), followed by 4-base pair (-CTTT) deletion at codon 41-42 (n = 13/39)(33.3%).

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部份凝血活酵素時間的延長在多發性骨髓瘤 Ig A 代表預後不好 The prolonged activated partial thromboplastin time at diagnosis indicates less favorable prognosis in IgA myeloma

鄧豪偉, 陳博明, 邱宗傑, 徐會棋, 周永強, 劉俊煌, 王緯書, 顏厥全, 蕭樑材, 楊慕華, 趙大中, 高志平. Hao-Wei Teng, Po-Min Chen, Tzeon-Jye Chiou, Hui-Chi Hsu, Jin-Hwang Liu, Wing-Keung Chau, Wei-Shu Wang, Chueh-Chuan Yen, Ling -Tsai Hsiao, Muh-Hwa Yang, Ta-Chung Chao, Jyh-Pyng Gau

台北榮總血液腫瘤科 Division of Hematology and Oncology, Department of Medicine, Taipei Veterans General Hospital and National Yang Ming University School of Medicine.

Background: The impact of coagulopathy on survival of patients with myeloma has not been studied in detail. Patients and method: Data including activated partial thrombin time (aPTT) and prothrombin time (PT) obtained before treatment and at the time of diagnosis of multiple myeloma (excluding: monoclonal gammopathy of undetermined significance, POEMS syndrome, IgM myeloma, and myeloma with amyloidosis) collected from 222 patients were analyzed. Result: Twenty-one patients (9.5%) had prolonged aPTT (9 with prolonged aPTT alone, 12 with both prolonged aPTT and PT) and 10 (4.5%) had prolonged PT alone. Coagulopathy occurred only in patients with IgA and IgG myeloma but not light-chain disease. In IgA myeloma, the prolonged aPTT was more frequent in patients with International Staging System (ISS) stage III than stage II (p=0.019, Pearson Chi-square test). Prolonged aPTT was an independent prognostic factor in IgA and IgG myeloma (median survival=12.7 months, p=0.004), while prolonged PT alone had no impact on survival. Subgroup analysis revealed that prolonged aPTT indicated less favorable survival in IgA myeloma (p=0.001), but not the IgG myeloma (p=0.341). Conclusion: Coagulopathy occurs in IgG and IgA myeloma and the presence of prolonged aPTT at diagnosis is a prognostic factor indicating poor outcome in the IgA subgroup.

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Hypofunction of Platelet Adhesion, Aggregation and Activation in Patients with Essential Thrombocythemia

陳宇欽、吳宜穎、林斈府、張平穎、姚乃舜、何景良、高偉堯、趙祖怡 國防醫學中心 三軍總醫院 內科部 血液腫瘤科

Purpose: Patients with essential thrombocythemia (ET) carry 20-30% risk to develop thrombohemorrhagic events with thrombosis or hemorrhage, for which it is not very clear until now what the pathogenesis is responsible. The aim of this study is to evaluate the platelet functions in patients with ET. Patients and Methods: From Jan. 2006 to Dec. 2006, 16 consecutive patients with ET (platelet count > 400 x 106/μL) were enrolled. Their median age was 50.5 years old with a rage of 20~88. Each patient had normal ESR and CRP, and iron deficiency anemia, infection, neoplasm, and hyposplenism were all excluded. JAK2 V617F mutation was detected by reverse transcript polymerase chain reaction (RT/PCR) or PCR. Platelet function tests were performed for each patient, including VWF antigen, ristocetin cofactor assay (VWF:RCo), platelet function analyzer (PFA) assay with epinephrine/collagen and ADP/collagen, platelet aggregation test, and flow cytometric analysis of platelet activation. These testings were also done in 14 normal subjects as normal control. Results: Of 16 patients with ET, 6 (37%) had vasomotor symptoms, 3 (16.5%) patients presented with bleeding, 1 patient developed cerebral infarction, and 6 (37%) patients were asymptomatic. Nine (56%) patients had JAK2 V617F mutation. Among platelet function testings, 2 patients had low VWF:RCo (<50%). The closure time of epinephrine/collagen and ADP/collagen were prolonged in around half patients, respectively (57% and 46%), and were more prolonged than those of normal control (192 vs 124 sec, p ,0.01; 125 vs 85 sec, p <0.05). Twelve (75%) patients had abnormal platelet aggregation, and 15 out of 16 (93%) patients had no response to ristocetin 1.0 mg/mL stimulus, which was higher than normal control (38%)(p <0.01). On the platelet activation by ADP stimulus, 31.77±18.32% of activated platelets was attained in ET patients, which was much lower than 57.12±17.59% of normal control (p <0.001). Conclusion: Our study demonstrated that patients with ET carried significant hypofunction of platelet adhesion, aggregation and activation than normal subjects.

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血小板對腎上腺素刺激弱反應的中國族群研究 Impaired Responsiveness of Platelets to Epinephrine in Taiwan Chinese

陳雅萍, 林技賢, 王雅惠, 林尊湄, 陳彩雲 Ya-Ping Chen, Jihshyan Lin, Ya-Hui Wang, Tsun-Mei Lin, Tsai-Yun Chen 成大醫院內科部血腫科,病理部 Section of Hematology/Oncology, Department of Internal Medicine, Departments of Medical Laboratory Science and Biotechnology, and Pathology, College of Medicine, National Cheng Kung University

Purpose: Platelet activation plays a central role in hemostasis and thrombosis. Epinephrine is known as a weak, but important, agonist for platelet activation. It has been reported that the responsiveness of platelets to epinephrine was markedly impaired in 6% Caucasian and 16% in Japanese. In this study, we attempted to screen and to characterize this abnormality in healthy volunteers in Taiwan Chinese. Materials and Methods: A total number of 50 male healthy individuals were recruited to investigate the responsiveness of platelets to epinephrine stimulation by aggregometry and flow cytometry. Results: Based on the platelet aggregation after stimulation with 10 μM epinephrine for 10 minutes, two distinct groups of subjects of epinephrine good and impaired responders were observed in 24 (48.0%) and 26 (52.0%) subjects, respectively. In comparison to the results of flow cytometic analysis after platelet challenged with 1 μM epinephrine, glycoproteins GPIIbIIIa expression of epinephrine good and impaired responders were 26.8±10.5%, and 9.9±5.4% (P<0.001), respectively. If cutoff ratio of GPIIbIIIa expression was defined below 30%, the sensitivity and specificity were 95.0% and 83.3%, respectively for epinephrine impaired responder detection by flow cytometry as compared to traditional platelet aggregation test. Incubating the good responder platelets with α2A adrenoceptor antagonist BRL44408 maleate renders them impaired response to epinephrine stimulation. Conclusions: Our results indicated that prevalence of impaired responsiveness of platelets to epinephrine was high and probably was due to α2A adrenoceptor deficiency in Taiwan Chinese. The polymorphisms in the promoter of the α2A adrenoceptor gene between the good and impaired responders will be searched to solve the reason responsible for this.

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超級華法令中毒: 血尿為主要臨床表徵 Superwarfarin intoxification: hematuria is a major clinical manifestation

吳懿峰 1 蘇培元 1 王全正 1 林炫聿 1 鍾智淵 1 張正雄 1 沈銘鏡 1,2 YF Wu1, PY Su1, CC Wang1, HY Lin1, TY Chung1, CH Chang1, MC Shen1,2
1 1 2 2

彰化基督教醫院 血液腫瘤科 Section of Hemato-oncology, Department of Internal Medicine, Changhua Christian Hospital 臺大醫院內科部 Department of Internal Medicine, National Taiwan University Hospital

Purpose:Since superwarfarin are popular and readily available in stores, superwarfarin intoxification or exposure can cause coagulopathy or abnormal bleedings in human beings and becomes an important public health problem. Hererin we report the clinical experiences of superwarfarin intoxification. Case presentations:Six patients fulfilled the diagnosis of superwarfarin intoxification were seen from 1998 to 2006. Three patients were male and three were female. The 3 patients who attempted suicide were a 72-year-old woman, a 50-year-old man and a 39-year-old woman. They had ingested 4.5mg, 12mg and 9.0mg of broadifacoum, respectively. First patient presented with gross hematuria, gum bleeding and multiple ecchymosis 3 to 5 days later; second patient presented with gum bleeding and easy bruising 9 days later; third patient developed lower abdominal pain and soreness of shoulders one week later, and gross hematuria 2 weeks later. The 2 patients with Munchausen Syndrome, i.e., deliberate self-poisoning with denial, were a 23-year-old soldier and a 36-year-old man. First patient presented with gross hematuria, hemoptysis, nasal and gum bleeding, bleeding at the puncture site, easy bruising and tarry stool, he denied ingestion of rodenticide most of the time but admitted to ingest on one occasion. Second patient presented with bleeding from right ear canal, gross hematuria, gum bleeding, bleeding into both calves and swelling of both knee joints, he denied taking superwarfarin, but his blood serum was tested positive for superwarfarin. Both patients were suspected of continuing to ingest superwarfarin for more than 1.5 years. The first patient was dismissed from the army due to abnormal bleeding and abnormal behavior. Both were lost for follow up. Bromadiolone, also a superwarfarin rodenticide was used to commit murder to a 49-year-old woman by her husband. She presented with generalized soreness, multiple ecchymosis, abdominal pain and gross hematuria. Laboratory tests in these 6 patients all yielded extremely prolonged PT and aPTT which could be corrected to normal by mixing 1:1 with normal pool plasma, and very low levels of factor II, VII, IX, X, protein C and protein S but normal levels of factors V, VIII, fibrinogen, and anti-thrombin III. Large doses of vitamin K1 were needed for 3 months or more to treat the prolonged coagulopahty in these patients Conclusions:Five of the 6 reported patients presented with gross hematuria suggesting that

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hematuria is probably the major clinical manifestation of superwarfarin intoxification. Prolonged use of large dose of vitamin K1 is needed for the diagnosis and treatment of superwarfarin intoxification.

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骨髓間質幹細胞特性隨著體外培養代數不同而改變 Changing Characteristics of Bone Marrow-Derived Mesenchymal Stem Cell During Ex Vivo Culture: Important Consideration For Research And Clinical Application

羅文吉 1 葉士芃 1,2 林嬌玲 1 廖裕民 2 黃馨慧 2 林振源 2 禮源 2 羅偉忠 2 謝清昀 1 邱昌芳 2 Wen-Jyi Lo, Su-Peng Yeh, Chiao-Lin Lin, Yu-Mine Liao, Hsin-Hui Huang, Chen-Yun Lin, Li-Yuan Bai, Woei-Chung Lo, Ching-Yun Hsieh, Chang-Fang Chiu,

中國醫藥大學附設醫院內科部
a

醫研部幹細胞研究室 1

血液腫瘤科 2

Stem Cell Research Lab., Department of Medical Research Division of Hematology and Oncology, Department of Internal Medicine, China Medical University Hospital, Taichung, Taiwan
b

Background and Purpose: Therapeutic application of ex vivo expanded mesenchymal stem cells (MSCs) are increasing rapidly in the recent years. However, the characteristics of MSCs may probably be changed during ex vivo culture because of the changing microenvironment. We have previously reported that the result of induction of CD45 expression on MSCs by using demethylating agent 5-aza-2-deoxycytidine is different from passage to passage (S-P Yeh, et al. Leukemia 2006,20:894-896). F-B Zhang et al. had also been report that the differentiation potential of MSCs into cardiomyocyte- like cells was ―passage-restrictive‖. These data suggested that MSCs can become different after ex vivo culture, even though they derived from the same origin. Materials and Methods: Bone marrow-derived MSCs were isolated from 3 patients of AML, myeloma, and normal adult. They were all ex vivo cultured at the same condition. RNA were extracted from P2 and P5 cells (of the same origin) and then subjected to cDNA microarray (Agilent Human 1A(V2) OligoMicroarray) to compare the difference of gene expression profile between P2 and P5 MSCs. Western blot and immunocytochemical staining were further used to confirm the difference at protein level. Results: We found the GEP is different between P2 and P5 in each pair, especially in case of AML. The highest differently expressed genes and their normalized expression ratio will be presented. Of these, increased expression of vimentin and proenkephalin in P2 cells were found in all the 3 specimens, which were further confirmed by western blot and immunocytochemical staining at protein level. Conclusion: Our study showed that bone marrow-derived MSCs will be changed during ex vivo culture

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and P2 MSCs are different to P5 MSCs, even though they came from the same origin. This factor should be considered seriously when using MSCs in clinical studies or experiments because MSCs of different passage may probably lead to different result.

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骨髓基質細胞內 DcR3 的分泌及表現 The Level and Expression of DcR3 in Bone Marrow Stromal Cells 邱宗傑 1,黃郁蓁 2,朱善德 3,陳明晃 1,劉峻宇 1,張牧新 1,蕭樑材 1,王緯書 1, 楊慕華 1,陳博明 1,曾婉芳 2 Tzeon-Jye Chiou1, Yi-Tsen Huang2, Sin-Tak Chu3, Min-Hung Chen1, Chu-Yu Liu1, Peter M.S. Chang1, Liang-Tsai Hsiao1, Wei-Hsu Wang1, Mu-Hwa Yang1, Po-Min Chen1, Woan-Fang Tzeng2
1

台北榮民總醫院及國立陽明大學醫學院內科部血液腫瘤科,2 輔仁大學生命科學系暨研究

所,3 中央研究院生化研究所 1 Division of Hematology and Oncology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan, ROC 2 Department and Graduate Institute of Life Science, Fu-Jen Catholic University, Taipei, Taiwan 3 Institute of Biological Chemistry, Academica Sinica, Taipei, Taiwan Background Decoy receptors 3 (DcR3) can bind to three TNF family ligands, i.e., Fas ligand (FasL), LIGHT, and TL1A. Earlier studies had demonstrated its roles in the immune system, osteoclast formation, angiongensis of human umbilical vein endothelial cells (HUVECs), pathogenesis of allergic disease, sepsis, and some tumors to escape from immuno-cytotoxic attack. Bone marrow stromal cells (BMSCs) play an important role in the hematopoietic recovery after cytotoxic treatment. Its function is related to the ability in the secretion of cytokine. Little is known about the role of DcR3 in BMSCs. Methods Patients those who received HSCT at VGH were enrolled after signing their consent forms. The bone marrow specimen was harvested before, 1, 3 and 6 months after HSCT at their regular follow-up. The peripheral blood specimen, bone marrow fluid, the supernatant fluid and the BMSCs of the 3-5 generation in the subculture of BMSCs were prepared and stored for the study. The soluble DcR3 level was assayed with ELISA method. RT-PCR was used to quantify the mRNA expression of DcR3 and FasL. The serum and 3-5 generation of BMSCs from healthy marrow donor and a human marrow-derived stromal cell line, i.e. HS-5, were used as control to evaluate the potential role of DcR3 in the BMSC. Results The levels of DcR3 in bone marrow fluid of MDS and HD patients were much higher than that in other patients. The levels of DcR3 secreted by BMSCs in MDS patients were the highest among the hematological malignant patients. The levels of DcR3 in bone marrow fluid were much higher than that in stromal cells secreting solution. BMSCs were not the main source of marrow DcR3.Tumor cells might play some roles in the secretion of DcR3 in marrow fluid and patient’s plasma. The levels of DcR3 in peripheral blood were detectable in hematological malignant patients. Its level in marrow fluid was correlated to the level in peripheral blood. DcR3 and FasL could be expressed in mononuclear cells (MNCs) of bone marrow. The expression of DcR3 and FasL in MNCs of bone marrow was contrary to the level in their marrow fluids. Conclusions DcR3 levels in BM fluid and BMSCs secretion of healthy donor and hematological malignant patients before chemotherapy was detectable and was much higher in MDS patients than that in other patients. DcR3 in plasma were detectable in hematological patients and correlated with the levels of BM fluid. The expression of DcR3 and FasL in BM MNC was not correlated to the levels of DcR3 and FasL in BM fluid for patients. To enroll more patients to clarify the role of the DcR3 and FasL in BM fluid, BMSCs secretion, and BM MNC before and after HSCT should be warrant. Further studying the possible mechanisms of DcR3 and FasL secretion in BM MNCs and the origin of BMSCs after HSCT should be scheduled in the future. (Supported by Grants of VGH-95-S5-004)

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異體移植前之全身放射治療會造成骨髓間質幹細胞染色體變異 Total Body Irradiation Before Allogeneic Transplantation Results In Chromosomal Abnormalities Of Bone Marrow-Derived Mesenchymal Stem Cells

邱昌芳 1 羅文吉 2 林嬌玲 2 廖裕民 2 林振源 2 黃馨慧 2 白禮源 2 葉士芃 1,2 Chang-Fang Chiu, Wen-Jyi Lo, Chiao-Lin Lin, Yu-Mine Liao, Chen-Yun Lin, Hsin-Hui Huang, Li-Yuan Bai, Su-Peng Yeh

中國醫藥大學附設醫院內科部
a

血液腫瘤科 1 醫研部幹細胞研究室 2

Division of Hematology and Oncology, Department of Internal Medicine, Stem Cell Research Lab., Department of Medical Research China Medical University Hospital, Taichung, Taiwan
b

Purpose: Total body irradiation (TBI) is a standard conditioning therapy before hematopoietic stem cell transplantation. Nevertheless, the effect of TBI on bone marrow-derived mesenchymal stem cells (MSCs) has never been investigated. We therefore conducted this study to evaluate the cytogenetic status of MSCs isolated from patients receiving TBI before sex-mismatched allogeneic peripheral blood stem cell transplantation. Materials and Methods: Bone marrow-derived MSCs were isolated and ex vivo expanded from leukemic patients before and/or after allogeneic transplantation. Immunophenotyping using flow cytometry and induction of adipocytic and osteocytic differentiation were conducted to confirm the characteristics of MSCs. Cytogenetic studies were conducted using traditional G-banding. For further investigation the effect of irradiation on MSCs, MSCs isolated from normal adults and had normal karyotypes were subjected to irradiation directly (by using blood irradiator) with the same regimen as TBI (200cGy bid for consecutive 3 days). Results: We found the bone marrow-derived MSCs were all recipient-origin after allogeneic transplantation. Interestingly, some of the MSCs had cytogenetic abnormalities after transplantation (table). One of these patients (Case No. 3) had a normal vairant der (13;14)(q10;q10) before allogeneic transplantation, and get a new t(1;17)(q21;p13) after transplantation. Besides, complex chromosomal abnormalities were also found on MSCs after irradiation. There were more than 10 different abnormalities in each specimen and they did not share the same cytogenetic characteristics. Conclusion: Irradiation, either using TBI before transplant or using blood irradiator in experiments, may result in chromosomal abnormalities of bone marrow-derived MSCs and these cells should be
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avoided from further clinical application. Further study is also needed to observe the tumorogenesis of these cells. Cytogenetic abnormalties after total body irradiation (TBI) Chromosome of BM-blood Case Chromosome of Disease Chromosome of BM-MSCs after TBI cells after TBI No BM-MSCs before TBI (Allotransplantation) 1 2 3 AML ALL ALL not available not available Robertsonian variant 46 XY, t(7;22)(p22;q11), del (13)(q12q22), del (15)(a15?) 47 XY, del (1)(p36), +2, t(3;13)(p21;q12), t(5;10)(q33;p15) 46 XY, Robertsonian translocation, t(1;17)(q21;p13) Normal XX Normal XX Normal XX

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以 Cyclophosphamide 合併 G-CSF 用於漿細胞惡性腫瘤患者收集造血幹細胞之成效 Cyclophosphamide plus G-CSF for Hematopoietic Stem Cell Mobilization for Patients with Plasma Cell Dyscrasia 林棟樑 施麗雲 王博南 郭明宗 張 鴻 鄧 波 洪玉馨

T-L Lin, L-Y Shih, P-N Wang, M-C Kuo, H Chang, P Dunn, Y-S Hung 長庚紀念醫院血液腫瘤科 Division of Hematology-Oncology, Chang Gung Memorial Hospital, Taipei, Taiwan Purpose: Multiple myeloma is an incurable hematological malignancy. Recent reports showed that autologous hematopoietic stem cell transplantation will prolong the overall survival. However, the method for hematopoietic stem cell mobilization is not standardized. We retrospectively analyzed patients with multiple myeloma or plasmacytoma who received cyclophosphamide plus granulocyte colony stimulating factor (G-CSF) for hematopoietic stem cell mobilization. Materials and Methods: The regimen for hematopoietic stem cell mobilization was one dose of cyclophosphamide (2g/m2) and G-CSF 10g/kg/day in 2 divided doses. We started to collect the stem cell if the total WBC count was more than 10x109/L. Results: The patient number was 20 with 12 females and 8 males. There were 18 patients diagnosed of multiple myeloma and 2 with multiple plasmacytoma of bone. The median age was 50 (40-60). The day of stem cell apheresis was 7 to 11 (median 9) days after cyclophosphamide infusion. The number of apheresis was 1 to 3 (median 2) with adequate CD34 doses for 2 transplants except one patient. The CD34 dose per apheresis was 0.79x106/kg to 17.72x106/kg (median 3.11x106/kg). The complications were limited, with fever (3 patients), pneumonia (2 patients), and gross hematuria (1 patient). Blood transfusion was necessary in 2 patients. The number of apheresis was not affected with previous courses of chemotherapy (P=0.4011), local radiotherapy (P=1.0000) nor age (P=0.6754). There were 16 patients undergoing transplantation. The median time of neutrophil engraftment was day 11 (9-13). The median time of platelet engraftment was day 15 (10-22). No transplant-related mortality was observed. Conclusions: The present study showed that one dose of cyclophosphamide (2g/m2) plus G-CSF is an effective method for hematopoietic stem cell mobilization with a low rate of complications in patients with multiple myeloma.

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用移植來治療嚴重再生不良貧血的患童-台北榮總的經驗 The outcome of pediatric severe aplastic anemia after hematopoietic stem cells transplantexperience in Taipei Veterans General Hospital 謝明芸 顏秀如 洪君儀 陳博明 邱宗傑 M-Y Hsieh, H-J Yen, G-Y Hung, P-M Chen, T-J Chiou 台北榮民總醫院兒童醫學部 內科部血液腫瘤科 Department of Pediatrics, Division of Hematology-Oncology, Taipei Veterans General Hospital Purpose: Hematopoietic stem cell transplant is an effective rescue way for severe aplastic anemia. In this retrospective study, we reported the outcome of hematopoietic stem cell transplant is children suffered from severe aplastic anemia. Materials & Methods: During 1995 and 2006, 23 patients younger than 18 years with severe aplastic anemia received transplant. All of their medical records were reviewed. Possible prognostic factors, including interval from diagnosis to transplant, different conditioning, different sources of hematopoietic stem cells, were analyzed. Results: In these 23 patients, there were 14 boys and 9 girls. The mean age was 9.44±0.63 years (range: 2~16 years). The mean interval between diagnosis and transplant was 3.74±0.94 months. Sixteen donors were related and seven donors were unrelated. Among related transplants, 4 were only haplotype matched. Two patients died of graft failure complicated with infection. Among 21 survivors, 6(28.6%) patients experienced acute graft versus host disease and 7 patients experienced chronic versus host disease. The mean survived time after transplant was 65.8±10.2 months. The probability of survival at 5 years was 91.3%. Transplant from unrelated donor (p=0.026) and transplantation more than 6 months after diagnosis(p=.005) were unfavorable factors in univariate analysis. But they were not statistically significant by multivariate analysis. Conclusions: Patients with severe aplastic anemia can survive long time with successful transplants. Allogenic hematopoietic stem cell transplant should be considered in pediatric severe aplastic anemia patients if patients have matched donors.

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用造血幹細胞移植來治療急性骨髓性白血病的患童-台北榮總的經驗 The Outcome of Pediatric Acute Myeloid Leukemia after Hematopoietic Stem Cells TransplantExperience at Taipei Veterans General Hospital 顏秀如 謝明芸 洪君儀 陳博明 邱宗傑 H-J Yen, M-Y Hsieh, G-Y Hung, P-M Chen, T-J Chiou 台北榮民總醫院兒童醫學部 內科部血液腫瘤科 國立陽明大學醫學系 Department of Pediatrics, Division of Hematology-Oncology, Taipei Veterans General Hospital and National Yang-Ming University School of Medicine

Purpose: It has been proved that hematopoietic stem cell transplantation(HSCT) is an effective therapy in treating acute myeloid leukemia(AML). Here, we present the result of HSCT for pediatric AML at a single institute. Materials & Methods: From September 1984 to January 2007, AML patients who were younger than 16 years old at transplant and received HSCT as part of the therapy were included. The patients’ characteristics, type & source of HSCT, engraftment status, post-transplant complications and outcome were analyzed. Results: There were 28 pediatric AML cases who received HSCT at first complete remission (CR1, n=19), second complete remission (CR2, n=2), partial remission (PR, n=1), refractory (n=1) or unknown status (n=4) were enrolled. The male to female ratio was 17 to 11. Median age at diagnosis and transplant was 10 (range 3m/o-16y/o) and 10 (range 14m/o-16y/o), respectively. The donor of HSCT was haplo-identical in 3, matched unrelated in 7, autologous in 5, and sibling donor in 13. The sources of stem cell included bone marrow in 20 and peripheral blood in 8. Ninety-six percent (24 of 25 patients) of patients achieved engraftment. The ten-year disease-free survival was 73%. Mortality rate was 25%, and transplant-related mortality was 8 %. Conclusions: The outcome of pediatric AML after HSCT at our institute appears to be promising. It suggests that HSCT is a feasible treatment modality for pediatric AML patients when HLA-matched donor is available.

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醫學中心的小兒骨髓移植經驗 Stem Cell Transplantation in Children: a Single institution Experience

吳瑋超、鄭兆能、陳建旭 Wei-Chao Wu, Chao-Neng Cheng, Jiann-Shiuh Chen

國立成功大學醫學院附設醫院小兒血液腫瘤科 Division of Pediatric Hematology-Oncology, Department of Pediatrics, National Cheng-Kung University Hospital, Tainan, Taiwan Purpose: Reconstitution of hematopoiesis by stem cell transplantation (SCT) has become an established therapeutic modality for a variety of childhood diseases. This study represents the 10 more years experience of SCT of children in a tertiary care center at southern Taiwan. Materials & Methods: From 1994 to 2006, medical records of all pediatric patients who received SCT were reviewed retrospectively. Data collected for analysis mainly focus on underlying diseases, sources of stem cells, conditioning regimens, outcome and complications of SCT. Results: Total 39 patients were enrolled. The mean follow-up duration was 46.7 months (range, 0.2 to 12y2m). 18 patients were girls and 21 boys. The mean age before transplantation was 9.6 years (range, 2.9 to 17. years). Underlying diseases included acute myelogenous leukemia (AML) in 12, chronic myelogenous leukemia in 2, acute lymphoblastic leukemia (ALL) in 6, severe aplastic anemia (SAA) in 7, Cooley’s anemia in 2, Hodgkin disease in 2, neuroblastoma (NB) in 4, and 1 for Non-Hodgkin lymphoma (NHL), Wilms’ tumor, Wiskott-Aldrich syndrome, and mucopolysaccharidosis (MPS), respectively. Among these patients, 16 received autologous transplantation and 23 allogeneic transplantations; 14 transplants were harvested from bone marrow and 25 were from peripheral blood. The average dosage of infused stem cell was 8.37108 TNC/kg, and CD34+ cells 9.13106 cell/kg, respectively. Graft-versus-host disease (GVHD) prophylaxis with cyclosporine and short course methotrexate was applied to all patients. There was mortality in 15 patients (7 AML, 2 ALL, 2 NB, 1 for NHL, SAA, MPS and Wilms tumor). The Kaplan-Meier overall survival was 61.3% and 58.4% at 2 years and 5 years, respectively. Of them, 2 patients with neuroblastoma experienced an early mortality in one month. Two patients had graft failure. Conclusions: SCT is a useful and feasible resort for a variety of children diseases in our hospital. But, our generalized overall survival for patients with AML seems inferior to others. In addition, patients with neuroblastoma are less effective to autologous SCT and carried a high risk of early
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morbidity and mortality.

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以髓鞘內化學藥物治療作為急性淋巴性白血病中樞神經預防性療法於一醫學中心之經驗 Triple Intrathecal Therapy Without Cranial Irradiation for Central Nervous System Preventive Therapy in Childhood Acute Lymphoblastic Leukemia at A Single Institution 林維英 劉希哲 葉庭吉 王麟燕 趙玉華 陳淑惠 梁德城

W-Y Lin, H-C Liu, T-C Yeh, L-Y Wang, S-H Chen, Y-H Jhao, D-C Liang, ,

馬偕醫院小兒血液腫瘤科 Division of Pediatric Hematology-Oncology, Mackay Memorial Hospital, Taipei, Taiwan

Purpose. To evaluate the treatment results of central nervous system preventive therapy (CNSP) with triple intrathecal therapy (TIT) alone in children with acute lymphoblastic leukemia (ALL). Material & Methods. We retrospectively studied a cohort of 59 patients with median follow-up time 50.6 months (range: 27 to 80 months) at a single institution in Taiwan. Patients with ALL were classified in risk groups at diagnosis. TPOG-ALL-93 protocols and TPOG-ALL-2002 protocols were used. Both protocols were for multicenter studies in Taiwan and contained protocols for standard-risk (SR), high-risk (HR), and very-high-risk (VHR) patients. In this study, we used TIT alone for CNSP. In all ALL patients, methotrexate, hydrocortisone, and cytarabine were given at age-dependent doses. Results. As of October 2006, our patients had a 3-year event-free survival and an overall survival 89.4% ± 4.1% (s.e.) and 93.1% ± 3.3%, respectively. Under TIT no patients had complications such as seizure, encephalitis, or infection, and no morbidities like those caused by cranial irradiation. In this study, we used TIT alone for CNSP and had no CNS relapse. Conclusions. In the context of effective systemic therapy, TIT alone is effective for CNSP in all ALL patients.

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Chlorambucil, Imatinib and methylprednisolone 引發致命性高膽紅素血症- 三個案例 報告 Fatal hyperbilirubinemia caused by Chlorambucil, Imatinib and methylprednisolone –three cases reports

蕭培靜

劉克森

Pei-Ching Hsiao, Ken-Sen Liu

中山醫學大學附設醫院內科部血液科, 感染科 Division of hematologic, infectious Department of Internal Medicine, Chung Shan Medical University Hospital, Taichung 402, Taiwan. Purpose: We reported three cases of fatal hyperbilirubinemia suspecting reactivation of chronic B virus infection in CLL, CML and atypical CML patients undergoing treatment of chlorambucil (leukeran), imatinib(glivec),and methylprednisolone(solu-medrol). Case presentation: Case1. This 52-year-old man had history of ankylosing spondylitis. CBC data was WBC 94200 lymphocyte 92%. CLL stage0 was diagnosed on May 2004. Leukeran 8mg.p.o qd was administered 3 weeks every 6 months. He developed fulminant hepatitis followed by marked elevation of HBV DNA polymerase probably induced by leukeran. Data revealed WBC 87200/mm3 ,lym. 98% Hb 11.1gm/dl, ALT 1379IU/I, AST1411IU/I at admission and total bilirubin elevated to 41.3mg/dl prior to death. Case2. This is a 43-year-old man with history of Diabetes mellitus presenting acute loss of vision (O.U) with significant leukocytosis. WBC215030 blast 0.3%,promyelo3.8%, myelo5.5%, meta2.5%, band 15%, seg 60.5%, band3.5%, baso1.o% mono2.4% lym.5.5% normobl 1% platelet120000. chronic phase of ph’ chromosome positive CML was diagnosed on Mar.2006. Glivec 400mg po qd was administered and complete hematologic response was obtained . Lab data revealed WBC 6860 Hb 10.9gm/dl platelet 30000. Total bilirubin 40.2mg/dl, direct bilirubin15.5mg/dl AST182IU/L ALT329IU/L. at admission. He had no prior liver dysfunction but with HBV carrier. Fatal hepatitis with severe hyperbilbirubinemia occurred during treatment of Glivec for 4 months. Case3. This 70-year-old man had asthma, hypertension and ph’-negative chronic myeloid disease diagnosed on Sep. 1998. He was well without treatment until intractable asthma attack occurred on Feb.2005. Lab. data revealed WBC 88370 myelo0.25%, meta7.5%, band 77%, mono10.2%, lym.0.75% Hb 7.5gm/dl, platelet 1280000. bcr/abl negative atypical CML was diagnosed at admission. Solumedrol 40mg q8h iv. for 4 days was described then following prednisolone 10 mg po. qd. for asthma. Following one week after discharge, he was admitted again because of severe jaundice. Total bilirubin 30.1 mg/dl, direct billirubin 17mg/dl AST 651
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IU/L, ALT 466IU/L and expired at the second day of admission. Methylprednisolone induced toxic hepatitis is possible. Conclusion: Chlorambucil, Imatinib and methylprednisolone induced hepatoxicity have previous been reported and caused fatalitied in our patients with CLL, CML and atypical CML respectively. Regular monitoring of liver function tests in essential in patients treated with these drugs, especially in HBV carrier.

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如何從合併 Desferrioxamine 及 Deferiprone 轉變至單獨使用 Deferiprone 來治療依賴輸血之 海洋性貧血症病人的鐵質沉積 How to Change Combination Therapy of Desferrioxamine and Deferiprone to Alone Use of Deferiprone for Iron-Chelation in Transfusion-Dependent Thalassemic Patients

章人欽 1 2

邱世欣 1 林佩瑾 1 林國信 2

張泰琮 1

R-C Jang1 2 , S-S Chiou1, P-C Lin1 , K-S Lin2 , T-T Chang1

高雄醫學大學附設中和紀念醫院小兒血液腫瘤科 1 台灣血液基金會高雄捐血中心 2 Department of Pediatric, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan1 Kaohsiung Blood Center, Taiwan Blood Services Foundation, Taiwan2 Purpose: Combination therapy with desferrioxamine (DFX) and Deferiprone (DFO) in the transfusion-dependent thalassemic patients is effective at reducing serum ferritin. The purpose of this study was to know whether the effect can be maintained after changing combination therapy to alone use of DFO. Materials & Methods: From March 2004 to July 2006, eighteen Chinese transfusion-dependent thalassemic patients (aged 9 to 34 years, seven females and eleven males) were enrolled with regular combination therapy. DFO at the standard daily dose of 75 mg/kg was given to these patients in whom conventional DFX therapy was used at a daily dose of 40 mg/kg given subcutaneously for 5 to 6 days per week. After ferritin level was less than 1000 mg/l, we tried to change therapy model from combination to alone Use of DFO, and the safety and effectiveness of the alone use of DFO was evaluated. Results: Mean serum ferritin levels on and after combination therapy with DFX and DFO were 2573.8 ± 857.2 (0 month), 1760.9 ± 787.6 (after 3 month), 1296.9 ± 744.2 (after 6 month) and 1312.7 ± 871.0 (after 12 month). Ten of eighteen patients were changed to receive alone therapy with DFO, the time from combination to alone therapy was 6.7 ± 1.25 month. In the alone therapy group, 7 of 10 were kept on alone therapy and only 2 needed to increase DFO dosage, 3 of 10 were returned to combination therapy intermittently and mean serum ferritin
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levels of the ten patients were 2390.9 ± 989.9 (0 month), 1404.2 ± 763.4 (after 3 month), 805.6 ± 282.2 (after 6 month) and 820.1 ± 282.3 (after 12 month). No significant liver function impairment and absolute neutrophil count change were revealed. The adverse effects were mild and transient. Conclusions: The combination therapy with DFX and DFO is an effective alternative in patients previously inadequately chelated on DFX, and the majority of them could be changed to alone use of DFO after 6 months of combination therapy.

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兩歲以下幼兒急性血小板低下紫斑症之疫苗相關性和長期預後 Vaccine association and long-term outcome of acute immune thrombocytopenic purpura in first 2 years of life

王建得 黃芳亮 陳伯彥 王德明 遲景上 張德高 Jiaan-Der Wang; Fang-Liang Huang; Po-Yen Chen; Teh-Ming Wang; Ching-Shiang Chi; and Te-Kau Chang

台中榮總兒童醫學部 Department of Pediatrics, Taichung Veterans General Hospital, Taichung, Taiwan Background/Purpose: Acute immune thrombocytopenic purpura (ITP) in children less than 2 years of age has rarely been discussed. In addition, associated factors of the disease in this age group have not been investigated. Patients and Methods: We retrospectively reviewed hospitalized patients less than 2 years of age with acute ITP from 1996 through June 2006. The data abstracted demographics, immunization records, clinical features, treatment and long-term outcome. Results: A total number of 46 patients, 26 males and 20 females, were identified. Fourteen cases (30 %) had a causal relationship with immunization, 7 associated with hepatitis B, 1 Mump-Measle-Rubella, 4 (acellular) diphtheria-pertussis-tetanus ± conjugated Haemophilus influenza type b ± inactive polivirus, 1 Japanese encephalitis, and 1 pneumoccocal vaccines. All of these 14 patients presented with petechiae and/or ecchymoses, and 11 had platelet counts less than 20 × 109 /L. Compared to the patients not associated with vaccination, these 14 patients all responded to a single course of therapy. And, none had progressed into chronicity. Moreover, all of them did not develop any episode of thrombocytopenia after the re-booster the same or different vaccines with a period of 6 months to 8 years follow-up. Conclusions: The study suggests immunization is an important factor of acute ITP in younger children and represents a good outcome. In addition, re-booster is not contraindicated for children experiencing the disease associated with vaccines.

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疫苗注射後發生伊凡氏症候群的二病例報告 Vaccine Related Evans’ Syndrome : Two Cases Report

謝玉林,李俊豪,那明珠,林隆煌 YL Hsieh, CH Lee, MK Nar, LH Lin

台北國泰醫院小兒科 Department of Pediatrics, Cathay General Hospital, Taipei, Taiwan; Purpose: Evans’ syndrome, characterized by autoimmune thrombocytopenia and autoimmune hemolytic anemia, after vaccination was scarcely reported in English literature. Only one 33 yrs old adult having Evans syndrome after hepatitis B vaccination was reported in 1992. No report concerning Evans syndrome after DPT vaccination was found till now. Case Presentation: First baby, a 1.5-month-old boy, appeared diffuse petechiae 2 wks after receiving 2nd dose gene recombinant hepatitis B vaccine Engerix with platelet(plt) count 3000/ul, Hb 10.2 g/dl. Plt transfusion was given immediately. Anti-plt aby after plt transfusion was negative. IVIG was given then. Eight hrs after plt transfusion but during IVIG tx, plt count rose to 77000/ul with plt corrected count increment:3950 which being less than normal:6000 indicating existence of antiplatelet aby, but Hb drop to 8.1 g/dl. Reticylocyte count was 2.95%. PB smear showed fragmented RBC, anisocytosis and poikilocytosis. Coomb’s test was negative result during IVIG tx. Hb and plt count returned to normal after PRBC transfusion and IVIG tx. He had smooth course 7months later after receiving DTPa-IPV-Hib-HB vaccination produced by another vaccine company. Second baby, a 2-month-old girl, appeared diffuse petechiae 3 days after receiving 1st dose DTPa-IPV-Hib vaccine with plt count 5000/ul, Hb 9.6 g/dl. PB smear showed fragmented RBC, schistocyte and polychromasia. Haptoglobin was less then 10mg/dl.Anti-plt aby and Coomb’s test were negative. CMV IgM was 0.38(N:0.28). Throat culture was positive for CMV. IVIG was given, but Hb dropped to 8.9 g/dl 5 days later, although plt count rose to 307000/ul. No PRBC was transfused. The Hb returned to normal 1 month later. Three months later, she had fever and diffuse skin rash 7 days after 2nd dose vaccine with normal CBC, and recovered without specific treatment. Same vaccine was given with smooth course 2 months later. Conclusion: Neonatal Coomb’s test, antiplt aby detection and hapatoglobin level often are falsely normal. But PB smear, reticulocyte count and calculating plt corrected count increment can support the diagnosis of neonatal autoimmune hemolytic anemia and thrombocytopenia.

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Role of Factor VIIa in Haematological and Oncological Disorders Dr Liane Lockwood, Royal Children’s Hospital, Brisbane, Australia

Recombinant factor VIIa is structurally almost identical to plasma derived VIIa and promotes haemostasis by activating factors IX and X when complexed to tissue factor. Recombinant VIIa has been widely used in the management of haemophilia patients who have developed inhibitors to factor VIII or factor IX and in patients with acquired haemophilia. There is now established use of factor VIIa in trauma, surgical and obstetric bleeding and in intracranial haemorrhage. Increasing interest in ―off label‖ use of this drug has developed in haematology and oncology practice with varied outcomes. The Royal Children’s Hospital, Brisbane experience with ―off label‖ use of factor VIIa in children and adolescents within the haematology and oncology practice will be presented. The varied outcomes and high cost of this drug have led to a number of groups establishing consensus statements on its use and these will be outlined.

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抗 CD20 單株抗體用於瀰漫性大細胞淋巴癌的治療 -- 馬偕醫院的臨床經驗 A retrospective study of CHOP Chemotherapy plus Rituximab versus CHOP Alone in treatment of diffuse large B cell lymphoma. ~ the experience in Mackay Memorial Hospital experiences

鄭弘毅,陳功深,張明志,張義芳,謝瑞坤,黃明哲,林炯森,林建鴻,林煥超,張園鑫 H-I, Cheng, G-S Chen, M-C Chang, Y-F Chang, R-K Hsien, J Lin, K-H Lim, H-C Lim, Y-H Chang

台北馬偕醫院血液腫瘤科 Department of Hematology and Oncology, Mackay Memorial Hospital

Background In diffuse large B cell lymphoma(DLBCL), it is well documented that the monoclonal antibody rituximab(R) improves the prognosis when combined with chemotherapy. We conducted a retrosepctive study which investigated CHOP compared with R-CHOP alone in our hospital from 2000 ~ 2006. Objective: To investigate the efficacy of CHOP Chemotherapy plus Rituximab versus CHOP Alone in diffuse large B cell lymphoma. Methods 86 Patients those that were diagnosed as DLBCL between December 2000 and December 2006 were involved in this study. Of them, the rate of complete response was significantly higher in the group that received CHOP plus rituximab than in the group that received CHOP alone ( 72 percent vs. 53 percent, P<0.05). The 4 year-survival were significantly higher in the CHOP-plus-rituximab group ( 78% vs 58% ; P = 0.01, respectively). Meanwhile, addition of rituximab to standard CHOP chemotherapy seemed significantly increase the risk of herpes zoaster infection (infection rate 22% vs 14% ; P = 0.053, respectively) Clinically relevant toxicity was not significantly greater with CHOP plus rituximab. Conclusions The addition of rituximab to the CHOP regimen increases the complete-response rate and prolongs event-free and overall survival in both younger and elderly patients with diffuse large-B-cell lymphoma, without a clinically significant increase in toxicity. Meanwhile, clinical increase rate in herpes zoaster infection is noted.

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N/K T 細胞惡性淋巴瘤的治療 Treatment of Nasal and Nasal-type NK/T cell lymphoma

譚傳德 1, 吳茂青 1, 邱倫瑋 1, 劉美瑾 1, 鄭鴻鈞 2, 蔡玉眞 2, 簡哲民 2, 曹美華 3 李明媛 3, 黃達夫 1 Tran-Der Tan1, Mau-Ching Wu 1, Jeff Lun-Wei Chiu 1, Mei-Ching Liu1, Skye H Cheng2, Stella Yu-Chen Tsai2, James Jer-Min Jian2, Mei-Hua Tsou3, Min-Yuan Lee3, Andrew T Huang1

辜公亮基金會和信治癌中心醫院 血液腫瘤科 1, 放射腫瘤科 2, 病理檢驗科 3 Division of Hematology-Oncology1, Radiation Oncology2, Pathology3 Koo-Foundation Sun Yat-Sen Cancer Center Purpose: For nasal and nasal-type NK/T cell lymphoma the prognosis is poor and there is no standard modality of treatment. Even patients with limited stages of disease undergoing radiotherapy with or without chemotherapy, there are substantial percentage of patients died of local tissue destruction complicated with infection and/or distant relapse of disease. According to the different experiences in different institutes, the two-years survival ranges from 20% to 40%. Materials & Methods: We present our experience to treat the nasal and nasal-type NK/T cell lymphoma with different modalities of treatment, from induction CHOP or CHOP-like chemotherapy followed by radiotherapy, to more intensive chemotherapy followed by radiotherapy, to concurrent chemoradiotherapy, in different periods of time(1996~2002, 2002~2005, and after 2005, respectively). Results: We have totally 26 patients with 16 patient in 1st period(1996~2002), 6 patient in 2nd period(2002~2005) and 4 patients in 3rd period(2005~ ). For patients treated in 1st period(1996~2002), the 2-year and 5-year survival are 40% and 20%, respectively. For patients treated in 2nd period(2002~2005), we have had 3 failed and 3 survived with no evidence of disease. For patients treated in 3rd period(2005~ ), we have 1 failed and 3 survived with no evidence of disease. Conclusions: In conclusion, it seemed to be better control of disease with concurrent chemoradiotherapy and there is no significantly increased treatment-related toxicity. However, our patient numbers are small and we need longer time to follow up the further result.

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兒童及青少年期非何杰生氏淋巴瘤–不同之組織亞型治療失敗之型態不同: 台灣兒童癌症共同研究群之報告 Childhood and Adolescent Non-Hodgkin’s Lymphomas-Patterns of Treatment Failure Differ Among Histologic Subtypes: A Report from the Taiwan Pediatric Oncology Group (TPOG)

楊兆平 台灣兒童癌症共同研究群 Chao-Ping Yang*, on behalf of the Taiwan Pediatric Oncology Group (TPOG) 林口長庚兒童醫院血液腫瘤科 *Division of Hematology/Oncology, Chang-Gung Children’s Hospital, Taoyuan, Taiwan Purpose: To know the patterns of treatment failure in diverse histologic subtypes of non-Hodgkin’s lymphoma (NHL) occurring in children and adolescents in Taiwan. Materials & Methods: We collected patients younger than 18 years of age diagnosed with NHL and registered to the TPOG during 1998 to 2006 (some pilot cases were enrolled in 1997). The majority of them were enrolled in TPOG-NHL 98 protocols, which were based mainly on BFM protocols for childhood NHLs. Two main arms with further stratifications were used for patients with different histologic subtypes and disease stages. The outcome was analyzed. Results: Totally 352 patients (245 males & 107 females) with known histologic subtype of NHL were collected during the 10-year study period. Their histopathologic types were: Burkitt’s lymphoma (BL) in 107 (30.3%, including 7 presenting as leukemia), median age at diagnosis (MA) for BL was 7.6y; lymphoblastic lymphoma (LBL) in 78 (22.1%, precursor-T LBL in 59 with MA 8.5y, precursor-B LBL in 19 with MA 5.5y); diffuse large B-cell lymphoma (DLB) in 77 (21.2%) with MA 12y; CD30+ anaplastic large cell lymphoma (ALCL) in 61 (17.3%) with MA 12.5y; peripheral T cell lymphoma (PTCL) in 26 (7.4%) with MA 12y; and follicular lymphoma in 4 (1.2%). The treatment results as of Dec. 31, 2006 were analyzed in 283 eligible patients (diagnosed with the 4 main subtypes of NHL, and before Dec. 31, 2005), with a median follow-up duration of 50 mo (12~116 mo). BL (96 cases): 74 of them (77.1%) are disease-free survivors (DFS) now. There were 6 toxic deaths during induction. Three failed induction and died of disease later. Twelve relapsed (12.5%), and all died of disease. The time to relapse from diagnosis ranged from 2m to 7.9m with a median of 4.9 mo. One patient was lost to follow-up. LBL (66 cases): 51 of them (77.3%) are DFS, including 2 in CR2 (for 5.8y, 7.7y). One died at diagnosis, 1 toxic death, and 2 failed induction and died. Twelve (18.2%) relapsed with a median time to relapse of 13.2m (2.5~32.7m), 10 died. One patient developed a 2nd brain tumor after
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remission for 79m. DLB (69 cases): 56 (81.2%) are DFS, including 2 in CR2 (6y, 7y). Three died during induction, 4 failed induction and died. Eight had relapsed (11.6%) with a median time to relapse of 9.8m (7.6~19.5m), 6 died. ALCL (52 cases): 43 (82.7%) are DFS, including 2 in CR2 (6.6y, 8.8y). Five failed induction and died. Six (11.5%) had relapsed with a median time to relapse of 8.6m (5~12.9m), 4 of them died of disease later. Of all these 283 patients eligible for survival analysis, 224 (79.2%) survive disease-free now with a median survival for 50 months. Induction death occurred in 10 patients, 14 failed induction and died of disease later. Thirty-eight relapsed (13.4%). 32 of them died. Conclusions: Near 80% of our patients with NHL can be cured. The overall survival rates are not much different among the 4 major subtypes, while the patterns of treatment failure are somewhat different. There were more toxic deaths in BL cases. Time to relapse was earlier in BL with no relapse occurring later than 8 months since diagnosis, and the salvage rate in this group was extremely low. ALCL recurred mostly within 1 year, DLB recurred within 20 months, and LBL may recur later than 2.5y after diagnosis.

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Phase II study of thalidomide in refractory and relapsed multiple myeloma 中華民國血液病臨床試驗委員會 鄧 波 長庚紀念醫院林口總院 血液腫瘤科

Accumulating knowledge and evidence has pushed thalidomide to place an important treatment option in the treatment of MM. From May 2001 to May 2005, a multi-centric cooperative phase II study of thalidomide in the treatment of relapsed or refractory MM was performed. The eligibility criteria were advanced stage MM and relapsed or refractory to first-line chemotherapy, ECOG performance status ≦2 (3-4 allowed if due solely to bone pain), age < 75 years old and have measurable serum or urine M protein, have normal liver function, creatinine no greater than 2x normal limit at the entry into the study. The starting dose was 200 mg/day orally twice daily, and the dose was increased by 200 mg every two weeks until it reached 800 mg per day. The doses were adjusted according to toxicity. The response criteria is defined as at least 50% of reduction in the plasma level of the myeloma protein or urinary M protein. The response should last for at least 6 weeks. At least 8 weeks of evaluation is indicated to assess the result of treatment response. Thirty-eight patients (ITT) patients were enrolled in this study. The subtypes of MM were IgG in 24, IgA in 10, IgD, light-chain in 2, respectively. Eight patients were early withdrawal. The reasons for early withdrawal were local radiotherapy in 2, refusal of treatment, severe sinus bradycardia, tumor progression, protocal violation, death due to hyperviscosity syndrome, cerebral hemorrhage in each, respectively. Thus, 30 patients (EP) were considered evaluable. The response rate for at least 50% reduction in M-protein compared to baseline was 33.3% in EP. Other response definitions for at least 25%, 75%, and 90% reduction in M-protein compared to baseline were calculated with response rates and the results for EP were 6.7%, 2.6% and 3.3%, respectively. Optimal dose of thalidomide was analyzed from both the effectiveness and tolerability aspects. For the subjects with at least 50% reduction in M-protein, the mean maximum daily dose was 640 mg with the range of 400 o 800 mg. From the tolerability point of views, 57.9% of the subjects have achieved maximum daily dose of at least 600 mg. The median time to response, median time to relapse, and median response duration for responders were 63, 154, 84 days, respectively. For time to progression, event-free survival, and overall survival, the median days in EP were 154, 154, and 607, respectively. In regard to safety, a total of 487 treatment-emergent adverse events (AE) were reported in all of the recruited subjects, 28 episodes of SAE were reported in 18 subjects. Constipation was the most frequent reported AEs with an incidence of 84.2%, followed by somnolence, dizziness, and asthenia. One case (2%) developed pulmonary embolism. In this study, we have proved that the response rate of thalidomide in relapsed or refractory MM was compatible to those reported from the Western countries and the drug is well tolerated.

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使用三氧化二砷治療頑固性多發性骨髓在馬偕醫院之臨床經驗- 病例報告 The Clinical Experience of Arsenic Trioxide in Multiple Myeloma: 5 Cases Reports

張園鑫,陳功深,張明志,張義芳,謝瑞坤,黃明哲,林炯森,林建鴻,林煥超,鄭弘毅 Y-H Chang, G-S Chen, M-C Chang, Y-F Chang, R-K Hsien, J Lin, K-H Lim, H-C Lim, H-I, Cheng

台北馬偕醫院血液腫瘤科 Department of Hematology and Oncology, Mackay Memorial Hospital Purpose: The therapeutic management of multiple myeloma (MM) has mainly involved regimens based on glucocorticoids and cytotoxic chemotherapeutics. Despite progress in delineating the activity of such regimens, at either conventional or high doses, MM has remained an incurable disease, without substantial improvement in the median overall survival. This has sparked major interest in the development of novel therapies. Arsenic trioxide induces growth inhibition and apoptosis in multiple myeloma cell lines. Reducing glutathione by ascorbic acid may enhance the efficacy of arsenic trioxide. Here we report 5 cases of refractory or relapse multiple myeloma with administration of arsenic trioxide in combination with/without ascorbic acid and/or dexamethasone. Case Presentation: Case 1: The 66y/o male had history of 1. multiple myeloma IgGλs/p VAD. Elevation of M-protein persisted after VAD, and he was enrolled in a clinical trial with AS2O3 and ascorbic acid. IgG andβ-2 microglobulin were gradually decreased. Anemia and renal function were improved. And he was shift to decadron as maintenance therapy. Finally myeloma progress and patient was expired. Case 2: The 45y/o male had history of 1. multiple myelomaλlight chain disease s/p VAD, high dose Endoxan, PBSCT and maintenance of interferon therapy. Myeloma relapse one year later after PBSCT. Thalidomide was used for 3 months, but withdrawal due to poor clinical benefit. So we started AS2O3 and low dose dexamethasone as a salvage therapy. Butβ-2 microglobulin was elevated and scalp tumor relapsed. He was expired due to myeloma progress.
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Case 3: The 69y/o male had history of 1 multiple myeloma IgGκ/p MP with hematological remission and recurrence /p VAD, VBCMP, and interferon as maintenance. We tried AS2O3 as salvage therapy. Disease was improved initially with decreased β-2 microglobulin. However myeloma still progress and his lumber-sacral plasmacytoma did not respond to AS2O3. He was expired in the hospice. Case 4: The 67y/o male had hx of multiple myeloma IgA/κ/p VAD /c paraspinal plasmacytoma /p RT. Then we shift to thalidomide and decadron. Poor response to VAD and thalidomide was noted then we shift to AS2O3 and ascorbic acid as salvage therapy. The M-protein evaluation done at Day 15 showed no decline of M-protein. Bone pain and chest wall pain were complained. CxR showed: extrapleura plasmacytoma and osteolytic lesion over T4 vertebra and palliative radiotherapy was arranged. Case 5: The 81y/o female had history of 1.multiple myeloma 2.chronic hepatitis C. We used AS2O3 and ascorbic acid as initial therapy for her myeloma and avoid steroid due to her hepatitis C. Clinical condition was improving after ASO3 used though myelosuppression was observed. IgG level was also decreased, To our surprise, her liver function was improving and HCV RNA was decreased. Conclusion: In our cases, combination therapy with arsenic trioxide, and /or ascorbic acid, and/or dexamethasone is feasible, but has modest efficacy and significant myelosupression in some patients. Besides, one patient who had underlying chronic hepatitis C got gradually liver function improving after Arsenic trioxide and ascorbic acid treatment.

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Autologous Haematopoietic Stem Cell Transplantation In Multiple Myeloma: Experience in a single institute

林建廷 1,林世強 2,姚明 1,柯博升 1,蔡偉 1,陳耀昌 1,田蕙芬 1,唐季祿 1,黃聖懿 1 Chien-Ting Lin1, Shih-Chiang Lin2, Ming Yao1, Bo-Sheng Ko1, Woei Tsay1, Yao-Chang Chen1, Hwei-Fang Tien1, Jih-Luh Tang1, Shang-Yi Huang1

1 台大醫院 內科部 血液腫瘤科 2 亞東醫院 內科部 血液腫瘤科

Haematopoietic stem cell transplantation (HSCT) has been accepted as a standard treatment for younger patients with multiple myeloma. The purpose of our study is to compare treatment outcome between conventional combined chemotherapy and high dose chemotherapy followed by stem cell transplantation of plasma cell disorders. Patients and Methods 24 patients who were diagnosed as plasma cell disorders including myeloma, plasma cell leukemia and plasmacytoma received autologous transplantation between 1989 December to 2005 December. They were compared with case controls with either 2:1 or 1:1 matched for age, sex, diagnosis, subtype of monoclonal protein, and stage who only received conventional combined chemotherapy during the same time period. Total 31 conventional chemotherapy (CT) responders were selected as control group for analysis. Conventional combined chemotherapy responders, ie minimal response or better, were eligible for stem cell mobilization. Peripheral blood stem cells were mobilized with either dexamethasone, etoposide, cyclophosphamide, cisplatin (DECP) or high dose cyclophosphamide. Conditioning regimens for most patients were high dose-melphalan. After transplantation, most patients were maintained with either interferon, thalidomide and/or steroid. Evaluation of treatment response (complete response, partial response, minima response, no change, progressive disease) was based on changes of serum and/or urine level of M-protein as proposed by EBMT/ IBMTR/ ABMTR. Results Response No response MR PR Good PR/ nCR CR Pre-HSCT 1 (4.2%) 3 (12.5%) 16 (66.7%) 4 (16.7%) 0 Post-HSCT 0 0 9 (37.5%) 7 (29.2%) 8 (33.3%)
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Total

24

24

The depth of response improves significantly after HSCT (Listed as table). CR and nCR are achieved in 15/24 (62.5%) patients. The median progress free survival between HSCT group and CT group are 42.0 months (95% CI= 22.5-61.5m) and 18.0 months (95% CI= 3.2-32.8m) respectively (Log rank p=0.027). The median overall survival between HSCT group and CT group are 73.9 months (95% CI= cannot calculated) and 45.0 months (95% CI= 20.5-69.5m) respectively (Log rank p=0.031). Conclusions Autologous transplantation for plasma cell disorder improved the depth of response significantly, and 62.3% patients achieve CR or nCR. Both progress free survival and overall survival significantly prolonged.

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Cost effectiveness of post-remission intensive therapy in patients with acute leukemia

徐會棋 余垣斌 盧漢騫 高志平 游介宇 周永強 曾成槐 陳志丞 何照洪 台北榮總血液腫瘤科暨輸血醫學科 國立陽明大學醫學院生理研究所暨內科學系

Background: We assessed the cost-effectiveness of high dose arabinoside (HiDAC)-based and allogeneic stem cell transplantation (alloSCT)-based therapy in patients with acute leukemia. Patients and Methods: We analyzed the outcome, cost and cost-effectiveness of 106 patients treated between 01/94 and 01/02 (94 AML/12 ALL). Forty-two young patients at either intermediate or unknown cytogenetic risk received post-remission intensive therapy (24 HiDAC-based / 18 alloSCT-based therapy). Results: After a median follow-up of 50 months, the estimated 7 year overall survival for the HiDAC-based group showed a tendency to be higher than the alloSCT-based group (48% versus 28%; p=0.1452). HiDAC-base group spent a significantly lower total cost (USD 51,857 versus 75,474; p=0.004) than the alloSCT-based group. Cost-effectiveness analysis showed that the mean cost per year of life saved for the HiDAC-based group is considerably less expensive than the alloSCT-based group (USD 11,224 versus 21,564). The reduced total cost for the HiDAC-based group originated from lower cost in room fees, medication, laboratory and procedure, but not in blood transfusion and professional man-power fees. Conclusion: For the post-remission therapy in young AML patients at either intermediate or unknown cytogenetic risk, cost effectiveness of HiDAC-based therapy compares favorably with that of alloSCT-based therapy, which deserves further clinical trials.

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利用裂解曲線分析來快速偵測骨髓增生性疾病是否有同合子或異合子 JAK2V617F 突變 Rapid Identification of Heterozygous or Homozygous JAK2V617F Mutation in Myeloproliferative Disorders Using Melting Curve Analysis

何景良 洪秀曼 張平穎 陳添盛 任慶堅 胡淑霞 高偉堯 陳宇欽 姚乃舜 林斈府 吳宜穎 趙祖怡 Ching-Liang Ho, Hsiu-Man Hung, Ping-Ying Chang, Tien-Sheng Chen, Robert Jen, Shu-Hsia Hu, Wei-You Kao, Yeu-Chin Chen, Nai-Shun Yao, Hsuen-Fu Lin, Yi-Ying Wu, Tsu-Yi Chao

國防醫學院 三軍總醫院 內科部血液腫瘤科 血液分子診斷實驗室 Division of Hematology/Oncology, Departments of Medicine, Tri-Service General Hospital, National Defense Medical Center Purpose: An activating JAK2 mutation recently has been associated with a wide spectrum of myeloproliferative disorders (MPD) which included polycythemia vera (PV), essential thrombocythemia (ET) and myelofibrosis with myeloid metaplasiaboth (MMM). This newly identified somatic point mutation is a G-C to T-A transversion, resulting in the substitution of valine by phenylalanine at codon 617 (JAK2V617F). Mutational frequencies were the highest for PV (65-97%) followed by ET (32-57%) and MMM (43-50%). However, 25% of patients with PV displayed homozygosity for the mutant allele which was infrequent in other myeloid disorders. We report the advance in the diagnosis of JAK2 mutation in MPD. Materials & Methods: In the current study, mutation analysis for JAK2V617F was performed prospectively either bone marrow or peripheral blood cells using allele-specific polymerase chain reaction (AS-PCR) and fluorescence resonance energy transfer (FRET) probes with melting curve analysis. From January to December of 2006, we prospectively enrolled 78 patients with PV (N=21), ET (N=32), MMM (N=5), secondary PV (N=4), secondary thrombocytosis (N=2), acute myelocytic leukemia (AML) (N=4), chronic myelocytic leukemia (CML) (N=8), and myelodysplastic syndrome (MDS) (N=2). Results: The detection rate was 76.2% in PV (homozygous in 14.3%), 46.9% in ET, 80% in MMM (homozygous in 20%) and none in other entities. In PV, the homozygous JAK2V617F patients displayed a significant longer duration of disease than heterozygous patients. In ET, the clinical parameters did not reveal any significant association between mutant and wild type of JAK2V617F patients. Conclusions:
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We demonstrated that heterozygous and homozygous JAK2V617F mutation can be identified by a rapid and reliable assay based on FRET probes and melting curve analysis. Detection of this mutation, although not specific to particular disease entities, should assist in the diagnostic evaluation of patients with suspected BCR/ABL-negative MPD.

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JAK2 V617F mutation in patients with essential thrombocythemia 蕭惠樺 李菁萍 楊文棋 蔡慧珍 劉益昌 劉大智 張肇松 陳田柏 林勝豐 H-H Hsiao, C-P Lee, W-C Yang, H-J Tsai, Y-C Liu, T-C Liu, C-S Chang, T-P Chen, S-F Lin

高雄醫學大學附設醫院 血液腫瘤內科 Division of Hemotology-Oncology, Department of Internal Medicine; Kaohsiung Medical University Hospital, Taiwan Purpose: Janus kinase 2 (JAK2) V617F is a somatic mutation that constitutively activates the JAK2 tyrosine kinase. It have been identified that about 50 of patients with essential thrombocythemia (ET) harboring this mutation. We will survey our ET patients for this mutation. Materials & Methods: We analized ET patients in our hospital during these 5 years. DNA was extracted by standard kit from granulocytes in peripheral blood or mononuclear cells in the marrow. Mutation survey was performed by ARMS PCR as Jones et al. reported. The laboratory data and clinical course of the patients were recorded from medical records retrospectively. Results: Among the patients analized, more than 10 patients harbored JAK2 mutation, including 3 of them are homozygous. In addition to marked thrombocytosis in patients with homozygous JAK2 mutation, severe leukocytosis was also found. Some of them also had ischemia heart diseases or cerebral blood vessel diseases. Conclusions: We report our experience of JAK2 V617F mutation in ET patients. In these limited patients, homozygous mutation was associated with marked leukocytosis and thrombocytosis. Further studies were warranted for a more clear relationship between JAK2 mutation and the clinical presentations.

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以試管法和流式細胞儀檢測之紅血球上免疫球蛋白 G 及補體與體內溶血的關聯 Correlations between in vivo hemolysis and red cell-bound immunoglobulin G and complement detected by tube method and flow cytometry 林烱熙 1,2,3 郝宗琪 1,3 劉昭儀 1,3 陳瀅如 1,3 曾成槐 1,2,3 Jeong-Shi Lin, Tsung-Chi Hao, Jau-Yi Lyou, Ying-Ju Chen, Cheng-Hwai Tzeng

台北榮民總醫院 內科部 輸血醫學科 1 血液腫瘤科 2 國立陽明大學醫學系 3 Divisions of Transfusion Medicine1 and Hematology & Oncology2, Department of Medicine, Taipei Veterans General Hospital, College of Medicine, National Yang-Ming University3 BACKGROUND: The importance of RBC-bound immunoglobulin (Ig) and complement (C) in relation to the degree of in vivo RBC destruction has always been controversial. STUDY DESIGN AND METHODS: We studied 380 patients about RBC-bound IgG and C3d using the direct antiglobulin test (DAT) in the form of conventional tube DAT and flow cytometric (FC) DAT simultaneously. These two methods were compared in terms of sensitivity and specificity. The correlations of the DAT results and the presence of in vivo hemolysis were analyzed. These patients were placed into 1 of the following disease categories based on their predominant diagnosis: autoimmune hemolytic anemia (AIHA), other autoimmune diseases without AIHA, hematological malignancies, nonhematological malignancies, hemolytic anemia other than AIHA, myelodysplastic syndrome without hemolytic anemia, and other medical and surgical diseases. RESULTS: A total of 380 patients (188 males, 192 females) with various diagnoses and a median age 59 years ( range, 1 day - 97 years) were studied. For detecting RBC-bound IgG, the sensitivity of tube DAT and FC-DAT were 87.0% and 91.3%, respectively; and the specificity of these two tests were 97.2% and 85.4%, respectively. For detecting of RBC-bound C3d, the sensitivity of tube DAT and FC-DAT were 47.7% and 95.5%, respectively; and the specificity of these two tests were 98.5% and 81.1%, respectively. The positive predictive values for hemolysis increased with the strength of tube DAT and the percent fluorescence of FC-DAT for either IgG or C3d. Combining the results of DAT for IgG and C3d, the predictive values of DAT for hemolysis were in the following order: both DAT (IgG) and DAT (C3d) positive > DAT (IgG) alone positive > DAT (C3d) alone positive. CONCLUSIONS: RBC-bound IgG seems to be better correlated with the presence of hemolysis than RBC-bound C3d. FC-DAT is more sensitive than tube agglutination in the detection of red-cell bound C3d. Both DAT (IgG) and DAT (C3d) positive has higher predictive value for hemolysis than either DAT (IgG) alone positive or DAT (C3d) alone positive.

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腹腔內濾泡樹突細胞腫瘤—一例報告及文獻回顧 Intraabdominal Folllicular Dendritic Cell tumor (FDCT) -- one case report and literatures review

Δ 黃叔牧 1 董俊良

2

林永發 3

盧彥哲 1 郭晉和 1 李明陽 1

Δ Shu-Mu Huang 1, Chun-Liang Tung 2 , Yung-Fa Lin 3 , Yin-Che Lu 1, Jin-He Kau 1, Ming-Yang Lee 1

嘉義基督教醫院 1 血液腫瘤科 2 病理科

3

麻醉科

Division of 1 Hemato-oncology, 2 Pathology, 3 Anesthesiology, Chia-Yi Christian Hospital INTRODUCTION: The goal of this report was to present a clinicopathologic feature of folllicular dendritic cell tumor , a very uncommon neoplasm, which was originally described by Monda in 1986 (Ref 1). To date, less than 100 FDCT have been documented in the english literature. Besides, intraabdominal FDCT (such as GI tract and mensentery/omentum) is exceptionally rare, with around 18 cases reported so far (Ref 2). CASE REPORT: A 49 y/o male suffered from body weight loss (8 kg/ 3 months ), poor appetite, back pain, and epigastralgia since July, 2006. Examination showed dull indurations of mass over upper mid-line abdominal area only, no peripheral lymphoadenopathy. Laboratory test and CXR were normal. An abd CT scan and PET scan revealed multiple confluent LAP in the mesentery, paraaortic region with extension to hepatic hilum, causing encasement of the mesenteric vessels, size 7.2 x 5.2 x 5 cm, and T2 spinal metastasis. PATHOLOGY: The specimen revealed ovoid to spindle-shaped cell forming whorls with multinucleated cells . The tumor cells were positive for CD68, CD21, CD35, and Vimentin , but negative for cytokeratins, EMA (epithelial membrane antigen, CD1a, CD3, CD5, CD10, CD 20, CD30, S100), and smooth muscle actin. DISCUSSION: First, the threshold for diagnosis should be raised and at least below paraffin-based markers (CD68, CD21, CD35 ) to identify FDCT. Secondary, maximal tumor debulking is recommended. Third, maximal radiation is recommended in most cases of FDCT, or as adjuvant treatment be reserved for incompletely resected tumor with poor prognostic factors. Forth, another possible adjuvant treatment is chemotherapy. However, several cases of FDCT have been treated with CHOP initially.But the behavior of these tumors are more akin to that of a soft tissue sarcoma than lymphoma . So anti-sarcoma regimen may be included as salvage treatment for FDCT.

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Antracycline 治療所引發之急性前骨髓性白血病,個案報告 Antracycline Based Treatment Related Acute Promyelocytic Leukemia: A Case Report

吳宜穎 1,2 夏和雄 2, 張俊彥 2,陳立宗 2,詹宗晃 2,陳宇欽 1 張平穎 1 林斈府 1 何景良 1 高偉 堯 1 趙祖怡 1 Y-Y Wu1,2, H-S Shiah2, G-Y Chang2, L-T Chan2, T-H Chan2, Y-C Chen1, P-Y Chang1, H-F Lin1, C-L Ho1, W-Y Kao1, T-Y Chao1

國防醫學院三軍總醫院 內科部 血液腫瘤科 1 國家衛生研究院癌症組 2 1. Internal Medicine department, Division of hematology-oncology, National Defense Medical Center, Tri-Service General Hospital 2. Institute of Cancer Research, National Health Research Institutes Purpose: Antracycline-based chemotherapy is a standard treatment for patients with breast cancer. However, it had a potential of cardiac toxicity with dose limitation. Besides, anthracycline had ever reported to be related to acute leukemic transformation. Here we presented a case of breast cancer, which underwent anthracycline based adjuvant chemotherapy. One year later she was diagnosed as acute promyelocytic leukemia. Treatment with All-Trans-Retinoid Acid (ATRA) help her hemogram return to normal. Case presentation: This 47 y/o woman is a case of breast cancer, left side /p MRM in 1996. She then received hormone therapy with Tamoxifen for 5 years due to ER, PR strong positive. In January 2005, right side malignant pleural effusion was found, and breast cancer with lung metastasis was impressed. She then underwent chemotherapy with Adriamycin plus cyclophophamide for 8 courses. Unfortunately, she suffered from dyspnea, and right side transudate pleural effusion in September 2005. Echocardiography was performed, and LVEF 31% was found. Congestive heart failure was impressed. Diuretics and digitalis was given and her symptom improved. Subsequently, she received capecitabine from February 2006 to October 2006. In October 2006 she suffered from pancytopenia with fever and initially capecitabine induced pancytopenic fever was suspected. Antibiotics with filgrastim were applied. However, white blood cell count increased in number with the appearance of blast form. DIC profile showed positive finding. Bone marrow study demonstrated a picture of acute promyelocytic leukemia, which was confirmed by the positive RT-PCR study. Oral ATRA was given, and her white blood count returned to normal. Conclusion: It is important to be aware of antracycline-related toxicity. Further treatment with
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ATRA or arsenic acid may helpful for these patients.

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