We examined the incidence and clinical outcome of late‐onset noninfectious pulmonary complications (LONIPC) in a series of 234 patients who underwent allogeneic bone marrow transplantation at our institution between April 1982 and October 1996. The 179 patients who survived 3 months or more were evaluated. Clinical, radiologic, pulmonary function, and pathologic tests were reviewed to identify 18 patients (10%) who fulfilled the diagnostic criteria of LONIPC. Accordingly, the pulmonary processes included bronchiolitis obliterans (BO, five patients), bronchiolitis obliterans with organizing pneumonia (BOOP, three patients), diffuse alveolar damage (DAD, one patient), lymphocytic interstitial pneumonia (LIP, one patient), and nonclassifiable interstitial pneumonia (NCIP, eight patients). Various methods of enhanced immunosuppressive therapy resulted in marked durable remission in nine patients (50%) (3/3 with BOOP, 3/8 with NCIP, 1/1 with DAD, 1/1 with LIP, 1/5 with BO). The presence of chronic graft‐versus‐host disease (cGVHD) and prophylaxis for GVHD with cyclosporine and prednisone were the only variables significantly associated with the development of LONIPC (P = 0.0001 and 0.008, respectively). Regardless of histology, a reduction in the forced expiratory volume to < 45% of the predicted range was associated with poor response to treatment. These findings suggest a strong association between cGVHD and LONIPC and that the risk of LONIPC development may be influenced by the particular method of GVHD prophylaxis. Most patients with BOOP or mild airflow limitation at diagnosis achieved durable remissions.

The ubiquitous toxic metalloid arsenic elicits pleiotropic adverse and adaptive responses in mammalian species. The biological targets of arsenic are largely unknown at present. We analyzed the signaling pathway for induction of detoxification gene NAD(P)H-quinone oxidoreductase (Nqo1) by arsenic. Genetic and biochemical evidence revealed that induction required cap 'n' collar basic leucine zipper transcription factor Nrf2 and the antioxidant response element (ARE) of Nqo1. Arsenic stabilized Nrf2 protein, extending the t1 ⁄ 2 of Nrf2 from 21 to 200 min by inhibiting the Keap1⅐Cul3-dependent ubiquitination and proteasomal turnover of Nrf2. Arsenic markedly inhibited the ubiquitination of Nrf2 but did not disrupt the Nrf2⅐Keap1⅐Cul3 association in the cytoplasm. In the nucleus, arsenic, but not phenolic antioxidant tert-butylhydroquinone, dissociated Nrf2 from Keap1 and Cul3 followed by dimerization of Nrf2 with a Maf protein (Maf G/Maf K). Chromatin immunoprecipitation demonstrated that Nrf2 and Maf associated with the endogenous Nqo1 ARE enhancer constitutively. Arsenic substantially increased the ARE occupancy by Nrf2 and Maf. In addition, Keap1 was shown to be ubiquitinated in the cytoplasm and deubiquitinated in the nucleus in the presence of arsenic without changing the protein level, implicating nuclear-cytoplasmic recycling of Keap1. Our data reveal that arsenic activates the Nrf2/Keap1 signaling pathway through a distinct mechanism from that by antioxidants and suggest an "onswitch" model of Nqo1 transcription in which the binding of Nrf2⅐Maf to ARE controls both the basal and inducible expression of Nqo1.Environmental toxic metal arsenic, which originates from both geochemical and anthropogenic activities, is a ubiquitous contaminant and an established human carcinogen (1, 2). Arsenic has become a major public health concern worldwide because millions of people are at risk of drinking water contaminated with arsenic that has been associated with multiple human diseases or lesions (3-5). The anthropogenic sources of arsenic contaminating soil and water include mining, metallurgical activities, and manufacture and agricultural use of pesticides and herbicides. Arsenic causes a spectrum of adverse responses in many species. Whereas acute exposure to inorganic arsenic in humans results in cardiac failure, peripheral neuropathy, anemia, leucopenia, and death, chronic arsenic exposure can cause a range of cancers (particularly of the skin, lung, bladder, and liver) as well as liver injury, neuropathy, cardiovascular lesions, ovarian dysfunction, aberrant embryo development, and postnatal growth retardation (4, 6 -10). Interestingly, arsenic-containing compounds have proven to be effective as therapeutic agents in treating cancer such as leukemia (11), chronic inflammatory disease such as psoriasis (12), and parasitic infection such as sleeping sickness (13, 14). Although chemical interaction with protein thiol groups and generation of reactive oxygen species have been implicated in the actions of arsenic, the...

Primary laryngeal lymphoma is a very rare entity, with fewer than 50 cases reported in the English literature in the past 60 years. Close scrutiny of some of these case reports reveals that the larynx was not always the only site of involvement, thereby diminishing the total number of patients with primary laryngeal lymphoma to fewer than 35. The authors report a series of six patients, who were seen and evaluated at the Mayo Clinic between 1952 and 1995, with stage IAE non-Hodgkin's lymphoma of the larynx. Three patients had large-cell lymphomas according to the REAL (Revised European-American Lymphoid) classification. The other three had a small lymphocytic lymphoma, follicular small cleaved lymphoma, and follicular mixed lymphoma. All patients received radiation therapy alone as initial therapy for their disease and all patients had a complete remission to initial therapy. Four patients subsequently relapsed and the histology at relapse was the same as the initial histology in all four patients. Five patients have died, three of lymphoma, with a median survival of 67 months (range, 40 to 228 months). In view of the heterogeneity of histologies in this group of lymphomas, the variability in duration of response, and the significant number of patients who died of their disease, it is more likely that primary laryngeal lymphoma is an unusual presentation of non-Hodgkin's lymphoma than a separate disease entity. Despite the small number of patients in this study, the data would suggest that patients are best treated according to the histology of the lymphoma, rather than the limited stage and location of the disease.

No abstract

Summary. Twenty-three patients who had myelofibrosis with myeloid metaplasia (MMM) were treated at our institution with 50 courses of splenic irradiation (SI) for symptomatic splenomegaly. The median dose of radiation per course was 277·5 cGy, administered in a median of 7·5 fractions. 8/23 patients received multiple courses of SI. Of 49 evaluable courses of SI, 46 (93·9%) resulted in an objective decrease in spleen size. The median duration of response was 6 months (range 1-41). Reduction in spleen size was associated with symptomatic relief in all patients. Overall median survival after SI was 22 months. Significant cytopenia occurred in 10 (43·5%) patients, or 16 (32%) of the 50 courses of SI. Prolonged, life-threatening pancytopenia after a single course of SI occurred in six patients (26%), resulting in fatal sepsis or haemorrhage in three (13%). Nine patients underwent subsequent splenectomy; the perioperative mortality rate was 11%. One third of patients experienced postoperative intra-abdominal haemorrhage necessitating surgical re-exploration. SI can provide symptomatic relief and a reduction in spleen size in most MMM patients. The increased risk of postoperative bleeding in patients requiring subsequent splenectomy dictates against considering SI as an alternative to splenectomy for patients who are otherwise good surgical candidates.

Chromium (Cr) (VI) is a major environmental toxic metal and a human carcinogen. The molecular events mediating cellular responses to Cr(VI) are not clear at present. We show that Cr(VI) potently induced apoptosis and production of reactive oxygen species (ROS) in mouse hepa1c1c7 cells in a concentration-dependent manner. Mouse embryonic fibroblast cells lacking Nrf2 exhibited elevated ROS production and apoptosis, which were markedly further increased by Cr(VI), suggesting a protective role of Nrf2 against Cr(VI) toxicity. Protection by Nrf2 correlated with induction of cytoprotective genes Ho-1 and Nqo1. Induction of the genes by Cr(VI) involved inhibition of ubiquitination of Nrf2 and accumulation of Nrf2 into the nucleus. In the nucleus, treatment with Cr(VI), but not phenolic antioxidant tert-butylhydroquinone, librates Nrf2 from the Nrf2/Keap1 association and recruits Nrf2 to the antioxidant response elements (ARE) located in the enhancers of Ho-1 and Nqo1. Activation of Nrf2 by Cr(VI) was accompanied by the nuclear translocation and deubiquitination of Keap1 implicating recycling of Keap1 in Nrf2 signaling. Thus, protection against Cr(VI) toxicity involves a transcriptional signaling loop that includes activation of Nrf2 by the toxic metal, transcription of ARE-driven genes, and reduction of ROS production.

Exposure to cadmium (Cd) elicits a range of adverse responses including oxidative damage and cancer. The molecular targets of Cd remain largely unidentified. Here, we analyzed the function and signal transduction of transcription factor Nrf2 in protection against Cd-induced oxidative stress. Wild-type (Nrf2 (+/+)) mouse embryonic fibroblasts (MEF) produced reactive oxygen species (ROS) at a low level, whereas treatment with Cd significantly increased the ROS production. On the other hand, Nrf2 knockout (Nrf2 (-/-)) MEF cells exhibited an elevated level of ROS under a basal condition, and Cd dramatically increased the ROS production at concentrations as low as 2 microM, resulting in increased sensitivity to Cd-induced cell death. Cd induced the basal and inducible expression of cytoprotective enzymes NQO1 and HO1 in WT MEF cells, but induction was lost in Nrf2 (-/-) MEF cells. Induction of the genes required antioxidant response elements (ARE) as Cd drove ARE-dependent reporter expression and Cd-activated Nrf2 bound to endogenous AREs in mouse hepa1c1c7 cells. Activation of Nrf2 by Cd involved stabilization of the Nrf2 protein, increased formation of Nrf2/Keap1 complex in the cytoplasm, translocation of the complex into the nucleus, and subsequently disruption of the complex. Lastly, Nrf2 was found ubiquitinated in the cytoplasm but deubiquitinated in the nucleus. The study provided a mechanistic transcriptional model in which Cd activates Nrf2 through a metal-activated signaling pathway involving a dynamic interplay between ubiquitination/deubiquitination and complex formation/dissociation of Nrf2 and Keap1.

The International Prognostic Factor Index, which significantly predicts outcome in patients with aggressive/intermediate-grade B-cell lymphomas, has similar prognostic importance in patients with PTCL.