A 46-year-old woman was diagnosed with acute promyelocytic leukemia (APL). The patient was given remission induction therapy with all-trans retinoic acid, and complete remission was achieved. Despite consolidation therapies with arsenic trioxide, daunorubicin and cytosine arabinoside (AraC), and gemtuzumab ozogamicin as well as maintenance therapy with tamibarotene, the patient experienced a relapse 6 months after the start of maintenance therapy. She was then given re-induction therapy with idarubicin+AraC and high-dose AraC, but remission was not achieved. Since the coordination of the unrelated donor had been completed at this time, she then underwent bone marrow transplantation with pre-conditioning of 4 Gy total body irradiation, fludarabine, and busulfan. However, on the 12th day after the transplantation, APL cells appeared in the peripheral blood and the disease progressed rapidly leading to the patient's death on the 15th day after the transplantation. APL usually has a good prognosis, and relapsed cases are often cured by autologous stem cell transplantation. However, this case was highly refractory to treatment and the patient deteriorated rapidly after the transplantation, suggesting a different pathogenesis from the usual from of APL.

Skeletal muscle is the largest organ in our body, consisting of bundles of multinuclear cells called myofibers. Skeletal muscle is responsible for locomotion, metabolism, and life activities such as swallowing and respiration, and is also attracting attention as an endocrine organ. Skeletal muscle has two abilities, regeneration and adaptation, and the understanding of these mechanisms is expected to contribute to the development of therapies for muscle diseases such as muscular dystrophies and muscle atrophy. Skeletal muscle-specific stem cells, muscle satellite cells (MuSCs), are involved in these abilities. As well as other tissue stem cells, MuSCs are also maintained in a dormant state under steady-state conditions. However, when myofibers are damaged, they start to proliferate and eventually rebuilt new myofibers. While, muscle hypertrophy is one of the "adaptation", and MuSCs contribute to muscle hypertrophy by supplying new nuclei to myofibers. In contrast to studies of MuSCs during regeneration, the dynamics of MuSCs during hypertrophy had not been well studied. One reason is that the specific regulatory mechanisms of MuSC in hypertrophic muscle had not been elucidated. In addition to physical stimuli, drugs such as dopings, hormones, and myostatin inhibition are known to induce muscle hypertrophy. The necessity of MuSCs and new myonuclei in various model of muscle hypertrophy has been highly debated. In this review, we introduce the mechanism of MuSC proliferation specific to hypertrophic muscle, and outline the mechanism of muscle hypertrophy induced by exercise and drugs and the involvement of MuSCs.

A 54-year-old woman was diagnosed with acute adult T-cell leukemia (ATL) in November 2015 and underwent allogeneic hematopoietic stem cell transplantation in March 2016. Cognitive impairment appeared suddenly around May 2019, and MRI of the brain showed cerebral white matter lesions. Cerebrospinal fluid examination showed no significant findings other than elevated protein. Brain biopsy showed inflammatory cells, (mainly CD8-positive T lymphocytes), infiltrating the white matter. Based on the pathological findings and the history of chronic graft versus host disease (GVHD) in the lungs and intestines, we diagnosed central nervous system involvement of GVHD (CNS-GVHD). Immunotherapy with steroids and mycophenolate mofetil resulted in improvement of the cognitive dysfunction and inflammatory findings in the spinal fluid. This case is the first report of CNS-GVHD in ATL, suggesting the importance of diagnosis by brain biopsy and the efficacy of immunotherapy.

The first step for development of a functionally and structurally intricate organ, the brain, involves precise control of the neural stem cell (NSC) fate. NSCs produce a variety of neurons and glial cells according to the developmental time and 3-dimensional (3D) position within the brain. Morphogens play a key role in determining the 3D positional information of NSCs and thus regulating brain arealization along the rostrocaudal and dorsoventral axes. In this review article, we summarize recent studies that described essential roles of Polycomb group proteins in the establishment of the 3D atlas of the brain, in part through suppressing brain area-specific genes such as morphogens.

The occurrence of a primary mediastinal germ cell tumor and hematological neoplasia provides a poor prognosis that is known to be fatal at a median of 6 months after onset. We report the case of a 15-year-old male who was treated with chemotherapy and hematopoietic cell transplantation based on a report of a surviving case. At diagnosis, the patient had an unresectable mediastinal tumor with elevated alpha-fetoprotein and human chorionic gonadotropin levels and acute megakaryoblastic leukemia. We prioritized treatment with chemotherapy for the tumor owing to the oncological emergency. We then performed leukemia induction therapy and achieved complete remission. Although we used CDDP in combination with intensive therapy, the mediastinal tumor grew too large for it to be safely resected. We transplanted bone marrow from the patient's human leukocyte antigen-haploidentical sibling upon conditioning with busulfan-melphalan. After 44 days, the leukemia recurred in the patient's central nervous system. This was followed by various post-transplant complications, and the patient died of organ failure that was associated with infectious diseases. At necropsy, a poorly engrafted bone marrow was observed. The mediastinal tumor was primarily necrotic, although some immature teratoma components were observed. No leukemic precursor cells were detected. Residual mediastinal tumors may be associated with the recurrence of leukemias. We seek a treatment strategy that enables early tumor resection and high-dose chemotherapy. Further case studies are warranted along with the development of effective treatment methods.

Epigenetics is the study that involves understanding of the DNA sequence-independent mechanism of transcriptional regulation. The epigenetic regulation of gene expression is exerted via the alteration of chromatin structures through covalent modifications of core histone tails and methylation of CpG dinucleotides. In general, histone acetylation and DNA methylation are associated with transcriptional activation and repression, respectively. Histone methylation offers an additional layer for transcriptional regulation. Epigenetic abnormalities underlie the development of various hematological malignancies; for example, recurrent mutations of the DNA methyltransferase DNMT3A or DNA demethylase TET2 transform hematopoietic stem cells into preleukemic stem cells. Consequently, preleukemic stem cells give rise to T-cell lymphomas, such as angioimmunoblastic T-cell lymphoma and T-cell lymphoblastic lymphoma. Epigenetic alterations could be ideal therapeutic targets; indeed, HDAC inhibitors and DNA demethylating agents have already been used for the treatment of peripheral T-cell lymphomas. It is anticipated that more number of epigenetic drugs would be developed for clinical application in the near future.

Leukemia is caused by uncontrolled proliferation of immature hematopoietic progenitors. MLL fusion proteins, generated by chromosomal translocations, activate a broad range of previously transcribed genes to achieve the same expression profile as that of the parent cell in the daughter cells, thereby promoting self-renewal. Normally, replication of the expression profile only occurs in the hematopoietic stem cells (HSCs). A transactivation system comprised of MLL and AF4/ENL/P-TEFb (AEP) complexes promotes it by reactivating CpG-rich promoters. In the normal hematopoietic development, this system is tightly regulated and progressively suppressed during the course of hematopoietic differentiation so that non-HSC hematopoietic cells would not self-renew. Genetic mutations such as fusions of MLL and AEP components generate a constitutively active form of the MLL transcriptional machinery, which aberrantly promotes self-renewal even in non-HSC hematopoietic cells. In this review, I depict a molecular mechanism of MLL fusion-mediated leukemogenesis from a standpoint that leukemogenesis is driven by aberrant self-renewal that is mediated by hyper-active transcriptional machinery, and introduce several molecularly targeted therapies in the making which specifically perturb this transactivation system.

Paroxysmal Nocturnal hemoglobinuria, PNH is usually caused by the somatic mutation of X-linked PIGA gene followed by the clonal expansion of the GPI (glycosylphosphatidylinositol) anchor defective hematopoietic stem cell clone. There are two hypotheses for the mechanism of clonal expansion, one is selection theory, in which GPI deficient cells escape from attacks of cytotoxic cells, and another is benign tumor theory in which GPI deficient cells get the additional mutations and acquire proliferative nature. Recently, we identified two types of PNH patients caused by the biallelic mutation of PIGT on chromosome 20 and PIGB on chromosome 15. Both PNH clones had the germ-line mutation in one allele and another allele was somatically mutated in a hematopoietic stem cell. Both somatic mutations were loss of heterozygosity (LOH), deletion in PIGT-PNH and copy neutral LOH (CN-LOH) in PIGB-PNH. These PNH patients had typical PNH symptoms, but they have in addition auto-inflammatory features. Unlike in PIGA-PNH cells, GPI is synthesized in PIGT-PNH cells and, since its attachment to proteins is blocked, free GPI is expressed on the cell surface. Similarly, in PIGB-PNH cells, GPI intermediates are accumulated and expressed on the cell surface. Those GPIs together with complement activation cause the inflammasome activation.

Sinusoidal obstruction syndrome (SOS), also called veno-occlusive disease (VOD) of the liver, is one of the most relevant complications of hepatic sinusoidal endothelial origin that appears early after hematopoietic cell transplantation (HCT). Despite its relatively low incidence and the spontaneous resolution of most SOS/VOD cases, severe SOS/VOD evolved to multi-organ failure with an >80% mortality rate and represents one of the major clinical problems after HCT. The sinusoidal endothelial cells and hepatocytes are damaged by toxic metabolites generated by the conditioning regimen in these patients. Several risk factors have been identified for SOS/VOD development. Although defibrotide is recommended for both prevention and treatment, no satisfactory therapy exists for managing severe SOS/VOD. Thus, this review describes the new definition of SOS/VOD diagnosis and the severity grading of suspected SOS/VOD from the European Society for Blood and Marrow Transplantation. Furthermore, it describes the results of current treatment including the Japanese therapeutic use program, defibrotide treatment protocol.

Systemic AL amyloidosis is a disease wherein amyloid proteins derived from monoclonal immunoglobulin light chains produced by abnormal plasma cells are deposited in the tissues through the whole body and cause organ failure. The treatment aims to minimize treatment-related toxicity and mortality to achieve a deeper and more persistent hematologic response as early as possible. Stem cell transplantation is preferred; however, only 20% of patients are eligible. Patients are selected as per strict transplant indication criteria. Transplant-ineligible patients receive chemotherapy with high efficacy, such as melphalan/dexamethasone, bortezomib/cyclophosphamide/dexamethasone, and daratumumab/bortezomib/cyclophosphamide/dexamethasone. The prognosis of advanced cardiac amyloidosis remains poor, and delays in diagnosis are fatal. Early diagnosis and early treatment are important to prevent and minimize organ damage.

Myeloproliferative neoplasms (MPN) are caused by somatic mutations in hematopoietic stem/progenitor cells and result in excessive increase in the blood cell mass in the peripheral blood and/or fibrosis in the bone marrow. JAK2, CALR, and MPL mutations are well-known driver mutations of MPN and are widely applied as diagnostic markers of MPN. Moreover, several studies using massive parallel sequencing technologies have shown that mutations in ASXL1, EZH2, SRSF2, and IDH1/2 affect the prognosis of overt primary myelofibrosis and have further clarified that the mutation order may influence the MPN phenotype. More recently, our group identified that CREB3L1 mRNA was overexpressed in a platelet- and megakaryocyte-specific manner in driver mutation positive MPN and that the quantitation of this gene expression can be used as a diagnostic marker for MPN. In this educational lecture, we discuss the clinical impacts of the mutations frequently identified in MPN patients.

Vertebral bone and limb bone are formed by endochondral ossification, which is replaced with bone tissue by osteoblasts after cartilage formation. Bone growth is regulated by the balance between epiphyseal chondrocyte proliferation and ossification. We attempted to elucidate the mechanism of chondrocyte differentiation and maturation regulated by the Extracellular-signal-regulated kinase 5 (Erk5) signal. Erk5 is a serine/threonine kinase belonging to the mitogen-activated protein kinase (MAPK) family, which includes Erk1/2, JNK, and p38. Mesenchymal stem cell-specific Erk5-deficient mice exhibited the phenotype of deformities of the metatarsal bones, enlargement of the long bones in limbs, and overgrowth of cartilage tissue. Based on this result, we searched for factors that directly phosphorylate Erk5, and We demonstrated that Erk5 directly phosphorylates and activates Smurf2 (a ubiquitin E3 ligase) at Thr249 to activate its function and promotes ubiquitination-mediated degradation. The TGF-β-Smad signal suppresses the proliferation of many cells and regulates the production of extracellular matrix. Our findings may lead to the development of novel drugs targeting TGF-β associated diseases. In this paper, we investigated the function of Smurf2Thr249 phosphorylation and the possibility as new therapeutic target for various diseases.

Chronic active Epstein-Barr virus (CAEBV) infection is a progressive disease characterized by persistent inflammatory symptoms accompanied by clonally proliferating EBV-positive T or NK cells. The optimal medical treatment for CAEBV to eradicate EBV-infected T or NK cells has not yet been established, with allogeneic hematopoietic stem cell transplantation as the only strategy currently available. Patients with CAEBV have been reported mainly from limited area of Japan and East Asia. However, CAEBV is drawing a global attention, and the number of reports is increasing worldwide after its definition was added to the EBV-positive T- or NK-cell neoplasms in the 2017 World Health Organization classification. We had previously discovered that STAT3 was constitutively activated in EBV-infected tumor cells in CAEBV inducing the immortalization and production of inflammatory cytokines. Based on these findings, an investigator-initiated clinical research of a JAK1/2 inhibitor ruxolitinib for CAEBV infection was initiated in January 2019. Japanese researchers have been expected to elucidate pathological mechanisms and to establish an effective treatment.

Acute lymphoblastic leukemia (ALL) in infants remains an intractable and difficult-to-treat leukemia as compared to other pediatric ALLs, for which considerable progress has been achieved in terms of treatment outcomes in recent years. The leukemic cells in infants with ALL frequently carry chromosome translocations involving 11q23, resulting in the rearrangement and fusion of the MLL (KMT2A) gene. Among many MLL fusion genes, MLL-AF4 (KMT2A-AFF1) fusion is characteristically observed in infants with ALL, representing a hallmark of poor prognosis. In MLL-AF4-positive infants with ALL, first leukemic cells with MLL-AF4 were generated in utero. Analysis of several murine and human leukemia models revealed that the target cells for tumorigenesis by MLL-AF4 were not the hematopoietic progenitor cells of the bone marrow, but the early hematopoietic progenitor cells present in the fetal liver during the embryonic period and possibly the undifferentiated cells prior to the commitment to hematopoietic cells in the fetus. Elucidation of the leukemogenic process of infant ALL with MLL-AF4 may lead to early, pre-symptomatic diagnosis of leukemia, resulting in the improvement of prognosis and prevention of the onset of ALL in infants.

Recent studies have revealed that the gut microbiota play a critical role in the regulation of hematopoiesis at multiple stages. Accumulated evidence of the relationship between the clinical outcome of allogeneic hematopoietic stem cell transplantation and diversity of the microbiota demonstrates the importance of the microbiota in the physiological and pathological regulation of hematopoiesis. In addition, recent studies have shown that aberrant diet-related changes in the microbiota may cause abnormal hematopoiesis and contribute to the progression of myeloproliferative neoplasm in combination with RAS-MAPK activation. Ten-eleven translocation 2 (Tet2) mutation in myeloid cells causes dysfunction of the small-intestinal barrier, which leads to induction of preleukemic myeloproliferation. Proliferation of leukemia cells is associated with reduced insulin secretion and enhancement of insulin resistance, partly due to microbiota-derived metabolites. Thus, the microbiota affects normal and malignant hematopoiesis mediated by multiple factors. Further analyses may contribute to the identification of critical environmental factors, which may lead to the discovery of novel diagnostic and therapeutic strategies for hematopoietic neoplasms.

Cell cycle quiescence is a fundamental property of hematopoietic stem cells (HSCs). Quiescent HSCs form a healthy pool of cells that serve as a reserve for massive HSC expansion under various conditions of stress. We previously reported that thrombopoietin (THPO) maintains quiescent HSCs and stimulates mitochondrial metabolism, megakaryocyte-lineage differentiation, and proliferation of HSCs. The underlying mechanism by which THPO balances its contradictory effect of promoting proliferation or quiescence on HSCs remains unknown. This review explores the role of THPO signaling in HSC differentiation and quiescence regulation. We present our data, which suggests that a THPO-independent HSC subpopulation sustaining a low mitochondrial metabolic profile reverts to quiescence and regains stem cell potential with external stimuli. There is a possibility that THPO-independent HSCs form a non-quiescent reserve HSC pool from which quiescent HSCs originate in the adult bone marrow.

In human hematopoiesis, cells of various lineages exist, such as neutrophils, lymphocytes, and erythrocytes. Unveiling the pathway from stem cells to the various lineages helps us understand the blood disorders and develop therapies for them. We have studied the developmental pathway of hematopoiesis for decades and found that myeloid potential is retained just before the differentiation into each lineage of the various lineage progenitors. This uniqueness of myeloid cells might reflect the character of mixed-phenotype leukemia and provide a very important clue in determining the evolutional history of blood cells. Recent studies concerning the differentiation pathways of megakaryocytes and granulocytes as well as the findings on the hemocytes of invertebrates have strongly supported the concept of the uniqueness of myeloid cells and enabled us to propose insights into the evolutional history of blood. In this paper, we discuss the origin of blood cells in the context of developmental pathways during ontogeny and phylogeny.

Adult T-cell leukemia/lymphoma (ATLL) is an aggressive peripheral T-cell lymphoma with a dismal prognosis. Its most effective treatment is allogeneic hematopoietic stem cell transplantation (allo-HSCT), which provides a chance of long-term remission through a graft-versus-ATLL (GvATLL) effect. However, the incidence of relapse after allo-HSCT remains high at approximately 40%, and treatment options for patients with ATLL who have relapsed disease after allo-HSCT are limited. Accumulating evidence shows that mogamulizumab or lenalidomide use for relapsed disease even after allo-HSCT might have advantages with effects similar to that of GvATLL. Recent genomic and transcriptomic studies have shown that ATLL cells evade immune surveillance. Further investigations of incorporating immune-based approaches with new molecular target drugs as therapeutic options of patients with ATLL after transplantation are warranted.

Acute graft-versus-host disease (GVHD) is a systemic immune reaction in which mature T cells in the donor inoculum are abnormally activated by the host and donor antigen-presenting cells. These activated cells then attack normal host tissue after allogeneic hematopoietic stem cell transplantation (HSCT). Clinical GVHD develops when the damage exceeds the threshold for tissue tolerance. Furthermore, functional damage of hematopoietic and non-hematopoietic organs due to this acute immune response triggers the subsequent development of chronic GVHD. The endpoint of HSCT is shifting from just surviving the acute phase to having an enriched life until later years; therefore, seamless and detailed immune management is required from the acute to chronic phase after HSCT. Acute GVHD prophylaxis consisted of calcineurin inhibitors and short-term methotrexate for a long time. However, various novel immune-modulating strategies have been developed against the background of recent diversification in donor sources and changes in treatment goals. In this review, we discuss recent clinical developments in basic and clinical research regarding acute or chronic GVHD.