Cancer in thalassemia and other hemoglobinopathies

First report of acute lymphoblastic leukemia in an Egyptian child with β-thalassemia major

β-Thalassemia (β-thal) is the most common hereditary anemia in humans. With improvement of treatment protocols, patients are living longer and new complications have emerged. Few articles have reported the occurrence of malignancies among patients with β-thal in different parts of the world. We herein report the first pediatric patient with β-thal major (β-TM), who developed acute lymphoblastic leukemia in Egypt with analysis of the different theories of pathogenesis.

Malignancies in patients with beta-thalassemia major and beta-thalassemia intermedia: a multicenter study in Iran

BACKGROUND

Beta thalassemia is one of the most common genetic disorders in the world. The aim of this study was to determine the frequency, characteristics, and pattern of malignancies in patients with beta thalassemia major (BTM) and beta thalassemia intermedia (BTI) in Iran.

METHODS

We conducted a multicenter study via a retrospective chart review of patients with BTM and BTI between 2002 and 2007 in four thalassemia centers in Iran. A total of 4,630 records of patients with thalassemia were evaluated. Statistical analyses were done with SPSS software v. 15. P-values <0.05 were considered significant.

RESULTS

We detected 11 patients with beta thalassemia who also had malignant disease. Five patients (45.4%) were diagnosed with lymphoma and five with leukemia. The proportion of patients with cancer was higher in those with BTI. Cancer was diagnosed in patients with thalassemia aged 0-39 years, but not in any of the older patients. In patients with thalassemia overall and in patients with BTI, the highest age-specific rate of cancer incidence was seen in children <10 years old, whereas in the BTM group the highest incidence was observed in patients 20-29 years old. There were no statistically significant differences between patients with BTM and BTI and cancer regarding age, sex, splenectomy, hemoglobin, ferritin level, or malignancy type.

CONCLUSION

The coexistence of malignancy and beta thalassemia is not rare. Any alarming signs and symptoms including worsening anemia, splenomegaly, or lymphadenopathy should be a motive for concern because these symptoms may signal malignant disease.

Non-Hodgkin disease in beta-thalassemia major

Thalassemia is a spectrum of diseases characterized by the decrease or absence of globin chains. The occurrence of lymphoma in thalassemia has rarely been reported, and our review of the English literature revealed only four cases. Because anemia is always masked by regular transfusions in thalassemic patients, physicians discover a hidden malignancy late in the course of the disease. We hereby report the case of a thalassemic patient developing non-Hodgkin disease and discuss the possibility of a link between the two disease entities. This case is intended to alert physicians of the possibility of a malignancy in thalassemia patients.

Malignancy in patients with sickle cell disease

Malignancy in patients with sickle cell disease (SCD) has been previously reported, but the types of cancer and its incidence remain undefined. With the advent of hydroxyurea therapy, there is concern about increasing the cancer risk for patients with SCD. The International Association of Sickle Cell Nurses and Physician Assistants identified 52 cases of cancer (49 patients) among 16,613 patients with SCD followed at 52 institutions. The median age at malignancy diagnosis was 34 years (range, 14 months-62 years). Twenty-one cases (40%) occurred in pediatric patients, primarily leukemia (n = 7) or Wilms' tumor (n = 5), with 15 children surviving. Most adults had solid tumors, especially carcinomas, and only nine were known to be alive. Three patients received hydroxyurea before the diagnosis of malignancy. These data provide essential baseline information for the accurate interpretation of future reports of malignancy in patients with SCD, especially those receiving hydroxyurea therapy.

Beta-thalassemia intermedia and non-Hodgkin's lymphoma

The presenting symptoms of malignancies like anemia and splenomegaly in thalassemic patients can be overlooked and considered as complications of thalassemia. Our paper deals with a case of large B cell lymphoma with bone marrow involvement in an old lady with thalassemia intermedia. The patient showed complete response after the second cycle of chemotherapy that consists of cyclophosphamide, vincristine, and prednisone (CVP protocol). However, the patient relapsed with bone marrow involvement shortly after (2 weeks) completion of the sixth cycle of chemotherapy, and she was started on monoclonal antibodies Rituximab. On reviewing the literature, only four cases of thalassemia and lymphoma have been reported worldwide, thus making our case the fifth report of this rare combination of diseases.

Late effects of bone marrow transplantation for thalassemia

Long term effects of BMT in thalassemia were monitored in 33 patients transplanted between 1987 and 1995 and compared with 155 patients matched for age and treated during the same period with conventional therapy (CT). The incidence of fulminant sepsis and growth impairment was significantly higher in transplanted patients, whereas the occurrence of hypothyroidism, hypogonadism, and cardiopathy was higher in CT patients. For diabetes, liver disease, and severe infections, the differences were not statistically significant. After BMT we performed monthly erythrocytaferesis for iron removal in 23 (70%) patients, obtaining a complete normalization of iron stores in 91% of cases; among untreated patients, 60% had evidence of iron up to 8.3 years after BMT. Protection against poliovirus, tetanus, diphtheria, and hepatitis B has been lost in 74%, 47%, 78%, and 44%, respectively. After BMT a careful follow-up is needed to monitor and treat late transplant-related and thalassemia-related complications.

Survival and causes of death in thalassaemia major

Survival and causes of death were studied in 1087 Italian patients with thalassaemia major who were born on or after Jan 1, 1960. At the age of 15 years, the Kaplan-Meier estimate of survival after the first decade of life was 80.6% for subjects born in 1960-64, 84.2% for those born in 1965-69, and 96.9% for those born in 1970-74. At the age of 20 years, survival from the age of 10 was 59.1% for patients born in 1960-64, and 70.2% for those born in 1965-69; at 25 years, survival from the age of 10 was 40.7% in the 1960-64 cohort. Overall survival from birth for patients born in 1970-74 was 97.4% at 10 years, and 94.4% at 15 years. The most common cause of death was heart disease, followed by infection, liver disease, and malignancy.