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Lübke J, Metzgeroth G, Reiter A, Schwaab J. Approach to the patient with eosinophilia in the era of tyrosine kinase inhibitors and biologicals. Curr Hematol Malig Rep 2024; 19:208-222. [PMID: 39037514 PMCID: PMC11416429 DOI: 10.1007/s11899-024-00738-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/02/2024] [Indexed: 07/23/2024]
Abstract
PURPOSE OF REVIEW In this review, we aim to explore the optimal approach to patients presenting with eosinophilia, considering recent advances in diagnostic and therapeutic strategies. Specifically, we focus on the integration of novel therapies into clinical practice to improve patient outcomes. RECENT FINDINGS Advanced insights into the clinical and genetic features of eosinophilic disorders have prompted revisions in diagnostic criteria by the World Health Organization classification (WHO-HAEM5) and the International Consensus Classification (ICC). These changes reflect a growing understanding of disease pathogenesis and the development of targeted treatment options. The therapeutic landscape now encompasses a range of established and novel therapies. For reactive conditions, drugs targeting the eosinophilopoiesis, such as those aimed at interleukin-5 or its receptor, have demonstrated significant potential in decreasing blood eosinophil levels and minimizing disease flare-ups and relapse. These therapies have the potential to mitigate the side effects commonly associated with prolonged use of oral corticosteroids or immunosuppressants. Myeloid and lymphoid neoplasms with eosinophilia and tyrosine kinase (TK) gene fusions are managed by various TK inhibitors with variable efficacy. Diagnosis and treatment rely on a multidisciplinary approach. By incorporating novel treatment options into clinical practice, physicians across different disciplines involved in the management of eosinophilic disorders can offer more personalized and effective care to patients. However, challenges remain in accurately diagnosing and risk-stratifying patients, as well as in navigating the complexities of treatment selection.
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Affiliation(s)
- Johannes Lübke
- Department of Hematology and Oncology, University Hospital Mannheim, Heidelberg University, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany
| | - Georgia Metzgeroth
- Department of Hematology and Oncology, University Hospital Mannheim, Heidelberg University, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany
| | - Andreas Reiter
- Department of Hematology and Oncology, University Hospital Mannheim, Heidelberg University, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany
| | - Juliana Schwaab
- Department of Hematology and Oncology, University Hospital Mannheim, Heidelberg University, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany.
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Shomali W, Gotlib J. World Health Organization and International Consensus Classification of eosinophilic disorders: 2024 update on diagnosis, risk stratification, and management. Am J Hematol 2024; 99:946-968. [PMID: 38551368 DOI: 10.1002/ajh.27287] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2024] [Accepted: 02/09/2024] [Indexed: 04/09/2024]
Abstract
DISEASE OVERVIEW The eosinophilias encompass a broad range of non-hematologic (secondary or reactive) and hematologic (primary or clonal) disorders with the potential for end-organ damage. DIAGNOSIS Hypereosinophilia (HE) has generally been defined as a peripheral blood eosinophil count greater than 1.5 × 109/L, and may be associated with tissue damage. After the exclusion of secondary causes of eosinophilia, diagnostic evaluation of primary eosinophilias relies on a combination of various tests. They include morphologic review of the blood and marrow, standard cytogenetics, fluorescence in situ hybridization, molecular testing and flow immunophenotyping to detect histopathologic or clonal evidence for an acute or chronic hematolymphoid neoplasm. RISK STRATIFICATION Disease prognosis relies on identifying the subtype of eosinophilia. After evaluation of secondary causes of eosinophilia, the 2022 World Health Organization and International Consensus Classification endorse a semi-molecular classification scheme of disease subtypes. This includes the major category "myeloid/lymphoid neoplasms with eosinophilia and tyrosine kinase gene fusions" (MLN-eo-TK), and the MPN subtype, "chronic eosinophilic leukemia" (CEL). Lymphocyte-variant HE is an aberrant T-cell clone-driven reactive eosinophila, and idiopathic hypereosinophilic syndrome (HES) is a diagnosis of exclusion. RISK-ADAPTED THERAPY The goal of therapy is to mitigate eosinophil-mediated organ damage. For patients with milder forms of eosinophilia (e.g., <1.5 × 109/L) without symptoms or signs of organ involvement, a watch and wait approach with close follow-up may be undertaken. Identification of rearranged PDGFRA or PDGFRB is critical because of the exquisite responsiveness of these diseases to imatinib. Pemigatinib was recently approved for patients with relapsed or refractory FGFR1-rearranged neoplasms. Corticosteroids are first-line therapy for patients with lymphocyte-variant HE and HES. Hydroxyurea and interferon-α have demonstrated efficacy as initial treatment and in steroid-refractory cases of HES. Mepolizumab, an interleukin-5 (IL-5) antagonist monoclonal antibody, is approved by the U.S Food and Drug Administration for patients with idiopathic HES. Cytotoxic chemotherapy agents, and hematopoietic stem cell transplantation have been used for aggressive forms of HES and CEL, with outcomes reported for limited numbers of patients. Targeted therapies such as the IL-5 receptor antibody benralizumab, IL-5 monoclonal antibody depemokimab, and various tyrosine kinase inhibitors for MLN-eo-TK, are under active investigation.
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Affiliation(s)
- William Shomali
- Division of Hematology, Stanford Cancer Institute/Stanford University School of Medicine, Stanford, California, USA
| | - Jason Gotlib
- Division of Hematology, Stanford Cancer Institute/Stanford University School of Medicine, Stanford, California, USA
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Nguyen L, Saha A, Kuykendall A, Zhang L. Clinical and Therapeutic Intervention of Hypereosinophilia in the Era of Molecular Diagnosis. Cancers (Basel) 2024; 16:1383. [PMID: 38611061 PMCID: PMC11011008 DOI: 10.3390/cancers16071383] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2024] [Revised: 03/17/2024] [Accepted: 03/17/2024] [Indexed: 04/14/2024] Open
Abstract
Hypereosinophilia (HE) presents with an elevated peripheral eosinophilic count of >1.5 × 109/L and is composed of a broad spectrum of secondary non-hematologic disorders and a minority of primary hematologic processes with heterogenous clinical presentations, ranging from mild symptoms to potentially lethal outcome secondary to end-organ damage. Following the introduction of advanced molecular diagnostics (genomic studies, RNA sequencing, and targeted gene mutation profile, etc.) in the last 1-2 decades, there have been deep insights into the etiology and molecular mechanisms involved in the development of HE. The classification of HE has been updated and refined following to the discovery of clinically novel markers and targets in the 2022 WHO classification and ICOG-EO 2021 Working Conference on Eosinophil Disorder and Syndromes. However, the diagnosis and management of HE is challenging given its heterogeneity and variable clinical outcome. It is critical to have a diagnostic algorithm for accurate subclassification of HE and hypereosinophilic syndrome (HES) (e.g., reactive, familial, idiopathic, myeloid/lymphoid neoplasm, organ restricted, or with unknown significance) and to follow established treatment guidelines for patients based on its clinical findings and risk stratification.
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Affiliation(s)
- Lynh Nguyen
- Department of Pathology, James A. Haley Veterans’ Hospital, Tampa, FL 33612, USA
| | - Aditi Saha
- Department of Malignant Hematology, H. Lee Moffitt Cancer Center, Tampa, FL 33612, USA (A.K.)
| | - Andrew Kuykendall
- Department of Malignant Hematology, H. Lee Moffitt Cancer Center, Tampa, FL 33612, USA (A.K.)
| | - Ling Zhang
- Department of Pathology, H. Lee Moffitt Cancer Center, Tampa, FL 33612, USA
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Muacevic A, Adler JR, Singh A, Mishra S, Verma SP. Acute Myeloid Leukaemia With Translocation (8;21) Masquerading as Peripheral Blood Eosinophilia Having Dysplastic Features: A Diagnostic Challenge. Cureus 2023; 15:e33858. [PMID: 36819451 PMCID: PMC9934935 DOI: 10.7759/cureus.33858] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/10/2023] [Indexed: 01/19/2023] Open
Abstract
Eosinophilia with a modest number of blasts (<20%) in the peripheral blood and bone marrow smears raises suspicion for myeloproliferative neoplasms (MPNs) and acute myeloid leukaemia (AML). Here, we present a case of AML in a 16-year-old boy who presented with high-grade fever, respiratory distress, and generalised weakness. Marked eosinophilia with dysplastic features and occasional blasts were found in the peripheral blood. In view of dysplastic eosinophils and occasional blasts in peripheral blood, a bone marrow examination was requested which revealed increased eosinophils and their progenitors with dysplasia and a modest number of blast cells (<20%). The bone marrow findings suggest MPNs, which were eventually identified as AML having translocation (8;21) with the aid of immunophenotyping and cytogenetic studies. Eosinophilia and its phenotypic anomalies are rarely found in peripheral blood smears of AML patients with translocation (8;21) which may have been related to the leukaemic process.
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Schwaab J, Lübke J, Reiter A, Metzgeroth G. Das idiopathische hypereosinophile Syndrom - Diagnostik und Therapie. ALLERGO JOURNAL 2022. [DOI: 10.1007/s15007-022-5600-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Lübke J, Schwaab J, Naumann N, Horny HP, Weiß C, Metzgeroth G, Kreil S, Cross NCP, Sotlar K, Fabarius A, Hofmann WK, Valent P, Gotlib J, Jawhar M, Reiter A. Superior Efficacy of Midostaurin Over Cladribine in Advanced Systemic Mastocytosis: A Registry-Based Analysis. J Clin Oncol 2022; 40:1783-1794. [PMID: 35235417 DOI: 10.1200/jco.21.01849] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
PURPOSE On the basis of data from the German Registry on Disorders of Eosinophils and Mast Cells, we compared the efficacy of midostaurin and cladribine in patients with advanced systemic mastocytosis (AdvSM). PATIENTS AND METHODS Patients with AdvSM (n = 139) were treated with midostaurin only (n = 63, 45%), cladribine only (n = 23, 17%), or sequentially (midostaurin-cladribine, n = 30, 57%; cladribine-midostaurin, n = 23, 43%). Prognosis was assessed through the Mutation-Adjusted Risk Score (MARS). Besides the comparison of efficacy between midostaurin and cladribine on response (eg, organ dysfunction, bone marrow mast cell [MC] infiltration, and tryptase), overall survival (OS), and leukemia-free survival, we focused on the impact of treatment on involved non-MC lineages, for example, monocytes or eosinophils, and the KIT D816V expressed allele burden. RESULTS Midostaurin only was superior to cladribine only with effects from responses on MC and non-MC lineages conferring on a significantly improved OS (median 4.2 v 1.9 years, P = .033) and leukemia-free survival (2.7 v 1.3 years, P = .044) on the basis of a propensity score-weighted analysis of parameters included in MARS. Midostaurin compensated the inferior efficacy of cladribine in first- and second-line treatment. On midostaurin in any line, response of eosinophilia did not improve its baseline adverse prognostic impact, whereas response of monocytosis proved to be a positive on-treatment parameter. Multivariable analysis allowed to establish three risk categories (low/intermediate/high) through the combination of MARS and the reduction of the KIT D816V expressed allele burden of ≥ 25% at month 6 (median OS not reached v 3.0 years v 1.0 year; P < .001). CONCLUSION In this registry-based analysis, midostaurin revealed superior efficacy over cladribine in patients with AdvSM. In midostaurin-treated patients, the combination of baseline MARS and molecular response provided a compelling three-tier risk categorization (MARSv2.0) for OS.
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Affiliation(s)
- Johannes Lübke
- Department of Hematology and Oncology, University Hospital Mannheim, Heidelberg University, Mannheim, Germany
| | - Juliana Schwaab
- Department of Hematology and Oncology, University Hospital Mannheim, Heidelberg University, Mannheim, Germany
| | - Nicole Naumann
- Department of Hematology and Oncology, University Hospital Mannheim, Heidelberg University, Mannheim, Germany
| | - Hans-Peter Horny
- Department of Pathology, Ludwig-Maximilians-University, Munich, Germany
| | - Christel Weiß
- Department of Medical Statistics and Biomathematics, University Hospital Mannheim, Heidelberg University, Mannheim, Germany
| | - Georgia Metzgeroth
- Department of Hematology and Oncology, University Hospital Mannheim, Heidelberg University, Mannheim, Germany
| | - Sebastian Kreil
- Department of Hematology and Oncology, University Hospital Mannheim, Heidelberg University, Mannheim, Germany
| | - Nicholas C P Cross
- Wessex Regional Genetics Laboratory, Salisbury, United Kingdom.,University of Southampton, Southampton, United Kingdom
| | - Karl Sotlar
- Department of Pathology, Paracelsus Medical University of Salzburg, Salzburg, Austria
| | - Alice Fabarius
- Department of Hematology and Oncology, University Hospital Mannheim, Heidelberg University, Mannheim, Germany
| | - Wolf-Karsten Hofmann
- Department of Hematology and Oncology, University Hospital Mannheim, Heidelberg University, Mannheim, Germany
| | - Peter Valent
- Division of Hematology and Hemostaseology, Department of Internal Medicine I, Medical University of Vienna, Vienna, Austria.,Ludwig Boltzmann Institute for Hematology and Oncology, Medical University of Vienna, Vienna, Austria
| | - Jason Gotlib
- Hematology Division, Stanford University School of Medicine/Stanford Cancer Institute, Stanford, CA
| | - Mohamad Jawhar
- Department of Hematology and Oncology, University Hospital Mannheim, Heidelberg University, Mannheim, Germany
| | - Andreas Reiter
- Department of Hematology and Oncology, University Hospital Mannheim, Heidelberg University, Mannheim, Germany
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Shomali W, Gotlib J. World Health Organization-defined eosinophilic disorders: 2022 update on diagnosis, risk stratification, and management. Am J Hematol 2022; 97:129-148. [PMID: 34533850 DOI: 10.1002/ajh.26352] [Citation(s) in RCA: 59] [Impact Index Per Article: 29.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2021] [Accepted: 09/14/2021] [Indexed: 12/13/2022]
Abstract
DISEASE OVERVIEW The eosinophilias encompass a broad range of nonhematologic (secondary or reactive) and hematologic (primary or clonal) disorders with potential for end-organ damage. DIAGNOSIS Hypereosinophilia (HE) has generally been defined as a peripheral blood eosinophil count greater than 1.5 × 109 /L. After exclusion of secondary causes of eosinophilia, diagnostic evaluation of primary eosinophilias relies on morphologic review of the blood and marrow, standard cytogenetics, fluorescence in situ hybridization, next generation sequencing gene assays, and flow immunophenotyping to detect histopathologic or clonal evidence for an acute or chronic hematolymphoid neoplasm. RISK STRATIFICATION Disease prognosis relies on identifying the subtype of eosinophilia. After evaluation of secondary causes of eosinophilia, the 2016 World Health Organization endorses a semi-molecular classification scheme of disease subtypes. This includes the major category "myeloid/lymphoid neoplasms with eosinophilia and rearrangement of PDGFRA, PDGFRB, or FGFR1 or with PCM1-JAK2", and the myeloproliferative neoplasm subtype, "chronic eosinophilic leukemia, not otherwise specified" (CEL, NOS). Lymphocyte-variant HE is an aberrant T-cell clone-driven reactive eosinophila, and idiopathic hypereosinophilic syndrome (HES) is a diagnosis of exclusion. RISK-ADAPTED THERAPY The goal of therapy is to mitigate eosinophil-mediated organ damage. For patients with milder forms of eosinophilia (eg, < 1.5 × 109 /L) without symptoms or signs of organ involvement, a watch and wait approach with close follow-up may be undertaken. Identification of rearranged PDGFRA or PDGFRB is critical because of the exquisite responsiveness of these diseases to imatinib. Corticosteroids are first-line therapy for patients with lymphocyte-variant HE and HES. Hydroxyurea and interferon-α have demonstrated efficacy as initial treatment and in steroid-refractory cases of HES. Mepolizumab, an interleukin-5 (IL-5) antagonist monoclonal antibody, was recently approved by the US Food and Drug Administration for patients with idiopathic HES. The use of the IL-5 receptor antibody benralizumab, as well as other targeted therapies such as JAK2 and FGFR1 inhibitors, is under active investigation.
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Affiliation(s)
- William Shomali
- Division of Hematology, Stanford Cancer Institute Stanford University School of Medicine Stanford California USA
| | - Jason Gotlib
- Division of Hematology, Stanford Cancer Institute Stanford University School of Medicine Stanford California USA
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Pozdnyakova O, Orazi A, Kelemen K, King R, Reichard KK, Craig FE, Quintanilla-Martinez L, Rimsza L, George TI, Horny HP, Wang SA. Myeloid/Lymphoid Neoplasms Associated With Eosinophilia and Rearrangements of PDGFRA, PDGFRB, or FGFR1 or With PCM1-JAK2. Am J Clin Pathol 2021; 155:160-178. [PMID: 33367495 DOI: 10.1093/ajcp/aqaa208] [Citation(s) in RCA: 32] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
OBJECTIVES To summarize cases submitted to the 2019 Society for Hematopathology/European Association for Haematopathology Workshop under the category of myeloid/lymphoid neoplasms with eosinophilia and PDGFRA, PDGFRB, or FGFR1 or with PCM1-JAK2 rearrangements, focusing on recent updates and relevant practice findings. METHODS The cases were summarized according to their respective gene rearrangement to illustrate the spectrum of clinical, laboratory, and histopathology manifestations and to explore the appropriate molecular genetic tests. RESULTS Disease presentations were heterogeneous, including myeloproliferative neoplasms (MPNs), myelodysplastic syndromes (MDSs), MDS/MPN, acute myeloid leukemia, acute B- or T-lymphoblastic lymphoma/acute lymphoblastic lymphoma (ALL/LBL), or mixed-lineage neoplasms. Frequent extramedullary involvement occurred. Eosinophilia was common but not invariably present. With the advancement of RNA sequencing, cryptic rearrangements were recognized in genes other than PDGFRA. Additional somatic mutations were more frequent in the FGFR1-rearranged cases. Cases with B-ALL presentations differed from Philadelphia-like B-ALL by the presence of an underlying MPN. Cases with FLT3 and ABL1 rearrangements could be potential candidates for future inclusion in this category. CONCLUSIONS Accurate diagnosis and classification of this category of myeloid/lymphoid neoplasms has important therapeutic implications. With the large number of submitted cases, we expand our understanding of these rare neoplasms and improve our ability to diagnose these genetically defined disorders.
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Affiliation(s)
- Olga Pozdnyakova
- Department of Pathology, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA
| | - Attilio Orazi
- Department of Pathology, Texas Tech University Health Sciences Center, P. L. Foster School of Medicine, El Paso
| | | | - Rebecca King
- Division of Hematopathology, Mayo Clinic, Rochester, MN
| | | | - Fiona E Craig
- Division of Hematopathology, Mayo Clinic, Rochester, MN
| | - Leticia Quintanilla-Martinez
- Institute of Pathology and Neuropathology, Eberhard Karls University of Tübingen and Comprehensive Cancer Center, Tübingen University Hospital, Tübingen, Germany
| | - Lisa Rimsza
- Division of Hematopathology, Mayo Clinic, Rochester, MN
| | - Tracy I George
- Department of Pathology, University of Utah School of Medicine, Salt Lake City
| | | | - Sa A Wang
- MD Anderson Cancer Center, Houston, TX
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Molecular Pathogenesis and Treatment Perspectives for Hypereosinophilia and Hypereosinophilic Syndromes. Int J Mol Sci 2021; 22:ijms22020486. [PMID: 33418988 PMCID: PMC7825323 DOI: 10.3390/ijms22020486] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2020] [Revised: 12/29/2020] [Accepted: 12/30/2020] [Indexed: 12/25/2022] Open
Abstract
Hypereosinophilia (HE) is a heterogeneous condition with a persistent elevated eosinophil count of >350/mm3, which is reported in various (inflammatory, allergic, infectious, or neoplastic) diseases with distinct pathophysiological pathways. HE may be associated with tissue or organ damage and, in this case, the disorder is classified as hypereosinophilic syndrome (HES). Different studies have allowed for the discovery of two major pathogenetic variants known as myeloid or lymphocytic HES. With the advent of molecular genetic analyses, such as T-cell receptor gene rearrangement assays and Next Generation Sequencing, it is possible to better characterize these syndromes and establish which patients will benefit from pharmacological targeted therapy. In this review, we highlight the molecular alterations that are involved in the pathogenesis of eosinophil disorders and revise possible therapeutic approaches, either implemented in clinical practice or currently under investigation in clinical trials.
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10
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Fan JC, You WW, Liu HX, Cai Y, Du X, Wang JX. [Acute myeloid leukemia with FIP1L1-PDGFRA fusion gene treated with imatinib: a case report and literature review]. ZHONGHUA XUE YE XUE ZA ZHI = ZHONGHUA XUEYEXUE ZAZHI 2020; 41:1044-1046. [PMID: 33445855 PMCID: PMC7840551 DOI: 10.3760/cma.j.issn.0253-2727.2020.12.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Download PDF] [Subscribe] [Scholar Register] [Received: 05/26/2020] [Indexed: 12/04/2022]
Affiliation(s)
- J C Fan
- Department of Hematology, Shenzhen Second People's Hospital, The Affiliated Hospital of Shenzhen University, Shenzhen 518035, China
| | - W W You
- Department of Hematology, Shenzhen Second People's Hospital, The Affiliated Hospital of Shenzhen University, Shenzhen 518035, China
| | - H X Liu
- Department of Hematology, Shenzhen Second People's Hospital, The Affiliated Hospital of Shenzhen University, Shenzhen 518035, China
| | - Y Cai
- Department of Hematology, Shenzhen Second People's Hospital, The Affiliated Hospital of Shenzhen University, Shenzhen 518035, China
| | - X Du
- Department of Hematology, Shenzhen Second People's Hospital, The Affiliated Hospital of Shenzhen University, Shenzhen 518035, China
| | - J X Wang
- Institute of Hematology and Blood Diseases Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Tianjin 300020, China
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Sreedharanunni S, Sachdeva MUS, Sharma S, Rana S, Sandal R, Kumar N, Sharma P, Naseem S, Ahluwalia J, Das R, Malhotra P, Varma N. Paratrabecular myelofibrosis and occult mastocytosis are strong morphological clues to suspect FIP1L1-PDGFRA translocation in hypereosinophilia. Indian J Hematol Blood Transfus 2020; 36:384-389. [PMID: 32425395 DOI: 10.1007/s12288-019-01236-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2019] [Accepted: 11/22/2019] [Indexed: 11/25/2022] Open
Abstract
To study the clinico-haematological and histopathological characteristics of FIP1L1-PDGFRA rearranged hypereosinophilia/hypereosinophilic syndrome (F/P+ve HE/HES), a retrospective analysis of patients with F/P+ve HE diagnosed over a period of 43 months was performed. Peripheral blood smears, bone marrow aspirate (BMA) and biopsies (BMB) were reviewed in each case and; reticulin stain and immunohistochemistry for mast cell tryptase (MCT) and CD117 was performed. F/P+ve HE was diagnosed in a total of ten patients during study period. All patients were males with a median age of 36 years (23-44 years). The median duration of presenting complaints was 7 months (2 months-3 years) which included specific symptoms related to various organs (80% of cases). Anaemia, thrombocytopenia and splenomegaly were seen in 60%, 50% and 90% of the cases respectively. Mastocytosis was not obvious in BMA but identified by MCT on BMB in all cases. Myelofibrosis (grade ≥ 1) was seen in 80% of the cases and includes multifocal paratrabecular fibrosis in 50% of the biopsies. Our study shows that bone marrow mastocytosis and myelofibrosis are very useful morphological indicators to suspect F/P+ve HE and suggests the routine use of reticulin staining and MCT immunohistochemistry in all BMBs performed for the evaluation of HE/HES.
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Affiliation(s)
- Sreejesh Sreedharanunni
- 1Department of Hematology, Post Graduate Institute of Medical Education and Research, 5th floor, Research block A, Chandigarh, 160012 India
| | - Man Updesh Singh Sachdeva
- 1Department of Hematology, Post Graduate Institute of Medical Education and Research, 5th floor, Research block A, Chandigarh, 160012 India
| | - Saniya Sharma
- 1Department of Hematology, Post Graduate Institute of Medical Education and Research, 5th floor, Research block A, Chandigarh, 160012 India
| | - Sonia Rana
- 1Department of Hematology, Post Graduate Institute of Medical Education and Research, 5th floor, Research block A, Chandigarh, 160012 India
| | - Rajeev Sandal
- 2Adult Clinical Hematology and Bone Marrow Transplantation Unit, Department of Internal Medicine, Post Graduate Institute of Medical Education and Research, Chandigarh, 160012 India
| | - Narender Kumar
- 1Department of Hematology, Post Graduate Institute of Medical Education and Research, 5th floor, Research block A, Chandigarh, 160012 India
| | - Prashant Sharma
- 1Department of Hematology, Post Graduate Institute of Medical Education and Research, 5th floor, Research block A, Chandigarh, 160012 India
| | - Shano Naseem
- 1Department of Hematology, Post Graduate Institute of Medical Education and Research, 5th floor, Research block A, Chandigarh, 160012 India
| | - Jasmina Ahluwalia
- 1Department of Hematology, Post Graduate Institute of Medical Education and Research, 5th floor, Research block A, Chandigarh, 160012 India
| | - Reena Das
- 1Department of Hematology, Post Graduate Institute of Medical Education and Research, 5th floor, Research block A, Chandigarh, 160012 India
| | - Pankaj Malhotra
- 2Adult Clinical Hematology and Bone Marrow Transplantation Unit, Department of Internal Medicine, Post Graduate Institute of Medical Education and Research, Chandigarh, 160012 India
| | - Neelam Varma
- 1Department of Hematology, Post Graduate Institute of Medical Education and Research, 5th floor, Research block A, Chandigarh, 160012 India
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12
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Iurlo A, Cattaneo D, Gianelli U. Hypereosinophilic syndromes in the precision medicine era: clinical, molecular aspects and therapeutic approaches (targeted therapies). Expert Rev Hematol 2019; 12:1077-1088. [PMID: 31588817 DOI: 10.1080/17474086.2019.1677461] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/30/2022]
Abstract
Introduction: Hypereosinophilic syndromes are a heterogeneous group of disorders that may be associated with life-threatening organ injury as a result of tissues infiltration by eosinophils. The main goal of therapy is to mitigate eosinophil-mediated organ damage. When possible, therapy should be directed at the underlying etiology. However, even in the absence of any known cause, when organ damage is present, hypereosinophilia must be treated promptly and aggressively to reduce potential morbidity and mortality.Areas covered: Conventional therapies, including corticosteroids, hydroxyurea (hydroxycarbamide) and interferon-alpha, have shown variable efficacy and a non-negligible toxicity emphasizing the need of new therapeutic strategies based on drugs with different mechanisms of action.Expert opinion: Tyrosine kinase inhibitors have a central role among targeted therapies of hypereosinophilic syndromes. Imatinib, initially empirically used based on its activity in chronic myeloid leukemia, achieved preliminary excellent results further confirmed in large series of patients. Third-generation tyrosine kinase inhibitors such as ponatinib, while active in vitro and in vivo in animals, still deserve confirmation in properly designed clinical trials. In addition, clinical investigation on monoclonal antibodies against interleukin-5, interleukin-5Rα, IgE, and CD52 represents a promising area of research.
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Affiliation(s)
- Alessandra Iurlo
- Hematology Division, Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, and University of Milan, Milan, Italy
| | - Daniele Cattaneo
- Hematology Division, Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, and University of Milan, Milan, Italy
| | - Umberto Gianelli
- Division of Pathology, Department of Pathophysiology and Transplantation, Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, and University of Milan, Milan, Italy
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13
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Shomali W, Gotlib J. World Health Organization-defined eosinophilic disorders: 2019 update on diagnosis, risk stratification, and management. Am J Hematol 2019; 94:1149-1167. [PMID: 31423623 DOI: 10.1002/ajh.25617] [Citation(s) in RCA: 116] [Impact Index Per Article: 23.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2019] [Accepted: 08/13/2019] [Indexed: 12/16/2022]
Abstract
DISEASE OVERVIEW The eosinophilias encompass a broad range of non-hematologic (secondary or reactive) and hematologic (primary, clonal) disorders with potential for end-organ damage. DIAGNOSIS Hypereosinophilia has generally been defined as a peripheral blood eosinophil count greater than 1.5 × 109 /L, and may be associated with tissue damage. After exclusion of secondary causes of eosinophilia, diagnostic evaluation of primary eosinophilias relies on a combination of various tests. They include morphologic review of the blood and marrow, standard cytogenetics, fluorescence in situ-hybridization, flow immunophenotyping, and T-cell clonality assessment to detect histopathologic or clonal evidence for an acute or chronic hematolymphoid neoplasm. RISK STRATIFICATION Disease prognosis relies on identifying the subtype of eosinophilia. After evaluation of secondary causes of eosinophilia, the 2016 World Health Organization endorses a semi-molecular classification scheme of disease subtypes. This includes the major category "myeloid/lymphoid neoplasms with eosinophilia and rearrangement of PDGFRA, PDGFRB, or FGFR1 or with PCM1-JAK2", and the MPN subtype, "chronic eosinophilic leukemia, not otherwise specified" (CEL, NOS). Lymphocyte-variant hypereosinophilia is an aberrant T-cell clone-driven reactive eosinophila, and idiopathic hypereosinophilic syndrome (HES) is a diagnosis of exclusion. RISK-ADAPTED THERAPY The goal of therapy is to mitigate eosinophil-mediated organ damage. For patients with milder forms of eosinophilia (eg, <1.5 × 109 /L) without symptoms or signs of organ involvement, a watch and wait approach with close-follow-up may be undertaken. Identification of rearranged PDGFRA or PDGFRB is critical because of the exquisite responsiveness of these diseases to imatinib. Corticosteroids are first-line therapy for patients with lymphocyte-variant hypereosinophilia and HES. Hydroxyurea and interferon-alfa have demonstrated efficacy as initial treatment and in steroid-refractory cases of HES. In addition to hydroxyurea, second line cytotoxic chemotherapy agents, and hematopoietic stem cell transplantation have been used for aggressive forms of HES and CEL, with outcomes reported for limited numbers of patients. The use of antibodies against interleukin-5 (IL-5) (mepolizumab), the IL-5 receptor (benralizumab), as well as other targets on eosinophils remains an active area of investigation.
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Affiliation(s)
- William Shomali
- Division of Hematology, Stanford Cancer Institute/Stanford University School of Medicine, Stanford, California
| | - Jason Gotlib
- Division of Hematology, Stanford Cancer Institute/Stanford University School of Medicine, Stanford, California
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Leru PM. Eosinophilic disorders: evaluation of current classification and diagnostic criteria, proposal of a practical diagnostic algorithm. Clin Transl Allergy 2019; 9:36. [PMID: 31367340 PMCID: PMC6657042 DOI: 10.1186/s13601-019-0277-4] [Citation(s) in RCA: 41] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2019] [Accepted: 07/11/2019] [Indexed: 12/11/2022] Open
Abstract
Eosinophilic disorders represent a group of pathologic conditions with highly heterogeneous pathophysiology and clinical presentation and variable prognosis, ranging from asymptomatic or mild, to severe and complex cases, with fatal outcome. Interest in this group of disorders has increased during the last two decades, with consistent progress made regarding understanding of molecular mechanisms, refining of diagnostic criteria, classification and evaluation of therapeutic options. There are still many gaps and difficulties in evaluating eosinophilic syndromes and diseases in medical practice. The disease prognosis depends mainly on the cause and mechanism of eosinophilia, on severity of organ dysfunction and on accurate diagnosis and response to treatment. Besides primary hypereosinophilic syndromes and secondary (reactive) eosinophilias, many associated or idiopathic forms have been described, making this topic a complex and difficult medical entity. An important aim of the experts in the field is to agree upon a more clear and practically useful classification, a better characterization of various phenotypes and endotypes of eosinophilic diseases and to identify novel biomarkers and more effective therapies. The aim of this paper is to review recent data from the literature regarding definition, classification and diagnosis criteria of eosinophilic diseases and to propose a revised and updated diagnostic algorithm useful in clinical practice.
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Affiliation(s)
- Polliana Mihaela Leru
- 1Carol Davila University of Medicine and Pharmacy, Bucharest, Romania.,2Internal Medicine Department, Colentina Clinical Hospital, Sos. Stefan cel Mare, No. 19-21, District 2, 020125 Bucharest, Romania
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15
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Naymagon L, Marcellino B, Mascarenhas J. Eosinophilia in acute myeloid leukemia: Overlooked and underexamined. Blood Rev 2019; 36:23-31. [PMID: 30948162 DOI: 10.1016/j.blre.2019.03.007] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2018] [Revised: 02/05/2019] [Accepted: 03/28/2019] [Indexed: 02/04/2023]
Abstract
The presence of eosinophilia in acute myeloid leukemia (AML) suggests an underlying core binding factor (CBF) lesion, a platelet derived growth factor (PDGFR) translocation, or another rare translocation (such as ETV6-ABL1). Each of these cytogenetic entities carries unique diagnostic, prognostic, and therapeutic implications. CBF AML is most common and as such, its treatment is more clearly established, consisting of intensive induction chemotherapy followed by cytarabine based consolidation. Due in large part to its intrinsic chemo-sensitivity, CBF AML is associated with relatively high rates of remission and survival. PDGFR mediated AML is comparatively rare, and as such, diagnostic and treatment paradigms are not as well defined. Early identification of PDGFR translocations is essential, as they confer profound imatinib sensitivity which may, in many instances, spare the need for chemotherapy. Prompt recognition of such lesions requires a strong index of suspicion, and as such these diagnoses are often initially overlooked. Unfortunately, many cases of PDGFR associated AML, particularly those with other concurrent cytogenetic abnormalities, demonstrate treatment emergent imatinib resistance. Such patients continue to present a challenge, even with the advent of novel tyrosine kinase inhibitors (TKIs). Patients with rare translocations such as ETV6-ABL1 are not well described however seem to follow an aggressive clinical course, with limited response to imatinib, and poor outcomes. This review examines the significance of eosinophilia in the context of AML, with respect to its presentation, pathology, and cytogenetics, and with special attention to appropriate evaluation and treatment.
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Affiliation(s)
- Leonard Naymagon
- Tisch Cancer Institute, Division of Hematology/Oncology, Icahn School of Medicine at Mount Sinai, One Gustave L Levy Place, Box 1079, New York, NY 10029, USA.
| | - Bridget Marcellino
- Tisch Cancer Institute, Division of Hematology/Oncology, Icahn School of Medicine at Mount Sinai, One Gustave L Levy Place, Box 1079, New York, NY 10029, USA.
| | - John Mascarenhas
- Tisch Cancer Institute, Division of Hematology/Oncology, Icahn School of Medicine at Mount Sinai, One Gustave L Levy Place, Box 1079, New York, NY 10029, USA.
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Sreedharanunni S, Varma N, Sachdeva MUS, Naseem S, Malhotra P, Bansal D, Trehan A, Varma S. The Spectrum of Hypereosinophilia and Associated Clonal Disorders - A Real-World Data Based on Combined Retrospective and Prospective Analysis from a Tropical Setting. Mediterr J Hematol Infect Dis 2018; 10:e2018052. [PMID: 30210745 PMCID: PMC6131107 DOI: 10.4084/mjhid.2018.052] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2018] [Accepted: 07/20/2018] [Indexed: 01/18/2023] Open
Abstract
OBJECTIVE To determine the frequency, etiological spectrum and treatment outcome of hypereosinophilia (HE) and hypereosinophilic syndromes (HES) in a tropical setting. METHODS A retrospective analysis of hospital data of five years (January 2009 to December 2013) and a comprehensive prospective evaluation of patients presenting with HE/HES over a period of 33 months (January 2014 to September 2016) was performed. RESULTS HE/HES was diagnosed in a total of 125 patients during the study period with an estimated prevalence of 0.5-1 case per 100,000 population in our hospital settings. 41 patients were excluded from the final analysis due to lack of sufficient data. Infections, especially helminths were the commonest cause (34%) followed by primary/clonal HE/HES (24%) and reactive HE/HES secondary to various clonal disorders (14.3%). A lymphocytic variant of HES and FIP1L1-PDGFRA positive HES were diagnosed in 3.6% each. Imatinib-responsive BCR-ABL1 negative HE/HES constitute 7.1% in our patients. None of the clinical or routine laboratory features including the age of patients, duration of HE, presence or absence of organomegaly, hemoglobin levels, eosinophil %, absolute eosinophil count, total leukocyte count, platelet counts, serum IgE levels or presence of myelofibrosis could predict or exclude malignancy in patients with HE/HES. The absence of blasts in peripheral blood or the absence of >5% blasts in bone marrow does not exclude primary/clonal HES. CONCLUSIONS An underlying malignancy (Primary HE/HES and neoplasms leading to reactive HES; 35.7%) is diagnosed with nearly equal frequency compared to infections (34.5%) in tropical settings. There are no hematological or serological parameters, which can reliably be used to exclude an underlying malignancy, necessitating a thorough follow-up and comprehensive work-up in patients with HE/HES.
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Affiliation(s)
- Sreejesh Sreedharanunni
- Department of Hematology, Postgraduate Institute of Medical Education and Research, Chandigarh, India - 160012
| | - Neelam Varma
- Department of Hematology, Postgraduate Institute of Medical Education and Research, Chandigarh, India - 160012
| | - Man Updesh Singh Sachdeva
- Department of Hematology, Postgraduate Institute of Medical Education and Research, Chandigarh, India - 160012
| | - Shano Naseem
- Department of Hematology, Postgraduate Institute of Medical Education and Research, Chandigarh, India - 160012
| | - Pankaj Malhotra
- Internal Medicine (Clinical Hematology), Postgraduate Institute of Medical Education and Research, Chandigarh, India -160012
| | - Deepak Bansal
- Pediatrics (Hematology/oncology unit), Postgraduate Institute of Medical Education and Research, Chandigarh, India -160012
| | - Amita Trehan
- Pediatrics (Hematology/oncology unit), Postgraduate Institute of Medical Education and Research, Chandigarh, India -160012
| | - Subhash Varma
- Internal Medicine (Clinical Hematology), Postgraduate Institute of Medical Education and Research, Chandigarh, India -160012
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Mäkitie RE, Niinimäki R, Kakko S, Honkanen T, Kovanen PE, Mäkitie O. Defective WNT signaling associates with bone marrow fibrosis-a cross-sectional cohort study in a family with WNT1 osteoporosis. Osteoporos Int 2018; 29:479-487. [PMID: 29147753 DOI: 10.1007/s00198-017-4309-4] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2017] [Accepted: 11/07/2017] [Indexed: 01/28/2023]
Abstract
UNLABELLED This study explores bone marrow function in patients with defective WNT1 signaling. Bone marrow samples showed increased reticulin and altered granulopoiesis while overall hematopoiesis was normal. Findings did not associate with severity of osteoporosis. These observations provide new insight into the role of WNT signaling in bone marrow homeostasis. INTRODUCTION WNT signaling regulates bone homeostasis and survival and self-renewal of hematopoietic stem cells. Aberrant activation may lead to osteoporosis and bone marrow pathology. We aimed to explore bone marrow findings in a large family with early-onset osteoporosis due to a heterozygous WNT1 mutation. METHODS We analyzed peripheral blood samples, and bone marrow aspirates and biopsies from 10 subjects with WNT1 mutation p.C218G. One subject was previously diagnosed with idiopathic myelofibrosis and others had no previously diagnosed hematologic disorders. The findings were correlated with the skeletal phenotype, as evaluated by number of peripheral and spinal fractures and bone mineral density. RESULTS Peripheral blood samples showed no abnormalities in cell counts, morphology or distributions but mild increase in platelet count. Bone marrow aspirates (from 8/10 subjects) showed mild decrease in bone marrow iron storages in 6 and variation in cell distributions in 5 subjects. Bone marrow biopsies (from 6/10 subjects) showed increased bone marrow reticulin (grade MF-2 in the myelofibrosis subject and grade MF-1 in 4 others), and an increase in overall, and a shift towards early-phase, granulopoiesis. The bone marrow findings did not associate with the severity of skeletal phenotype. CONCLUSIONS Defective WNT signaling associates with a mild increase in bone marrow reticulin and may predispose to myelofibrosis, while overall hematopoiesis and peripheral blood values are unaltered in individuals with a WNT1 mutation. In this family with WNT1 osteoporosis, bone marrow findings were not related to the severity of osteoporosis.
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Affiliation(s)
- R E Mäkitie
- Folkhälsan Institute of Genetics, University of Helsinki, P.O. Box 63, FIN-00014, Helsinki, Finland.
| | - R Niinimäki
- Department of Children and Adolescents, Oulu University Hospital and Oulu University, Oulu, Finland
| | - S Kakko
- Internal Medicine and Clinical Research Center, University of Oulu, Oulu, Finland
| | - T Honkanen
- Department of Hematology, Päijät-Häme Central Hospital, Lahti, Finland
| | - P E Kovanen
- HUSLAB, Helsinki University Hospital and Department of Pathology, University of Helsinki, Helsinki, Finland
| | - O Mäkitie
- Folkhälsan Institute of Genetics, University of Helsinki, P.O. Box 63, FIN-00014, Helsinki, Finland
- Children's Hospital, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
- Center for Molecular Medicine, Karolinska Institutet and Clinical Genetics, Karolinska University Hospital, Stockholm, Sweden
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18
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Gotlib J. World Health Organization-defined eosinophilic disorders: 2017 update on diagnosis, risk stratification, and management. Am J Hematol 2017; 92:1243-1259. [PMID: 29044676 DOI: 10.1002/ajh.24880] [Citation(s) in RCA: 140] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2017] [Accepted: 08/03/2017] [Indexed: 12/20/2022]
Abstract
DISEASE OVERVIEW The eosinophilias encompass a broad range of nonhematologic (secondary or reactive) and hematologic (primary, clonal) disorders with potential for end-organ damage. DIAGNOSIS Hypereosinophilia has generally been defined as a peripheral blood eosinophil count greater than 1500/mm3 and may be associated with tissue damage. After exclusion of secondary causes of eosinophilia, diagnostic evaluation of primary eosinophilias relies on a combination of morphologic review of the blood and marrow, standard cytogenetics, fluorescent in situ-hybridization, flow immunocytometry, and T-cell clonality assessment to detect histopathologic or clonal evidence for an acute or chronic myeloid or lymphoproliferative disorder. RISK STRATIFICATION Disease prognosis relies on identifying the subtype of eosinophilia. After evaluation of secondary causes of eosinophilia, the 2016 World Health Organization endorses a semi-molecular classification scheme of disease subtypes which includes the major category "myeloid/lymphoid neoplasms with eosinophilia and rearrangement of PDGFRA, PDGFRB, or FGFR1 or with PCM1-JAK2," and the "MPN subtype, chronic eosinophilic leukemia, not otherwise specified" (CEL, NOS). Lymphocyte-variant hypereosinophilia is an aberrant T-cell clone-driven reactive eosinophila, and idiopathic hypereosinophilic syndrome (HES) is a diagnosis of exclusion. RISK-ADAPTED THERAPY The goal of therapy is to mitigate eosinophil-mediated organ damage. For patients with milder forms of eosinophilia (e.g., < 1500/mm3 ) without symptoms or signs of organ involvement, a watch and wait approach with close-follow-up may be undertaken. Identification of rearranged PDGFRA or PDGFRB is critical because of the exquisite responsiveness of these diseases to imatinib. Corticosteroids are first-line therapy for patients with lymphocyte-variant hypereosinophilia and HES. Hydroxyurea and interferon-alpha have demonstrated efficacy as initial treatment and steroid-refractory cases of HES. In addition to hydroxyurea, second line cytotoxic chemotherapy agents and hematopoietic cell transplant have been used for aggressive forms of HES and CEL with outcomes reported for limited numbers of patients. The use of antibodies against interleukin-5 (IL-5) (mepolizumab), the IL-5 receptor (benralizumab), and CD52 (alemtuzumab), as well as other targets on eosinophils remains an active area of investigation.
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Affiliation(s)
- Jason Gotlib
- Stanford Cancer Institute, Stanford, California 94305-5821
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Wang SA, Hasserjian RP, Tam W, Tsai AG, Geyer JT, George TI, Foucar K, Rogers HJ, Hsi ED, Rea BA, Bagg A, Bueso-Ramos CE, Arber DA, Verstovsek S, Orazi A. Bone marrow morphology is a strong discriminator between chronic eosinophilic leukemia, not otherwise specified and reactive idiopathic hypereosinophilic syndrome. Haematologica 2017; 102:1352-1360. [PMID: 28495918 PMCID: PMC5541870 DOI: 10.3324/haematol.2017.165340] [Citation(s) in RCA: 49] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2017] [Accepted: 05/04/2017] [Indexed: 12/19/2022] Open
Abstract
Chronic eosinophilic leukemia, not otherwise specified can be difficult to distinguish from idiopathic hypereosinophilic syndrome according to the current World Health Organization guideline. To examine whether the morphological features of bone marrow might aid in the differential diagnosis of these two entities, we studied a total of 139 patients with a diagnosis of chronic eosinophilic leukemia, not otherwise specified (n=17) or idiopathic hypereosinophilic syndrome (n=122). As a group, abnormal bone marrow morphological features, resembling myelodysplastic syndromes, myeloproliferative neoplasm or myelodysplastic/myeloproliferative neoplasm, were identified in 40/139 (27%) patients: 16 (94%) of those with chronic eosinophilic leukemia and 24 (20%) of those with hypereosinophilic syndrome. Abnormal bone marrow correlated with older age (P<0.001), constitutional symptoms (P<0.001), anemia (P=0.041), abnormal platelet count (P=0.002), organomegaly (P=0.008), elevated lactate dehydrogenase concentration (P=0.005), abnormal karyotype (P<0.001), as well as the presence of myeloid neoplasm-related mutations (P<0.001). Patients with abnormal bone marrow had shorter survival (48.1 months versus not reached, P<0.001), a finding which was independent of other confounding factors (P<0.001). The association between abnormal bone marrow and shorter survival was also observed in hypereosinophilic syndrome patients alone. In summary, most patients with chronic eosinophilic leukemia, not otherwise specified and a proportion of those with idiopathic hypereosinophilic syndrome show abnormal bone marrow features similar to the ones encountered in patients with myelodysplastic syndromes, myelodysplastic/myeloproliferative neoplasm or BCR-ABL1-negative myeloproliferative neoplasm. Among patients who are currently considered to have idiopathic hypereosinophilic syndrome, abnormal bone marrow is a strong indicator of clonal hematopoiesis. Similar to other myeloid neoplasms, bone marrow morphology should be one of the major criteria to distinguish patients with chronic eosinophilic leukemia, not otherwise specified or clonal hypereosinophilic syndrome from those with truly reactive idiopathic hypereosinophilic syndrome.
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Affiliation(s)
- Sa A Wang
- Department of Hematopathology, M.D. Anderson Cancer Center, Houston, TX, USA
| | | | - Wayne Tam
- Department of Pathology and Laboratory Medicine, Weill Cornell Medical College, New York, NY
| | - Albert G Tsai
- Department of Pathology, Stanford University, CA, USA
| | - Julia T Geyer
- Department of Pathology and Laboratory Medicine, Weill Cornell Medical College, New York, NY
| | - Tracy I George
- Department of Pathology, University of New Mexico, Albuquerque, NM, USA
| | - Kathryn Foucar
- Department of Pathology, University of New Mexico, Albuquerque, NM, USA
| | - Heesun J Rogers
- Department of Laboratory Medicine, Cleveland Clinic, OH, USA
| | - Eric D Hsi
- Department of Laboratory Medicine, Cleveland Clinic, OH, USA
| | - Bryan A Rea
- Department of Pathology and Laboratory Medicine, the University of Pennsylvania, Philadelphia, PA, USA
| | - Adam Bagg
- Department of Pathology and Laboratory Medicine, the University of Pennsylvania, Philadelphia, PA, USA
| | | | - Daniel A Arber
- Department of Pathology and Laboratory Medicine, University of Chicago, IL, USA
| | - Srdan Verstovsek
- Department of Leukemia, M.D. Anderson Cancer Center, Houston, TX, USA
| | - Attilio Orazi
- Department of Pathology and Laboratory Medicine, Weill Cornell Medical College, New York, NY
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Abstract
Abstract
Molecular diagnostics has generated substantial dividends in dissecting the genetic basis of myeloid neoplasms with eosinophilia. The family of diseases generated by dysregulated fusion tyrosine kinase (TK) genes is recognized by the World Health Organization (WHO) category, “Myeloid/lymphoid neoplasms with eosinophilia and rearrangement of PDGFRA, PDGFRB, or FGFR1, or with PCM1-JAK2.” In addition to myeloproliferative neoplasms (MPN), these patients can present with myelodysplastic syndrome/MPN, as well as de novo or secondary mixed-phenotype leukemias or lymphomas. Eosinophilia is a common, but not invariable, feature of these diseases. The natural history of PDGFRA- and PDGFRB-rearranged neoplasms has been dramatically altered by imatinib. In contrast, patients with FGFR1 and JAK2 fusion TK genes exhibit a more aggressive course and variable sensitivity to current TK inhibitors, and in most cases, long-term disease-free survival may only be achievable with allogeneic hematopoietic stem cell transplantation. Similar poor prognosis outcomes may be observed with rearrangements of FLT3 or ABL1 (eg, both of which commonly partner with ETV6), and further investigation is needed to validate their inclusion in the current WHO-defined group of eosinophilia-associated TK fusion-driven neoplasms. The diagnosis chronic eosinophilic leukemia, not otherwise specified (CEL, NOS) is assigned to patients with MPN with eosinophilia and nonspecific cytogenetic/molecular abnormalities and/or increased myeloblasts. Myeloid mutation panels have identified somatic variants in patients with a provisional diagnosis of hypereosinophilia of undetermined significance, reclassifying some of these cases as eosinophilia-associated neoplasms. Looking forward, one of the many challenges will be how to use the results of molecular profiling to guide prognosis and selection of actionable therapeutic targets.
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