Second neoplasms in patients with chronic lymphocytic leukemia

Subsequent malignant neoplasms after primary hematological malignancy in adult patients

Patients with primary hematological malignancy (HM) are at an elevated risk of subsequent malignant neoplasms (SMNs), which is a common concern after treatment of primary cancer. We identified 45,533 patients aged ≥20 years and diagnosed with primary HM in Finland from 1992 to 2019 from the Finnish Cancer Registry and estimated standardized incidence ratios (SIR) and excess absolute risks per 1000 person-years (EAR) for SMNs. A total of 6076 SMNs were found (4604 solid and 1472 hematological SMNs). The SIRs were higher for hematological SMNs (SIR 4.9, 95% confidence interval [CI] 4.7-5.2) compared to solid SMNs (SIR 1.5, 95% CI 1.4-1.5). The SIRs for hematological SMNs were highest in the young HM patients aged 20-39 years (SIR 9.2, 95% CI 6.8-12.2 in males and SIR 10.5, 95% CI 7.2-14.7 in females) and decreased by age of first primary HM. However, EARs for hematological SMNs were highest in the older patients, aged 60-79 years at their first primary HM (EAR 5.7/1000 and 4.7/1000 in male and female patients, respectively). In conclusion, the incidence of both hematological and solid SMNs were increased in hematological cancer patients. The relative risk (SIR) was highest among younger HM patients with hematological SMNs. The absolute second cancer burden reflected by high EAR arises from solid malignancies in older patients. Our results accentuate the need for vigilance in the surveillance of HM patients.

Cutaneous Squamous Cell Carcinoma in Immunocompromised Patients—A Comparison between Different Immunomodulating Conditions

Background: Immunosuppression is strongly associated with an increased risk of developing cutaneous squamous cell carcinoma (cSCC). Studies on solid organ transplant recipients (SOTR) and chronic lymphocytic leukemia (CLL) patients have already demonstrated higher rates of aggressive cSCC tumors in these populations compared to immunocompetent controls. Studies on other immunosuppressed patient groups are scarce. This study was aimed at assessing the effects of different immunomodulating conditions on patients diagnosed with cSCC. We sought to compare the clinical features, treatments, and survival rates among the different study groups, as well as outcomes to those of immunocompetent controls with cSCC. Methods: A retrospective analysis of 465 cSCC patients, both immunosuppressed (IS) and immunocompetent controls. Etiologies for immunosuppression included SOTR, CLL, chronic kidney disease (CKD), psoriasis, rheumatoid arthritis (RA) and systemic lupus erythematous (SLE). Results: Compared to the control group, IS patients demonstrated several significant differences. These include higher rates of positive resection margins, higher recurrence rates, and multiple SCC tumors. Patients in the IS group, who were also given immunomodulating agents, demonstrated even lower survival rates. Cox regression analysis demonstrated statistically significant decreased overall survival (OS) rates for IS patients compared to the controls (OR = 1.9, p = 0.031). SOTR patients tend to have multiple cSCC tumors (35%), with the highest number of primary tumors compared to controls (2.54 tumors per patient on average, p < 0.001), but also compared to all other IS groups. The average SCC lesion size in the SOTR group was the smallest, measuring at 13.5 mm, compared to the control group and all other IS groups. Decreased survival rates were seen on Cox regression analysis compared to controls (HR = 2.4, p = 0.001), but also to all other IS groups. CLL patients also had the highest rates of positive margins compared to controls (36% vs. 9%, p < 0.01) and to all other IS groups. They were also most likely to get adjuvant or definitive oncological treatments, either radiotherapy or chemotherapy, compared to controls (36% vs. 15%, p = 0.02) and to other IS groups. Patients in the CKD group demonstrated the highest rates for multiple cSCC (OR = 4.7, p = 0.001) and the worst rates of survival on Cox regression analysis (HR = 3.2, p = 0.001). Both rheumatoid arthritis and psoriasis patients demonstrated the shortest disease-free survival rates (2.9y ± 1.1, 2.3y ± 0.7, respectively), compared to controls (4.1y ± 2.8) and to all other IS groups. Conclusions: Among cSCC patients, immunosuppression due to SOTR, CLL, CKD, RA, and psoriasis is associated with worse outcomes compared to controls and other IS groups. These patients should be regarded as high-risk for developing aggressive cSCC tumors. This study is the first to assess and compare cSCC outcomes among multiple IS patient groups.

Synchronous oral squamous cell carcinoma and a lymphoproliferative disorder in an adult: a challenge in diagnosis and management

Synchronous primary malignancies present challenges in diagnosis, treatment sequencing and management. We present a rare case of a synchronous oral cavity and lymphoproliferative malignancy in a middle-age man. Our patient presented with a primary oral cavity squamous cell carcinoma and was subsequently found to have a secondary lymphoproliferative malignancy (chronic lymphocytic leukaemia/small lymphocytic lymphoma). The challenge of staging and sequencing of treatment is discussed. In addition, this case highlights the importance of multidisciplinary consultation, designing a personalised treatment plan that is coincident with the standard of care for each malignancy, and close follow-up.

Secondary Immunodeficiency in Hematological Malignancies: Focus on Multiple Myeloma and Chronic Lymphocytic Leukemia

Secondary immunodeficiency is reported in most patients with hematological malignancies such as chronic lymphocytic leukemia and multiple myeloma. The aim of our review was to evaluate the existing literature data on patients with hematological malignancies, with regard to the effect of immunodeficiency on the outcome, the clinical and therapeutic approach, and on the onset of noninfectious complications, including thrombosis, pleural effusion, and orofacial complications. Immunodeficiency in these patients has an intense impact on their risk of infection, in turn increasing morbidity and mortality even years after treatment completion. However, these patients with increased risk of severe infectious diseases could be treated with adequate vaccination coverage, but the vaccines' administration can be associated with a decreased immune response and an augmented risk of adverse reactions. Probably, immunogenicity of the inactivated is analogous to that of healthy subjects at the moment of vaccination, but it undertakes a gradual weakening over time. However, the dispensation of live attenuated viral vaccines is controversial because of the risk of the activation of vaccine viruses. A particular immunization schedule should be employed according to the clinical and immunological condition of each of these patients to guarantee a constant immune response without any risks to the patients' health.

Positive association between actinic keratosis and internal malignancies: a nationwide population-based cohort study

Little is known about the comorbidities in actinic keratosis patients. To evaluate the association of actinic keratosis with certain malignancies. All patients with actinic keratosis (n = 61,438) and age- and sex-matched control subjects (n = 307,190) at a 5:1 ratio were enrolled using data from the Korean National Health Insurance Service between the years 2007 and 2014. In subjects with actinic keratosis, overall cancer incidence was higher than that for controls after income level, habitat, diabetes, hypertension, and dyslipidemia were adjusted (Hazard Ratio [HR] = 1.43 [95% confidence interval 1.38–1.47]). The positive association of specific cancers were observed in the following order: skin cancer (HR = 3.43 [2.47–4.75]), oral cavity and pharyngeal cancer (HR = 1.99 [1.57–2.52]), lymphoma (HR = 1.59 [1.28–1.96]), leukemia (HR = 1.35 [1.03–1.77]), prostate cancer (HR = 1.35 [1.21–1.51]), renal cancer (HR = 1.29 [1.02–1.63]), liver cancer (HR = 1.21 [1.09–1.35]), thyroid cancer (HR = 1.20 [1.05–1.38]), and gastric cancer (HR = 1.13 [1.03–1.23]). Although further research on pathologic mechanism is needed, the implications of a positive correlation between actinic keratosis and internal organ malignancies has great significance.

Cutaneous squamous cell carcinoma in patients with chronic lymphocytic leukemia: a systematic review of the literature

The continuous improvement of life expectancy of patients with chronic lymphocytic leukemia (CLL) has resulted in increased risk of second primary malignancy that potentially may affect survival and quality of life of CLL patients. We performed a systematic review to assess the risk and the clinical‐pathological features and prognosis of cutaneous squamous cell carcinoma (cSCC) in patients with CLL. We searched PubMed, Embase, and Cochrane Central Register of Control Trials databases for articles published from database inception to December 31, 2019. English‐language studies reporting original data on patients with a specific diagnosis of CLL and cSCC were included. Data were extracted using a standardized extraction form, and any discordance was resolved by consensus. Descriptive data were generated by pooling patients from eligible studies. Of the 4588 non‐duplicate records identified, 55 articles met our inclusion criteria. These studies reported that CLL patients have a 3.2% prevalence of cSCC, with an 11.5% cSCC‐related lethality and an overall risk of metastasis of 5.7% (7.3% for regional lymph node involvement and 3.8% for distant metastasis). The quality of evidence was limited by the high heterogeneity in the design, populations, and objectives of the included studies. This systematic review suggests that cSCC in CLL patients tends to behave less aggressively compared with the solid organ transplant recipients but has a higher morbidity and mortality than in the general population. Future prospective studies are needed to increase the quality of evidence and to determine the best treatment modalities and screening intervals for these patients.

Risk of Head and Neck Cancer in Patients With Prior Hematologic Malignant Tumors

Importance

More than 1.3 million people in the United States have a hematologic malignant tumor currently or in remission. Previous studies have demonstrated an increased risk of secondary neoplasms in patients with hematologic malignant tumors, but research specifically on the risk of head and neck solid tumors in patients with prior hematologic malignant tumors is limited.

Objectives

To examine a possible association between prior hematologic malignant tumors and risk of head and neck cancer and to assess the overall survival (OS) among these patients.

Design, Setting, and Participants

This retrospective analysis used the Veterans Affairs (VA) Corporate Data Warehouse (CDW) to identify patients with diagnoses of hematologic malignant tumors and head and neck cancers. All patients in the VA CDW with a birthdate between January 1, 1910, and December 31, 1969, were included, for a cohort of 30 939 656 veterans. Data analysis was performed from August 15, 2018, to January 31, 2019.

Exposures

Outpatient problem lists were queried for diagnoses of hematologic malignant tumor and associated malignant tumors using International Classification of Diseases, Ninth Revision (ICD-9) and International Statistical Classification of Diseases and Related Health Problems, Tenth Revision (ICD-10) codes to categorize patients by history of hematologic malignant tumors.

Main Outcomes and Measures

Presence of head and neck cancer was determined from ICD-9 and ICD-10 codes of outpatient problem lists, and cancers were grouped by subsite. The OS was determined from date of death or last outpatient visit date.

Results

Of 30 939 656 patients (27 636 683 [89.3%] male; 13 971 259 [45.2%] white), 207 322 patients had a hematologic malignant tumor, of whom 1353 were later diagnosed with head and neck cancer. A history of hematologic malignant tumors was significantly associated with overall aerodigestive tract cancer, with a relative risk (RR) of 1.6 (95% CI, 1.5-1.7), as well as oral cavity (RR, 1.7; 95% CI, 1.5-1.9), oropharynx (RR, 1.7; 95% CI, 1.5-1.9), larynx (RR, 1.3; 95% CI, 1.2-1.5), nasopharynx (RR, 2.8; 95% CI, 2.1-3.9), sinonasal (RR, 3.0; 95% CI, 2.2-4.1), salivary gland (RR, 2.8; 95% CI, 2.4-3.3), and thyroid (RR, 2.1; 95% CI, 1.9-2.4) tumors on subsite analysis. A prior hematologic malignant tumor was also negatively associated with 2-year and 5-year OS for multiple subsites.

Conclusions and Relevance

A prior diagnosis of hematologic or associated malignant tumors was associated with an increased risk of solid head and neck cancers in a range of subsites. In addition, for several head and neck cancer subsites, patients with prior hematologic malignant tumors had worse 2-year and 5-year OS. These results indicate that a prior hematologic malignant tumor may be an adverse risk factor in the development and progression of head and neck cancer.

An Unusual Coexistence of Chronic Lymphocytic Leukemia/Small Lymphocytic Lymphoma with Endometrioid-Type Endometrial Cancer in a 58-Year-Old Woman: A Case Study with Literature Review

Introduction

The coexistence of chronic lymphocytic leukemia/small lymphocytic lymphoma (CLL/SLL) with different gynecologic neoplasms is a rare phenomenon. Here, we report a case of simultaneously developed CLL/SLL with endometrioid-type uterine cancer.

Case Report

A 58-year-old woman was admitted to the 2nd Department of Gynecology, Lublin Medical University, Lublin, Poland, in June 2017, where the uterine cancer was diagnosed. After the surgery, pathological examination revealed a uterine moderately differentiated adenocarcinoma of endometrioid subtype (subtype I according to Bokhman) deeply infiltrating the myometrium as well as the uterine cervix. Surprisingly, CLL/SLL was subsequently diagnosed in all removed pelvic as well as para-aortic lymph nodes. Immunohistochemical analysis showed CD45 (++), CD20 (+), CD3 (–/+), CD19 (+), CD23 (+), CD5 (+), and CD34 (+). Proliferative activity, assessed by MIB-1 proliferative index immunostaining, reached 18%. The patient was admitted to radiotherapy and chemotherapy at the Oncology Hospital, Lublin, Poland, and is still on follow-up.

Conclusions

The coexistence of CLL/SLL with various gynecological malignancies, especially primary human endometrial cancer, is a rare entity. The detection of both tumors simultaneously, in general, is accidental, and the management should not be different from the situation in which malignancy appears de novo.

Two rare diagnoses during chronic lymphocytic leukaemia follow-up: Kaposi's sarcoma and Merkel cell carcinoma

Chronic lymphocytic leukaemia often has a clinical presentation characterised by increased neoplastic lymphocytes which are mostly mature looking due to B lymphocytes. Increased secondary cancer prevalence has been detected among patients with chronic lymphocytic leukaemia diagnosis. In this report, we present three chronic lymphocytic leukaemia patients who developed secondary rare cancers during their follow-up at our clinic. Case 1: A 54-year-old female patient was diagnosed with stage I chronic lymphocytic leukaemia in 2003 and was diagnosed with Merkel cell carcinoma in February 2013. Case 2: A 66-year-old male patient was diagnosed with stage II chronic lymphocytic leukaemia in 2009 and was diagnosed with Kaposi's sarcoma in March 2013. Case 3: A 77-year-old male patient was diagnosed with stage I chronic lymphocytic leukaemia in 2006 and was diagnosed with Kaposi's sarcoma in 2011. In conclusion, secondary cancers are observed in patients diagnosed with chronic lymphocytic leukaemia. Therefore, follow-up of chronic lymphocytic leukaemia requires additional attention in this context.

Outcomes for patients with chronic lymphocytic leukemia and acute leukemia or myelodysplastic syndrome

Acute leukemia (AL) and myelodysplastic syndrome (MDS) are uncommon in chronic lymphocytic leukemia (CLL). We retrospectively identified 95 patients with CLL, also diagnosed with AL (n=38) or MDS (n=57), either concurrently (n=5) or subsequent (n=90) to CLL diagnosis and report their outcomes. Median number of CLL treatments prior to AL and MDS was 2 (0-9) and 1 (0-8), respectively; the most common regimen was purine analog combined with alkylating agent±CD20 monoclonal antibody. Twelve cases had no prior CLL treatment. Among 38 cases with AL, 33 had acute myelogenous leukemia (AML), 3 had acute lymphoid leukemia (ALL; 1 Philadelphia chromosome positive), 1 had biphenotypic and 1 had extramedullary (bladder) AML. Unfavorable AML karyotype was noted in 26, and intermediate risk in 7 patients. There was no association between survival from AL and number of prior CLL regimens or karyotype. Expression of CD7 on blasts was associated with shorter survival. Among MDS cases, all International Prognostic Scoring System (IPSS) were represented; karyotype was unfavorable in 36, intermediate in 6 and favorable in 12 patients; 10 experienced transformation to AML. Shorter survival from MDS correlated with higher risk IPSS, poor-risk karyotype and increased number of prior CLL treatments. Overall, outcomes for patients with CLL subsequently diagnosed with AL or MDS were very poor; AL/MDS occurred without prior CLL treatment. Effective therapies for these patients are desperately needed.

Differential diagnosis problems in a patient with dysphonia and chronic lymphocytic leukemia

Dysphonia is frequently an expression of laryngitis, especially when it comes in the evolution of an immunosuppressed patient, as happens in chronic lymphoproliferation. But other causes of dysphonia should also not be forgotten, including the possibility of new malignancies, especially due to the fact that these patients have genomic instability that predisposes to appearance of a second or even a third cancer. We present the case of a patient who developed dysphonia during chronic lymphocytic leukemia evolution. Its etiology was a mediastinal compression through lymph nodes, not linked to leukemia, but produced by metastases of a bronchopulmonary cancer, appeared recently. Dysphonia condition due to vocal cord dysfunction must include diseases of the mediastinum, the neck and the brain stem. The rapid and correct diagnosis and the prompt start of an appropriate treatment are of paramount importance for clinician who manage their care and for patient survival.

Increased incidence of malignant melanoma and other rare cutaneous cancers in the setting of chronic lymphocytic leukemia

BACKGROUND

Patients with chronic lymphocytic leukemia (CLL), small lymphocytic lymphoma (SLL), or non-Hodgkin lymphoma (NHL) are at increased risk for the development of skin malignancies.

OBJECTIVES

This study was conducted to estimate the incidences of rare skin malignancies in patients with CLL/SLL or NHL.

METHODS

Patients with a diagnosis of CLL/SLL or NHL recorded in the Surveillance, Epidemiology and End Results (SEER) database during 1992-2007 were identified. Diagnoses of specific skin malignancies were identified from SEER files.

RESULTS

During 1992-2007, a total of 128,674 patients with first diagnoses of CLL/SLL or NHL were recorded in SEER; 4743 were excluded because follow-up data were unavailable. Among the remaining 123,931 patients, 28,964 had CLL/SLL and 94,967 had NHL. Standardized incidence ratios (SIRs) for invasive malignant melanoma, Merkel cell carcinoma, malignant fibrous histiocytoma, dermatofibrosarcoma protuberans, Kaposi's sarcoma, and sebaceous carcinoma were 2.3, 8.2, 3.6, 2.5, 2.9, and 1.4, respectively, in CLL/SLL patients and 1.6, 3.2, 1.5, 1.3, 17.6, and 0.8, respectively, in NHL patients. When invasive melanoma was stratified by patient age and sex, the highest SIR (17.8) was found in men aged 0-49 years with CLL (P < 0.001).

CONCLUSIONS

Patients with CLL/SLL or NHL have a higher risk for the subsequent development of rare skin cancers. Given the more aggressive nature of these malignancies in this setting, regular monitoring for the development and prompt treatment of cutaneous malignancy is prudent in patients with NHL and particularly in patients with CLL. Regular use of sun protection may decrease the morbidity associated with skin cancer in this immunosuppressed population.

Increased incidence and recurrence rates of nonmelanoma skin cancer in patients with non-Hodgkin lymphoma: a Rochester Epidemiology Project population-based study in Minnesota

BACKGROUND

Cutaneous malignancy is associated with worse outcomes in patients with chronic lymphocytic leukemia (CLL).

OBJECTIVE

We sought to identify the incidence and recurrence rate of nonmelanoma skin cancer (NMSC) in patients with non-Hodgkin lymphoma (NHL).

METHODS

NMSC incidence was calculated and Cox proportional hazards models were used to evaluate associations with risk of recurrence for patients with NHL between 1976 and 2005 who were in the Rochester Epidemiology Project research infrastructure.

RESULTS

We identified 282 patients with CLL or small lymphocytic lymphoma and 435 with non-CLL NHL. The incidence of basal cell carcinoma and squamous cell carcinoma was 1829.3 (95% confidence interval [CI] 1306.7-2491.1) and 2224.9 (95% CI 1645.9-2941.6), respectively, in patients with CLL. The cumulative recurrence rate at 8 years after treatment with Mohs micrographic surgery was 8.3% (95% CI 0.0%-22.7%) for basal cell carcinoma and 13.4% (95% CI 0.0%-25.5%) for squamous cell carcinoma in patients with CLL.

LIMITATIONS

This was a retrospective cohort study.

CONCLUSIONS

After Mohs micrographic surgery and standard excision of NMSC, patients with NHL had a skin cancer recurrence rate that was higher than expected. Careful treatment and monitoring of patients with NHL and NMSC are warranted.

Second Malignancies and Richter's Syndrome in Patients with Chronic Lymphocytic Leukemia

Second malignancies are frequent complications in patients with chronic lymphocytic leukemia (CLL). Patients with this leukemia may develop large cell lymphoma (LCL) known as Richter's syndrome (RS). RS occurs in CLL patients of about 3% and may develop in a single lymph node or more often in a group of nodes. However, in some patients extranodal localization of aggressive lymphoma in RS has been observed. Besides LCL, Hodgkin's disease, prolymphocytoid leukemia, multiple myeloma and acute lymphoblastic leukemia may also occur as RS variants. The origin of lymphoid cells in RS remains tentative. However, CLL and RS originate from the same clone for some patients, whereas, in other patients cells of aggressive lymphoma do not have the features of the same clone as the CLL cells. The prognosis of RS is poor. Survival in different studies will be usually 2-5 months. The secondary development or coexistence of myeloproliferative disorders or myelodysplastic syndrome and solid tumors have also been rarely documented in CLL patients. It is of great concern that therapy may further increase the risk of a second neoplasm. However, until now, there are no clear evidence that alkylating agents or purine nucleoside analogs may be associated with an increased incidence of second malignancies in patients with CLL. In this review, epidemiology, biology, clinical characteristic and treatment approaches in RS and other secondary neoplasms in patients with CLL are discussed.

Overall and Cancer-Specific Survival of Patients With Breast, Colon, Kidney, and Lung Cancers With and Without Chronic Lymphocytic Leukemia: A SEER Population-Based Study

Purpose

Chronic lymphocytic leukemia (CLL) is associated with an increased risk of developing second cancers. However, it is unknown whether CLL alters the disease course of these cancers once they occur.

Patients and Methods

All patients with cancers of the breast (n = 579,164), colorectum (n = 412,366), prostate (n = 631,616), lung (n = 489,053), kidney (n = 95,795), pancreas (n = 82,116), and ovary (n = 61,937) reported to the SEER program from 1990 to 2007 were identified. Overall survival (OS; death resulting from any cause) and cancer-specific survival were examined, comparing patients with and without pre-existing CLL. Cancer-specific survival was evaluated for each tumor type in a site-specific manner (eg, death resulting from breast cancer in a patient with breast cancer).

Results

Patients with cancers of the breast (hazard ratio [HR], 1.70; P < .001), colorectum (HR, 1.65; P < .001), kidney (HR, 1.54; P < .001), prostate (HR, 1.92; P < .001), or lung (HR, 1.19; P < .001) had inferior OS if they had a pre-existing diagnosis of CLL after adjusting for age, sex, race, and disease stage. These results for OS remained significant for patients with cancers of the breast, colorectum, and prostate after excluding or censoring CLL-related deaths. Cancer-specific survival was also inferior for patients with cancers of the breast (HR, 1.41; P = .005) and colorectum (HR, 1.46; P < .001) who had pre-existing CLL after adjusting for age, sex, race, and disease stage.

Conclusion

Inferior OS and cancer-specific survival was observed for several common cancers in patients with pre-existing CLL. Additional studies are needed to determine the optimal management of these malignancies in patients with CLL and whether more aggressive screening or alternative approaches to adjuvant therapy are needed.

Spontaneous regression of chronic lymphocytic leukemia to a monoclonal B-lymphocytosis or to a normal phenotype

Spontaneous remission of chronic lymphocytic leukemia (CLL) is an unusual and poorly characterized event. We performed a search for spontaneous remission in patients with CLL. Cases must have had a pathological diagnosis of CLL with disease duration > 6 months. Spontaneous remission was defined as absence of lymphadenopathy or splenomegaly with lymphocyte counts < 5 × 10(9)/L for > 9 months without therapy. We identified 20 cases and included one additional case from our institution. Fourteen cases (67%) showed remission into monoclonal B lymphocytosis (MBL) and seven (33%) into a normal phenotype. There was no difference in age distribution, lymphocyte count or stage between groups. There was a significant difference in the median duration of CLL prior to remission, 13 years in the MBL versus 3 years in the normal phenotype group (p = 0.03). This difference in the duration of CLL prior to remission could be due to a possible distinct pathophysiology for these events.

The impact of initial fludarabine therapy on transformation to Richter syndrome or prolymphocytic leukemia in patients with chronic lymphocytic leukemia: analysis of an intergroup trial (CALGB 9011)

The impact of initial fludarabine therapy on transformation to Richter syndrome (RS) or prolymphocytic leukemia (PLL) in patients with chronic lymphocytic leukemia (CLL) is uncertain. We studied the outcomes of 521 patients with CLL who were randomized to initial fludarabine (F), chlorambucil (C) or F + C therapy on an intergroup trial (CALGB 9011). RS developed in 34 (7%) patients and PLL in 10 (2%). RS and PLL occurred in 14 (7%) and three (2%) of 188 patients randomized to F; nine (5%) and four (2%) of 191 patients treated with C; and 11 (8%) and three (2%) of 142 receiving F + C, respectively. Four percent of the 206 patients with Rai stage III/IV developed PLL, compared to only 1% of the 315 patients with Rai stage I/II (p = 0.02). Initial fludarabine therapy in patients with CLL did not impact transformation to RS or PLL, nor were any other baseline characteristics predictive for such transformation in this series.

Spectrum of neurologic complications in chronic lymphocytic leukemia

Neurologic disease is believed to be an unusual complication during the course of chronic lymphocytic leukemia. Nevertheless, it has already been proven in autopsy series that the incidence of occult nervous system infiltration is much higher than was previously expected. The advent of more potent drugs to treat this lymphoproliferative disorder has brought a new hope for a possible cure in the future. However, an appropriate systemic treatment for central nervous system infiltration of this disease is still lacking. Also, due to the potent immunosuppressive properties of the agents used in the up-front treatment, for example, the purine nucleoside analogues, we have witnessed an increase in the incidence of opportunistic infections, with progressive multifocal leukoencephalopathy being one of the most serious. The goal of this review is to summarize the spectrum of neurologic derangements linked to chronic lymphocytic leukemia and to raise clinicians' awareness to recognize the possibility of such associations.

Second cancer incidence and cancer mortality among chronic lymphocytic leukaemia patients: a population-based study

Background:

Patients with chronic lymphocytic leukaemia (CLL) are known to have increased risks of second cancer. The incidence of second cancers after CLL has not been reported in detail for Australia, a country with particularly high levels of ultraviolet radiation (UVR).

Methods:

The study cohort comprised of all people diagnosed with a primary CLL between 1983 and 2005 in Australia. Standardised incidence ratios (SIRs) and standardised mortality ratios (SMRs) were calculated using Australian population rates.

Results:

Overall, the risk of any second incident cancer was more than double that of the general population (SIR=2.17, 95% confidence interval (CI)=2.07, 2.27) and remained elevated for at least 9 years after CLL. Risks were increased for many cancers, particularly melanoma (SIR=7.74, 95% CI=6.85, 8.72). The risk of melanoma increased at younger ages, but was constant across >9 years of follow-up. Chronic lymphocytic leukaemia patients also had an increased risk of death because of melanoma (SMR=4.79, 95% CI=3.83, 5.90) and non-melanoma skin cancer (NMSC; SMR=17.0, 95% CI=14.4, 19.8), suggesting that these skin cancers may be more aggressive in CLL patients.

Conclusion:

We speculate that a shared risk factor, such as general immune suppression, modulated by UVR exposure may explain the increased risk of melanoma and NMSC in CLL patients.

Increased metastasis of malignant fibrous histiocytoma in patients with chronic lymphocytic leukemia and non-hodgkin lymphoma

OBJECTIVE

To further understand the characteristics and behavior of malignant fibrous histiocytoma (MFH) in the clinical setting of chronic lymphocytic leukemia (CLL) or non-Hodgkin lymphoma (NHL).

PATIENTS AND METHODS

The patient database of MHF diagnosed at our institution from January 1, 1976, to December 31, 2008, was reviewed. For each MFH case with prior NHL or CLL, 3 matched controls from the same cohort without prior CLL or NHL were randomly selected. A retrospective chart review collected patient data, including sex; age; pathologic confirmation of MFH; tumor grade, size, and location; time since MFH diagnosis; history of chemotherapy or irradiation; treatment of MFH; recurrence; metastasis; and death. The Kaplan-Meier method was used to estimate overall survival, survival free of recurrence, and survival free of metastasis. Cox proportional hazards models were fit to evaluate associations between case status and outcomes.

RESULTS

Fifteen MFH cases with prior NHL or CLL were identified. Cases had frequent bone (n=7 [47%]) and cutaneous (n=5 [33%]) involvement. Five cases (33%) had previous irradiation, 6 (40%) had metastases, and 4 (27%) had recurrence. Overall survival and survival free of recurrence were not significantly different between the cases and controls (5-year overall survival, 49.9% and 58.7%; 12-month survival free of recurrence, 79.4% and 90.3%). However, cases were significantly more likely than controls to have metastasis (hazard ratio, 3.79; 95% confidence interval, 1.22-11.79; P=.02). In addition, survival free of metastasis at 12 months was 65.2% and 90.7%, respectively.

CONCLUSION

In the presence of CLL or NHL, MFH seems to behave more aggressively, suggested by the increased likelihood of metastases compared with controls without prior CLL or NHL. However, overall survival does not appear to be worse in cases of MFH and CLL or NHL than in MFH alone.

Therapy-Related Myeloid Neoplasms in Chronic Lymphocytic Leukemia and Waldenstrom's Macroglobulinemia

Secondary myelodysplasia (MDS) and acute myeloid leukemia (AML) are frequent long term complications in Chronic Lymphocytic Leukemia (CLL) and Waldenström Macroglobulinemia (WM) patients. Although disease-related immune-suppression plays a crucial role in leukemogenesis there is great concern that therapy may further increase the risk of developing these devastating complications.Nucleoside analogs (NA) and alkylating agents are considered appropriate agents in the treatment of both CLL and WM patients. Prolonged immunosuppression related to NA therapy and the incorporation of these agents or their metabolites into DNA, with potentially mutagenic action, leads to speculation that their therapeutic use might be responsible for an increased incidence of second cancer especially when combined with other DNA damaging agents like alkylating agents.In this review the published studies considering the occurrence of secondary MDS and AML in CLL and WM patients are reported and the potential role of chemotherapeutic agents in leukemogenesis is discussed.

Second neoplasms in chronic lymphocytic leukemia: incidence and pathogenesis with emphasis on the role of different therapies

Several surveys have defined chronic lymphocytic leukemia (CLL) patients as a high-risk patient population for developing second neoplasms. As possible mechanisms underlying the increased risk of specific second malignancies in CLL patients the immunodeficiency associated with disease is generally proposed. As far as secondary acute leukemia is concerned, greater insight into the molecular pathogenesis of therapy-related acute myeloid leukemia (AML) developing in CLL would allow to avoid treatment regimens that can lead to this complication. Richter's syndrome continues to be a fatal and highly refractory to chemotherapy disease complicating the clinical course of CLL. Therefore, experimental approaches of therapy should be considered in its treatment. Given the prolonged survival of patients with CLL, it is important to recognize early a second cancer especially whether new symptoms or physical findings arise.

Spontaneous regression of chronic lymphocytic leukemia: clinical and biologic features of 9 cases

In chronic lymphocytic leukemia (CLL), spontaneous regressions are an exceptional phenomenon, whose biologic features are unknown. We describe 9 CLL patients who underwent a spontaneous clinical regression over an 11-year follow-up, despite a residual neoplastic clone detected by flow cytometry. CD38 and ZAP-70 were negative in all cases. Immunoglobulin heavy chain variable region (IgVH) genes, mutated in all 7 evaluable patients, were restricted to the VH3 family in 6, with the usage of V(H)3-30 gene in 2. The light chain variable region genes were mutated in 6 of 8 cases, with the use of V(kappa)4-1 gene in 3. Microarray analysis of CLL cells showed a distinctive genomic profile with an overrepresentation of BCR-related and ribosomal genes, regulators of signal transduction and transcription. The number of activated T lymphocytes expressing IFN-gamma, TNF-alpha, and IL-4 was similar between CLL in spontaneous regression and healthy persons. In conclusion, spontaneous clinical regressions can occur in CLL despite the persistence of the neoplastic clone, and the biologic features include negative CD38 and ZAP-70, mutated V(H)3-30 and V(kappa)4-1 genes. The peculiar gene profile suggests that BCR signaling may play an important role in this scenario as the most significant feature of the leukemic clone in regression.

Genetic counseling for DAPK1 mutation in a chronic lymphocytic leukemia family

Genetic counseling has become the clinical bedrock of hereditary cancer management. Countless advances in molecular genetics contributing to the identification of cancer-causing germline mutations have increased its importance. We report a unique genetic counseling experience involving a family with hereditary chronic lymphocytic leukemia and the cancer-causing mutation in the death-associated protein kinase 1 gene (DAPK1). This hereditary disorder currently lacks any preventive or curative interventions for mutation carriers. This family has been under our investigation for a decade, during which time genealogy, cancer of all anatomic sites, medical and pathology records, and, whenever possible, slides and tissue blocks were reviewed. Family attendance at three group-oriented family information service sessions provided intensive education about this disease. Blood and skin fibroblasts were obtained for molecular genetic studies of DNA leading to the discovery of the DAPK1 mutation in the family. Their intellectual and emotional reaction to its presence or absence in them was assessed. This family serves as a model for genetic counseling in disorders for which lifesaving intervention is not yet possible.

ALK-Positive Anaplastic Large Cell Lymphoma in a Patient With Chronic Lymphocytic Leukemia

This article reports the case of a 59-year-old patient with an 8-year history of chronic lymphocytic leukemia (CLL), prostate carcinoma, and squamous cell carcinoma who developed an ALK-positive anaplastic large cell lymphoma (ALCL). Lymph node and bone marrow biopsies showed 2 distinct morphologic populations: ( a) the CLL component showing a diffuse monomorphous infiltrate of small lymphocytes with the typical immunophenotype showing positive CD20, CD5, CD23, and κ light chain restriction and ( b) the ALCL component showing large anaplastic pleomorphic cells positive for CD30, CD45, ALK, CD45Ro, CD4, and vimentin. Polymerase chain reaction performed on the lymph node for immunoglobulin heavy chain and T-cell receptor γ and β showed gene rearrangements after macrodissection of morphologically distinct populations, indicating confirmed genetically distinct populations. Despite intensive chemotherapy, the patient died. This case represents the rare occurrence of an ALK-positive ALCL developing in a patient with CLL.

Risk factors for development of a second lymphoid malignancy in patients with chronic lymphocytic leukaemia

Previous studies suggested that patients with chronic lymphocytic leukaemia (CLL) are at a three- to fivefold increased risk of developing a second lymphoproliferative disorder (LPD). This observational cohort study used the Mayo Clinic CLL Database to identify factors associated with developing a second LPD. A second LPD was identified in 26 (2.7%) of 962 CLL patients during a median follow-up of 3.3 years. Diffuse large B-cell lymphoma was the most common subtype of secondary LPD (12 of 26 cases). Patients previously treated for CLL had a trend toward higher prevalence of second LPD (4%) compared with previously untreated patients (2%; P = 0.053). More strikingly, patients treated with purine nucleoside analogues (PNA) had a significantly increased risk of subsequent second LPD (5.2%) compared with patients who had not received PNA (1.9%; P = 0.008). No statistically significant association was observed between risk of second LPD and other CLL characteristics (ZAP-70, CD38, IgV(H) mutation status or cytogenetic abnormalities). In this series, prior treatments with PNA or anthracyclines were the only significant factors associated with risk of developing a second LPD in patients with CLL. Physicians should strictly adhere to established criteria to initiate treatment for CLL patients who are not participating in clinical trials.

Concomitant presentation of acute myeloid leukemia with T-cell large granular lymphocytic leukemia

T-cell large granular lymphocyte leukemia (T-LGL) also known as T-cell chronic lymphocytic leukemia is rare and comprises a small minority of all small lymphocytic leukemias. The concomitant presentation of T-LGL with acute myeloid leukemia (AML) has not been previously reported. We present an elderly gentleman with concomitant T-LGL and AML (non-M3) diagnosed by a combination of morphologic evaluation, immunophenotyping by flow cytometry, and T-cell gene rearrangement studies. The patient was managed with combination AML chemotherapy. He remains alive and well seven months after initial diagnosis. A brief review of literature is also presented.

Emerging dermatologic issues in the oncology patient

The spectrum of skin diseases that occurs in the oncology patient differs somewhat from that seen in other immunosuppressed populations. We review the cutaneous manifestations of invasive mold infections in the leukemia/lymphoma population. Aspergillus mold infections are now the leading infectious cause of death in this population. We also review the pustular eruption caused by a new class of chemotherapy for solid malignancies. An update on cutaneous graft-versus-host disease appears elsewhere in this journal. Cutaneous squamous cell carcinomas and basal cell carcinomas occur more frequently in the chronic lymphocytic leukemia and non-Hodgkin's lymphoma population; this is discussed, as is the more aggressive clinical course of these tumors.

Risk of second cancer after chronic lymphocytic leukemia

Smoking is not considered a risk factor for chronic lymphocytic leukemia (CLL) yet increased lung cancer risk has been reported for these patients. Little data exist on the temporal variation in lung cancer risk after CLL, or its histological composition. We investigated the occurrence of second cancers in a large cohort of CLL patients with particular emphasis on lung cancer and its major subtypes. We followed all patients diagnosed with CLL in Denmark in the period 1943-2003 (n = 12,373) for the occurrence of second cancers. The relative risk was expressed as the standardized incidence ratio (SIR), i.e. the ratio of observed to expected number of cancers, based on incidence rates for the Danish population. During follow-up 1,105 cancers occurred among the CLL patients (SIR = 1.59 (95% CI 1.50-1.69)). SIR for all cancers combined remained elevated more than 10 years after CLL (SIR = 1.80 (1.56-2.08)). Lung cancer occurred in 141 patients (SIR = 1.61 (1.37-1.90)). The relative risk of lung cancer did not vary by gender, or time of follow-up, but was higher in younger (SIR(<60 years) = 2.22 (1.62-3.06)) than in older (SIR(70-79 years) = 1.21 (0.88-1.68)) age-groups. Elevated risks were observed for adenocarcinoma (SIR = 2.20 (1.57-3.08)) and squamous cell carcinoma (SIR = 1.52 (1.06-2.17)) of the lung. We speculate that shared genetic risk factors may explain the accumulation of lung and other cancers in CLL patients.

HIV and skin cancer

AIDS produces profound alterations in normal immunity. Impaired cellular immunity permits new tumor formation as evidenced by the solid-organ transplant literature. The weakened cellular immune system of HIV-infected patients resembles in some ways the iatrogenic immunosuppression in solid-organ transplant recipients. This article summarizes what is known about skin cancer in the solid-organ transplant population and compares the immunodysregulation of HIV infection with the iatrogenic immunosuppression following solid-organ transplantation.

Non-Hodgkin lymphoma and skin cancer: A dangerous combination

There is a significant association between non-Hodgkin lymphoma, including chronic lymphocytic leukaemia, and both melanoma and non-melanoma skin cancer. This review highlights the existing data on the phenomenon of accelerated skin cancer in patients with non-Hodgkin lymphoma and specifically chronic lymphocytic leukaemia. The outcomes of patients with non-Hodgkin lymphoma (including chronic lymphocytic leukaemia) and non-melanoma skin cancer are worse than in patients without concomitant lymphoreticular malignancy, as shown by increased rates of local recurrence, regional metastasis and death. Pathogenic factors may be common between non-Hodgkin lymphoma and chronic lymphocytic leukaemia and skin cancer. The treatment of skin cancer in patients with non-Hodgkin lymphoma must factor in the worse prognosis and adapt standard therapeutic approaches to minimize the risk of metastasis and death. Preventive strategies and early detection are paramount in this high-risk population.