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Barcellini W, Giannotta JA, Fattizzo B. Autoimmune Complications in Hematologic Neoplasms. Cancers (Basel) 2021; 13:cancers13071532. [PMID: 33810369 PMCID: PMC8037071 DOI: 10.3390/cancers13071532] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2021] [Revised: 03/22/2021] [Accepted: 03/24/2021] [Indexed: 12/14/2022] Open
Abstract
Autoimmune cytopenias (AICy) and autoimmune diseases (AID) can complicate both lymphoid and myeloid neoplasms, and often represent a diagnostic and therapeutic challenge. While autoimmune hemolytic anemia (AIHA) and immune thrombocytopenia (ITP) are well known, other rarer AICy (autoimmune neutropenia, aplastic anemia, and pure red cell aplasia) and AID (systemic lupus erythematosus, rheumatoid arthritis, vasculitis, thyroiditis, and others) are poorly recognized. This review analyses the available literature of the last 30 years regarding the occurrence of AICy/AID in different onco-hematologic conditions. The latter include chronic lymphocytic leukemia (CLL), lymphomas, multiple myeloma, myelodysplastic syndromes (MDS), chronic myelomonocytic leukemia (CMML), myeloproliferative neoplasms, and acute leukemias. On the whole, AICy are observed in up to 10% of CLL and with higher frequencies in certain subtypes of non-Hodgkin lymphoma, whilst they occur in less than 1% of low-risk MDS and CMML. AID are described in up to 30% of myeloid and lymphoid patients, including immune-mediated hemostatic disorders (acquired hemophilia, thrombotic thrombocytopenic purpura, and anti-phospholipid syndrome) that may be severe and fatal. Additionally, AICy/AID are found in about 10% of patients receiving hematopoietic stem cell transplant or treatment with new checkpoint inhibitors. Besides the diagnostic difficulties, these AICy/AID may complicate the clinical management of already immunocompromised patients.
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Affiliation(s)
- Wilma Barcellini
- Hematology Unit, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, 20122 Milan, Italy; (J.A.G.); (B.F.)
- Correspondence: ; Tel.: +39-025-503-3256
| | - Juri Alessandro Giannotta
- Hematology Unit, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, 20122 Milan, Italy; (J.A.G.); (B.F.)
| | - Bruno Fattizzo
- Hematology Unit, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, 20122 Milan, Italy; (J.A.G.); (B.F.)
- Department of Oncology and Oncohematology, University of Milan, 20122 Milan, Italy
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Krecak I, Medic MG, Gveric–Krecak V, Roncevic P, Bašić Kinda S, Babel J, Radonic R. Coombs-positive refractory acquired thrombotic thrombocytopenic purpura in a patient with chronic myelomonocytic leukemia successfully treated with rituximab. Acta Clin Belg 2020; 75:357-361. [PMID: 31007140 DOI: 10.1080/17843286.2019.1608395] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
OBJECTIVES Acquired thrombotic thrombocytopenic purpura (aTTP) is a rare autoimmune disorder characterized by auto-antibodies to Willebrand factor (vWF) cleaving enzyme (ADAMTS13), resulting in unusually large vWF multimers that lead to platelet aggregation, microthrombi formation and microangiopathic hemolytic anemia. Hemolysis in aTTP is mechanical; thus, direct antiglobulin test (Coombs test) is usually negative. Multiple autoimmune conditions and various auto-antibodies have been described in the context of chronic myelomonocytic leukemia (CMML). In this paper, we describe the first case of CMML with auto-antibodies to ADAMTS13, presenting initially as plasmapheresis-refractory Coombs-positive aTTP. Results: Although our patient was not treated for CMML, a complete remission of aTTP was eventually achieved with rituximab. Conclusion; We propose that aTTP should be in the differential diagnosis of CMML patients with thrombocytopenia and anemia (Coombs positive or not) who develop signs of thrombotic microangiopathy. Further studies are much needed to decipher the immune-mediated processes in CMML.
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Affiliation(s)
- Ivan Krecak
- Department of Internal Medicine, General Hospital of Sibenik - Knin County, Sibenik, Croatia
| | - Marijana Grgic Medic
- Intensive Care Unit, Department of Internal Medicine, University Hospital Centre Zagreb, Zagreb, Croatia
| | - Velka Gveric–Krecak
- Department of Internal Medicine, General Hospital of Sibenik - Knin County, Sibenik, Croatia
| | - Pavle Roncevic
- Division of Hematology, Department of Internal Medicine, University Hospital Centre Zagreb, Zagreb, Croatia
| | - Sandra Bašić Kinda
- Division of Hematology, Department of Internal Medicine, University Hospital Centre Zagreb, Zagreb, Croatia
| | - Jaksa Babel
- Intensive Care Unit, Department of Internal Medicine, University Hospital Centre Zagreb, Zagreb, Croatia
| | - Radovan Radonic
- Intensive Care Unit, Department of Internal Medicine, University Hospital Centre Zagreb, Zagreb, Croatia
- School of Medicine, University of Zagreb, Zagreb, Croatia
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Valent P. Oligo-monocytic CMML and other pre-CMML states: Clinical impact, prognostication and management. Best Pract Res Clin Haematol 2019; 33:101137. [PMID: 32460976 DOI: 10.1016/j.beha.2019.101137] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2019] [Revised: 12/11/2019] [Accepted: 12/13/2019] [Indexed: 11/18/2022]
Abstract
Chronic myelomonocytic leukemia (CMML) is defined by myelodysplasia, pathologic accumulation of monocytes and a substantial risk to transform to secondary acute myeloid leukemia (sAML). In recent years, minimal diagnostic criteria for classical CMML and CMML-variants were proposed. Moreover, potential pre-stages of CMML and interface conditions have been postulated. Oligomonocytic CMML is a condition where the absolute peripheral blood monocyte count does not reach a diagnostic level but all other criteria for CMML are fulfilled. Among potential pre-stages of CMML, clonal and non-clonal conditions have been described, including idiopathic monocytosis (IMUS) and clonal monocytosis of unknown significance (CMUS). Patients with myelodysplastic syndromes (MDS), clonal cytopenia of unknown significance (CCUS), clonal hematopoiesis of indeterminate potential (CHIP) and idiopathic cytopenia of undetermined significance (ICUS) may also progress to CMML. The current article provides an overview of pre-CMML conditions and oligomonocytic CMML, with special reference to diagnostic criteria, differential diagnoses, clinical outcomes and management.
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Affiliation(s)
- Peter Valent
- Department of Internal Medicine I, Division of Hematology & Hemostaseology, Medical University of Vienna, Vienna, Austria; Ludwig Boltzmann Institute for Hematology & Oncology, Vienna, Austria.
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Valent P, Orazi A, Savona MR, Patnaik MM, Onida F, van de Loosdrecht AA, Haase D, Haferlach T, Elena C, Pleyer L, Kern W, Pemovska T, Vladimer GI, Schanz J, Keller A, Lübbert M, Lion T, Sotlar K, Reiter A, De Witte T, Pfeilstöcker M, Geissler K, Padron E, Deininger M, Orfao A, Horny HP, Greenberg PL, Arber DA, Malcovati L, Bennett JM. Proposed diagnostic criteria for classical chronic myelomonocytic leukemia (CMML), CMML variants and pre-CMML conditions. Haematologica 2019; 104:1935-1949. [PMID: 31048353 PMCID: PMC6886439 DOI: 10.3324/haematol.2019.222059] [Citation(s) in RCA: 88] [Impact Index Per Article: 17.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2019] [Accepted: 04/29/2019] [Indexed: 12/15/2022] Open
Abstract
Chronic myelomonocytic leukemia (CMML) is a myeloid neoplasm characterized by dysplasia, abnormal production and accumulation of monocytic cells and an elevated risk of transforming into acute leukemia. Over the past two decades, our knowledge about the pathogenesis and molecular mechanisms in CMML has increased substantially. In parallel, better diagnostic criteria and therapeutic strategies have been developed. However, many questions remain regarding prognostication and optimal therapy. In addition, there is a need to define potential pre-phases of CMML and special CMML variants, and to separate these entities from each other and from conditions mimicking CMML. To address these unmet needs, an international consensus group met in a Working Conference in August 2018 and discussed open questions and issues around CMML, its variants, and pre-CMML conditions. The outcomes of this meeting are summarized herein and include diag nostic criteria and a proposed classification of pre-CMML conditions as well as refined minimal diagnostic criteria for classical CMML and special CMML variants, including oligomonocytic CMML and CMML associated with systemic mastocytosis. Moreover, we propose diagnostic standards and tools to distinguish between 'normal', pre-CMML and CMML entities. These criteria and standards should facilitate diagnostic and prognostic evaluations in daily practice and clinical studies in applied hematology.
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Affiliation(s)
- Peter Valent
- Department of Internal Medicine I, Division of Hematology & Hemostaseology, Medical University of Vienna, Vienna, Austria .,Ludwig Boltzmann Institute for Hematology & Oncology, Vienna, Austria
| | - Attilio Orazi
- Department of Pathology, Texas Tech University Health Sciences Center, El Paso, TX, USA
| | - Michael R Savona
- Department of Medicine, Vanderbilt University School of Medicine, Vanderbilt-Ingram Cancer Center, Nashville, TN, USA
| | - Mrinal M Patnaik
- Division of Hematology, Department of Medicine, Mayo Clinic, Rochester, MN, USA
| | - Francesco Onida
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, University of Milan, Milan, Italy
| | - Arjan A van de Loosdrecht
- Department of Hematology, Amsterdam UMC, location VU University Medical Center, Cancer Center Amsterdam, the Netherlands
| | - Detlef Haase
- Clinic of Hematology and Medical Oncology, University Medical Center Göttingen, Göttingen, Germany
| | | | - Chiara Elena
- Department of Molecular Medicine, University of Pavia, Pavia, Italy
| | - Lisa Pleyer
- 3 Medical Department with Hematology and Medical Oncology, Hemostaseology, Rheumatology and Infectious Diseases, Paracelsus Medical University, Salzburg, Austria
| | | | - Tea Pemovska
- CeMM Research Center for Molecular Medicine of the Austrian Academy of Sciences, Vienna, Austria
| | - Gregory I Vladimer
- CeMM Research Center for Molecular Medicine of the Austrian Academy of Sciences, Vienna, Austria
| | - Julie Schanz
- Clinic of Hematology and Medical Oncology, University Medical Center Göttingen, Göttingen, Germany
| | - Alexandra Keller
- Department of Internal Medicine I, Division of Hematology & Hemostaseology, Medical University of Vienna, Vienna, Austria
| | - Michael Lübbert
- Department of Medicine I, Medical Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Thomas Lion
- Children's Cancer Research Institute and Department of Pediatrics, Medical University of Vienna, Vienna, Austria
| | - Karl Sotlar
- Institute of Pathology, Paracelsus Medical University, Salzburg, Austria
| | - Andreas Reiter
- Department of Hematology and Oncology, University Hospital Mannheim, University of Heidelberg, Mannheim, Germany
| | - Theo De Witte
- Department of Tumor Immunology-Nijmegen Center for Molecular Life Sciences, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Michael Pfeilstöcker
- Ludwig Boltzmann Institute for Hematology & Oncology, Vienna, Austria.,3 Medical Department, Hanusch Hospital, Vienna, Vienna, Austria
| | | | - Eric Padron
- Malignant Hematology Department, H. Lee Moffitt Cancer Center & Research Institute, Tampa, FL, USA
| | - Michael Deininger
- Huntsman Cancer Institute & Division of Hematology and Hematologic Malignancies, University of Utah, Salt Lake City, UT, USA
| | - Alberto Orfao
- Servicio Central de Citometría, Centro de Investigación del Cáncer (IBMCC, CSIC-USAL), CIBERONC and IBSAL, Universidad de Salamanca, Salamanca, Spain
| | - Hans-Peter Horny
- Institute of Pathology, Ludwig-Maximilians University, Munich, Germany
| | | | - Daniel A Arber
- Department of Pathology, University of Chicago, Chicago, IL, USA
| | - Luca Malcovati
- Department of Molecular Medicine, University of Pavia, Pavia, Italy
| | - John M Bennett
- Department of Pathology, Hematopathology Unit and James P Wilmot Cancer Institute, University of Rochester Medical Center, Rochester, NY, USA
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