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Coombes C, Horikawa K, Jain S, Jiang S, Lim JH, Saxena K, Shadbolt B, Smyth L, Tobin J, Talaulikar D. Diffuse large B-cell lymphoma and red cell autoimmunity: clinical role and pathogenesis. Pathology 2023; 55:104-112. [PMID: 36420560 DOI: 10.1016/j.pathol.2022.07.017] [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: 05/04/2022] [Revised: 07/17/2022] [Accepted: 07/28/2022] [Indexed: 01/09/2023]
Abstract
Diffuse large B-cell lymphoma (DLBCL) is the most common form of B-cell non-Hodgkin lymphoma (B-NHL) with significant morbidity and mortality despite advancements in treatment. Lymphoma and autoimmune disease both result from breakdowns in normal cell regulatory pathways, and epidemiological studies have confirmed both that B-NHL is more likely to develop in the setting of autoimmune diseases and vice versa. Red cell immunity, as evidenced by direct antiglobulin test (DAT) positivity, has been linked to DLBCL and more recently the pathogenic causes of this association have begun to be better understood using molecular techniques. This project aimed to explore the relationship between red cell autoimmunity and DLBCL. DAT positivity was more common in DLBCL as compared to healthy controls (20.4% vs 3.7%, p=0.0005). Univariate analysis found a non-significant trend towards poorer overall survival in the DAT positive (DAT+) compared to the DAT negative (DAT-) groups (p=0.087). High throughput sequencing was used to compare mutations in DLBCL from DAT+ and DAT- patients. The most frequently mutated genes in 15 patient samples were KMT2D (n=13), MYOM2 (n=9), EP300 (n=8), SPEN (n=7), and ADAMTSL3 (n=7), which were mutated in both DAT+ and DAT- groups. BIRC3 (n=3), FOXO1 (n=3) and CARD11 (n=2) were found to be mutated only in samples from the DAT+ group. These gene mutations may be involved in disease development and progression, and potentially represent targets for future therapy. The immunoglobulin genotype IGHV4-34 is seen more frequently in DLBCL clones than in normal B cells and has intrinsic autoreactivity to self-antigens on red cells, which is largely mediated by two motifs within the first framework region (FR1); Q6W7 and A24V25Y.26 These motifs form a hydrophobic patch which determines red cell antigen binding and are frequently mutated away from self-reactivity in normal B cells. If this does not occur this may provide constant B cell receptor signalling which encourages lymphoma development, a theory known as antigen driven lymphomagenesis. As with previous studies, IGHV4-34 was over-represented (15.6%) in our DLBCL cohort. Furthermore, of 6 IGHV4-34-expressing DLBCL samples five had unmutated hydrophobic patch mutations providing further evidence for antigen-driven lymphomagenesis. Mutation analysis of these five samples demonstrated high frequency of mutations in several genes, including CREBBP and NCOR2. Further research could explore if mutations in CREBBP and NCOR2 work in conjunction with the preserved QW and AVY motifs to promote lymphomagenesis in IGHV4-34-expressing B cells, and if so, could guide future targeted therapy.
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Affiliation(s)
- Caitlin Coombes
- School of Medicine and Psychology, College of Health and Medicine, Australian National University, Canberra, ACT, Australia; Haematology Translational Research Unit, Haematology Department, Canberra Health Services, Canberra, ACT, Australia
| | - Keisuke Horikawa
- Department of Cancer Biology and Therapeutics, The John Curtin School of Medical Research, Australian National University, Canberra, ACT, Australia
| | - Sanjiv Jain
- Anatomical Pathology Department, Canberra Health Services, Canberra, ACT, Australia
| | - Simon Jiang
- Department of Immunology and Infectious Disease, John Curtin School of Medical Research, Australian National University, Canberra, ACT, Australia; Renal Medicine Department, Canberra Health Services, Canberra, ACT, Australia
| | - Jun Hee Lim
- Department of Cancer Biology and Therapeutics, The John Curtin School of Medical Research, Australian National University, Canberra, ACT, Australia
| | - Kartik Saxena
- Haematology Translational Research Unit, Haematology Department, Canberra Health Services, Canberra, ACT, Australia
| | - Bruce Shadbolt
- Centre for Advances in Epidemiology and IT, Canberra Health Services, Canberra, ACT, Australia
| | - Lillian Smyth
- School of Medicine and Psychology, College of Health and Medicine, Australian National University, Canberra, ACT, Australia
| | - Joshua Tobin
- Princess Alexandra Hospital, Brisbane, Qld, Australia; Diamantina Institute, University of Queensland, Brisbane, Qld, Australia
| | - Dipti Talaulikar
- School of Medicine and Psychology, College of Health and Medicine, Australian National University, Canberra, ACT, Australia; Haematology Translational Research Unit, Haematology Department, Canberra Health Services, Canberra, ACT, Australia; Department of Cancer Biology and Therapeutics, The John Curtin School of Medical Research, Australian National University, Canberra, ACT, Australia.
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Yui JC, Brodsky RA. Updates in the Management of Warm Autoimmune Hemolytic Anemia. Hematol Oncol Clin North Am 2022; 36:325-339. [DOI: 10.1016/j.hoc.2021.11.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Impact of Immune Parameters and Immune Dysfunctions on the Prognosis of Patients with Chronic Lymphocytic Leukemia. Cancers (Basel) 2021; 13:cancers13153856. [PMID: 34359757 PMCID: PMC8345723 DOI: 10.3390/cancers13153856] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2021] [Revised: 07/26/2021] [Accepted: 07/28/2021] [Indexed: 12/13/2022] Open
Abstract
Simple Summary In chronic lymphocytic leukemia (CLL), immune alterations—affecting both the innate and adaptive immunity—are very common. As a clinical consequence, patients with CLL frequently present with autoimmune phenomena, increased risk of infections and second malignancies. The aim of this review article is to present available data on CLL-associated alterations of immune parameters that correlate with known prognostic markers and with clinical outcome. Also, data on the impact of immune-related clinical manifestations on the prognosis of patients with CLL will be discussed. Abstract Chronic lymphocytic leukemia (CLL) is characterized by a wide spectrum of immune alterations, affecting both the innate and adaptive immunity. These immune dysfunctions strongly impact the immune surveillance, facilitate tumor progression and eventually affect the disease course. Quantitative and functional alterations involving conventional T cells, γδ T cells, regulatory T cells, NK and NKT cells, and myeloid cells, together with hypogammaglobulinemia, aberrations in the complement pathways and altered cytokine signature have been reported in patients with CLL. Some of these immune parameters have been shown to associate with other CLL-related characteristics with a known prognostic relevance or to correlate with disease prognosis. Also, in CLL, the complex immune response dysfunctions eventually translate in clinical manifestations, including autoimmune phenomena, increased risk of infections and second malignancies. These clinical issues are overall the most common complications that affect the course and management of CLL, and they also may impact overall disease prognosis.
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Autoimmune Cytopenia in CLL: Prognosis and Management in the Era of Targeted Therapies. ACTA ACUST UNITED AC 2021; 27:286-296. [PMID: 34398555 DOI: 10.1097/ppo.0000000000000537] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
ABSTRACT Chronic lymphocytic leukemia (CLL) is frequently associated with autoimmune hemolytic anemia and immune thrombocytopenia and, less frequently, with pure red cell aplasia and immune neutropenia. The emergence of these complications is related to an intertwined and complex relationship between patient, disease, and treatment characteristics. The prognostic repercussion of autoimmune cytopenia (AIC) in patients with CLL mainly depends on its response to therapy. For patients with AIC and nonactive CLL, treatment is as in primary, uncomplicated AIC, keeping in mind that no response is an indication for CLL therapy. The success of treating active CLL-related AIC widely relies on a flexible strategy that should include initial therapy with corticosteroids and a rapid shift to effective CLL therapy in nonresponding patients. Targeted therapies (e.g., ibrutinib) that have already demonstrated to be effective in CLL-related AIC will likely offer a unique possibility of treating both AIC and CLL as a single target.
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Ahmed SA, Abdallah GEM, Aly MM, Abdelsalam EMN, Mohammed Saleh MF. Revisiting Autoimmunity in Chronic Lymphocytic Leukemia: Prognostic Value of Positive Direct Antiglobulin Test in a Retrospective Study and Literature Review. J Blood Med 2021; 12:225-234. [PMID: 33880072 PMCID: PMC8053514 DOI: 10.2147/jbm.s296225] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2021] [Accepted: 03/16/2021] [Indexed: 12/14/2022] Open
Abstract
INTRODUCTION A positive direct antiglobulin test (DAT) with or without autoimmune hemolytic anemia is a frequent finding in chronic lymphocytic leukemia (CLL). The heterogenic clinical course of CLL mainly depends on different pathogenetic mechanisms which appears in a form of variable biological and clinical features. These features allow stratification of patients into subsets with different outcomes. PATIENTS AND METHODS We evaluated the DAT as a prognostic marker in 120 CLL patients treated with chemoimmunotherapy. Clinical and laboratory features, treatment response, and survival outcomes of CLL patients were assessed in relation to their DAT test status. Additionally, the English literature was extensively reviewed regarding the prognostic impact of a positive DAT in CLL. RESULTS DAT positivity was detected in 36 patients (30%) and was associated advanced disease staging (P = 0.03). No correlations were found with other clinical, laboratory, or biological factors such as ZAP-70 or CD38. Both a positive DAT and an Eastern Cooperative Oncology Group performance status >2 were predictors for non-response to first-line treatment in the multivariate analysis (OR = 0.3, 95% CI: 0.12-0.8 and OR = 0.2, 95% CI: 0.08-0.8, respectively). The five-year progression-free survival was significantly lower in the DAT-positive group (P = 0.004). No significant association was found with overall survival (P = 0.2). Sixteen reports analyzing more than 11,000 patients were identified in our review. CONCLUSION In conclusion, DAT positivity in CLL patients is associated with poor response to treatment and disease progression.
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Affiliation(s)
- Shimaa A Ahmed
- Department of Internal Medicine, Faculty of Medicine, South Valley University, Qena, Egypt
| | - Ghada E M Abdallah
- Clinical Hematology Unit, Department of Internal Medicine, Faculty of Medicine, Assiut University, Assiut, Egypt
| | - Mai M Aly
- Clinical Hematology Unit, Department of Internal Medicine, Faculty of Medicine, Assiut University, Assiut, Egypt
| | | | - Mostafa F Mohammed Saleh
- Clinical Hematology Unit, Department of Internal Medicine, Faculty of Medicine, Assiut University, Assiut, Egypt
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Abbas SA, Zeeshan R, Sultan S, Irfan SM. Direct Coombs Test Positivity in B-Chronic Lymphoid Leukemia: a Marker of Advanced Clinical Disease. Asian Pac J Cancer Prev 2016; 16:6007-10. [PMID: 26320488 DOI: 10.7314/apjcp.2015.16.14.6007] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Chronic lymphoid leukemia (CLL) is a malignant hematopoietic disorder, the most common of all adult leukemias with a distinctive immunophenotype. It is well established that CLL patients can have autoimmune complications, amongst them autoimmune hemolytic anemia as the most frequent. This study was carried out to determine the frequency of direct Coombs Test positivity in CLL patients and its possible correlation with Rai staging, hematological parameters and biochemical markers. MATERIALS AND METHODS This descriptive cross sectional study was carried at Liaquat National Hospital from January 2011 to June 2013. Sixty untreated patients with B- chronic lymphoid leukemia were enrolled. Complete blood count, direct Coombs test, serum urea, creatinine, uric acid and LDH levels were determined. Data were compiled and analyzed using SPSS version 21. RESULTS Out of 60 patients, 42(70%) were males and 18(30%) were females. Mean age was 59±9.2 years. Male to female ratio was 2.1: 1. The frequency of direct antiglobulin test (DAT) positivity was found to be 23.3%. The monospecific IgG was positive in 11 patients (18.3%); C3d positivity was evident in 1 patient (1.6%) and 2 patients (3.3%) had dual IgG and C3d positivity. The mean hemoglobin was 10.8±2.4gm/ dl. Significantly low mean hemoglobin of 8.3±3.0 gm/dl was seen in Coombs positive patients compared with negative patients having a mean hemoglobin level of 11.7±1.6 gm/dl (P<0.001). DAT positivity also demonstrated a positive association with advanced Rai stage III disease (P<0.01). No associations were noted with age, gender and biochemical markers. CONCLUSIONS Direct Coombs test positivity in CLL in our patients, unlike in Western studies, appears relatively high, indicating significant autoimmune hemolytic anemia and advanced Rai stage in our setting. DAT positivity can be considered as a surrogative marker for advanced clinical disease.
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Affiliation(s)
- Syeda Alia Abbas
- Hematology Department, Liaquat National Hospital and Medical College, Karachi, Pakistan E-mail :
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Abstract
Warm autoimmune hemolytic anemia (AIHA) is defined as the destruction of circulating red blood cells (RBCs) in the setting of anti-RBC autoantibodies that optimally react at 37°C. The pathophysiology of disease involves phagocytosis of autoantibody-coated RBCs in the spleen and complement-mediated hemolysis. Thus far, treatment is aimed at decreasing autoantibody production with immunosuppression or reducing phagocytosis of affected cells in the spleen. The role of complement inhibitors in warm AIHA has not been explored. This article addresses the diagnosis, etiology, and treatment of warm AIHA and highlights the role of complement in disease pathology.
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Affiliation(s)
- Rakhi Naik
- Division of Hematology, Department of Medicine, The Johns Hopkins University School of Medicine, 1830 East Monument Street, Baltimore, MD 21230, USA.
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Quinquenel A, Al Nawakil C, Baran-Marszak F, Eclache V, Letestu R, Khalloufi M, Boubaya M, Le Roy C, Varin-Blank N, Delmer A, Levy V, Ajchenbaum-Cymbalista F. Old DAT and new data: positive direct antiglobulin test identifies a subgroup with poor outcome among chronic lymphocytic leukemia stage A patients. Am J Hematol 2015; 90:E5-8. [PMID: 25263543 DOI: 10.1002/ajh.23861] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2014] [Revised: 09/21/2014] [Accepted: 09/24/2014] [Indexed: 12/12/2022]
Abstract
Only a minority of chronic lymphocytic leukemia (CLL) patients harboring a positive direct antiglobulin test (DAT) will develop autoimmune hemolytic anemia (AIHA). In a single institution cohort of 378 CLL patients, 56 patients (14.8%) had at least one positive DAT during the course of the disease, either at diagnosis or later. We found no relationship between the time of the first positive DAT and overall survival (OS). However, patients with a positive DAT who did not develop AIHA had the same adverse outcome as patients who developed AIHA. Of the patients who were in Binet stage A at diagnosis, those with a positive DAT had a significantly shorter OS, regardless of their IGHV mutational status, however, there was a strong association with VH1-69. By multivariate analysis, a positive DAT was found to be an independent adverse prognostic factor for OS. Thus, DAT represents a strong adverse prognostic factor and its determination should be repeated during follow-up.
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Affiliation(s)
- Anne Quinquenel
- CHU Reims, Hôpital Robert Debré, Service d'Hématologie Clinique; Reims France
- INSERM U978; Bobigny France
- Université Paris 13, Sorbonne Paris Cité, “Adaptateurs de Signalisation en Hématologie,” Labex “Inflamex,” Unité de Formation et de Recherche Santé-Médecine-Biologie Humaine; Bobigny France
| | - Chadi Al Nawakil
- Hôpital Avicenne, Assistance Publique-Hôpitaux de Paris (APHP), Unité de Recherche Clinique; BOBIGNY France
| | - Fanny Baran-Marszak
- INSERM U978; Bobigny France
- Université Paris 13, Sorbonne Paris Cité, “Adaptateurs de Signalisation en Hématologie,” Labex “Inflamex,” Unité de Formation et de Recherche Santé-Médecine-Biologie Humaine; Bobigny France
- Hôpital Avicenne, Assistance Publique-Hôpitaux de Paris (APHP), Service d'Hématologie Biologique; Bobigny France
| | - Virginie Eclache
- INSERM U978; Bobigny France
- Université Paris 13, Sorbonne Paris Cité, “Adaptateurs de Signalisation en Hématologie,” Labex “Inflamex,” Unité de Formation et de Recherche Santé-Médecine-Biologie Humaine; Bobigny France
- Hôpital Avicenne, Assistance Publique-Hôpitaux de Paris (APHP), Service d'Hématologie Biologique; Bobigny France
| | - Remi Letestu
- INSERM U978; Bobigny France
- Université Paris 13, Sorbonne Paris Cité, “Adaptateurs de Signalisation en Hématologie,” Labex “Inflamex,” Unité de Formation et de Recherche Santé-Médecine-Biologie Humaine; Bobigny France
- Hôpital Avicenne, Assistance Publique-Hôpitaux de Paris (APHP), Service d'Hématologie Biologique; Bobigny France
| | | | - Marouane Boubaya
- Hôpital Avicenne, Assistance Publique-Hôpitaux de Paris (APHP), Unité de Recherche Clinique; BOBIGNY France
| | - Christine Le Roy
- INSERM U978; Bobigny France
- Université Paris 13, Sorbonne Paris Cité, “Adaptateurs de Signalisation en Hématologie,” Labex “Inflamex,” Unité de Formation et de Recherche Santé-Médecine-Biologie Humaine; Bobigny France
| | - Nadine Varin-Blank
- INSERM U978; Bobigny France
- Université Paris 13, Sorbonne Paris Cité, “Adaptateurs de Signalisation en Hématologie,” Labex “Inflamex,” Unité de Formation et de Recherche Santé-Médecine-Biologie Humaine; Bobigny France
| | - Alain Delmer
- CHU Reims, Hôpital Robert Debré, Service d'Hématologie Clinique; Reims France
| | - Vincent Levy
- Hôpital Avicenne, Assistance Publique-Hôpitaux de Paris (APHP), Unité de Recherche Clinique; BOBIGNY France
| | - Florence Ajchenbaum-Cymbalista
- INSERM U978; Bobigny France
- Université Paris 13, Sorbonne Paris Cité, “Adaptateurs de Signalisation en Hématologie,” Labex “Inflamex,” Unité de Formation et de Recherche Santé-Médecine-Biologie Humaine; Bobigny France
- Hôpital Avicenne, Assistance Publique-Hôpitaux de Paris (APHP), Service d'Hématologie Biologique; Bobigny France
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Patel SS, Aasen GA, Dolan MM, Linden MA, McKenna RW, Rudrapatna VK, Trottier BJ, Drawz SM. Early Diagnosis of Intravascular Large B-Cell Lymphoma: Clues From Routine Blood Smear Morphologic Findings. Lab Med 2014; 45:248-52; quiz e93. [DOI: 10.1309/lmsveokln18m5xtv] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022] Open
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