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Lafargue MC, Duong Van Huyen JP, Rennke HG, Essig M, Bobot M, Jourde-Chiche N, Sakhi H, KARRAS A, Boudhabhay I, Brunet P, Boulay H, Grobost V, Philipponnet C, Jeannel J, Chemouny J, Boffa JJ, Braham-Stambouli D, Selamet U, Riella LV, Fain O, Adès L, Fenaux P, Cohen C, Mekinian A. Kidney involvement in myelodysplastic syndromes. Clin Kidney J 2024; 17:sfae185. [PMID: 39099564 PMCID: PMC11292217 DOI: 10.1093/ckj/sfae185] [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] [Received: 03/19/2024] [Indexed: 08/06/2024] Open
Abstract
Introduction The objective of this study was to describe kidney involvement in patients with myelodysplastic syndromes (MDS), their treatments, and outcomes. Methods We conducted a multicenter retrospective study in seven centers, identifying MDS patients with acute kidney injury (AKI), chronic kidney disease (CKD), and urine abnormalities. Results Fifteen patients developed a kidney disease 3 months after MDS diagnosis. Median urine protein-to-creatinine ratio was 1.9 g/g, and median serum creatinine was 3.2 mg/dL. Ten patients had AKI at presentation, and 12 had extra-renal symptoms. The renal diagnoses included anti-neutrophil cytoplasmic antibody (ANCA)-associated vasculitis (AAV), ANCA negative vasculitis, C3 glomerulonephritis, immune complex-mediated glomerulonephritis, polyarteritis nodosa, and IgA vasculitis. All patients but one received a specific treatment for the MDS-associated kidney injury. The effect of MDS treatment on kidney injury could be assessed in six patients treated with azacitidine, and renal function evolution was heterogenous. After a median follow-up of 14 months, four patients had CKD stage 3, five had CKD stage 4, and three had end stage kidney disease. On the other hand, three evolved to an acute myeloid leukemia and three died. Compared to 84 MDS controls, patients who had kidney involvement were younger, had a higher number of dysplasia lineages, and were more eligible to receive hypomethylating agents, but no survival difference was seen between the two groups. Compared to 265 AAV without MDS, the ten with MDS-associated pauci-immune vasculitis were older, ANCA serology was more frequently negative, and more cutaneous lesions were seen. Conclusion The spectrum of kidney injuries associated with MDS is mostly represented by vasculitis with glomerular involvement, and especially AAV.
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Affiliation(s)
- Marie-Camille Lafargue
- Department of Nephrology, Tenon's Hospital, Assistance Publique-Hôpitaux de Paris, Université Paris Cité, Paris, France
| | - Jean-Paul Duong Van Huyen
- Department of Pathology, Université Paris Cité, Necker's Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Helmut G Rennke
- Department of Pathology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Marie Essig
- Department of Nephrology, Assistance Publique-Hôpitaux de Paris, Hôpital Ambroise Paré, Boulogne-Billancourt, Université Paris-Saclay, Paris, France
| | - Mickaël Bobot
- Centre de Néphrologie et Transplantation Rénale, AP-HM, Hôpital de la Conception, CHU de la Conception, Marseille, France
| | - Noémie Jourde-Chiche
- Centre de Néphrologie et Transplantation Rénale, AP-HM, Hôpital de la Conception, CHU de la Conception, Marseille, France
| | - Hamza Sakhi
- Department of Nephrology, Necker's Hospital, Assistance Publique-Hôpitaux de Paris, Université Paris Cité, Paris, France
| | | | - Idris Boudhabhay
- Department of Nephrology, Necker's Hospital, Assistance Publique-Hôpitaux de Paris, Université Paris Cité, Paris, France
| | - Philippe Brunet
- Centre de Néphrologie et Transplantation Rénale, AP-HM, Hôpital de la Conception, CHU de la Conception, Marseille, France
| | - Hugoline Boulay
- University of Rennes, CHU Rennes, INSERM, EHESP, IRSET (Institut de recherche en santé, environnement et travail), UMR_S 1085, Rennes, France
| | | | - Carole Philipponnet
- Nephrology, Dialysis and Transplantation Department, University Hospital, Clermont-Ferrand, France
| | - Juliette Jeannel
- Internal Medicine Department, Strasbourg University Hospital, Strasbourg, France
| | - Jonathan Chemouny
- Transplant Unit, Department of Nephrology, University Hospital, Rennes, France
| | - Jean-Jacques Boffa
- Department of Nephrology, Sorbonne University, Tenon's Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France
| | | | - Umut Selamet
- Division of Renal Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Leonardo V Riella
- Center for Transplantation Sciences, Division of Nephrology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Olivier Fain
- Sorbonne Université, Hôpital Saint-Antoine, Service de Médecine Interne et de l'Inflammation-(DHU i2B), Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Lionel Adès
- Hématologie, Hôpital Saint-Louis, Assistance Publique-Hôpitaux de Paris, Université Paris Cité, Paris, France
| | - Pierre Fenaux
- Hématologie, Hôpital Saint-Louis, Assistance Publique-Hôpitaux de Paris, Université Paris Cité, Paris, France
| | - Camille Cohen
- Service de Néphrologie Hémodialyse, Hôpital Bichat - Claude Bernard, Assistance Publique-Hôpitaux de Paris, Université Paris Cité, Paris, France
| | - Arsène Mekinian
- Sorbonne Université, Hôpital Saint-Antoine, Service de Médecine Interne et de l'Inflammation-(DHU i2B), Assistance Publique-Hôpitaux de Paris, Paris, France
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Attieh RM, Begum F, Chitty D, Izzedine H, Jhaveri KD. Kidney and Urinary Tract Involvement in Chronic Myelomonocytic Leukemia. Kidney Med 2024; 6:100769. [PMID: 38313809 PMCID: PMC10837097 DOI: 10.1016/j.xkme.2023.100769] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2024] Open
Abstract
Chronic myelomonocytic leukemia (CMML) is a hematologic malignancy affecting the bone marrow and resulting in peripheral blood monocytosis. Kidney and urinary tract involvement is common and can present dramatically with life-threatening consequences. Kidney involvement can be the result of direct or indirect mechanisms, including prerenal azotemia, glomerular disease, tubulointerstitial involvement, and renovascular disorders. Urinary tract involvement, electrolyte and acid-base disorders, as well as nephrotoxicity from treatment of the disorder can also occur. Given this multifactorial pathogenesis involving several mechanisms concomitantly, nephrologists must exercise heightened awareness and maintain a low threshold for kidney biopsy. There is a pressing need for future research endeavors to elucidate and target the manifestations of CMML that involve the kidneys with the ultimate goal of augmenting overall prognosis and therapeutic outcomes.
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Affiliation(s)
- Rose Mary Attieh
- Division of Kidney Diseases and Hypertension, Department of Medicine, Glomerular Center at Northwell Health, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Great Neck, New York
| | - Farhana Begum
- Department of Medicine, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Manhasset, New York
| | - David Chitty
- Northwell Health Cancer Institute, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Feinstein Institute for Medical Research, Lake Success, New York
| | - Hassan Izzedine
- Department of Nephrology, Peupliers Private Hospital, Ramsay Générale de Santé, Paris, France
| | - Kenar D Jhaveri
- Division of Kidney Diseases and Hypertension, Department of Medicine, Glomerular Center at Northwell Health, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Great Neck, New York
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Lafargue MC, Bobot M, Rennke HG, Essig M, Carre M, Mercadal L, Farhi J, Sakhi H, Comont T, Golbin L, Isnard P, Chemouny J, Cambier N, Laribi K, Selamet U, Riella LV, Fain O, Adès L, Fenaux P, Cohen C, Mekinian A. Chronic Myelomonocytic Leukemia Patients With Lysozyme Nephropathy and Renal Infiltration Display Markers of Severe Disease. Kidney Int Rep 2023; 8:2733-2741. [PMID: 38106568 PMCID: PMC10719588 DOI: 10.1016/j.ekir.2023.09.005] [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] [Received: 06/30/2023] [Revised: 08/29/2023] [Accepted: 09/04/2023] [Indexed: 12/19/2023] Open
Abstract
Introduction Chronic myelomonocytic leukemia (CMML) is a hematologic disorder that is an overlap syndrome between myelodysplastic syndromes and myeloproliferative neoplasms, and can be associated with autoimmune and inflammatory diseases. This study aimed to describe kidney involvement in patients with CMML, their treatments, and outcomes. Methods We conducted a French and American multicenter retrospective study in 15 centers, identifying patients with CMML with acute kidney injury (AKI), chronic kidney disease (CKD), and urine abnormalities. Results Sixteen patients (males, n = 14; median age 76.5 years [71.9-83]) developed a kidney disease 6 months [1.6-25.6] after the diagnosis of CMML. At the time of kidney disease diagnosis, median urinary protein-to-creatinine ratio was 2 g/g [1.25-3.4], and median serum creatinine was 2.26 mg/dl [1.46-2.68]. Fourteen patients (87.5%) underwent a kidney biopsy, and the 2 main pathological findings were lysozyme nephropathy (56%) and renal infiltration by the CMML (37.5%). Ten patients received a new treatment following the CMML-associated kidney injury. Among patients with monitored kidney function, and after a median follow-up of 15 months [9.9-34.9], 4 patients had CKD stage 3, 4 had CKD stage 4, 1 had an end-stage kidney disease. In our patient series, 2 patients evolved to an acute myeloid leukemia (AML), and 5 died. Compared with 116 CMML controls, patients who had a kidney involvement had a higher monocyte count (P < 0.001), had more CMML-1 (P = 0.005), were more susceptible to develop an AML (P = 0.02), and were more eligible to receive a specific hematologic treatment, with hydroxyurea, or hypomethylating agents (P < 0.001), but no survival difference was seen between the 2 groups (P = 0.6978). Conclusion In this cohort of patients with CMML with a kidney injury, the 2 most frequent renal complications were lysozyme-induced nephropathy and renal infiltration by the CMML. Kidney involvement should be closely monitored in patients with CMML.
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Affiliation(s)
- Marie-Camille Lafargue
- Department of Nephrology, Tenon’s Hospital, Assistance Publique-Hôpitaux de Paris, Université Paris Cité, Paris, France
| | - Mickaël Bobot
- Centre de Néphrologie et Transplantation Rénale, AP-HM, Hôpital de la Conception, CHU de la Conception, 13005, Marseille, France
| | - Helmut G. Rennke
- Department of Pathology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Marie Essig
- Department of Nephrology, Assistance Publique-Hôpitaux de Paris, Hôpital Ambroise Paré, Boulogne-Billancourt, Université Paris-Saclay, Paris, France
| | - Martin Carre
- Service d'Hématologie, Centre Hospitalier Universitaire, Grenoble, France
| | - Lucile Mercadal
- Department of Nephrology and Renal Transplantation, Assistance Publique-Hôpitaux de Paris, Hôpital de La Pitié Salpêtrière, Paris, France
| | | | - Hamza Sakhi
- Department of Nephrology and renal transplantation, Necker’s Hospital, Assistance Publique-Hôpitaux de Paris, Université Paris Cité, Paris, France
| | - Thibault Comont
- Department of Internal Medicine, Institut universitaire du cancer de Toulouse, Centre Hospitalier Universitaire de Toulouse, Université Toulouse III - Paul Sabatier, Toulouse, France
| | - Léonard Golbin
- Service de Néphrologie, Dialyse et Transplantation Rénale, CHU Rennes, Hôpital Pontchaillou, Rennes, France
| | - Pierre Isnard
- Department of Pathology, Université Paris Cité, Necker Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Jonathan Chemouny
- Hématologie Clinique, Centre Hospitalier de Valenciennes, Valenciennes, France
| | | | | | - Umut Selamet
- Division of Renal Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Leonardo V. Riella
- Center of Transplantation Sciences, Department of Medicine, Division of Nephrology, Massachusetts General Hospital, Harvard Medical School, Charlestown, MA, United States
| | - Olivier Fain
- Hôpital Saint-Antoine, Service de Médecine Interne et de l'Inflammation-(DHU i2B), F-75012, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Lionel Adès
- Hématologie, Hôpital Saint-Louis, Assistance Publique-Hôpitaux de Paris, Université Paris Diderot, Paris, France
| | - Pierre Fenaux
- Hématologie, Hôpital Saint-Louis, Assistance Publique-Hôpitaux de Paris, Université Paris Diderot, Paris, France
| | - Camille Cohen
- INSERM U1151 « mechanisms and therapeutic strategies of chronic kidney diseases », Hôpital Necker, Université Paris Cité, Paris, France; Service de Néphrologie et Transplantation rénale, Assistance Publique-Hôpitaux de Paris, Hôpital Necker, Paris, France
| | - Arsène Mekinian
- Hôpital Saint-Antoine, Service de Médecine Interne et de l'Inflammation-(DHU i2B), F-75012, Assistance Publique-Hôpitaux de Paris, Paris, France
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Nathan DI, Dougherty M, Bhatta M, Mascarenhas J, Marcellino BK. Clonal hematopoiesis and inflammation: A review of mechanisms and clinical implications. Crit Rev Oncol Hematol 2023; 192:104187. [PMID: 37879493 DOI: 10.1016/j.critrevonc.2023.104187] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2023] [Revised: 09/21/2023] [Accepted: 10/16/2023] [Indexed: 10/27/2023] Open
Abstract
Clonal hematopoiesis (CH) is defined by the presence of somatic mutations in hematopoietic stem and progenitor cells (HSPC). CH is associated primarily with advancing age and confers an elevated risk of progression to overt hematologic malignancy and cardiovascular disease. Increasingly, CH is associated with a wide range of diseases driven by, and sequelae of, inflammation. Accordingly, there is great interest in better understanding the pathophysiologic and clinical relationship between CH, aging, and disease. Both observational and experimental findings support the concept that CH is a potential common denominator in the inflammatory outcomes of aging. However, there is also evidence that local and systemic inflammatory states promote the growth and select for CH clones. In this review, we aim to provide an up-to-date summary of the nature of the relationship between inflammation and CH, which is central to unlocking potential therapeutic opportunities to prevent progression to myeloid malignancy.
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Affiliation(s)
- Daniel I Nathan
- Tisch Cancer Institute, Division of Hematology and Medical Oncology, The Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Max Dougherty
- Tisch Cancer Institute, Division of Hematology and Medical Oncology, The Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Manasa Bhatta
- Department of Medicine, The Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - John Mascarenhas
- Tisch Cancer Institute, Division of Hematology and Medical Oncology, The Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Bridget K Marcellino
- Tisch Cancer Institute, Division of Hematology and Medical Oncology, The Icahn School of Medicine at Mount Sinai, New York, NY, USA.
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5
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Deng LJ, Dong Y, Li MM, Sun CG. Co-existing squamous cell carcinoma and chronic myelomonocytic leukemia with ASXL1 and EZH2 gene mutations: A case report. World J Clin Cases 2023; 11:3643-3650. [PMID: 37383892 PMCID: PMC10294182 DOI: 10.12998/wjcc.v11.i15.3643] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2023] [Revised: 04/07/2023] [Accepted: 04/19/2023] [Indexed: 05/25/2023] Open
Abstract
BACKGROUND Chronic myelomonocytic leukemia (CMML), a rare clonal hematopoietic stem cell disorder characterized by myelodysplastic syndrome and myeloproliferative neoplasms, has a generally poor prognosis, and easily progresses to acute myeloid leukemia. The simultaneous incidence of hematologic malignancies and solid tumors is extremely low, and CMML coinciding with lung malignancies is even rarer. Here, we report a case of CMML, with ASXL1 and EZH2 gene mutations, combined with non-small cell lung cancer (lung squamous cell carcinoma).
CASE SUMMARY A 63-year-old male, suffering from toothache accompanied by coughing, sputum, and bloody sputum for three months, was given a blood test after experiencing continuous bleeding resulting from a tooth extraction at a local hospital. Based on morphological results, the patient was diagnosed with CMML and bronchoscopy was performed in situ to confirm the diagnosis of squamous cell carcinoma in the lower lobe of the lung. After receiving azacitidine, programmed cell death protein 1, and platinum-based chemotherapy drugs, the patient developed severe myelosuppression and eventually fatal leukocyte stasis and dyspnea.
CONCLUSION During the treatment and observation of CMML and be vigilant of the growth of multiple primary malignant tumors.
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Affiliation(s)
- Lai-Jun Deng
- Department of Hematology, Weifang Hospital of Traditional Chinese Medicine, Weifang 261000, Shandong Province, China
| | - Yang Dong
- Department of Clinical Pharmacy, Weifang Hospital of Traditional Chinese Medicine, Weifang 261000, Shandong Province, China
| | - Mi-Mi Li
- Department of Pathology, Weifang Hospital of Traditional Chinese Medicine, Weifang 261000, Shandong Province, China
| | - Chang-Gang Sun
- Department of Hematology, Weifang Hospital of Traditional Chinese Medicine, Weifang 261000, Shandong Province, China
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Impact of Mutational Status and Prognostic Factors on Survival in Chronic Myelomonocytic Leukemia With Systemic Inflammation and Autoimmune Disorders. Hemasphere 2023; 7:e847. [PMID: 36844177 PMCID: PMC9953038 DOI: 10.1097/hs9.0000000000000847] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2022] [Accepted: 01/12/2023] [Indexed: 02/25/2023] Open
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7
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Lötscher F, Pop R, Seitz P, Recher M, Seitz L. Spectrum of Large- and Medium-Vessel Vasculitis in Adults: Neoplastic, Infectious, Drug-Induced, Autoinflammatory, and Primary Immunodeficiency Diseases. Curr Rheumatol Rep 2022; 24:293-309. [PMID: 35920952 PMCID: PMC9362566 DOI: 10.1007/s11926-022-01083-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/24/2022] [Indexed: 02/06/2023]
Abstract
PURPOSE OF REVIEW To provide a comprehensive review of drugs and neoplastic, infectious, autoinflammatory, and immunodeficiency diseases causing medium- to large-vessel vasculitis in adults with emphasis on information essential for the initial diagnostic process. RECENT FINDINGS Entities with medium- to large-vessel vasculitis as clinical manifestations have been described recently (e.g., adenosine deaminase-2 deficiency, VEXAS-Syndrome), and vasculitis in established autoinflammatory or immunodeficiency diseases is increasingly being identified. In the diagnostic process of medium- to large-vessel vasculitis in adults, a large variety of rare diseases should be included in the differential diagnosis, especially if diagnosis is made without histologic confirmation and in younger patients. Although these disorders should be considered, they will undoubtedly remain rare in daily practice.
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Affiliation(s)
- Fabian Lötscher
- Department of Rheumatology and Immunology, Inselspital, University Hospital, University of Bern, Freiburgstrasse, CH-3010, Bern, Switzerland
| | - Roxana Pop
- Department of Infectious Diseases and Hospital Hygiene, University Hospital, University of Zurich, Zurich, Switzerland
| | - Pascal Seitz
- Department of Rheumatology and Immunology, Inselspital, University Hospital, University of Bern, Freiburgstrasse, CH-3010, Bern, Switzerland
| | - Mike Recher
- Immunodeficiency Laboratory, Department of Biomedicine, University Hospital and University of Basel, Basel, Switzerland
- University Center for Immunology, University Hospital, Basel, Switzerland
| | - Luca Seitz
- Department of Rheumatology and Immunology, Inselspital, University Hospital, University of Bern, Freiburgstrasse, CH-3010, Bern, Switzerland.
- Immunodeficiency Laboratory, Department of Biomedicine, University Hospital and University of Basel, Basel, Switzerland.
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8
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Mangaonkar AA, Patnaik MM. Role of the bone marrow immune microenvironment in chronic myelomonocytic leukemia pathogenesis: novel mechanisms and insights into clonal propagation. Leuk Lymphoma 2022; 63:1792-1800. [PMID: 35377828 DOI: 10.1080/10428194.2022.2056175] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Recent studies in chronic myelomonocytic leukemia (CMML) involving clonal dendritic cell (DC) aggregates and association with systemic immune dysregulation have highlighted novel and potentially targetable pathways of disease progression. CMML DC aggregates are populated by heterogeneous cell types such as CD123+ plasmacytoid dendritic cells (pDCs), CD11c + myeloid-derived DCs (mDCs), myeloid-derived suppressor cells (MDSCs), monocytes, and associate with an immune checkpoint called indoleamine 2,3-dioxygenase (IDO). Systemically, these IDO + DC aggregates are associated with immune tolerance marked by regulatory T cell expansion, likely mediated by aberrant DC-T cell interactions occurring within the bone marrow (BM) microenvironment. Somatic mutational events in CMML such as ASXL1 and NRAS mutations cooperate to induce T cell exhaustion and contribute toward disease progression to acute myeloid leukemia (AML). In this review, we explore the role of aging-induced alterations in the BM immune microenvironment, aberrant innate immune and proinflammatory signaling, and the adaptive immune system in CMML.
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Affiliation(s)
| | - Mrinal M Patnaik
- Department of Medicine, Division of Hematology, Mayo Clinic, Rochester, MN, USA
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9
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Oganesyan A, Hakobyan Y, Terrier B, Georgin-Lavialle S, Mekinian A. Looking beyond VEXAS: Coexistence of undifferentiated systemic autoinflammatory disease and myelodysplastic syndrome. Semin Hematol 2021; 58:247-253. [PMID: 34802547 DOI: 10.1053/j.seminhematol.2021.10.003] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2021] [Revised: 09/08/2021] [Accepted: 10/01/2021] [Indexed: 01/24/2023]
Abstract
It has been established that individuals with myelodysplastic syndromes (MDS) have a higher frequency of systemic inflammatory disorders. On the other hand, patients with autoimmune diseases are at increased risk of MDS development. Both diseases can be associated with various genetic lesions and share diverse pathogenetic mechanisms. Recently identified VEXAS (Vacuoles, E1 enzyme, X-linked, Autoinflammatory, Somatic) syndrome, associated with somatic mutations in UBA1, encompasses a range of inflammatory conditions involving multiple organs along with hematological pathologies, including MDS, as well as characteristic bone marrow vacuolization of myeloid and erythroid precursors. This novel syndrome drove further attention to complex associations between MDS and adult-onset inflammatory conditions. The present narrative literature review discusses the clinical presentation, pathophysiology, management of concurrent MDS and systemic inflammatory diseases in parallel to the clinical picture of VEXAS syndrome.
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Affiliation(s)
- Artem Oganesyan
- Department of Adult Hematology, Yeolyan Hematology Center, Yerevan, Armenia; Department of Hematology and Transfusion Medicine, National Institute of Health, Yerevan, Armenia
| | - Yervand Hakobyan
- Department of Adult Hematology, Yeolyan Hematology Center, Yerevan, Armenia; Department of Hematology and Transfusion Medicine, National Institute of Health, Yerevan, Armenia
| | - Benjamin Terrier
- Department of Internal Medicine, National Referral Center for Rare and Systemic Autoimmune Diseases, Cochin Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Sophie Georgin-Lavialle
- Internal Medicine Department, National Reference Center for Autoinflammatory Diseases and Amyloidosis (CEREMAIA), Sorbonne Université, INSERM U938, Tenon Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Arsene Mekinian
- Internal Medicine Department and Inflammation-Immunopathology-Biotherapy Department (DHU i2B), Hospital Saint-Antoine, Assistance Publique-Hôpitaux de Paris, Paris, France; Centre de Recherche Saint-Antoine (CRSA), Sorbonne Universités, UMPC University Paris 06, INSERM U938, Paris, France.
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10
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Barcellini W, Fattizzo B. Immune Phenomena in Myeloid Neoplasms: An " Egg or Chicken" Question. Front Immunol 2021; 12:751630. [PMID: 34659257 PMCID: PMC8511478 DOI: 10.3389/fimmu.2021.751630] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2021] [Accepted: 09/13/2021] [Indexed: 11/13/2022] Open
Abstract
Immune phenomena are increasingly reported in myeloid neoplasms, and include autoimmune cytopenias/diseases and immunodeficiency, either preceding or complicating acute myeloid leukemia, myelodysplastic syndromes (MDS), chronic myeloproliferative neoplasms, and bone marrow failure (BMF) syndromes. Autoimmunity and immunodeficiency are the two faces of a dysregulated immune tolerance and surveillance and may result, along with contributing environmental and genetic factors, in an increased incidence of both tumors and infections. The latter may fuel both autoimmunity and immune activation, triggering a vicious circle among infections, tumors and autoimmune phenomena. Additionally, alterations of the microbiota and of mesenchymal stem cells (MSCs) pinpoint to the importance of a permissive or hostile microenvironment for tumor growth. Finally, several therapies of myeloid neoplasms are aimed at increasing host immunity against the tumor, but at the price of increased autoimmune phenomena. In this review we will examine the epidemiological association of myeloid neoplasms with autoimmune diseases and immunodeficiencies, and the pivotal role of autoimmunity in the pathogenesis of MDS and BMF syndromes, including the paroxysmal nocturnal hemoglobinuria conundrum. Furthermore, we will briefly examine autoimmune complications following therapy of myeloid neoplasms, as well as the role of MSCs and microbiota in these settings.
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Affiliation(s)
- Wilma Barcellini
- Hematology Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Bruno Fattizzo
- Hematology Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy.,Department of Oncology and Hemato-Oncology, University of Milan, Milan, Italy
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11
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Dupuy H, Dussiau C, Bidet A, Sauvezie M, De-Grande AC, Decombe J, Rivière É, Forcade E, Bonnet F, Dumas PY, Duffau P, Pigneux A, Viallard JF, Lazaro E, Dimicoli-Salazar S. Looking for somatic mutations in UBA1 in patients with chronic myelomonocytic leukemia associated with systemic inflammation and autoimmune diseases. Leuk Lymphoma 2021; 63:250-252. [PMID: 34474632 DOI: 10.1080/10428194.2021.1973674] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Affiliation(s)
- Henry Dupuy
- Department of Internal Medicine and Infectious Diseases, Bordeaux University Hospital, Haut-Lévêque Hospital, Pessac, France
| | - Charles Dussiau
- Department of Hematology Biology, Molecular Hematology, Bordeaux University Hospital, Haut-Lévêque Hospital, Pessac, France
| | - Audrey Bidet
- Department of Hematology Biology, Molecular Hematology, Bordeaux University Hospital, Haut-Lévêque Hospital, Pessac, France
| | - Mathieu Sauvezie
- Department of Clinical Hematology and Cell Therapy, Bordeaux University Hospital, Haut-Lévêque Hospital, Pessac, France
| | - Anne-Charlotte De-Grande
- Department of Clinical Hematology and Cell Therapy, Bordeaux University Hospital, Haut-Lévêque Hospital, Pessac, France
| | - Joël Decombe
- Department of Hematology Biology, Molecular Hematology, Bordeaux University Hospital, Haut-Lévêque Hospital, Pessac, France
| | - Étienne Rivière
- Department of Internal Medicine and Infectious Diseases, Bordeaux University Hospital, Haut-Lévêque Hospital, Pessac, France
| | - Edouard Forcade
- Department of Clinical Hematology and Cell Therapy, Bordeaux University Hospital, Haut-Lévêque Hospital, Pessac, France
| | - Fabrice Bonnet
- Department of Internal Medicine and Infectious Diseases, Bordeaux University Hospital, Saint André Hospital, Bordeaux, France
| | - Pierre-Yves Dumas
- Department of Clinical Hematology and Cell Therapy, Bordeaux University Hospital, Haut-Lévêque Hospital, Pessac, France
| | - Pierre Duffau
- Department of Internal Medicine and Clinical Immunology, Bordeaux University Hospital, Saint André Hospital, Bordeaux, France
| | - Arnaud Pigneux
- Department of Clinical Hematology and Cell Therapy, Bordeaux University Hospital, Haut-Lévêque Hospital, Pessac, France
| | - Jean-François Viallard
- Department of Internal Medicine and Infectious Diseases, Bordeaux University Hospital, Haut-Lévêque Hospital, Pessac, France
| | - Estibaliz Lazaro
- Department of Internal Medicine and Infectious Diseases, Bordeaux University Hospital, Haut-Lévêque Hospital, Pessac, France
| | - Sophie Dimicoli-Salazar
- Department of Clinical Hematology and Cell Therapy, Bordeaux University Hospital, Haut-Lévêque Hospital, Pessac, France
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12
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Hochman MJ, Savani BN, Jain T. Examining disease boundaries: Genetics of myelodysplastic/myeloproliferative neoplasms. EJHAEM 2021; 2:607-615. [PMID: 35844680 PMCID: PMC9175746 DOI: 10.1002/jha2.264] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/17/2021] [Revised: 06/30/2021] [Accepted: 07/12/2021] [Indexed: 12/19/2022]
Abstract
Myelodysplastic/myeloproliferative neoplasms (MDS/MPN) are clonal myeloid malignancies that are characterized by dysplasia resulting in cytopenias as well as proliferative features such as thrombocytosis or splenomegaly. Recent studies have better defined the genetics underlying this diverse group of disorders. Trisomy 8, monosomy 7, and loss of Y chromosome are the most common cytogenetic abnormalities seen. Chronic myelomonocytic leukemia (CMML) likely develops from early clones with TET2 mutations that drive granulomonocytic differentiation. Mutations in SRSF2 are common and those in the RAS-MAPK pathway are typically implicated in disease with a proliferative phenotype. Several prognostic systems have incorporated genetic features, with ASXL1 most consistently demonstrating worse prognosis. Atypical chronic myeloid leukemia (aCML) is most known for granulocytosis with marked dysplasia and often harbors ASXL1 mutations, but SETBP1 and ETNK1 are more specific to this disease. MDS/MPN with ring sideroblasts and thrombocytosis (MDS/MPN-RS-T) most commonly involves spliceosome mutations (namely SF3B1) and mutations in the JAK-STAT pathway. Finally, MDS/MPN-unclassifiable (MDS/MPN-U) is least characterized but a significant fraction carries mutations in TP53. The remaining patients have clinical and/or genetic features similar to the other MDS/MPNs, suggesting there is room to better characterize this entity. Evolution from age-related clonal hematopoiesis to MDS/MPN likely depends on the order of mutation acquisition and interactions between various biologic factors. Genetics will continue to play a critical role in our understanding of these illnesses and advancing patient care.
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Affiliation(s)
- Michael J. Hochman
- Division of Hematological Malignancies and Bone Marrow TransplantationSidney Kimmel Comprehensive Cancer CenterJohns Hopkins UniversityBaltimoreMarylandUSA
| | - Bipin N. Savani
- Division of Hematology and OncologyVanderbilt University Medical CenterNashvilleTennesseeUSA
| | - Tania Jain
- Division of Hematological Malignancies and Bone Marrow TransplantationSidney Kimmel Comprehensive Cancer CenterJohns Hopkins UniversityBaltimoreMarylandUSA
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13
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Yuce Inel T, Gulcu A, Karakas A, Erdogan Yucel E, Onen F. Coexistence of Takayasu arteritis and chronic myeloid leukemia: Coincidental or paraneoplastic phenomenon? Int J Rheum Dis 2021; 24:1213-1216. [PMID: 34308563 DOI: 10.1111/1756-185x.14186] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2021] [Revised: 06/29/2021] [Accepted: 07/12/2021] [Indexed: 11/29/2022]
Abstract
Vasculitis may rarely be seen in the course of myeloproliferative neoplasms (MPN). In vasculitis associated with hematological diseases, mostly small- and medium-vessel involvement is expected, aortitis is very rare. It is not exactly known whether large-vessel vasculitis associated with MPN is a paraneoplastic phenomenon or coincidental. We aimed to present an uncommon case diagnosed with chronic myeloid leukemia and Takayasu arteritis concurrently.
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Affiliation(s)
- Tuba Yuce Inel
- Department of Rheumatology, Dokuz Eylul University School of Medicine, Izmir, Turkey
| | - Aytac Gulcu
- Department of Radiology, Faculty of Medicine, Dokuz Eylul University, Izmir, Turkey
| | - Ali Karakas
- Department of Rheumatology, Dokuz Eylul University School of Medicine, Izmir, Turkey
| | - Elcin Erdogan Yucel
- Department of Hematology, Dokuz Eylul University School of Medicine, Izmir, Turkey
| | - Fatos Onen
- Department of Rheumatology, Dokuz Eylul University School of Medicine, Izmir, Turkey
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14
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Chan O, Renneville A, Padron E. Chronic myelomonocytic leukemia diagnosis and management. Leukemia 2021; 35:1552-1562. [PMID: 33714974 DOI: 10.1038/s41375-021-01207-3] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2020] [Revised: 01/23/2021] [Accepted: 02/18/2021] [Indexed: 01/31/2023]
Abstract
Chronic myelomonocytic leukemia (CMML) is a rare, heterogeneous myeloid malignancy classified as a myelodysplastic syndromes/myeloproliferative neoplasm (MDS/MPN) overlap syndrome by the World Health Organization (WHO). Its initial presentation can be incidental or associated with myelodysplastic or myeloproliferative symptoms and up to 20% of patients harbor a concurrent inflammatory or autoimmune condition. Persistent monocytosis is the hallmark of CMML but diagnosis can be challenging. Increased understanding of human monocyte subsets, chromosomal abnormalities, and somatic gene mutations have led to more accurate diagnosis and improved prognostication. A number of risk stratification systems have been developed and validated but using those that incorporate molecular information such as CMML Prognostic Scoring System (CPSS)-Mol, Mayo Molecular, and Groupe Francophone des Myelodysplasies (GFM) are preferred. Symptom-directed approaches forms the basis of CMML management. Outcomes vary substantially depending on risk ranging from observation for a number of years to rapidly progressive disease and acute myeloid leukemia (AML) transformation. Patients who are low risk but with symptoms from cytopenias or proliferative features such as splenomegaly may be treated with hypomethylating agents (HMAs) or cytoreductive therapy, respectively, with the goal of durable symptoms control. Allogeneic hematopoietic cell transplantation should be considered for intermediate to high risk patients. The lack of effective pharmaceutical options has generated interest in novel therapeutics for this disease, and early phase clinical trial results are promising.
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Affiliation(s)
- Onyee Chan
- Department of Malignant Hematology, Moffitt Cancer Center, Tampa, FL, USA
| | | | - Eric Padron
- Department of Malignant Hematology, Moffitt Cancer Center, Tampa, FL, USA.
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15
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Abstract
Systemic auto-inflammatory or autoimmune diseases (SIADs) develop in up to a quarter of patients with myelodysplastic syndromes (MDS) or chronic myelomonocytic leukemia (CMML). With or without the occurrence of SIADs, the distribution of MDS subtypes and the international or CMML-specific prognostic scoring systems have been similar between MDS/CMML patients. Moreover, various SIADs have been described in association with MDS, ranging from limited clinical manifestations to systemic diseases affecting multiple organs. Defined clinical entities including systemic vasculitis, connective tissue diseases, inflammatory arthritis and neutrophilic diseases are frequently reported; however, unclassified or isolated organ impairment can also be seen. Although the presence of SIADs does not impact the overall survival nor disease progression to acute myeloid leukemia, they can help with avoiding steroid dependence and make associated adverse events of immunosuppressive drugs challenging. While therapies using steroids and immunosuppressive treatment remain the backbone of first-line treatment, increasing evidence suggests that MDS specific therapy (hypomethylating agents) and sparing steroids may be effective in treating such complications based on their immunomodulatory effect. The aim of this review was to analyze the epidemiological, pathophysiological, clinical and therapeutic factors of systemic inflammatory and immune disorders associated with MDS.
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16
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Bone marrow dendritic cell aggregates associate with systemic immune dysregulation in chronic myelomonocytic leukemia. Blood Adv 2021; 4:5425-5430. [PMID: 33152058 DOI: 10.1182/bloodadvances.2020002415] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2020] [Accepted: 09/28/2020] [Indexed: 11/20/2022] Open
Abstract
Key Points
Systemic immune microenvironment signatures in CMML indicate an altered T- and natural killer cell balance. CMML bone marrow dendritic cell aggregates associate with disease progression and systemic regulatory T-cell phenotypic switch.
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17
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Mangaonkar AA, Tande AJ, Bekele DI. Differential Diagnosis and Workup of Monocytosis: A Systematic Approach to a Common Hematologic Finding. Curr Hematol Malig Rep 2021; 16:267-275. [PMID: 33880680 PMCID: PMC8057007 DOI: 10.1007/s11899-021-00618-4] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/23/2021] [Indexed: 12/19/2022]
Abstract
Purpose of Review Monocytosis is a frequently encountered clinical condition that needs appropriate investigation due to a broad range of differential diagnoses. This review is meant to summarize the latest literature in the diagnostic testing and interpretation and offer a stepwise diagnostic approach for a patient presenting with monocytosis. Recent Findings Basic studies have highlighted the phenotypic and functional heterogeneity in the monocyte compartment. Studies, both translational and clinical, have provided insights into why monocytosis occurs and how to distinguish the different etiologies. Flow cytometry studies have illustrated that monocyte repartitioning can distinguish chronic myelomonocytic leukemia, a prototypical neoplasm with monocytosis from other reactive or neoplastic causes. Summary In summary, we provide an algorithmic approach to the diagnosis of a patient presenting with monocytosis and expect this document to serve as a reference guide for clinicians.
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Affiliation(s)
| | - Aaron J Tande
- Division of Infectious Diseases, Mayo Clinic, Rochester, MN, USA
| | - Delamo I Bekele
- Division of Rheumatology, Department of Medicine, Mayo Clinic, Rochester, MN, USA
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18
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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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19
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Gauchy A, Hentzien M, Wynckel A, de Marcellus V, Rodier C, Delmer A, Quinquenel A. Efficacy of eculizumab in refractory life-threatening warm autoimmune hemolytic anemia associated with chronic myelomonocytic leukemia. Clin Case Rep 2020; 8:2641-2644. [PMID: 33363796 PMCID: PMC7752594 DOI: 10.1002/ccr3.3250] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2020] [Revised: 07/04/2020] [Accepted: 07/21/2020] [Indexed: 02/06/2023] Open
Abstract
Eculizumab may be considered as an emergency therapeutic option in refractory life-threatening warm autoimmune hemolytic anemia especially if direct antiglobulin test is positive for both IgG and C3d and after failure of all conventional treatments.
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Affiliation(s)
- Anne‐Cécile Gauchy
- Service d'Hématologie CliniqueHôpital Robert DebréCentre Hospitalier UniversitaireReimsFrance
- UFR Médecine Université Reims Champagne‐ArdenneReimsFrance
| | - Maxime Hentzien
- UFR Médecine Université Reims Champagne‐ArdenneReimsFrance
- Service de Médecine InterneMaladies Infectieuse et Immunologie CliniqueHôpital Robert DebréCentre Hospitalier UniversitaireReimsFrance
| | - Alain Wynckel
- Service de NéphrologieHôpital Robert DebréCentre Hospitalier UniversitaireReimsFrance
| | - Victoire de Marcellus
- Service d'Hématologie CliniqueHôpital Robert DebréCentre Hospitalier UniversitaireReimsFrance
- UFR Médecine Université Reims Champagne‐ArdenneReimsFrance
| | - Cyrielle Rodier
- Service d'Hématologie CliniqueHôpital Robert DebréCentre Hospitalier UniversitaireReimsFrance
- UFR Médecine Université Reims Champagne‐ArdenneReimsFrance
| | - Alain Delmer
- Service d'Hématologie CliniqueHôpital Robert DebréCentre Hospitalier UniversitaireReimsFrance
- UFR Médecine Université Reims Champagne‐ArdenneReimsFrance
| | - Anne Quinquenel
- Service d'Hématologie CliniqueHôpital Robert DebréCentre Hospitalier UniversitaireReimsFrance
- UFR Médecine Université Reims Champagne‐ArdenneReimsFrance
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20
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[Polymyalgia rheumatic and chronic myelomonocytic leukemia]. Rev Med Interne 2020; 42:434-437. [PMID: 33129580 DOI: 10.1016/j.revmed.2020.08.008] [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: 12/16/2019] [Revised: 07/13/2020] [Accepted: 08/03/2020] [Indexed: 11/22/2022]
Abstract
INTRODUCTION Myelodysplasia (MDS) can occur as systemic manifestations such as connective tissue diseases or vasculitis. Rheumatological manifestations are also described in such context. Herein, we report the observation of a patient with chronic myelomonocytic leukemia (CMML) who developed systemic manifestations: polymyalgia rheumatica and pericarditis. CASE REPORT A 78-year-old patient was referred for the exploration of two months history of inflammatory shoulder pain associated with biological inflammatory syndrome. He presented with asthenia, anorexia and loss of 5kg in one month. He had a three years follow-up for a CMML without any specific treatment. All of the explorations carried out showed a typical polymyalgia rheumatica. A pericardial effusion requiring emergency drainage was synchronously diagnosed. All the symptoms occurred during a worsening of his hematological disease. The rheumatological manifestation was favorable after a short corticosteroid therapy and pericarditis did not recur after 2 years of follow-up. CONCLUSION It should be necessary to screen patients for MDS in a context of systemic manifestation, especially in elderly patients with an abnormal blood count (cytopenia, macrocytosis and monocytosis).
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21
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Gonsalves JF, Bazargan A, Ku M. Acquired Pure Red Cell Aplasia Associated with Chronic Myelomonocytic Leukemia: Too Many of One, Not Enough of the Other. Case Rep Oncol 2020; 13:1270-1274. [PMID: 33250742 PMCID: PMC7670337 DOI: 10.1159/000508934] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2020] [Accepted: 05/20/2020] [Indexed: 12/15/2022] Open
Abstract
There is a growing body of literature outlining the association between certain hematological malignancies, such as chronic myelomonocytic leukemia (CMML), and systemic autoimmune diseases. Diagnosis and management can be difficult, particularly when autoimmune phenomena overlap with features of the underlying illness. This is especially the case in patients who develop immune-mediated cytopenias in the context of underlying bone marrow disease. CMML associated with immune thrombocytopenia and hemolytic anemia has been reported a number of times in the literature; however, there are only scattered case reports describing CMML associated with acquired pure red cell aplasia. Here, we describe the diagnostic and management approach to a patient who developed both diseases.
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Affiliation(s)
- Jose Filipe Gonsalves
- Department of Clinical Hematology, St Vincent's Hospital, Melbourne, Victoria, Australia
| | - Ali Bazargan
- Department of Clinical Hematology, St Vincent's Hospital, Melbourne, Victoria, Australia
| | - Matthew Ku
- Department of Clinical Hematology, St Vincent's Hospital, Melbourne, Victoria, Australia
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22
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Roupie AL, Guedon A, Terrier B, Lahuna C, Jachiet V, Regent A, de Boysson H, Carrat F, Seguier J, Terriou L, Versini M, Queyrel V, Groh M, Benhamou Y, Maurier F, Ledoult E, Clech LL, D'Aveni M, Rossignol J, Galland J, Willems L, Chiche NJ, Peterlin P, Roux-Sauvat M, Parcelier A, Wemeau M, Lambert M, Belizna C, Puechal X, Swiader L, Cohen-Valensi R, Noc V, Dao E, Thepot S, de Frémont GM, Tanguy-Schmidt A, Koka AM, Bussone G, Philipponnet C, Konate A, Cavaille G, Guilpain P, Allain JS, Broner J, Solary E, Ruivard M, de Renzis B, Corm S, Baati N, Schleinitz N, Ponsoye M, Stamatoullas-Bastard A, Ades L, Dellal A, Tchirkov A, Aouba A, Fenaux P, Fain O, Mekinian A. Vasculitis associated with myelodysplastic syndrome and chronic myelomonocytic leukemia: French multicenter case-control study. Semin Arthritis Rheum 2020; 50:879-884. [PMID: 32896704 DOI: 10.1016/j.semarthrit.2020.07.002] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2020] [Revised: 06/13/2020] [Accepted: 07/06/2020] [Indexed: 12/20/2022]
Abstract
INTRODUCTION Our objective was to evaluate characteristics, treatment and outcome of vasculitis associated with myelodysplastic syndrome (MDS) and chronic myelomonicytic leukemia (CMML) PATIENTS AND METHODS: Retrospective descriptive analysis of MDS/CMML-related vasculitis and comparison with MDS/CMML patients without dysimmune features. RESULTS Seventy patients with vasculitis and MDS/CMML were included, with median age of 71.5 [21-90] years and male/female ratio of 2.3. Vasculitis was diagnosed prior to MDS/CMML in 31 patients (44%), and after in 20 patients. In comparison with MDS/CMML without autoimmune/inflammatory features, vasculitis with MDS/MPN showed no difference in MDS/CMML subtypes distribution nor International Prognostic Scoring System and CMML-specific prognostic (IPSS/CPSS) scores. Vasculitis subtypes included Giant cell arteritis in 24 patients (34%), Behçet's-like syndrome in 11 patients (20%) and polyarteritis nodosa in 6 patients (9%). Glucocorticoids (GCs) were used as first-line therapy for MDS/CMML vasculitis in 64/70 patients (91%) and 41 (59%) received combined immunosuppressive therapies during the follow-up. After a median follow-up of 33.2 months [1-162], 31 patients (44%) achieved sustained remission. At least one relapse occurred in 43 patients (61%). Relapse rates were higher in patients treated with conventional Disease Modifying Anti-Rheumatic Drug (DMARDs) (odds ratio 4.86 [95% CI 1.38 - 17.10]), but did not differ for biologics (odds ratio 0.59 [95% CI 0.11-3.20]) and azacytidine (odds ratio 1.44 [95% CI 0.21-9.76]) than under glucocorticoids. Overall survival in MDS/CMML vasculitis was not significantly different from MDS/CMML patients without autoimmune/inflammatory features (p = 0.5), but acute leukemia progression rates were decreased (log rank <0.05). CONCLUSION This study shows no correlation of vasculitis diagnoses with subtypes and severity of MDS/CMML, and no significant impact of vasculitis on overall survival. Whereas conventional DMARDs seem to be less effective, biologics or azacytidine therapy could be considered for even low-risk MDS/CMML vasculitis.
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Affiliation(s)
- Anne Laure Roupie
- Department of Internal Medicine, Inflammation-Immunopathology-Biotherapy Department (DHU i2B), Assistance Publique-Hôpitaux de Paris, Hôpital Saint-Antoine, 184, rue du Faubourg Saint-Antoine, 75012 Paris, France Sorbonne Université, Paris, France; Sorbonne Universités, INSERM U938, Centre de Recherche Saint-Antoine (CRSA), Paris, France
| | - Alexis Guedon
- Sorbonne Universités, INSERM U938, Centre de Recherche Saint-Antoine (CRSA), Paris, France
| | - Benjamin Terrier
- Department of Internal Medicine - National Reference Center for Rare and Systemic Autoimmune Diseases, Assistance Publique - Hôpitaux deAP-HP, Hôpital Cochin, Université de Paris, Paris, France
| | - Constance Lahuna
- Department of Internal Medicine, Inflammation-Immunopathology-Biotherapy Department (DHU i2B), Assistance Publique-Hôpitaux de Paris, Hôpital Saint-Antoine, 184, rue du Faubourg Saint-Antoine, 75012 Paris, France Sorbonne Université, Paris, France; Sorbonne Universités, INSERM U938, Centre de Recherche Saint-Antoine (CRSA), Paris, France
| | - Vincent Jachiet
- Department of Internal Medicine, Inflammation-Immunopathology-Biotherapy Department (DHU i2B), Assistance Publique-Hôpitaux de Paris, Hôpital Saint-Antoine, 184, rue du Faubourg Saint-Antoine, 75012 Paris, France Sorbonne Université, Paris, France; Sorbonne Universités, INSERM U938, Centre de Recherche Saint-Antoine (CRSA), Paris, France
| | - Alexis Regent
- Department of Internal Medicine - National Reference Center for Rare and Systemic Autoimmune Diseases, Assistance Publique - Hôpitaux deAP-HP, Hôpital Cochin, Université de Paris, Paris, France
| | - Hubert de Boysson
- Department of Internal Medicine, CHU Caen, Avenue de la côte de nacre, 14033 Caen, France
| | - Fabrice Carrat
- Sorbonne Université, INSERM, Institut Pierre Louis d'Epidémiologie et de Santé Publique, AP-HP Sorbonne Université, Hôpital Saint Antoine, 75012 Paris, France
| | - Julie Seguier
- Department of Internal Medicine, Assistance Publique-Hôpitaux de Marseille, Hôpital La Timone, Marseille, France
| | - Louis Terriou
- Department of Internal Medicine, CHU Lille, Lille, France
| | | | | | - Matthieu Groh
- Department of Internal Medicine, National Referral Center for Hypereosinophilic Syndromes (CEREO), Foch Hospital, Suresnes, France
| | - Ygal Benhamou
- Department of Internal Medicine, CHU Rouen, Rouen, France
| | - Francois Maurier
- Department of Internal Medicine, Hôpitaux Privés de Metz, Metz, France
| | - Emmanuel Ledoult
- Department of Internal Medicine and Clinical Immunology, CHU Lille, Lille, France
| | | | - Maud D'Aveni
- Department of Hematology, CHU Nancy, Nancy, France
| | - Julien Rossignol
- Department of Hematology, Gustave Roussy Cancer Center, 94805, Villejuif, France
| | - Joris Galland
- Department of Internal Medicine, Hôpital Lariboisière, Assistance Publique-Hôpitaux de Paris, Université de Paris, Paris, France
| | - Lise Willems
- Department of Hematology, Assistance Publique-Hôpitaux de Paris, Hôpital Cochin, 75014 Paris, France
| | - Noemie Jourde Chiche
- Department of Nephrology, Centre de Néphrologie et de Transplantation Rénale, Assistance Publique-Hôpitaux de Marseille, Hôpital La Conception, Marseille, France
| | | | | | - Anne Parcelier
- Department of Hematology, Centre Hospitalier Bretagne Atlantique, Vannes, France
| | | | - Marc Lambert
- Department of Internal Medicine, CHU Lille, Lille, France
| | - Cristina Belizna
- Department of Vascular Medicine, CHU d'Angers, UMR-CNRS 6015 INSERM 1083, Angers, France
| | - Xavier Puechal
- Department of Internal Medicine - National Reference Center for Rare and Systemic Autoimmune Diseases, Assistance Publique - Hôpitaux deAP-HP, Hôpital Cochin, Université de Paris, Paris, France
| | - Laure Swiader
- Department of Internal Medicine, Assistance Publique-Hôpitaux de Marseille, Hôpital La Timone, Marseille, France
| | - Rolande Cohen-Valensi
- Department of Internal Medicine, CH de Martigues Hôpital des Rayettes, Martigues, France
| | - Valérie Noc
- Department of Nephrology, CH Hyères, Hyères, France
| | - Emmanuel Dao
- Department of Nephrology, CH Hyères, Hyères, France
| | | | | | | | | | - Guillaume Bussone
- Department of Internal Medicine, Hôpital Antoine Béclère, Clamart, France
| | | | - Amadou Konate
- Department of Internal Medicine, CHU Montpellier, Montpellier, France
| | - Guilhem Cavaille
- Department of Hematology, Assistance Publique-Hôpitaux de Paris, Hôpital Cochin, 75014 Paris, France
| | - Philippe Guilpain
- Department of Internal Medicine, CHU Montpellier, Montpellier, France
| | - Jean-Sébastien Allain
- Department of Internal Medicine and Clinical Immunology, CHU Lille, Lille, France; Pôle cardio vasculaire et métabolisme, CH Saint-Malo, Saint-Malo, France
| | - Jonathan Broner
- Department of Internal Medicine, CHU de Nîmes, Nîmes, France
| | - Eric Solary
- Department of Hematology, Gustave Roussy Cancer Center, 94805, Villejuif, France
| | - Marc Ruivard
- Department of Internal Medicine, CHU Clermont-Ferrand, Clermont-Ferrand, France
| | - Benoit de Renzis
- Department of Hematology, CHU Clermont-Ferrand, Clermont-Ferrand, France
| | - Sélim Corm
- Department of Hematology, Médipôle de Savoie, Charles Les Eaux, France
| | - Nadia Baati
- Department of Hematology, CH Strasbourg, Strasbourg, France
| | - Nicolas Schleinitz
- Department of Internal Medicine, Assistance Publique-Hôpitaux de Marseille, Hôpital La Timone, Marseille, France
| | - Matthieu Ponsoye
- Department of Internal Medicine, CHU Ambroise Paré, Boulogne- Billancourt, France
| | | | - Lionel Ades
- Department of Hematology, Assistance Publique-Hôpitaux de Paris, Hôpital Saint Louis, 1 avenue Claude Vellefaux, 75010 Paris, France
| | - Azeddine Dellal
- Department of Rheumatology, Montfermeil Hospital, 93370 Montfermeil, France
| | - Andrei Tchirkov
- Department of Medical Cytogenetics, CHU Clermont-Ferrand, Clermont-Ferrand, France
| | - Achille Aouba
- Department of Internal Medicine, CHU Montpellier, Montpellier, France
| | - Pierre Fenaux
- Department of Medical Cytogenetics, CHU Clermont-Ferrand, Clermont-Ferrand, France
| | - Olivier Fain
- Department of Internal Medicine, Inflammation-Immunopathology-Biotherapy Department (DHU i2B), Assistance Publique-Hôpitaux de Paris, Hôpital Saint-Antoine, 184, rue du Faubourg Saint-Antoine, 75012 Paris, France Sorbonne Université, Paris, France; Sorbonne Universités, INSERM U938, Centre de Recherche Saint-Antoine (CRSA), Paris, France
| | - Arsène Mekinian
- Department of Internal Medicine, Inflammation-Immunopathology-Biotherapy Department (DHU i2B), Assistance Publique-Hôpitaux de Paris, Hôpital Saint-Antoine, 184, rue du Faubourg Saint-Antoine, 75012 Paris, France Sorbonne Université, Paris, France; Sorbonne Universités, INSERM U938, Centre de Recherche Saint-Antoine (CRSA), Paris, France.
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23
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Kunnumpurath A, Desikan SP, McClain C, Desikan R. Chronic Myelomonocytic Leukemia Presenting With Polyserositis and Seropositivity for Rheumatoid Arthritis. J Investig Med High Impact Case Rep 2020; 8:2324709620966863. [PMID: 33084368 PMCID: PMC7871280 DOI: 10.1177/2324709620966863] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2020] [Revised: 09/14/2020] [Accepted: 09/19/2020] [Indexed: 11/15/2022] Open
Abstract
Chronic myelomonocytic leukemia (CMML) is a rare clonal stem cell disorder associated with clinical and pathologic of myelodysplasia and myeloproliferation. Systemic autoimmune/inflammatory disorders (SAID) and polyserositis have been associated with CMML. These manifestations can be observed concomitantly, shortly before diagnosis or anytime along the course of illness. We report a case of myeloproliferative CMML who presented with polyserositis and positive serology for rheumatoid arthritis. Retrospective studies of myelodysplasia/CMML have reported 15% to 25% incidence of SAID. The most commonly observed disorders include systemic vasculitis, connective tissue diseases, polychondritis, seronegative arthritis, and immune thrombocytopenia. SAID does not confer adverse prognosis in retrospective studies. Polyserositis is less common; this may result from leukemic infiltrate or result from autoimmunity. Treatment of serositis includes steroids and cytoreductive agents. Serositis may confer poor prognosis and hypomethylating therapy may improve the outcome.
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24
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Autoimmune disease in CMML-the chicken or the egg? Best Pract Res Clin Haematol 2019; 33:101136. [PMID: 32460986 DOI: 10.1016/j.beha.2019.101136] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2019] [Revised: 12/09/2019] [Accepted: 12/10/2019] [Indexed: 12/14/2022]
Abstract
Chronic myelomonocytic leukemia (CMML) is a clonal disorder that is associated with a wide range of systemic inflammatory and autoimmune diseases (SIADs). Approximately 20% of patients with CMML will have an associated SIAD and recognizing this association is critical to the evaluation, prognostication and management of patients with CMML. In this paper, we review the evidence supporting a causative link between these two entities as well as the direction of this relationship. We argue that the data favors CMML as the antecedent and causative disease state with a few notable exceptions. Better understanding of this relationship aids clinicians in the education of their patients and in determining the optimal management approach at the bedside. It is important to recognize opportunities to harmonize the treatments of these disease processes, which may enhance the effectiveness of treatment while reducing the burden of adverse effects from redundant therapies.
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25
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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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26
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Amin SD, Vickers A, Hong BY, Ponce CMP, Ibrahim IF, Chevez-Barrios P, Lee AG. Chronic myelomonocytic leukemia-related vasculitis mimicking giant cell arteritis. Can J Ophthalmol 2019; 54:e140-e145. [PMID: 31109503 DOI: 10.1016/j.jcjo.2018.08.017] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2018] [Revised: 08/26/2018] [Accepted: 08/29/2018] [Indexed: 11/25/2022]
Affiliation(s)
- Sima D Amin
- Texas A&M College of Medicine, College Station, Texas
| | - Aroucha Vickers
- Department of Ophthalmology, Blanton Eye Institute, Houston Methodist Hospital, Houston, Texas
| | - Bennett Y Hong
- Department of Ophthalmology, The University of Texas Medical Branch, Galveston, Texas
| | | | - Ibrahim F Ibrahim
- Department of Hematology and Oncology, Houston Methodist Hospital, Houston, Texas
| | - Patricia Chevez-Barrios
- Department of Pathology and Genomic Medicine, Houston Methodist Hospital, Houston, Texas; Baylor College of Medicine, Houston, Texas; Department of Pathology and Laboratory Medicine, Weill Cornell Medicine, New York, N.Y.; The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Andrew G Lee
- Texas A&M College of Medicine, College Station, Texas; Department of Ophthalmology, Blanton Eye Institute, Houston Methodist Hospital, Houston, Texas; Department of Ophthalmology, The University of Texas Medical Branch, Galveston, Texas; Department of Ophthalmology, Neurology, and Neurosurgery Ophthalmology, Weill Cornell Medicine, New York, N.Y.; Division of Ophthalmology, The University of Texas MD Anderson Cancer Center, Houston, Texas; Department of Ophthalmology, The University of Iowa Hospitals and Clinics, Iowa City, Iowa; Department of Ophthalmology, Texas A&M College of Medicine, College Station, Texas..
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27
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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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28
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Tanaka H, Yano M, Kuwabara C, Kume A, Tamura Y, Murakami M, Shimizu R, Saito H, Suzuki Y. Massive Hemoptysis Due to the Rupture of Thoracic Aortic Aneurysm Caused by Leukemic Cell Infiltration in a Patient With Chronic Myelomonocytic Leukemia. J Clin Med Res 2019; 11:145-150. [PMID: 30701008 PMCID: PMC6340676 DOI: 10.14740/jocmr3712] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2018] [Accepted: 12/21/2018] [Indexed: 12/18/2022] Open
Abstract
Hemoptysis is occasionally experienced in patients with hematological malignancies who have respiratory tract infection and severe thrombocytopenia. Thrombocytopenia due to hematological disease is one cause of hemoptysis. Chronic myelomonocytic leukemia (CMML) is a clonal hematopoietic malignancy characterized by both a myeloproliferative neoplasm and a myelodysplastic syndrome. This malignancy often infiltrates various extramedullary organs and has a poor prognosis. An 84-year-old Japanese man with CMML was suffered from hemoptysis and dyspnea. When he arrived at the emergency room, hemoptysis stopped. His white blood cell count was 866 × 109/L with 3.5% blast cells and 36.5% monocytes; hemoglobin was 6.7 g/dL; platelets count was 19 × 109/L; and C-reactive protein was 16.23 mg/dL. Chest X-ray examination revealed an invasion shadow near the mediastinum in the left upper lung field. Chest computed tomography revealed a tumorous lesion in the left upper lobe, which had progressed to the mediastinum and formed an infiltration shadow around it. He was administered the antibiotics and the hemostatic agents under hospitalization. He also received blood transfusion for anemia and thrombocytopenia. Rapid improvement in oxygenation was observed along with a rapid decrease in blood levels in the sputum. On the eighth days of hospitalization, however, the patient newly developed massive hemoptysis and died. Autopsy revealed rupture of a thoracic pseudoaneurysm due to infiltration of leukemia cells in the tunica media and lung. Clinicians should consider thoracic aortic aneurysms as a possible cause of hemoptysis even in cases with small hemoptysis. It should be noted that in CMML patients, direct infiltration of leukemia cells in the vascular wall can cause aneurysm formation.
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Affiliation(s)
- Hiroaki Tanaka
- Department of Hematology, Asahi General Hospital, Chiba, Japan
| | - Mizuki Yano
- Department of Internal Medicine, Asahi General Hospital, Chiba, Japan
| | | | - Ayaka Kume
- Department of Hematology, Asahi General Hospital, Chiba, Japan
| | - Yuri Tamura
- Department of Hematology, Asahi General Hospital, Chiba, Japan
| | - Miki Murakami
- Department of Clinical Pathology, Asahi General Hospital, Chiba, Japan
| | - Ryo Shimizu
- Department of Hematology, Asahi General Hospital, Chiba, Japan
| | - Haruhisa Saito
- Department of Respiratory Medicine, Asahi General Hospital, Chiba, Japan
| | - Yoshio Suzuki
- Department of Clinical Pathology, Asahi General Hospital, Chiba, Japan
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29
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Jacobse J, Sijpkens YWJ, van 't Wout JW, Peters EEM, Vlasveld LT. Vasculitis in Myelodysplastic Syndrome and Chronic Myelomonocytic Leukemia: A Report of Two Cases. J Hematol 2018; 7:158-162. [PMID: 32300432 PMCID: PMC7155851 DOI: 10.14740/jh461w] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2018] [Accepted: 10/18/2018] [Indexed: 11/30/2022] Open
Abstract
There is a clear association between myelodysplastic syndrome (MDS)/chronic myelomonocytic leukemia (CMML) and autoimmune manifestations such as vasculitis. It is not clear if autoimmune manifestations in myelodysplastic syndrome are a cause or consequence. We describe two patients with polyarteritis nodosa and large vessel vasculitis, as presenting symptom of a myelodysplastic syndrome with excess blasts type 2 and chronic myelomonocytic leukemia respectively. Immunosuppressive treatment resulted in amelioration of the vasculitis with improvement of the myelodysplastic features in the first patient and rapid evolution to acute myeloid leukemia in the other patient. The association between MDS/CMML and autoimmune manifestations, such as vasculitis, emphasizes the role of autoimmunity in the clinical features and even pathogenesis of MDS/CMML.
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Affiliation(s)
- Justin Jacobse
- Department of Internal Medicine, HMC Bronovo, The Hague, Netherlands
| | - Yvo W J Sijpkens
- Department of Internal Medicine, HMC Bronovo, The Hague, Netherlands
| | - Jan W van 't Wout
- Department of Internal Medicine, HMC Bronovo, The Hague, Netherlands
| | - Elke E M Peters
- Department of Pathology, HMC Bronovo, The Hague, Netherlands
| | - L Tom Vlasveld
- Department of Internal Medicine, HMC Bronovo, The Hague, Netherlands
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30
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Shargian-Alon L, Raanani P, Rozovski U, Siegal T, Yust-Katz S, Yeshurun M. Immune Mediated Cerebellar Ataxia: An Unknown Manifestation of Graft-versus-Host Disease. Acta Haematol 2018; 141:19-22. [PMID: 30439710 DOI: 10.1159/000494423] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2018] [Accepted: 10/01/2018] [Indexed: 11/19/2022]
Abstract
Neurologic complications of allogeneic hematopoietic cell transplantation (allo-HCT) include infections, cerebrovascular events, therapy-induced neurotoxicity, recurrent malignancies, and neurologic manifestations of graft-versus-host disease (GVHD). Anti-glutamic acid decarboxylase (GAD) antibody-associated cerebellar ataxia is a well-established disorder of autoimmune origin, but there are no reports in the literature of its occurrence following allo-HCT. We describe a middle-aged woman with chronic GVHD after allo-HCT who presented with a rapidly progressive cerebellar syndrome. Thorough investigation revealed only cerebellar atrophy on brain imaging and positive anti-GAD65 antibodies in serum and cerebrospinal fluid suggesting the diagnosis of anti-GAD antibody-associated cerebellar ataxia. Despite prompt treatment with high-dose corticosteroids, intravenous immunoglobulins, and rituximab, the patient's condition rapidly deteriorated, and she died 4 months later. This case suggests that anti-GAD antibody-associated cerebellar ataxia may be a rare manifestation of chronic GVHD.
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Affiliation(s)
- Liat Shargian-Alon
- Institute of Hematology, Davidoff Cancer Center, Rabin Medical Center, Petach Tikva, Israel,
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel,
| | - Pia Raanani
- Institute of Hematology, Davidoff Cancer Center, Rabin Medical Center, Petach Tikva, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Uri Rozovski
- Institute of Hematology, Davidoff Cancer Center, Rabin Medical Center, Petach Tikva, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Tali Siegal
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- Neuro-Oncology Center, Davidoff Cancer Center, Rabin Medical Center, Petach Tikva, Israel
| | - Shlomit Yust-Katz
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- Neuro-Oncology Center, Davidoff Cancer Center, Rabin Medical Center, Petach Tikva, Israel
| | - Moshe Yeshurun
- Institute of Hematology, Davidoff Cancer Center, Rabin Medical Center, Petach Tikva, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
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31
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Pophali P, Horna P, Lasho TL, Finke CM, Ketterling RP, Gangat N, Nagorney D, Tefferi A, Patnaik MM. Splenectomy in patients with chronic myelomonocytic leukemia: Indications, histopathological findings and clinical outcomes in a single institutional series of thirty-nine patients. Am J Hematol 2018; 93:1347-1357. [PMID: 30105755 PMCID: PMC6196105 DOI: 10.1002/ajh.25246] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2018] [Revised: 08/03/2018] [Accepted: 08/06/2018] [Indexed: 12/13/2022]
Abstract
In a 28-year period, 39 (7%) patients with chronic myelomonocytic leukemia (CMML) (median age 66 years, 64% male) underwent a splenectomy at our institution. Primary indications for splenectomy were refractory thrombocytopenia (36%), progressive spleen related symptoms (33%), emergent splenectomy for splenic rupture (21%), refractory anemia (8%), and prior to allogeneic stem cell transplant (3%). Eleven (28%) patients had anemia at the time of splenectomy, of which 3 (27%) were autoimmune. The median time to splenectomy from CMML diagnosis was 6 months (0-40); perioperative morbidity and mortality rates were 43% and 13%, while the median postsplenectomy survival was 25 months (11-38). Durable remission in spleen related symptoms, thrombocytopenia, complications from splenic rupture, and anemia were achieved in 85%, 50%, 62%, and 21% of patients, respectively. Perioperative morbidity (n = 30) included infections/sepsis in 6 (20%), intraabdominal bleeding in 4 (13%), venous thromboembolism (VTE) in 3 (10%), and acute lung injury in 2 (7%) patients. The median duration of hospital stay was 6 days (1-25), with 5 deaths occurring secondary to respiratory failure (n = 2), multiorgan dysfunction (n = 2) and hemorrhagic shock (n = 1). There was no difference in overall survival between CMML patients that underwent splenectomy, in comparison to those that did not. Unlike in myelofibrosis, portal hypertension was not an indication for splenectomy and no patients developed post-splenectomy thrombocytosis. In conclusion, apart from being a lifesaving emergent modality in the event of splenic rupture, splenectomy has an important palliative role in patients with CMML, with significant and durable improvements in spleen related symptoms and refractory cytopenias.
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Affiliation(s)
- Prateek Pophali
- Division of Hematology, Department of Internal Medicine,
Mayo Clinic, Rochester, MN
| | - Pedro Horna
- Division of Hematopathology, Department of Laboratory
Medicine, Mayo Clinic, Rochester, MN
| | - Terra L. Lasho
- Division of Hematology, Department of Internal Medicine,
Mayo Clinic, Rochester, MN
| | - Christy M. Finke
- Division of Hematology, Department of Internal Medicine,
Mayo Clinic, Rochester, MN
| | - Rhett P. Ketterling
- Division of Hematopathology, Department of Laboratory
Medicine, Mayo Clinic, Rochester, MN
| | - Naseema Gangat
- Division of Hematology, Department of Internal Medicine,
Mayo Clinic, Rochester, MN
| | - David Nagorney
- Department of General Surgery, Mayo Clinic, Rochester,
MN
| | - Ayalew Tefferi
- Division of Hematology, Department of Internal Medicine,
Mayo Clinic, Rochester, MN
| | - Mrinal M. Patnaik
- Division of Hematology, Department of Internal Medicine,
Mayo Clinic, Rochester, MN
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32
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Autoimmune manifestations associated with myelodysplastic syndromes. Ann Hematol 2018; 97:2015-2023. [PMID: 30091023 DOI: 10.1007/s00277-018-3472-9] [Citation(s) in RCA: 49] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2018] [Accepted: 08/06/2018] [Indexed: 12/19/2022]
Abstract
Autoimmune disorders (ADs) are encountered in 10 to 20% of patients with myelodysplastic syndromes (MDS). Available data suggest that ADs concern more often younger patients with higher risk IPSS. MDS subtypes associated with ADs are mainly MDS with single lineage dysplasia (MDS-SLD) and MDS with excess blasts (MDS-EB). Various types of ADs have been described in association with MDS, ranging from limited clinical manifestations to systemic diseases affecting multiple organs. Defined clinical entities as vasculitis, connective tissue diseases, inflammatory arthritis, and neutrophilic diseases are frequently reported; however, unclassified or isolated organ impairment can be seen. In general, ADs do not seem to confer worse survival, although certain ADs may be associated with adverse outcomes (i.e., vasculitis) or progression of MDS (Sweet syndrome). While steroids and immunosuppressive treatment (IST) remain the backbone of first-line treatment, increasing evidence suggests that MDS-specific therapy as hypomethylating agents, based on their immunomodulatory effect, may be effective in treating these complications and for sparing steroids.
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33
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Chronic Myelomonocytic Leukemia following Multicentric Castleman Disease. Case Rep Hematol 2018; 2018:5895903. [PMID: 29607228 PMCID: PMC5828649 DOI: 10.1155/2018/5895903] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2017] [Accepted: 12/07/2017] [Indexed: 11/18/2022] Open
Abstract
Multicentric Castleman disease (MCD) is a rare nonmalignant lymphoproliferative disorder presenting systemic symptoms such as fever, night sweats, fatigue, anemia, effusions, and multifocal lymphadenopathy. The etiology of MCD has not been clarified to date. The coexistence of MCD with chronic myelomonocytic leukemia (CMML) has been rarely reported. Although the pathogenesis remains unclear, this association probably reflects an incidental and fortuitous finding rather than the alteration of a common pluripotent stem cell precursor. Herein, we report on one case of MCD coexisting with CMML and elucidate the underlying mechanism of pathology in some aspects.
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34
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Ricard L, Abisror N, Droin N, Selimoglu-Buet D, Martin A, Soussan M, Willekens C, Deligny C, Fain O, Solary E, Mekinian A. Retroperitoneal fibrosis as extramedullary hematopoiesis of a chronic myelomonocytic leukemia. Leuk Lymphoma 2018; 59:2503-2505. [PMID: 29368535 DOI: 10.1080/10428194.2018.1427857] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Affiliation(s)
- Laure Ricard
- a Service de médecine interne, UPMC, AP-HP, Hôpital Saint Antoine, Sorbonne University , Paris , France
| | - Noémie Abisror
- a Service de médecine interne, UPMC, AP-HP, Hôpital Saint Antoine, Sorbonne University , Paris , France
| | - Nathalie Droin
- b Département d'hématologie, Institut Gustave Roussy , Université Paris Sud , Villejuif, Paris , France.,c INSERM U1170, Gustave Roussy, Université Paris-Sud , Villejuif, Paris , France
| | - Dorothée Selimoglu-Buet
- b Département d'hématologie, Institut Gustave Roussy , Université Paris Sud , Villejuif, Paris , France.,c INSERM U1170, Gustave Roussy, Université Paris-Sud , Villejuif, Paris , France
| | - Antoine Martin
- d Service d'Anatomopathologie, Université Paris 13 Hôpital Avicenne Bobigny , Paris , France
| | - Michael Soussan
- e Service de Médecine Nucléaire, Université Paris 13 Hôpital Avicenne Bobigny , Paris , France
| | - Christophe Willekens
- b Département d'hématologie, Institut Gustave Roussy , Université Paris Sud , Villejuif, Paris , France
| | - Christophe Deligny
- f Service de Médecine interne, CHU de Martinique, Fort de France , Martinique , France
| | - Olivier Fain
- a Service de médecine interne, UPMC, AP-HP, Hôpital Saint Antoine, Sorbonne University , Paris , France
| | - Eric Solary
- b Département d'hématologie, Institut Gustave Roussy , Université Paris Sud , Villejuif, Paris , France.,c INSERM U1170, Gustave Roussy, Université Paris-Sud , Villejuif, Paris , France
| | - Arsène Mekinian
- a Service de médecine interne, UPMC, AP-HP, Hôpital Saint Antoine, Sorbonne University , Paris , France
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Abstract
Chronic myelomonocytic leukemia (CMML) is a clonal hematopoietic malignancy that may deserve specific management. Defined by a persistent peripheral blood monocytosis ≥1 × 109/L and monocytes accounting for ≥10% of the white blood cells, this aging-associated disease combines cell proliferation as a consequence of myeloid progenitor hypersensitivity to granulocyte-macrophage colony-stimulating factor with myeloid cell dysplasia and ineffective hematopoiesis. The only curative option for CMML remains allogeneic stem cell transplantation. When transplantation is excluded, CMML is stratified into myelodysplastic (white blood cell count <13 × 109/L) and proliferative (white blood cell count ≥13 × 109/L) CMML. In the absence of poor prognostic factors, the management of myelodysplastic CMML is largely inspired from myelodysplastic syndromes, relying on erythropoiesis-stimulating agents to cope with anemia, and careful monitoring and supportive care, whereas the management of proliferative CMML usually relies on cytoreductive agents such as hydroxyurea, although ongoing studies will help delineate the role of hypomethylating agents in this patient population. In the presence of excessive blasts and other poor prognostic factors, hypomethylating agents are the preferred option, even though their impact on leukemic transformation and survival has not been proved. The therapeutic choice is illustrated by 4 clinical situations among the most commonly seen. Although current therapeutic options can improve patient's quality of life, they barely modify disease evolution. Improved understanding of CMML pathophysiology will hopefully lead to the exploration of novel targets that potentially would be curative.
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36
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Abstract
Aortitis is a broad term describing inflammation of the aorta. The most common causes of aortitis are the large-vessel vasculitides giant cell arteritis and Takayasu arteritis. Other etiologies include aortitis associated with other autoimmune disorders, infectious causes, and paraneoplastic and idiopathic cases. We describe a rare case of a large-vessel arteritis occurring in association with chronic myelomonocytic leukemia (CMML). A 68-year-old female with recent diagnosis of CMML presented to our office for evaluation of abnormal chest computed tomography (CT) that showed inflammation surrounding the entirety of thoracic and abdominal aorta, consistent with aortitis. In the absence of other evident causes of large-vessel vasculitis, we attributed this finding to a paraneoplastic autoimmune phenomenon and started treatment with systemic glucocorticoids. This rare case emphasizes the need to recognize autoimmune complications in CMML and treat the inflammation along with the primary malignancy promptly.
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37
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Abstract
Chronic Myelomonocytic Leukemia is a chronic myeloid neoplasm occurring mostly in the elderly with overlapping features of myelodysplastic syndromes (MDS) and myeloproliferative neoplasms (MPN) characterized by chronic monocytosis. Recent progresses in the molecular and cellular pathogenesis of CMML have stirred a renewed interest in this clinically heterogeneous disorder. Here, we review the recent progresses in the biology of CMML and how it affects its current and future clinical management.
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38
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El-Fattah MA. Second malignancies in survivors of chronic myelomonocytic leukemia: a U.S. population-based study. Leuk Lymphoma 2017; 58:1-7. [DOI: 10.1080/10428194.2016.1276289] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Affiliation(s)
- Mohamed Abd El-Fattah
- Department of Internal Medicine, Faculty of Medicine, Suez Canal University, Ismailia, Egypt
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39
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When clinical heterogeneity exceeds genetic heterogeneity: thinking outside the genomic box in chronic myelomonocytic leukemia. Blood 2016; 128:2381-2387. [DOI: 10.1182/blood-2016-07-692988] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2016] [Accepted: 09/25/2016] [Indexed: 12/26/2022] Open
Abstract
Abstract
Exome sequencing studies in chronic myelomonocytic leukemia (CMML) illustrate a mutational landscape characterized by few somatic mutations involving a subset of recurrent gene mutations in ASXL1, SRSF2, and TET2, each approaching 40% in incidence. This has led to the clinical implementation of next-generation sequencing panels that effectively identify clonal monocytosis and complement clinical prognostic scoring systems in most patients. However, most murine models based on single gene mutations fail to recapitulate the CMML phenotype, and many gene mutations are loss of function, making the identification of traditional therapeutic vulnerabilities challenging. Further, as a subtype of the myelodysplastic/myeloproliferative neoplasms, CMML has a complex clinical heterogeneity not reflected by the mutational landscape. In this review, we will discuss the discordance between mutational homogeneity and clinical complexity and highlight novel genomic and nongenomic approaches that offer insight into the underlying clinical characteristics of CMML.
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40
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Zahid MF, Barraco D, Lasho TL, Finke C, Ketterling RP, Gangat N, Hanson CA, Tefferi A, Patnaik MM. Spectrum of autoimmune diseases and systemic inflammatory syndromes in patients with chronic myelomonocytic leukemia. Leuk Lymphoma 2016; 58:1488-1493. [DOI: 10.1080/10428194.2016.1243681] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Affiliation(s)
- Mohammad Faizan Zahid
- Division of Hematology, Department of Internal Medicine, Mayo Clinic, Rochester, MN, USA
| | - Daniela Barraco
- Division of Hematology, Department of Internal Medicine, Mayo Clinic, Rochester, MN, USA
| | - Terra L. Lasho
- Division of Hematology, Department of Internal Medicine, Mayo Clinic, Rochester, MN, USA
| | - Christy Finke
- Division of Hematology, Department of Internal Medicine, Mayo Clinic, Rochester, MN, USA
| | - Rhett P. Ketterling
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, USA
| | - Naseema Gangat
- Division of Hematology, Department of Internal Medicine, Mayo Clinic, Rochester, MN, USA
| | - Curtis A. Hanson
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, USA
| | - Ayalew Tefferi
- Division of Hematology, Department of Internal Medicine, Mayo Clinic, Rochester, MN, USA
| | - Mrinal M. Patnaik
- Division of Hematology, Department of Internal Medicine, Mayo Clinic, Rochester, MN, USA
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