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Paillassa J, Maitre E, Belarbi Boudjerra N, Madani A, Benlakhal R, Matthes T, Van Den Neste E, Cailly L, Inchiappa L, Bekadja MA, Tomowiak C, Troussard X. Recommendations for the Management of Patients with Hairy-Cell Leukemia and Hairy-Cell Leukemia-like Disorders: A Work by French-Speaking Experts and French Innovative Leukemia Organization (FILO) Group. Cancers (Basel) 2024; 16:2185. [PMID: 38927891 PMCID: PMC11201647 DOI: 10.3390/cancers16122185] [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: 04/15/2024] [Revised: 05/28/2024] [Accepted: 05/29/2024] [Indexed: 06/28/2024] Open
Abstract
INTRODUCTION Hairy-cell leukemia (HCL) is a rare B-cell chronic lymphoproliferative disorder (B-CLPD), whose favorable prognosis has changed with the use of purine nucleoside analogs (PNAs), such as cladribine (CDA) or pentostatin (P). However, some patients eventually relapse and over time HCL becomes resistant to chemotherapy. Many discoveries have been made in the pathophysiology of HCL during the last decade, especially in genomics, with the identification of the BRAFV600E mutation and cellular biology, including the importance of signaling pathways as well as tumor microenvironment. All of these new developments led to targeted treatments, especially BRAF inhibitors (BRAFis), MEK inhibitors (MEKis), Bruton's tyrosine kinase (BTK) inhibitors (BTKis) and recombinant anti-CD22 immunoconjugates. RESULTS The following major changes or additions were introduced in these updated guidelines: the clinical relevance of the changes in the classification of splenic B-cell lymphomas and leukemias; the increasingly important diagnostic role of BRAFV600E mutation; and the prognostic role of the immunoglobulin (IG) variable (V) heavy chain (H) (IGHV) mutational status and repertory. We also wish to insist on the specific involvement of bones, skin, brain and/or cerebrospinal fluid (CSF) of the disease at diagnosis or during the follow-up, the novel targeted drugs (BRAFi and MEKi) used for HCL treatment, and the increasing role of minimal residual disease (MRD) assessment. CONCLUSION Here we present recommendations for the diagnosis of HCL, treatment in first line and in relapsed/refractory patients as well as for HCL-like disorders including HCL variant (HCL-V)/splenic B-cell lymphomas/leukemias with prominent nucleoli (SBLPN) and splenic diffuse red pulp lymphoma (SDRPL).
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Affiliation(s)
- Jérôme Paillassa
- Service des Maladies du Sang, CHU d’Angers, 49000 Angers, France;
| | - Elsa Maitre
- Hématologie Biologique, Structure Fédérative D’oncogénétique Cyto-Moléculaire du CHU de Caen (SF-MOCAE), CHU de Caen, 14000 Caen, France;
- Unité MICAH, INSERM1245, Université Caen-Normandie, 14000 Caen, France
| | | | - Abdallah Madani
- Service d’Hématologie, CHU de Casablanca, Casablanca 20000, Morocco;
| | | | - Thomas Matthes
- Service d’Hématologie, Département d’Oncologie et Service de Pathologie Clinique, Département de Diagnostic, Hôpital Universitaire de Genève, 1205 Genève, Switzerland;
| | - Eric Van Den Neste
- Cliniques Universitaires Saint-Luc, Université Catholique de Louvain, 1000 Brussels, Belgium;
| | - Laura Cailly
- Service d’Onco-Hématologie et de Thérapie Cellulaire, CHU de Poitiers, 86000 Poitiers, France; (L.C.)
| | - Luca Inchiappa
- Service d’Hématologie, Institut Paoli-Calmette, 13397 Marseille, France
| | | | - Cécile Tomowiak
- Service d’Onco-Hématologie et de Thérapie Cellulaire, CHU de Poitiers, 86000 Poitiers, France; (L.C.)
| | - Xavier Troussard
- Hématologie Biologique, Structure Fédérative D’oncogénétique Cyto-Moléculaire du CHU de Caen (SF-MOCAE), CHU de Caen, 14000 Caen, France;
- Hematologie CHU Caen Normandie, 14000 Caen, France
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Troussard X, Maître E, Paillassa J. Hairy cell leukemia 2024: Update on diagnosis, risk-stratification, and treatment-Annual updates in hematological malignancies. Am J Hematol 2024; 99:679-696. [PMID: 38440808 DOI: 10.1002/ajh.27240] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2023] [Revised: 01/10/2024] [Accepted: 01/19/2024] [Indexed: 03/06/2024]
Abstract
DISEASE OVERVIEW Hairy cell leukemia (HCL) and HCL-like disorders, including HCL variant (HCL-V) and splenic diffuse red pulp lymphoma (SDRPL), are a very heterogenous group of mature lymphoid B-cell disorders characterized by the identification of hairy cells, a specific genetic profile, a different clinical course and the need for appropriate treatment. DIAGNOSIS Diagnosis of HCL is based on morphological evidence of hairy cells, an HCL immunologic score of 3 or 4 based on the CD11c, CD103, CD123, and CD25 expression, the trephine biopsy which makes it possible to specify the degree of tumoral bone marrow infiltration and the presence of BRAFV600E somatic mutation. RISK STRATIFICATION Progression of patients with HCL is based on a large splenomegaly, leukocytosis, a high number of hairy cells in the peripheral blood, and the immunoglobulin heavy chain variable region gene mutational status. VH4-34 positive HCL cases are associated with a poor prognosis, as well as HCL with TP53 mutations and HCL-V. TREATMENT Patients should be treated only if HCL is symptomatic. Chemotherapy with risk-adapted therapy purine analogs (PNAs) are indicated in first-line HCL patients. The use of chemo-immunotherapy combining cladribine (CDA) and rituximab (R) represents an increasingly used therapeutic approach. Management of relapsed/refractory disease is based on the use of BRAF inhibitors (BRAFi) plus R, MEK inhibitors (MEKi), recombinant immunoconjugates targeting CD22, Bruton tyrosine kinase inhibitors (BTKi), and Bcl-2 inhibitors (Bcl-2i). However, the optimal sequence of the different treatments remains to be determined.
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Affiliation(s)
| | - Elsa Maître
- Laboratoire Hématologie, CHU Côte de Nacre, Caen Cedex, France
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Romero-Olmedo AJ, Schulz AR, Das Gupta D, Staudenraus D, Hirseland H, Camara B, Ferrara S, Schulze-Koops H, Rummel M, Mei HE, Lohoff M, Keller C. Unusual T SCM -like cells with poly-chemokine-receptor expression in a B-cell-depleted survivor of severe COVID-19. J Med Virol 2024; 96:e29367. [PMID: 38235935 DOI: 10.1002/jmv.29367] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2023] [Revised: 12/05/2023] [Accepted: 12/20/2023] [Indexed: 01/19/2024]
Affiliation(s)
- Addi Josua Romero-Olmedo
- Institute of Medical Microbiology and Hospital Hygiene, Philipps-University Marburg, Marburg, Germany
| | - Axel Ronald Schulz
- Deutsches Rheuma-Forschungszentrum Berlin, a Leibniz Institute, Berlin, Germany
| | - Dennis Das Gupta
- Institute of Medical Microbiology and Hospital Hygiene, Philipps-University Marburg, Marburg, Germany
| | - Daniel Staudenraus
- Institute of Medical Microbiology and Hospital Hygiene, Philipps-University Marburg, Marburg, Germany
| | - Heike Hirseland
- Deutsches Rheuma-Forschungszentrum Berlin, a Leibniz Institute, Berlin, Germany
| | - Bärbel Camara
- Institute of Medical Microbiology and Hospital Hygiene, Philipps-University Marburg, Marburg, Germany
| | - Sebastian Ferrara
- Deutsches Rheuma-Forschungszentrum Berlin, a Leibniz Institute, Berlin, Germany
| | - Hendrik Schulze-Koops
- Division of Rheumatology and Clinical Immunology, Department of Medicine IV, Ludwig-Maximilians-Universität München, Munich, Germany
| | - Mathias Rummel
- Department for Haematology, Clinic for Haematology and Medical Oncology, Justus-Liebig University-Hospital, Gießen, Germany
| | - Henrik E Mei
- Deutsches Rheuma-Forschungszentrum Berlin, a Leibniz Institute, Berlin, Germany
| | - Michael Lohoff
- Institute of Medical Microbiology and Hospital Hygiene, Philipps-University Marburg, Marburg, Germany
| | - Christian Keller
- Institute of Virology, Philipps-University Marburg, Marburg, Germany
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[Chinese guideline for diagnosis and treatment of hairy cell leukemia (2023)]. ZHONGHUA XUE YE XUE ZA ZHI = ZHONGHUA XUEYEXUE ZAZHI 2023; 44:969-976. [PMID: 38503518 PMCID: PMC10834873 DOI: 10.3760/cma.j.issn.0253-2727.2023.12.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Subscribe] [Scholar Register] [Received: 11/02/2023] [Indexed: 03/21/2024]
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Kreitman RJ, Yu T, James L, Feurtado J, Eager H, Ortiz OS, Gould M, Mauter J, Zhou H, Burbelo PD, Cohen JI, Wang HW, Yuan CM, Arons E. COVID-19 in patients with classic and variant hairy cell leukemia. Blood Adv 2023; 7:7161-7168. [PMID: 37729613 PMCID: PMC10698257 DOI: 10.1182/bloodadvances.2023011147] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2023] [Revised: 08/10/2023] [Accepted: 09/07/2023] [Indexed: 09/22/2023] Open
Abstract
Hairy cell leukemia (HCL), similar to its variant HCLv, is a B-cell malignancy associated with decreased humoral immunity. We prospectively monitored the largest cohort of patients with HCL/HCLv to date (n = 503) for COVID-19 by symptoms, antibody, and polymerase chain reaction (PCR) and/or antigen positivity. Fifty percent (253 of 503) of the patients with HCL/HCLv (238 HCL and 15 HCLv) had evidence of COVID-19, with 210 (83%) testing positive by PCR or rapid-antigen test. Of the 43 patients without positive tests, all had nucleocapsid antibodies indicating COVID-19 exposure, 7 recalled no symptoms, and 36 had mild symptoms. Of the 210 who tested positive, 23, 46, 129, and 12 cases occurred in 2020, 2021, 2022, and 2023, respectively. Among them, 175 began treatment for HCL/HCLv 0.4 to 429 (median, 66) months before, and 132 had their last dose of anti-CD20 monoclonal antibody 0.2 to 229 (median, 63) months before. Two patients died, including a young woman who began rituximab 2 months after first-line cladribine before vaccine availability. Nearly all patients with HCL/HCLv recovered uneventfully from COVID-19 including those without vaccination or those with significant immunosuppression and recent treatment. However, decreased normal B cells from HCL or treatment was associated with lower spike antibody levels as a response to COVID-19 (P = .0094) and longer recovery time (P = .0036). Thus, in a large cohort of patients with HCL/HCLv and in the first to determine relationships between COVID-19 outcome and immune markers, mortality was relatively low (∼1%), sequelae were uncommon, and recovery from COVID-19 was longer if normal B cells were low after recent treatment. The trials are registered at www.clinicaltrials.gov as #NCT01087333 and #NCT04362865.
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Affiliation(s)
- Robert J. Kreitman
- Laboratory of Molecular Biology, National Cancer Institute, National Institutes of Health, Bethesda, MD
| | - Theresa Yu
- Office of Research Nursing, National Cancer Institute, National Institutes of Health, Bethesda, MD
| | - Lacey James
- Laboratory of Molecular Biology, National Cancer Institute, National Institutes of Health, Bethesda, MD
| | - Julie Feurtado
- Office of Research Nursing, National Cancer Institute, National Institutes of Health, Bethesda, MD
| | - Holly Eager
- Office of Research Nursing, National Cancer Institute, National Institutes of Health, Bethesda, MD
| | - Olena Sierra Ortiz
- Office of Research Nursing, National Cancer Institute, National Institutes of Health, Bethesda, MD
| | - Mory Gould
- Laboratory of Molecular Biology, National Cancer Institute, National Institutes of Health, Bethesda, MD
| | - Jack Mauter
- Laboratory of Molecular Biology, National Cancer Institute, National Institutes of Health, Bethesda, MD
| | - Hong Zhou
- Laboratory of Molecular Biology, National Cancer Institute, National Institutes of Health, Bethesda, MD
| | - Peter D. Burbelo
- National Institute of Dental and Craniofacial Research, National Institutes of Health, Bethesda, MD
| | - Jeffrey I. Cohen
- Laboratory of Infectious Diseases, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD
| | - Hao-Wei Wang
- Laboratory of Pathology, National Cancer Institute, National Institutes of Health, Bethesda, MD
| | - Constance M. Yuan
- Laboratory of Pathology, National Cancer Institute, National Institutes of Health, Bethesda, MD
| | - Evgeny Arons
- Laboratory of Molecular Biology, National Cancer Institute, National Institutes of Health, Bethesda, MD
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Ferenczi K, Nagy ZF, Istenes I, Eid H, Bödör C, Timár B, Demeter J. Long term follow-up of refractory/relapsed hairy cell leukaemia patients treated with low-dose vemurafenib between 2013 and 2022 at the Department of Internal Medicine and Oncology, Semmelweis University. Pathol Oncol Res 2023; 29:1611378. [PMID: 38025907 PMCID: PMC10663343 DOI: 10.3389/pore.2023.1611378] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2023] [Accepted: 10/27/2023] [Indexed: 12/01/2023]
Abstract
Introduction: Hairy cell leukemia (HCL) is an indolent B-cell lymphoproliferative disease. BRAF V600E mutation is detected in nearly all classical HCL cases which offers the possibility of targeted therapy. Objective: The aim of our study was to assess the efficacy of low-dose vemurafenib as well as to assess the long term outcome of HCL patients treated with this drug at the Department of Internal Medicine and Oncology at Semmelweis University. Methods: We report on 10 patients with classical HCL treated with low-dose vemurafenib at our Department between 2013 and 2022. Results: As a result of fixed time low-dose vemurafenib treatment, 5 of 10 patients (5/10) achieved partial remission, 4 (4/10) had stable disease, and 1 (1/10) had MRD positivity. No patients achieved complete remission. The median progression-free survival was 28.5 months while the overall survival was 82 months. Conclusion: We confirm that low dose of vemurafenib is effective and safe in the vast majority of patients with HCL. This small-molecule oral treatment allows to gain valuable time-months or even years-before further, usually parenteral treatment options have to be given or before previous treatment has to be repeated. There are also promising data supporting the combination of vemurafenib with other drugs for the treatment of HCL patients which could provide even further possibility to bridge treatment.
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Affiliation(s)
- Kata Ferenczi
- Department of Internal Medicine and Oncology, Semmelweis University, Budapest, Hungary
| | - Zsófia Flóra Nagy
- Department of Internal Medicine and Oncology, Semmelweis University, Budapest, Hungary
| | - Ildikó Istenes
- Department of Internal Medicine and Oncology, Semmelweis University, Budapest, Hungary
| | - Hanna Eid
- Department of Internal Medicine and Oncology, Semmelweis University, Budapest, Hungary
| | - Csaba Bödör
- 1st Department of Pathology and Experimental Cancer Research, Semmelweis University, Budapest, Hungary
| | - Botond Timár
- 1st Department of Pathology and Experimental Cancer Research, Semmelweis University, Budapest, Hungary
| | - Judit Demeter
- Department of Internal Medicine and Oncology, Semmelweis University, Budapest, Hungary
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Oshiro NN, Nogueira LDA, dos Santos YH, Guimarães PRB, Kalinke LP. Quality of life and financial toxicity of hematopoietic stem cell transplant recipients in COVID-19. Rev Lat Am Enfermagem 2023; 31:e3995. [PMID: 37729248 PMCID: PMC10508220 DOI: 10.1590/1518-8345.6688.3995] [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: 01/27/2023] [Accepted: 06/30/2023] [Indexed: 09/22/2023] Open
Abstract
OBJECTIVE to evaluate and correlate the quality of life and financial toxicity of adult patients undergoing hematopoietic stem cell transplantation during the COVID-19 pandemic. METHOD observational, analytical study, carried out with 35 patients in a reference hospital for transplantation in Latin America. For data collection, the Functional Assessment Cancer Therapy Bone Marrow Transplantation and COmprehensive Score for Financial Toxicity questionnaires were used. Spearman and Mann-Whitney correlation tests were used for data analysis. RESULTS general quality of life during COVID-19 had a low score (67.09/108) with greater impairment in functional well-being (14.47/28), social well-being (16.76/28) and additional concerns (23.41/40). The means of the allogeneic group were lower than those of the autologous group in all domains, showing a significant difference in relation to additional concerns (p=0.01) and in the treatment evaluation index (p=0.04). Financial toxicity was considered to have a slight impact (22.11/44). There was a relationship, albeit not significant, between quality of life and financial toxicity (p=0.051). CONCLUSION the quality of life of the sample was low; there is a correlation between quality of life and financial toxicity, although not significant. The higher the financial toxicity, the lower the quality of life.
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Affiliation(s)
- Natália Naome Oshiro
- Universidade Federal do Paraná, Departamento de Enfermagem, Curitiba, PR, Brasil
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8
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Grever MR. Two-inhibitor salvage therapy for hairy cell leukemia. Blood 2023; 141:965-966. [PMID: 36862436 DOI: 10.1182/blood.2022018319] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/03/2023] Open
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Konrat J, Rösler W, Roiss M, Meier-Abt F, Widmer CC, Balabanov S, Manz MG, Zenz T. BRAF inhibitor treatment of classical hairy cell leukemia allows successful vaccination against SARS-CoV-2. Ann Hematol 2023; 102:403-406. [PMID: 36494600 PMCID: PMC9735012 DOI: 10.1007/s00277-022-05026-z] [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: 10/18/2022] [Accepted: 11/04/2022] [Indexed: 12/13/2022]
Abstract
In classical hairy cell leukemia (HCL), standard treatments including purine analogs achieve a durable response (up to 90%), but lead to severe immunosuppression and long-lasting depletion of CD4 + T lymphocytes. The BRAF inhibitor vemurafenib is effective in HCL, but its use in first-line treatment is restricted to select clinical situations (e.g. active infection). Its impact on immune function or response to vaccines in HCL is unclear. We treated four HCL patients with vemurafenib during the COVID-19 pandemic and monitored immune reconstitution and response to SARS-CoV-2 immunization. All patients responded to HCL treatment with normalization of peripheral blood counts. No severe infections occurred. As an indication of limited immunosuppression by vemurafenib, stable CD4 + and CD8 + T lymphocyte counts and immunoglobulin levels were observed. Three out of four patients received SARS-CoV-2 vaccination (Pfizer-BioNTech) during treatment with vemurafenib. IgG antibody levels against the spike-protein of SARS-CoV-2 were detected (40-818 AE/ml). Our data suggest that vemurafenib has limited effects on cellular and humoral immune function in HCL, which allows for successful SARS-CoV-2 vaccination. These data support the use of BRAF inhibitors during the current pandemic where continued immune response is necessary for minimizing the COVID-19-related risk of non-vaccinated patients.
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Affiliation(s)
- Judith Konrat
- Department of Medical Oncology and Hematology, University Hospital Zürich and University of Zürich, Raemistrasse 100, CH-8091 Zürich, Switzerland
| | - Wiebke Rösler
- Department of Medical Oncology and Hematology, University Hospital Zürich and University of Zürich, Raemistrasse 100, CH-8091 Zürich, Switzerland
| | - Michael Roiss
- Department of Medical Oncology and Hematology, University Hospital Zürich and University of Zürich, Raemistrasse 100, CH-8091 Zürich, Switzerland
| | - Fabienne Meier-Abt
- Department of Medical Oncology and Hematology, University Hospital Zürich and University of Zürich, Raemistrasse 100, CH-8091 Zürich, Switzerland ,Institute of Medical Genetics, University of Zürich, Zürich, Switzerland
| | - Corinne C. Widmer
- Department of Medical Oncology and Hematology, University Hospital Zürich and University of Zürich, Raemistrasse 100, CH-8091 Zürich, Switzerland ,Department of Hematology, University Hospital of Basel, Basel, Switzerland
| | - Stefan Balabanov
- Department of Medical Oncology and Hematology, University Hospital Zürich and University of Zürich, Raemistrasse 100, CH-8091 Zürich, Switzerland
| | - Markus G. Manz
- Department of Medical Oncology and Hematology, University Hospital Zürich and University of Zürich, Raemistrasse 100, CH-8091 Zürich, Switzerland
| | - Thorsten Zenz
- Department of Medical Oncology and Hematology, University Hospital Zürich and University of Zürich, Raemistrasse 100, CH-8091 Zürich, Switzerland
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It's a BRAF new world for hairy cell leukemia. Blood 2022; 140:2649-2650. [PMID: 36548021 DOI: 10.1182/blood.2022017939] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
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Maitre E, Paillassa J, Troussard X. Novel targeted treatments in hairy cell leukemia and other hairy cell-like disorders. Front Oncol 2022; 12:1068981. [PMID: 36620555 PMCID: PMC9815161 DOI: 10.3389/fonc.2022.1068981] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2022] [Accepted: 11/21/2022] [Indexed: 12/24/2022] Open
Abstract
In the category of mature B-cell neoplasms, splenic B-cell lymphoma and leukemia were clearly identified and include four distinct entities: hairy cell leukemia (HCL), splenic marginal zone lymphoma (SMZL), splenic diffuse red pulp lymphoma (SDRPL) and the new entity named splenic B-cell lymphoma/leukemia with prominent nucleoli (SBLPN). The BRAFV600E mutation is detected in nearly all HCL cases and offers a possibility of targeted therapy. BRAF inhibitors (BRAFi) represent effective and promising therapeutic approaches in patients with relapsed/refractory HCL. Vemurafenib and dabrafenib were assessed in clinical trials. The BRAFV600E mutation is missing in SDRPL and SBLPN: mitogen-activated protein kinase 1 (MAP2K1) mutations were found in 40% of SBLPN and VH4-34+ HCL patients, making possible to use MEK inhibitors (MEKi) such as trametinib, cobimetinib or binimetinib in monotherapy or associated with BRAFi. Other mutations may be associated and other signaling pathways involved, including the B-cell receptor signaling (BCR), cell cycle, epigenetic regulation and/or chromatin remodeling. In SDRPL, cyclin D3 (CCND3) mutations were found in 24% of patients, offering the possibility of using cell cycle inhibitors. Even if new emerging drugs, particularly those involved in the epigenetic regulation, have recently been added to the therapeutic armamentarium in HCL and HCL-like disorders, purine nucleoside analogs more and more associated with anti-CD20 monoclonal antibodies, are still used in the frontline setting. Thanks to the recent discoveries in genetics and signaling pathways in HCL and HCL-like disorders, new targeted therapies have been developed, have proven their efficacy and safety in several clinical trials and become essential in real life: BRAFi, MEKi, Bruton Tyrosine Kinase inhibitors (BTKi) and anti-CD22 immunotoxins. New other drugs emerged and have to be assessed in the future. In this article, we will discuss the main mutations identified in HCL and HCL-like disorders and the signaling pathways potentially involved in the pathogenesis of the different hairy cell disorders. We will discuss the results of the recent clinical trials, which will help us to propose an algorithm useful in clinical practice and we will highlight the different new drugs that may be used in the near future.
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Affiliation(s)
- Elsa Maitre
- Hématologie, Centre Hospitalier Universitaire Caen Normandie, Avenue Côte de Nacre, Caen, France
| | - Jerome Paillassa
- Service des Maladies du Sang, Centre Hospitalier Universitaire d’Angers, Angers, France
| | - Xavier Troussard
- Hématologie, Centre Hospitalier Universitaire Caen Normandie, Avenue Côte de Nacre, Caen, France,*Correspondence: Xavier Troussard,
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Tiacci E, Mancini A, Marchetti M, D'Elia GM, Candoni A, Morotti A, Romano A, Gozzetti A, Broccoli A, De Carolis L, Bruna R, Tisi MC, Selleri C, Capponi M, Vallisa D, Cattaneo C, Della Porta MG, Busca A, Falini B, Massaia M, Bertù L, Pulsoni A, Rivela P, Corradini P, Passamonti F. SARS-CoV-2 infection and vaccination in patients with hairy-cell leukaemia. Br J Haematol 2022; 201:411-416. [PMID: 36541031 PMCID: PMC9877728 DOI: 10.1111/bjh.18606] [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: 09/29/2022] [Revised: 11/25/2022] [Accepted: 12/04/2022] [Indexed: 12/24/2022]
Abstract
Little is known of the course of COVID-19 and the antibody response to infection or vaccination in patients with hairy-cell leukaemia (HCL). Among a total of 58 HCL cases we studied in these regards, 37 unvaccinated patients, mostly enjoying a relatively long period free from anti-leukaemic treatment, developed COVID-19 between March 2020 and December 2021 with a usually favourable outcome (fatality rate: 5/37, 14%); however, active leukaemia, older age and more comorbidities were associated with a worse course. Postinfection (n = 11 cases) and postvaccination (n = 28) seroconversion consistently developed, except after recent anti-CD20 or venetoclax therapy, correlating with perivaccine B-cell count. Vaccination appeared to protect from severe COVID-19 in 11 patients with breakthrough infection.
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Affiliation(s)
- Enrico Tiacci
- Istituto di Ematologia e Centro di Ricerche Emato‐Oncologiche, Dipartimento di Medicina e Chirurgia, Università e Ospedale di PerugiaPerugiaItaly
| | - Alessandro Mancini
- Istituto di Ematologia e Centro di Ricerche Emato‐Oncologiche, Dipartimento di Medicina e Chirurgia, Università e Ospedale di PerugiaPerugiaItaly
| | - Monia Marchetti
- Hematology UnitAzienda Ospedaliera Ss Antonio e Biagio e Cesare ArrigoAlessandriaItaly
| | | | - Anna Candoni
- Clinica Ematologica, Azienda Sanitaria Universitaria Friuli Centrale‐ASUFCUdineItaly
| | - Alessandro Morotti
- Dipartimento di Scienze Cliniche e Biologiche, Università di TorinoTurinItaly
| | | | | | - Alessandro Broccoli
- IRCCS Azienda Ospedaliero‐Universitaria di Bologna, Istituto di Ematologia “Seràgnoli”e Dipartimento di Medicina Specialistica, Diagnostica e Sperimentale, Università di BolognaBolognaItaly
| | - Luca De Carolis
- Istituto di Ematologia e Centro di Ricerche Emato‐Oncologiche, Dipartimento di Medicina e Chirurgia, Università e Ospedale di PerugiaPerugiaItaly
| | | | | | | | - Monia Capponi
- Istituto di Ematologia e Centro di Ricerche Emato‐Oncologiche, Dipartimento di Medicina e Chirurgia, Università e Ospedale di PerugiaPerugiaItaly
| | | | | | - Matteo Giovanni Della Porta
- IRCCS Humanitas Clinical and Research Center & Humanitas University, Department of Biomedical SciencesMilanItaly
| | - Alessandro Busca
- SSD Trapianto Cellule Staminali, AOU Città della Salute e della ScienzaTurinItaly
| | - Brunangelo Falini
- Istituto di Ematologia e Centro di Ricerche Emato‐Oncologiche, Dipartimento di Medicina e Chirurgia, Università e Ospedale di PerugiaPerugiaItaly
| | - Massimo Massaia
- SC Ematologia, AO S. Croce e Carle, Cuneo, and Molecular Biotechnology Center "G. Tarone" ‐ Università di TorinoTurinItaly
| | - Lorenza Bertù
- Dipartimento di Medicina e Chirurgia, Università dell'InsubriaVareseItaly
| | | | - Paolo Rivela
- Hematology UnitAzienda Ospedaliera Ss Antonio e Biagio e Cesare ArrigoAlessandriaItaly
| | - Paolo Corradini
- Divisione di Ematologia, IRCCS Istituto Nazionale Tumori di Milano, Università di MilanoMilanItaly
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13
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Simultaneous Onset of Haematological Malignancy and COVID: An Epicovideha Survey. Cancers (Basel) 2022; 14:cancers14225530. [PMID: 36428621 PMCID: PMC9688278 DOI: 10.3390/cancers14225530] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2022] [Revised: 10/27/2022] [Accepted: 11/04/2022] [Indexed: 11/12/2022] Open
Abstract
Background: The outcome of patients with simultaneous diagnosis of haematological malignancies (HM) and COVID-19 is unknown and there are no specific treatment guidelines. Methods: We describe the clinical features and outcome of a cohort of 450 patients with simultaneous diagnosis of HM and COVID-19 registered in the EPICOVIDEHA registry between March 2020 to February 2022. Results: Acute leukaemia and lymphoma were the most frequent HM (35.8% and 35.1%, respectively). Overall, 343 (76.2%) patients received treatment for HM, which was delayed for longer than one month since diagnosis in 57 (16.6%). An overall response rate was observed in 140 (40.8%) patients after the first line of treatment. After a median follow-up of 35 days, overall mortality was 177/450 (39.3%); 30-day mortality was significantly higher in patients not receiving HM treatment (42.1%) than in those receiving treatment (27.4%, p = 0.004), either before and/or after COVID-19, or compared to patients receiving HM treatment at least after COVID-19 (15.2%, p < 0.001). Age, severe/critical COVID-19, ≥2 comorbidities, and lack of HM treatment were independent risk factors for mortality, whereas a lymphocyte count >500/mcl at COVID-19 onset was protective. Conclusions: HM treatment should be delivered as soon as possible for patients with simultaneous diagnosis of COVID-19 and HM requiring immediate therapy.
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14
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COVID-19 and Hairy-Cell Leukemia: An EPICOVIDEHA Survey. Blood Adv 2022; 6:3870-3874. [PMID: 35500220 PMCID: PMC9068260 DOI: 10.1182/bloodadvances.2022007357] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2022] [Accepted: 04/03/2022] [Indexed: 12/15/2022] Open
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15
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Falini B, De Carolis L, Tiacci E. How I treat refractory/relapsed hairy cell leukemia with BRAF inhibitors. Blood 2022; 139:2294-2305. [PMID: 35143639 PMCID: PMC11022828 DOI: 10.1182/blood.2021013502] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2021] [Accepted: 01/26/2022] [Indexed: 11/20/2022] Open
Abstract
Hairy cell leukemia (HCL) responds very well to frontline chemotherapy with purine analogs (cladribine and pentostatine). However, approximately half of patients experience 1 or more relapses, which become progressively resistant to these myelotoxic and immunosuppressive agents. At progression, standard therapeutic options include a second course of purine analogs alone or in combination with rituximab and, upon second relapse, therapy with the anti-CD22 immunotoxin moxetumomab pasudotox. Furthermore, blockade of the mutant BRAF-V600E kinase (the pathogenetic hallmark of HCL) through orally available specific inhibitors (vemurafenib or dabrafenib) effaces the peculiar morphologic, phenotypic, and molecular identity of this disease and its typical antiapoptotic behavior and is emerging as an attractive chemotherapy-free strategy in various clinical scenarios. These include patients with, or at risk of, severe infections and, in a highly effective combination with rituximab, patients with relapsed or refractory HCL. Other treatments explored in clinical trials are BTK inhibition with ibrutinib and co-inhibition of BRAF (through dabrafenib or vemurafenib) and its downstream target MEK (through trametinib or cobimetinib). Here, we focus on our experience with BRAF inhibitors in clinical trials and as off-label use in routine practice by presenting 3 challenging clinical cases to illustrate their management in the context of all available treatment options.
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Affiliation(s)
- Brunangelo Falini
- Brunangelo Falini, Section of Hematology and Center for Hemato-Oncological Research (CREO), Department of Medicine and Surgery, University of Perugia and Hospital Santa Maria della Misericordia, Piazzale Menghini 8, 06132 Perugia, Italy
| | - Luca De Carolis
- Section of Hematology and Center for Hemato-Oncological Research (CREO), Department of Medicine and Surgery, University of Perugia and Hospital Santa Maria della Misericordia, Perugia, Italy
| | - Enrico Tiacci
- Enrico Tiacci, Section of Hematology and Center for Hemato-Oncological Research (CREO), Department of Medicine and Surgery, University of Perugia and Hospital Santa Maria della Misericordia, Piazzale Menghini 8, 06132 Perugia, Italy
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16
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Troussard X, Maître E, Cornet E. Hairy cell leukemia 2022: Update on diagnosis, risk-stratification, and treatment. Am J Hematol 2022; 97:226-236. [PMID: 34710243 DOI: 10.1002/ajh.26390] [Citation(s) in RCA: 23] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2021] [Revised: 10/18/2021] [Accepted: 10/20/2021] [Indexed: 12/13/2022]
Abstract
DISEASE OVERVIEW Hairy cell leukemia (HCL) and HCL-like disorders, including HCL variant (HCL-V) and splenic diffuse red pulp lymphoma (SDRPL), are a very heterogeneous group of mature lymphoid B-cell disorders characterized by the identification of hairy cells, a specific genetic profile, a different clinical course, and the need for appropriate treatment. DIAGNOSIS Diagnosis of HCL is based on morphological evidence of hairy cells, an HCL immunologic score of 3 or 4 based on the CD11C, CD103, CD123, and CD25 expression, the trephine biopsy which makes it possible to specify the degree of tumoral medullary infiltration and the presence of BRAFV600E somatic mutation. RISK STRATIFICATION Progression of patients with HCL is based on a large splenomegaly, leukocytosis, a high number of hairy cells in the peripheral blood, and the immunoglobulin heavy chain variable region gene mutational status. VH4-34-positive HCL cases are associated with a poor prognosis. TREATMENT Patients should be treated only if HCL is symptomatic. Chemotherapy with risk adapted therapy purine analogs (PNAs) are indicated in first-line HCL patients. The use of chemo-immunotherapy combining PNAs and rituximab (R) represents an increasingly used therapeutic approach. Management of relapsed/refractory disease is based on the use of BRAF inhibitors (BRAFi) plus rituximab or MEK inhibitors (MEKi), recombinant immunoconjugates targeting CD22 or Bruton Tyrosine Kinase inhibitors (BTKi). However, the optimal sequence of the different treatments remains to be determined. The Bcl2-inhibitors (Bcl-2i) can play a major role in the future.
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Affiliation(s)
- Xavier Troussard
- Laboratoire Hématologie CHU Côte de Nacre Caen Cedex France
- Université Caen Normandie Caen Cedex France
| | - Elsa Maître
- Laboratoire Hématologie CHU Côte de Nacre Caen Cedex France
- Université Caen Normandie Caen Cedex France
| | - Edouard Cornet
- Laboratoire Hématologie CHU Côte de Nacre Caen Cedex France
- Université Caen Normandie Caen Cedex France
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17
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Diagnosis and treatment of hairy cell leukemia as the COVID-19 pandemic continues. Blood Rev 2022; 51:100888. [PMID: 34535326 PMCID: PMC8418384 DOI: 10.1016/j.blre.2021.100888] [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] [Received: 07/07/2021] [Revised: 08/26/2021] [Accepted: 08/31/2021] [Indexed: 02/06/2023]
Abstract
Hairy cell leukemia (HCL) is an indolent B-cell malignancy, usually driven by the BRAF V600E mutation. For 30 years, untreated and relapsed HCL was successfully treated with purine analogs, but minimal residual disease (MRD) remained in most patients, eventually causing relapse. Repeated purine analogs achieve decreasing efficacy and increasing toxicity, particularly to normal T-cells. MRD-free complete remissions (CRs) are more common using rituximab with purine analogs in both 1st-line and relapsed settings. BRAF inhibitors and Ibrutinib can achieve remission, but due to persistence of MRD, must be used chronically to prevent relapse. BRAF inhibition combined with Rituximab can achieve high MRD-free CR rates. Anti-CD22 recombinant immunotoxin moxetumomab pasudotox is FDA-approved in the relapsed setting and is unique in achieving high MRD-free CR rates as a single-agent. Avoiding chemotherapy and rituximab may be important in ensuring both recovery from COVID-19 and successful COVID-19 vaccination, an area of continued investigation.
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18
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Long term follow-up of a phase II study of cladribine with concurrent rituximab with hairy cell leukemia variant. Blood Adv 2021; 5:4807-4816. [PMID: 34607348 PMCID: PMC9153043 DOI: 10.1182/bloodadvances.2021005039] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2021] [Accepted: 08/23/2021] [Indexed: 01/21/2023] Open
Abstract
CDAR achieved 95% CR and 80% negative MRD, durable up to 10 years. Carrying TP53 mutation and not achieving negative MRD after CDAR were associated with shorter survival outcomes.
Hairy cell leukemia variant (HCLv) responds poorly to purine analogue monotherapy. Rituximab concurrent with cladribine (CDAR) improves response rates, but long-term outcomes are unknown. We report final results of a phase 2 study of CDAR for patients with HCLv. Twenty patients with 0 to 1 prior courses of cladribine and/or rituximab, including 8 who were previously untreated, received cladribine 0.15 mg/kg on days 1 to 5 with 8 weekly rituximab doses of 375 mg/m2 beginning day 1. Patients received a second rituximab course ≥6 months after cladribine, if and when minimal residual disease (MRD) was detected in blood. The complete remission (CR) rate from CDAR was 95% (95% confidence interval, 75-100). Sixteen (80%) of 20 patients (95% confidence interval, 56-94) became MRD negative according to bone marrow at 6 months. The median duration of MRD-negative CR was 70.1 months, and 7 of 16 are still MRD negative up to 120 months. With a median follow-up of 69.7 months, 11 patients received delayed rituximab, and the 5-year progression-free survival (PFS) and overall survival (OS) were 63.3% and 73.9%, respectively. Five patients with TP53 mutations had shorter PFS (median, 36.4 months vs unreached; P = .0024) and OS (median, 52.4 months vs unreached; P = .032). MRD-negative CR at 6 months was significantly associated with longer PFS (unreached vs 17.4 months; P < .0001) and OS (unreached vs 38.2 months; P < .0001). Lack of MRD in blood at 6 months was also predictive of longer PFS and OS (P < .0001). After progression following CDAR, median OS was 29.7 months. CDAR is effective in HCLv, with better outcomes in patients who achieve MRD-negative CR. This trial is registered at www.clinicaltrials.gov as #NCT00923013.
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19
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Broccoli A, Argnani L, Nanni L, Terragna C, Sabattini E, Gabrielli G, Stefoni V, Pellegrini C, Casadei B, Morigi A, Lolli G, Carella M, Coppola PE, Zinzani PL. The treatment of hairy cell leukemia with a focus on long lasting responses to cladribine: A 30-year experience. Am J Hematol 2021; 96:1204-1210. [PMID: 34245477 DOI: 10.1002/ajh.26287] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2021] [Revised: 06/28/2021] [Accepted: 06/29/2021] [Indexed: 12/21/2022]
Abstract
The treatment of hairy cell leukemia (HCL) has considerably changed over years. Purine analogues, namely cladribine, now represent the treatment of choice. One hundred and eighty-four patients were followed between 1986 and 2018 and treated according to era-specific guidelines. Responses were classified by combining Consensus Resolution criteria and marrow immunohistochemistry. Patients were grouped according to the number of treatment lines they received. Patients treated first line responded in 86% of cases, with complete response (CR) in 44% of cases. Response rates remained high throughout the first four lines (84%, 81%, 79% for the second line onward, with CR in 38%, 37%, 15% of cases respectively). One hundred and twenty-two patients received cladribine as first line treatment, with a response rate of 86% and a CR rate of 54%. Among the 66 CR patients, 45 (68%) have never received further therapy: 11 patients are in continuous CR between 5 and 10 years after treatment, 14 between 10 and 20 years and three patients at more than 20 years. Median time-to-next treatment (TTNT) for frontline cladribine-treated patients was 8.2 years: partial responders had a significantly shorter median TTNT than CR patients (5.3 years vs median not reached at 25.8 years, p < 0.001). Patients with HCL require subsequent lines of therapy in more than 50% of cases. Purine analogues allow significant response rates when applied first line and upon retreatment. Some patients may enjoy long lasting treatment-free intervals after one course of cladribine.
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Affiliation(s)
- Alessandro Broccoli
- IRCCS Azienda Ospedaliero‐Universitaria di Bologna Istituto di Ematologia "Seràgnoli" Bologna Italy
- Dipartimento di Medicina Specialistica, Diagnostica e Sperimentale Università degli Studi Bologna Italy
| | - Lisa Argnani
- IRCCS Azienda Ospedaliero‐Universitaria di Bologna Istituto di Ematologia "Seràgnoli" Bologna Italy
- Dipartimento di Medicina Specialistica, Diagnostica e Sperimentale Università degli Studi Bologna Italy
| | - Laura Nanni
- IRCCS Azienda Ospedaliero‐Universitaria di Bologna Istituto di Ematologia "Seràgnoli" Bologna Italy
- Dipartimento di Medicina Specialistica, Diagnostica e Sperimentale Università degli Studi Bologna Italy
| | - Carolina Terragna
- IRCCS Azienda Ospedaliero‐Universitaria di Bologna Istituto di Ematologia "Seràgnoli" Bologna Italy
| | - Elena Sabattini
- IRCCS Azienda Ospedaliero‐Universitaria di Bologna Istituto di Ematologia "Seràgnoli" Bologna Italy
| | - Giulia Gabrielli
- A.O.U. Città della Salute e della Scienza di Torino University of Torino Torino Italy
| | - Vittorio Stefoni
- IRCCS Azienda Ospedaliero‐Universitaria di Bologna Istituto di Ematologia "Seràgnoli" Bologna Italy
- Dipartimento di Medicina Specialistica, Diagnostica e Sperimentale Università degli Studi Bologna Italy
| | - Cinzia Pellegrini
- IRCCS Azienda Ospedaliero‐Universitaria di Bologna Istituto di Ematologia "Seràgnoli" Bologna Italy
| | - Beatrice Casadei
- IRCCS Azienda Ospedaliero‐Universitaria di Bologna Istituto di Ematologia "Seràgnoli" Bologna Italy
- Dipartimento di Medicina Specialistica, Diagnostica e Sperimentale Università degli Studi Bologna Italy
| | - Alice Morigi
- IRCCS Azienda Ospedaliero‐Universitaria di Bologna Istituto di Ematologia "Seràgnoli" Bologna Italy
- Dipartimento di Medicina Specialistica, Diagnostica e Sperimentale Università degli Studi Bologna Italy
| | - Ginevra Lolli
- IRCCS Azienda Ospedaliero‐Universitaria di Bologna Istituto di Ematologia "Seràgnoli" Bologna Italy
- Dipartimento di Medicina Specialistica, Diagnostica e Sperimentale Università degli Studi Bologna Italy
| | - Matteo Carella
- IRCCS Azienda Ospedaliero‐Universitaria di Bologna Istituto di Ematologia "Seràgnoli" Bologna Italy
- Dipartimento di Medicina Specialistica, Diagnostica e Sperimentale Università degli Studi Bologna Italy
| | - Paolo Elia Coppola
- IRCCS Azienda Ospedaliero‐Universitaria di Bologna Istituto di Ematologia "Seràgnoli" Bologna Italy
- Dipartimento di Medicina Specialistica, Diagnostica e Sperimentale Università degli Studi Bologna Italy
| | - Pier Luigi Zinzani
- IRCCS Azienda Ospedaliero‐Universitaria di Bologna Istituto di Ematologia "Seràgnoli" Bologna Italy
- Dipartimento di Medicina Specialistica, Diagnostica e Sperimentale Università degli Studi Bologna Italy
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20
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Mümmler C, Zhang D, Zimmermann A, Mertsch P, Fischer L, Greither M, Khatamzas E, Ormanns S, Heiß-Neumann M, Dreyling M, von Bergwelt-Baildon M, Boeck S. Rituximab Treatment of Hairy Cell Leukemia in a Patient with Mycobacterium kansasii Infection: A Case Report. Oncol Res Treat 2021; 44:637-640. [PMID: 34547751 DOI: 10.1159/000519301] [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: 06/13/2021] [Accepted: 08/20/2021] [Indexed: 11/19/2022]
Abstract
INTRODUCTION Infectious complications represent a major cause of morbidity and mortality in hairy cell leukemia (HCL) patients. Due to the immunosuppressive nature of the disease, these patients are frequently affected by opportunistic infections and rare pathogens. Furthermore, cytotoxic chemotherapy might lead to poor or even fatal outcomes in the setting of an active infection. CASE PRESENTATION We report the case of a 62-year-old HCL patient who presented with recurrent fever episodes, pancytopenia, and mediastinal lymphadenopathy. A treatment decision against purine analogs and for rituximab mono was made as lymph node tissue revealed disseminated Mycobacterium kansasii infection. Together with specific antimycobacterial treatment, rituximab mono led to complete hematologic remission after 6 months without aggravating the accompanying infection. CONCLUSION Here, we demonstrate successful treatment of HCL with rituximab in a patient with concomitant disseminated M. kansasii infection.
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Affiliation(s)
- Carlo Mümmler
- Department of Medicine V, University Hospital, LMU Munich, Munich, Germany.,Comprehensive Pneumology Center (CPC-M), Member of the German Center for Lung Research (DZL), Munich, Germany
| | - Danmei Zhang
- Department of Medicine III, University Hospital, LMU Munich, Munich, Germany
| | - Andreas Zimmermann
- Department of Medicine III, University Hospital, LMU Munich, Munich, Germany
| | - Pontus Mertsch
- Department of Medicine V, University Hospital, LMU Munich, Munich, Germany.,Comprehensive Pneumology Center (CPC-M), Member of the German Center for Lung Research (DZL), Munich, Germany
| | - Luca Fischer
- Department of Medicine III, University Hospital, LMU Munich, Munich, Germany
| | - Margarete Greither
- Department of Medicine III, University Hospital, LMU Munich, Munich, Germany
| | - Elham Khatamzas
- Department of Medicine III, University Hospital, LMU Munich, Munich, Germany
| | - Steffen Ormanns
- Institute of Pathology, University Hospital, LMU Munich, Munich, Germany
| | | | - Martin Dreyling
- Department of Medicine III, University Hospital, LMU Munich, Munich, Germany
| | | | - Stefan Boeck
- Department of Medicine III, University Hospital, LMU Munich, Munich, Germany
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