Sickle cell anemia and hematological neoplasias

Sickle cell disease and acute leukemia: one case report and an extensive review

Population-based studies and case reports suggest that there may be an increased risk of acute leukemia associated with sickle cell disease (SCD). Following the description of a new case report, an extensive review of the literature identified 51 previously described cases. Most cases study showed myelodysplastic features confirmed, when available, by genetic markers such as chromosome 5 and/or chromosome 7 abnormalities and TP53 gene mutations. The increased risk of leukemogenesis is certainly multifactorial and related to the pathophysiologic mechanisms of the clinical manifestations of SCD. Chronic hemolysis and secondary hemochromatosis may cause increased chronic inflammation, resulting in persistent marrow stress, which could potentially compromise the genomic stability of the hematopoietic stem cells generating genomic damage and somatic mutations over the course of SCD and its treatment, resulting in a clone that led to acute myeloid leukemia.

Sickle Cell Disease in Early Infancy: A Case Report

Sickle cell disease (SCD) refers to a group of hereditary disorders that result in faulty hemoglobin carriage by the red blood cells. This paper discusses an atypical presentation of SCD in early infancy. Despite current literature suggesting protection by fetal hemoglobin in the first few months of life, we report a diagnosis of SCD at 2 months of age with severe symptoms requiring hospitalization. It is therefore important for clinicians to raise their clinical index of suspicion of SCD in children presenting with severe anemia even though they are less than 6 months old and do not present with classic dactylitis or pain syndromes. Expansion and sustained newborn screening programs for SCD in developing countries could help clinicians and parents plan for early treatment, appropriate prophylaxis, and improved management of SCD complications.

Treatment and outcomes of hepatocellular carcinoma in patients with Sickle cell disease: a population-based study in the U.S

BACKGROUND

Sickle cell disease (SCD) is a rare hemoglobinopathy which can result in chronic liver disease and cirrhosis. Patients with SCD have an increased risk of hematologic malignancy, but the prevalence of hepatocellular carcinoma (HCC) in this population is unknown. Herein, the association of SCD with HCC was examined using registry data.

METHODS

The SEER-Medicare database was queried to identify patients diagnosed with HCC between 2000 and 2015, and further stratified by SCD status. Propensity matching was performed to examine cancer-related survival and treatment outcomes.

RESULTS

Overall 56,934 patients with HCC were identified, including 81 patients with SCD. Patients with SCD more frequently had cirrhosis [48.1% (39/81) vs 23.5% (13,377/56,853), p < 0.01] yet presented with smaller tumors [<5 cm: 51.9% (42/81) vs 38.5% (21,898/56,853), p = 0.01]. After propensity matching, SCD was not associated with attenuated survival (aHR 0.73 95%CI 0.52-1.01). When stratified by treatment, patients with SCD had equivalent outcomes to chemotherapy (p = 0.65), TACE/TARE (p = 0.35), resection (p = 0.15) and transplantation (p = 0.67) when compared to non-SCD patients.

CONCLUSION

This study confirms that a subset of patients with SCD will develop HCC. Importantly, therapeutic options for HCC should not be limited by pre-existing SCD, and similar survival should be expected when compared to non-SCD patients.

Hydroxyurea (hydroxycarbamide) genotoxicity in pediatric patients with sickle cell disease

BACKGROUND

Hydroxyurea (HU) reduces the severity of sickle cell disease (SCD) in children; nevertheless, its long-term safety is an important concern. This paper evaluates HU genotoxicity at dose ≤ 30 mg/kg/day after over 2 years of treatment.

PROCEDURE

The study included 76 children: 32 SCD patients treated with HU, 27 SCD patients not treated with HU, and 17 unaffected children. HU patients were classified as good or poor responders according to their clinical response. Comet assay allows the comparison of DNA damage between both groups of patients and unaffected children. Maximal concentration (C_max ) of HU in plasma was determined after drug administration.

RESULTS

Mean values of DNA in the comet tail were 5.13 ± 6.84 for unaffected children, 5.80 ± 7.78 for patients with SCD treated with HU, and 5.61 ± 6.91 for patients with SCD not treated with HU. Significant differences were observed between unaffected children and children with SCD. No difference was evident between comets from SCD patients treated and not treated with HU. In the case of HU, mean DNA in the comet tail was significantly lower in good responders than in poor responders: 5.54 ± 7.77 and 6.69 ± 8.43, respectively. Mean C_max value on plasma was 39.08 ± 15.65 mg/l; N = 31.

CONCLUSIONS

SCD increases, slightly but significantly, DNA damage in lymphocytes from patients with SCD. Patients with SCD treated with HU do not present more nucleoid damage than patients with SCD not treated with HU. Good responders to the HU treatment have significantly less nucleoid damage than poor responders. HU treatment at ≤30 mg/kg/day does not expose patients to a genotoxic plasma concentration.

Risk of individual malignant neoplasms in patients with sickle cell disease: English national record linkage study

OBJECTIVE

Case reports suggest that there may be an increased risk of some cancers associated with sickle cell disease. However, population-based studies are scarce and there is no comprehensive enumeration of the risks across the whole range of site-specific cancers. Our aim was to provide this.

DESIGN

We used an English national dataset of linked statistical records of hospital admissions and deaths from 1999 to 2011 to undertake a retrospective cohort study.

SETTING

England.

PARTICIPANTS

Records of all hospital admissions in England with SCD or with conditions included in the control cohort.

MAIN OUTCOME MEASURES

Rate ratios were calculated comparing rates of cancer in a sickle cell disease cohort and a control cohort, confining the analyses to people whose ethnicity was recorded as Black.

RESULTS

Comparing the sickle cell disease cohort with the cohort without sickle cell disease, the rate ratio for all cancers combined was 2.1 (95% confidence interval 1.7-2.5). There were significantly high rate ratios for haematological malignancies, including Hodgkin's lymphoma (rate ratio 3.7, 1.5-8.4), non-Hodgkin's lymphoma (2.6, 1.3-4.8), multiple myeloma (5.5, 2.8-10.1), lymphoid leukaemia (3.3, 1.3-8.0) and myeloid leukaemia (10.0, 4.6-21.5). Four solid tumours showed elevated rate ratios: colon cancer (2.8, 1.2-5.5), non-melanoma skin cancer (4.4, 1.3-12.2), kidney cancer (5.4, 2.3-11.5) and thyroid cancer (5.1, 1.3-15.4).

CONCLUSIONS

The risk of some malignancies may be raised in patients with sickle cell disease. However, this study was based on administrative data without the scope to validate these against patients' full clinical records. Our findings need confirmation or refutation. If confirmed, work to elucidate, at the genetic and molecular level, why people with sickle cell disease have elevated risks of individual cancers might make contributions to the fundamental understanding of carcinogenesis.

Harvesting autologous stem cells from a patient with red blood cell abnormalities of β-thalassemia intermedia

BACKGROUND

Autologous stem cell transplants in patients with hemoglobinopathies are limited. Previous reports used granulocyte-colony-stimulating factor (G-CSF) for mobilization of stem cells; there are no reported cases undergoing plerixafor mobilization. We report such a patient, providing guidance for peripheral blood stem cells collection when aberrant red blood cells (RBCs) disrupt normal separation.

STUDY DESIGN AND METHODS

A patient with β-thalassemia intermedia and hereditary persistence of fetal hemoglobin presented for peripheral blood stem cell collection for autologous transplant for myeloma. He underwent splenectomy for anemia secondary to hemoglobinopathy and chemotherapy, ceasing RBC transfusions. The patient was mobilized using plerixafor after collection with G-CSF failed.

RESULTS

Collections were performed using an apheresis system, processing 24 L daily. Peripheral blood and apheresis product CD34 determinations were performed daily. On Day 1, the product yield was 0.04 × 10(6) CD34 cells/kg, less than expected based on white blood cell count and CD34-positive cells. Peripheral blood smear showed nucleated RBCs and RBC morphologic abnormalities. Changes in instrument variables were made after consultation with Terumo BCT to adjust for variable distribution of mononuclear and stem cells during centrifugation. Collecting stem cells at a deeper location and centrifuging faster improved collection, and a cumulative total of 4.40 × 10(6) CD34 cells/kg was achieved after four collections. The patient underwent tandem autologous transplantation and engrafted within 12 to 13 days of each transplant.

CONCLUSIONS

Adjustments in apheresis variables allowed successful collection of peripheral blood stem cells from a patient with RBC anomalies of β-thalassemia that interfered with standard stem cell harvesting.

Mobilization, collection, and transplantation of peripheral blood hematopoietic progenitor cells in a patient with multiple myeloma and hemoglobin SC disease

BACKGROUND

The use of granulocyte-colony-stimulating factor (G-CSF) for mobilization, collection, and transplantation of autologous hematopoietic progenitor cells (HPCs) in patients with hemoglobinopathies can be complicated by severe vasoocclusive crises. Erythrocytapheresis before G-CSF administration may help prevent these complications. To date, no cases regarding the safety and outcome of erythrocytapheresis followed by autologous high-dose G-CSF mobilization in hemoglobinopathy populations have been reported.

STUDY DESIGN AND METHODS

A patient with hemoglobin (Hb) SC disease and multiple myeloma underwent erythrocytapheresis followed by high-dose (16 microg/kg) G-CSF in preparation for HPC mobilization and collection.

RESULTS

Erythrocytapheresis reduced the patient's combined Hb S and C levels to less than 20 percent. Subsequent HPC mobilization and peripheral blood harvesting using high-dose G-CSF yielded approximately 9 x 10(6) CD34+ HPCs per kg over 3 days of collection. Mobilization and leukapheresis were completed without vasoocclusive complications. Two weeks after collection, and after myeloablative chemotherapy, 5.33 x 10(6) CD34+ HPCs per kg were infused to the patient; platelet and white cell engraftment occurred, respectively, on Days +9 and +10 posttransplant. The patient experienced no vasoocclusive complications in the posttransplant period.

CONCLUSIONS

The results of this case demonstrate that erythrocytapheresis before high-dose G-CSF HPC mobilization and collection appears to be an effective means for prevention of vasoocclusive crisis in patients with hemoglobinopathies undergoing autologous stem cell transplantation.

Hodgkin lymphoma in a child with sickle cell anemia

There are reports of patients with sickle cell disease who developed hematological malignancies but the relationship between these malignancies and sickle cell disease (SCD) is not yet defined. The co-existence of a hematological malignancy with SCD poses certain challenges for the management of each condition. We describe a 7-year-old boy with sickle cell anemia who developed Hodgkin's lymphoma and the challenges of management. He presented with a 4-year history of bilateral neck swelling and a 2-month history of weight loss and high-grade fever. Histology of a lymph node biopsy was consistent with mixed cellularity Hodgkin's lymphoma. He was treated with five cycles of Cyclophosphamide, Vincristine, Procarbazine and Prednisolone (COPP) and had complete clinical response. Chemotherapy was associated with an increase in frequency of painful crises and complicated by septicaemia. Blood transfusion needs were minimal; apart from the transfusion preceding the first cycle of chemotherapy, there was no need for further transfusion. Myelosuppression was not a problem in the patient; he responded well to antibiotics during the two episodes of septicemia without the use of hemopoetic growth factor. Patients with sickle cell anaemia who develop Hodgkin's lymphoma can be successfully treated with chemotherapy along with supportive management for crises and infections.