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Wang L, Wu S, Yu G, Sui X, Chu X, Liu X. Pure red cell aplasia occurring during ibrutinib therapy for chronic lymphocytic leukemia. J Oncol Pharm Pract 2023; 29:2031-2036. [PMID: 37518980 DOI: 10.1177/10781552231189192] [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] [Indexed: 08/01/2023]
Abstract
INTRODUCTION Chronic lymphocytic leukemia (CLL) has long been known for its complications related to immune deregulation, of which autoimmune cytopenias (AIC) were frequently reported. Ibrutinib has dramatically changed the overall prognosis of patients with CLL. However, whether ibrutinib can induce or aggravate AIC in CLL patients is still disputable. Here we report a CLL patient with pure red cell aplasia (PRCA) occurring during ibrutinib treatment and review available data to discuss the possible role of ibrutinib in developing AIC. CASE REPORT A 70-year-old female was diagnosed with CLL with indications to initiate ibrutinib treatment given progressive bulky disease. She was admitted for advanced fatigue on the 14th day of ibrutinib monotherapy. A complete blood count revealed severe anemia of hemoglobin (Hb) 37 g/L and a meager reticulocyte count. After excluding other conditions that could cause anemia, PRCA was diagnosed as a complication of CLL. MANAGEMENT AND OUTCOME Ibrutinib was discontinued on the day of admission. At the same time, the patient received prednisone and intravenous immunoglobulin (IVIg). Five days later, the Hb did not improve. Cyclosporine A (CsA) was added; IVIg was discontinued, and prednisone was tapered. Ten days later, the Hb had risen to 92 g/L with a high reticulocyte count of 0.279 × 1012/L. The CLL treatment restarted with Zanbrutinib in combination with a low dose of prednisone and CsA. Her CLL was in partial remission by the latest follow-up with an average Hb count. DISCUSSION Our case demonstrates a need to evaluate the risk of developing AIC before initiating ibrutinib. For patients with high-risk factors for AIC episodes, the transient addition of other immunosuppressive therapies should be taken into consideration.
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Affiliation(s)
- Lei Wang
- Department of Hematology, The Affiliated Yantai Yuhuangding Hospital of Qingdao University, Yantai, Shandong, China
| | - Shishou Wu
- Department of Pathology, The Affiliated Yantai Yuhuangding Hospital of Qingdao University, Yantai, Shandong, China
| | - Guohua Yu
- Department of Pathology, The Affiliated Yantai Yuhuangding Hospital of Qingdao University, Yantai, Shandong, China
| | - Xiaolong Sui
- Department of Pathology, The Affiliated Yantai Yuhuangding Hospital of Qingdao University, Yantai, Shandong, China
| | - Xiaoxia Chu
- Department of Hematology, The Affiliated Yantai Yuhuangding Hospital of Qingdao University, Yantai, Shandong, China
| | - Xiaoqian Liu
- Department of Hematology, The Affiliated Yantai Yuhuangding Hospital of Qingdao University, Yantai, Shandong, China
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Alshemmari SH, Siddiqui MA, Pandita R, Osman HY, Cherif H, O'Brien S, Marashi M, Al Farsi K. Evidence-Based Management of Chronic Lymphocytic Leukemia: Consensus Statements from the Gulf Region. Acta Haematol 2023; 147:260-279. [PMID: 37751733 DOI: 10.1159/000531675] [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: 09/13/2022] [Accepted: 06/16/2023] [Indexed: 09/28/2023]
Abstract
INTRODUCTION Despite recent advances in diagnosis, prognostication, and treatment options, chronic lymphocytic leukemia (CLL) is still a largely incurable disease. New concepts on diagnosis, staging, treatment, and follow-up on CLL have been incorporated throughout recent years. The lack of regional consensus guidelines has led to varying practices in the management of patients with CLL in the region. This manuscript aims to reach a consensus among expert hematologists regarding the definitions, classifications, and related practices of CLL. The experts developed a set of statements utilizing their personal experience together with the current literature on CLL management. This consensus aims to provide guidance for healthcare professionals involved in the management of CLL and serves as a step in developing regional guidelines. METHODS Eight experts responded to 50 statements regarding the diagnosis, staging, treatment, and prognosis of CLL with three potential answering alternatives ranging between agree, disagree, and abstain. This consensus adopted a modified Delphi consensus methodology. A consensus was reached when at least 75% of the agreement to the answer was reached. This manuscript presents the scientific insights of the participating attendees, panel discussions, and the supporting literature review. RESULTS Of the 50 statements, a consensus was reached on almost all statements. Statements covered CLL-related topics, including diagnostic evaluation, staging, risk assessment, different patient profiles, prognostic evaluation, treatment decisions, therapy sequences, response evaluation, complications, and CLL during the COVID-19 pandemic. CONCLUSION In recent years, CLL management has progressed significantly, with many diagnostic tests and several novel treatments becoming available. This consensus gathers decades of consolidated principles, novel research, and promising prospects for the management of this disease.
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Affiliation(s)
- Salem H Alshemmari
- Department of Medicine, Faculty of Medicine and Department of Hematology, Kuwait Cancer Control Centre, Shuwaikh, Kuwait
| | - Mustaqeem A Siddiqui
- Hematology and Oncology Division, Sheikh Shakhbout Medical City, Abu Dhabi, United Arab Emirates
- Mayo Clinic Division of Hematology, Rochester, Minnesota, USA
| | - Ramesh Pandita
- Department of Hematology, Kuwait Cancer Control Centre, Shuwaikh, Kuwait
| | - Hani Y Osman
- Oncology Department, Tawam Hospital, Al Ain, United Arab Emirates
| | - Honar Cherif
- Departmant of Hematology, National Center for Cancer Care and Research, Hamad Medical Corporation, Doha, Qatar
| | - Susan O'Brien
- Chao Family Comprehensive Cancer Center, University of California Irvine, Irvine, California, USA
| | - Mahmoud Marashi
- Department of Hematology, Dubai Healthcare Authority, Dubai, United Arab Emirates
| | - Khalil Al Farsi
- Department of Hematology, Sultan Qaboos University Hospital Muscat, Seeb, Oman
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Cennamo M, Sirocchi D, Giudici C, Giagnacovo M, Petracco G, Ferrario D, Garganigo S, Papa A, Veniani E, Squizzato A, Del Vecchio L, Patriarca C, Partenope M, Modena P. A Peculiar CLL Case with Complex Chromosome 6 Rearrangements and Refinement of All Breakpoints at the Gene Level by Genomic Array: A Case Report. J Clin Med 2023; 12:4110. [PMID: 37373803 DOI: 10.3390/jcm12124110] [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: 04/30/2023] [Revised: 06/13/2023] [Accepted: 06/14/2023] [Indexed: 06/29/2023] Open
Abstract
INTRODUCTION Chronic lymphocytic leukemia (CLL), the most common leukemia in Western countries, is a mature B-cell chronic lymphoproliferative disorder characterized by the accumulation of neoplastic CD5+ B lymphocytes, functionally incompetent and usually monoclonal in origin, in bone marrow, lymph nodes and blood. Diagnosis occurs predominantly in elderly patients, with a median age reported between 67 and 72 years. CLL has a heterogeneous clinical course, which can vary from indolent to, less frequently, aggressive forms. Early-stage asymptomatic CLL patients do not require immediate therapeutic intervention, but only observation; treatment is necessary for patients with advanced disease or when "active disease" is observed. The most frequent autoimmune cytopenia (AIC) is autoimmune haemolytic anaemia (AHIA). The main mechanisms underlying the appearance of AIC in CLL are not fully elucidated, the predisposition of patients with CLL to suffering autoimmune complications is variable and autoimmune cytopenia can precede, be concurrent, or follow the diagnosis of CLL. CASE PRESENTATION A 74-year-old man was admitted to the emergency room following the finding of severe macrocytic anaemia during blood tests performed that same day, in particular the patient showed a profound asthenia dating back several months. The anamnesis was silent and the patient was not taking any medications. The blood examination showed an extremely high White Blood Cell count and findings of AIHA in CLL-type mature B-cell lymphoproliferative neoplasia. Genetic investigations: Conventional karyotyping was performed and it obtained a trisomy 8 and an unbalanced translocation between the short arm of chromosome 6 and the long arm of chromosome 11, concurrent with interstitial deletions in chromosomes 6q and 11q that could not be defined in detail. Molecular cytogenetics (FISH) analyses revealed Ataxia Telangiectasia Mutated (ATM) monoallelic deletion (with loss of ATM on derivative chromosome 11) and retained signals for TP53, 13q14 and centromere 12 FISH probes. TP53 and IGHV were not mutated. Array-CGH confirmed trisomy of the entire chromosome 8 and allowed us to resolve in detail the nature of the unbalanced translocation, revealing multiple regions of genomic losses on chromosomes 6 and 11. DISCUSSION The present case report is an unusual CLL case with complex karyotype and refinement of all breakpoints at the gene level by the genomic array. From a genetic point of view, the case under study presented several peculiarities. CONCLUSIONS We report the genetic findings of a CLL patient with abrupt disease onset, so far responding properly to treatments despite the presence of distinct genetic adverse traits including ATM deletion, complex karyotype and chromosome 6q chromoanagenesis event. Our report confirms that interphase FISH alone is not able to provide an overview of the whole genomic landscape in selected CLL cases and that additional techniques are required to reach an appropriate cytogenetic stratification of patients.
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Affiliation(s)
- Michele Cennamo
- Department of Translational Medical Sciences, University of Naples "Federico II", 80131 Naples, Italy
- Clinical Pathology and Microbiology Unit, Laboratory Analysis, ASST Lariana, Hospital Sant'Anna, 22100 Como, Italy
| | - Davide Sirocchi
- General Medicine Unit, ASST Lariana, Hospital Sant'Anna, 22100 Como, Italy
| | - Carolina Giudici
- Genetics Unit, ASST Lariana, Hospital Sant'Anna, 22100 Como, Italy
| | | | - Guido Petracco
- Pathological Unit, ASST Lariana, Hospital Sant'Anna, 22100 Como, Italy
| | - Daniela Ferrario
- Pathological Unit, ASST Lariana, Hospital Sant'Anna, 22100 Como, Italy
| | - Simona Garganigo
- Clinical Pathology and Microbiology Unit, Laboratory Analysis, ASST Lariana, Hospital Sant'Anna, 22100 Como, Italy
| | - Angela Papa
- Clinical Pathology and Microbiology Unit, Laboratory Analysis, ASST Lariana, Hospital Sant'Anna, 22100 Como, Italy
| | - Emanuela Veniani
- Clinical Pathology and Microbiology Unit, Laboratory Analysis, ASST Lariana, Hospital Sant'Anna, 22100 Como, Italy
| | - Alessandro Squizzato
- General Medicine Unit, ASST Lariana, Hospital Sant'Anna, 22100 Como, Italy
- Department of Medicine and Surgery, Research Centre on Thromboembolic Disorders and Antithrombotic Therapies, University of Insubria, 21110 Varese, Italy
| | - Lucia Del Vecchio
- Department of Nephrology and Dialysis, ASST Lariana, Hospital Sant'Anna, 22100 Como, Italy
| | - Carlo Patriarca
- Pathological Unit, ASST Lariana, Hospital Sant'Anna, 22100 Como, Italy
| | - Michelarcangelo Partenope
- Clinical Pathology and Microbiology Unit, Laboratory Analysis, ASST Lariana, Hospital Sant'Anna, 22100 Como, Italy
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Crickx E, Mahévas M, Michel M, Godeau B. Older Adults and Immune Thrombocytopenia: Considerations for the Clinician. Clin Interv Aging 2023; 18:115-130. [PMID: 36726813 PMCID: PMC9885884 DOI: 10.2147/cia.s369574] [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: 10/26/2022] [Accepted: 01/10/2023] [Indexed: 01/28/2023] Open
Abstract
Many epidemiological studies have shown that the incidence of immune thrombocytopenia (ITP) increases after age 60 years and peaks in patients over age 80 years. Therefore, ITP is a concern for physicians taking care of older patients, especially regarding its diagnosis and management. The diagnostic work-up should exclude other causes of thrombocytopenia and secondary ITP, including myelodysplastic syndrome and drug-induced ITP. The treatment decision is influenced by an increased risk of bleeding, infectious diseases and thrombosis in this population and should take into account comorbidities and concomitant medications such as anticoagulant drugs. First-line treatment is based on short corticosteroids courses and intravenous immunoglobulin, which should be reserved for patients with more severe bleeding complications, with their higher risk of toxic effects as compared with younger patients. Second-line treatment should be tailored to the patient's history, comorbidities and preferences. Preferred second-line treatments are thrombopoietin receptor agonists for most groups and guidelines given their good efficacy/tolerance ratio, but the thrombotic risk is increased in older people. Other second-line options that can be good alternatives depending on the clinical context include rituximab, dapsone, fostamatinib or immunosuppressive drugs. Splenectomy is less often performed but remains an option for fit patients with chronic refractory disease. Emerging treatments such as Syk or Bruton tyrosine kinase inhibitors and FcRn antagonists are becoming available for ITP and may modify the treatment algorithm in the near future. The aim of this review is to describe the particularities of the diagnosis and treatment of ITP in older people, including the response and tolerance to the currently available drugs. We also discuss some situations related to co-morbidities that can frequently lead to adapt the management strategy in older patients.
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Affiliation(s)
- Etienne Crickx
- Service de Médecine Interne, Centre national de référence des cytopénies auto-immunes de l’adulte, Hôpital Henri Mondor, Fédération Hospitalo-Universitaire TRUE InnovaTive theRapy for immUne disordErs, Assistance Publique Hôpitaux de Paris (AP-HP), Université Paris Est Créteil, Créteil, France,Université de Paris, Imagine Institute, Laboratory of Immunogenetics of Pediatric Autoimmune Diseases, Paris, F-75015, France
| | - Matthieu Mahévas
- Service de Médecine Interne, Centre national de référence des cytopénies auto-immunes de l’adulte, Hôpital Henri Mondor, Fédération Hospitalo-Universitaire TRUE InnovaTive theRapy for immUne disordErs, Assistance Publique Hôpitaux de Paris (AP-HP), Université Paris Est Créteil, Créteil, France,Institut Necker Enfants Malades (INEM), INSERM U1151/CNRS UMS 8253, ATIP-Avenir Team AI2B, Université de Paris, Université Paris-Est-Créteil, Paris, France,INSERM U955, équipe 2, Université Paris-Est Créteil (UPEC), Créteil, France
| | - Marc Michel
- Service de Médecine Interne, Centre national de référence des cytopénies auto-immunes de l’adulte, Hôpital Henri Mondor, Fédération Hospitalo-Universitaire TRUE InnovaTive theRapy for immUne disordErs, Assistance Publique Hôpitaux de Paris (AP-HP), Université Paris Est Créteil, Créteil, France
| | - Bertrand Godeau
- Service de Médecine Interne, Centre national de référence des cytopénies auto-immunes de l’adulte, Hôpital Henri Mondor, Fédération Hospitalo-Universitaire TRUE InnovaTive theRapy for immUne disordErs, Assistance Publique Hôpitaux de Paris (AP-HP), Université Paris Est Créteil, Créteil, France,Correspondence: Bertrand Godeau, Service de Médecine Interne, Hôpital Henri Mondor, Assistance Publique Hôpitaux de Paris (AP-HP), 51 avenue du maréchal de Lattre de Tassigny, Créteil, 94000, France, Tel +331 49 81 29 05, Fax +331 49 81 29 02, Email
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Gordon MJ, Ferrajoli A. Unusual complications in the management of chronic lymphocytic leukemia. Am J Hematol 2022; 97 Suppl 2:S26-S34. [PMID: 35491515 DOI: 10.1002/ajh.26585] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2022] [Revised: 04/20/2022] [Accepted: 04/25/2022] [Indexed: 02/04/2023]
Abstract
Chronic lymphocytic leukemia (CLL) is a common, indolent disease that typically presents with a proliferation of mature, immunologically dysfunctional CD5+ B-cells which preferentially occupy the bone marrow, peripheral blood and lymphoid organs. Immune dysfunction leads to an increase in autoimmune diseases which occur in approximately 10% of patients with CLL. Autoimmune cytopenias are the most common, but other organs may be affected as well. The treatment of these conditions typically depends on the extent of CLL and severity of symptoms, but generally consists of CLL-directed therapies, immunosuppression or both. CLL may also infiltrate extranodal sites in the body. Symptomatic extranodal CLL or extranodal disease which threatens normal organ function is an indication for initiation of CLL-directed therapy. The following review summarizes autoimmune and extranodal complications that can occur in patients with CLL and our suggested approach to their treatment.
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Affiliation(s)
- Max J Gordon
- MD Anderson Cancer Center, University of Texas, Houston, Texas, USA
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6
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Marini I, Uzun G, Jamal K, Bakchoul T. Treatment of drug-induced immune thrombocytopenias. Haematologica 2022; 107:1264-1277. [PMID: 35642486 PMCID: PMC9152960 DOI: 10.3324/haematol.2021.279484] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2022] [Indexed: 01/19/2023] Open
Abstract
Several therapeutic agents can cause thrombocytopenia by either immune-mediated or non-immune-mediated mechanisms. Non-immune-mediated thrombocytopenia is due to direct toxicity of drug molecules to platelets or megakaryocytes. Immune-mediated thrombocytopenia, on the other hand, involves the formation of antibodies that react to platelet-specific glycoprotein complexes, as in classic drug-induced immune thrombocytopenia (DITP), or to platelet factor 4, as in heparin-induced thrombocytopenia (HIT) and vaccine-induced immune thrombotic thrombocytopenia (VITT). Clinical signs include a rapid drop in platelet count, bleeding or thrombosis. Since the patient's condition can deteriorate rapidly, prompt diagnosis and management are critical. However, the necessary diagnostic tests are only available in specialized laboratories. Therefore, the most demanding step in treatment is to identify the agent responsible for thrombocytopenia, which often proves difficult because many patients are taking multiple medications and have comorbidities that can themselves also cause thrombocytopenia. While DITP is commonly associated with an increased risk of bleeding, HIT and VITT have a high mortality rate due to the high incidence of thromboembolic complications. A structured approach to drug-associated thrombocytopenia/thrombosis can lead to successful treatment and a lower mortality rate. In addition to describing the treatment of DITP, HIT, VITT, and vaccine-associated immune thrombocytopenia, this review also provides the pathophysiological and clinical information necessary for correct patient management.
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Affiliation(s)
- Irene Marini
- Centre for Clinical Transfusion Medicine, Medical Faculty of Tübingen, University of Tübingen
| | - Gunalp Uzun
- Centre for Clinical Transfusion Medicine, Medical Faculty of Tübingen, University of Tübingen
| | - Kinan Jamal
- Centre for Clinical Transfusion Medicine, Medical Faculty of Tübingen, University of Tübingen
| | - Tamam Bakchoul
- Centre for Clinical Transfusion Medicine, Medical Faculty of Tübingen, University of Tübingen.
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Kuter DJ. Treatment of chemotherapy-induced thrombocytopenia in patients with non-hematologic malignancies. Haematologica 2022; 107:1243-1263. [PMID: 35642485 PMCID: PMC9152964 DOI: 10.3324/haematol.2021.279512] [Citation(s) in RCA: 29] [Impact Index Per Article: 14.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2022] [Indexed: 01/19/2023] Open
Abstract
Chemotherapy-induced thrombocytopenia (CIT) is a common complication of the treatment of non-hematologic malignancies. Many patient-related variables (e.g., age, tumor type, number of prior chemotherapy cycles, amount of bone marrow tumor involvement) determine the extent of CIT. CIT is related to the type and dose of chemotherapy, with regimens containing gemcitabine, platinum, or temozolomide producing it most commonly. Bleeding and the need for platelet transfusions in CIT are rather uncommon except in patients with platelet counts below 25x109/L in whom bleeding rates increase significantly and platelet transfusions are the only treatment. Nonetheless, platelet counts below 70x109/L present a challenge. In patients with such counts, it is important to exclude other causes of thrombocytopenia (medications, infection, thrombotic microangiopathy, post-transfusion purpura, coagulopathy and immune thrombocytopenia). If these are not present, the common approach is to reduce chemotherapy dose intensity or switch to other agents. Unfortunately decreasing relative dose intensity is associated with reduced tumor response and remission rates. Thrombopoietic growth factors (recombinant human thrombopoietin, pegylated human megakaryocyte growth and development factor, romiplostim, eltrombopag, avatrombopag and hetrombopag) improve pretreatment and nadir platelet counts, reduce the need for platelet transfusions, and enable chemotherapy dose intensity to be maintained. National Comprehensive Cancer Network guidelines permit their use but their widespread adoption awaits adequate phase III randomized, placebo-controlled studies demonstrating maintenance of relative dose intensity, reduction of platelet transfusions and bleeding, and possibly improved survival. Their potential appropriate use also depends on consensus by the oncology community as to what constitutes an appropriate pretreatment platelet count as well as identification of patient-related and treatment variables that might predict bleeding.
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Affiliation(s)
- David J Kuter
- Massachusetts General Hospital, Harvard Medical School, Boston, MA.
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8
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Porpaczy E, Jäger U. How I manage autoimmune cytopenias in patients with lymphoid cancer. Blood 2022; 139:1479-1488. [PMID: 34517415 PMCID: PMC11017954 DOI: 10.1182/blood.2019003686] [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: 07/02/2020] [Accepted: 04/29/2021] [Indexed: 11/20/2022] Open
Abstract
Autoimmune conditions can occur in a temporary relationship with any malignant lymphoma. In many instances, treatment at diagnosis is not required, but symptomatic autoimmune conditions represent an indication for treatment, particularly in chronic lymphoproliferative diseases. Treatment is selected depending on the predominant condition: autoimmune disease (immunosuppression) or lymphoma (antilymphoma therapy). Steroids and anti-CD20 antibodies are effective against both conditions and may suppress the autoimmune complication for a prolonged period. The efficacy of B-cell receptor inhibitors has provided us with novel insights into the pathophysiology of antibody-producing B cells. Screening for underlying autoimmune conditions is part of the lymphoma workup, because other drugs, such as immunomodulators and checkpoint inhibitors, should be avoided or used with caution. In this article, we discuss diagnostic challenges and treatment approaches for different situations involving lymphomas and autoimmune cytopenias.
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Affiliation(s)
- Edit Porpaczy
- Department of Medicine I, Division of Hematology and Hemostaseology
| | - Ulrich Jäger
- Department of Medicine I, Division of Hematology and Hemostaseology
- Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria
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Autoimmune Hemolytic Anemia in Chronic Lymphocytic Leukemia: A Comprehensive Review. Cancers (Basel) 2021; 13:cancers13225804. [PMID: 34830959 PMCID: PMC8616265 DOI: 10.3390/cancers13225804] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2021] [Revised: 11/06/2021] [Accepted: 11/11/2021] [Indexed: 12/19/2022] Open
Abstract
Simple Summary This review analyzes the occurrence, clinical characteristics, and prognostic impact and treatment of autoimmune hemolytic anemia (AIHA) in chronic lymphocytic leukemia (CLL). Autoimmune hemolytic anemia is observed in about 10% of CLL. Pathogenesis is multifactorial involving humoral, cellular, and innate immunity, so the different mechanisms are well described in this review which also focuses on drugs associated to CLL-AIHA and on difficulties to diagnose it. There is a comprehensive revision of the main published casistics and then of the treatments; in particular the paper analyzes the main chemo-immunotherapeutic agents used in this setting. Since the therapy depends on the presence and severity of clinical symptoms, disease status, and comorbidities, treatment is nowadays more individualized in CLL and also in CLL-AIHA. Patients not responding to corticosteroids and rituximab are treated with CLL-specific drugs as per current guidelines according to age and comorbidities and new targeted agents against BCR and BCL-2 which can be given orally and have few side effects, are very effective both in progressive CLL and in situations such as AIHA. Abstract Chronic lymphocytic leukemia (CLL) patients have a greater predisposition to develop autoimmune complications. The most common of them is autoimmune hemolytic anemia (AIHA) with a frequency of 7–10% of cases. Pathogenesis is multifactorial involving humoral, cellular, and innate immunity. CLL B-cells have damaged apoptosis, produce less immunoglobulins, and could be responsible for antigen presentation and releasing inflammatory cytokines. CLL B-cells can act similar to antigen-presenting cells activating self-reactive T helper cells and may induce T-cell subsets imbalance, favoring autoreactive B-cells which produce anti-red blood cells autoantibodies. Treatment is individualized and it depends on the presence and severity of clinical symptoms, disease status, and comorbidities. Corticosteroids are the standardized first-line treatment; second-line treatment comprises rituximab. Patients not responding to corticosteroids and rituximab should be treated with CLL-specific drugs as per current guidelines according to age and comorbidities. New targeted drugs (BTK inhibitors and anti BCL2) are recently used after or together with steroids to manage AIHA. In the case of cold agglutinin disease, rituximab is preferred, because steroids are ineffective. Management must combine supportive therapies, including vitamins; antibiotics and heparin prophylaxis are indicated in order to minimize infectious and thrombotic risk.
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Impact of Immune Parameters and Immune Dysfunctions on the Prognosis of Patients with Chronic Lymphocytic Leukemia. Cancers (Basel) 2021; 13:cancers13153856. [PMID: 34359757 PMCID: PMC8345723 DOI: 10.3390/cancers13153856] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2021] [Revised: 07/26/2021] [Accepted: 07/28/2021] [Indexed: 12/13/2022] Open
Abstract
Simple Summary In chronic lymphocytic leukemia (CLL), immune alterations—affecting both the innate and adaptive immunity—are very common. As a clinical consequence, patients with CLL frequently present with autoimmune phenomena, increased risk of infections and second malignancies. The aim of this review article is to present available data on CLL-associated alterations of immune parameters that correlate with known prognostic markers and with clinical outcome. Also, data on the impact of immune-related clinical manifestations on the prognosis of patients with CLL will be discussed. Abstract Chronic lymphocytic leukemia (CLL) is characterized by a wide spectrum of immune alterations, affecting both the innate and adaptive immunity. These immune dysfunctions strongly impact the immune surveillance, facilitate tumor progression and eventually affect the disease course. Quantitative and functional alterations involving conventional T cells, γδ T cells, regulatory T cells, NK and NKT cells, and myeloid cells, together with hypogammaglobulinemia, aberrations in the complement pathways and altered cytokine signature have been reported in patients with CLL. Some of these immune parameters have been shown to associate with other CLL-related characteristics with a known prognostic relevance or to correlate with disease prognosis. Also, in CLL, the complex immune response dysfunctions eventually translate in clinical manifestations, including autoimmune phenomena, increased risk of infections and second malignancies. These clinical issues are overall the most common complications that affect the course and management of CLL, and they also may impact overall disease prognosis.
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Autoimmune Cytopenia in CLL: Prognosis and Management in the Era of Targeted Therapies. ACTA ACUST UNITED AC 2021; 27:286-296. [PMID: 34398555 DOI: 10.1097/ppo.0000000000000537] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
ABSTRACT Chronic lymphocytic leukemia (CLL) is frequently associated with autoimmune hemolytic anemia and immune thrombocytopenia and, less frequently, with pure red cell aplasia and immune neutropenia. The emergence of these complications is related to an intertwined and complex relationship between patient, disease, and treatment characteristics. The prognostic repercussion of autoimmune cytopenia (AIC) in patients with CLL mainly depends on its response to therapy. For patients with AIC and nonactive CLL, treatment is as in primary, uncomplicated AIC, keeping in mind that no response is an indication for CLL therapy. The success of treating active CLL-related AIC widely relies on a flexible strategy that should include initial therapy with corticosteroids and a rapid shift to effective CLL therapy in nonresponding patients. Targeted therapies (e.g., ibrutinib) that have already demonstrated to be effective in CLL-related AIC will likely offer a unique possibility of treating both AIC and CLL as a single target.
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Preexisting and treatment-emergent autoimmune cytopenias in patients with CLL treated with targeted drugs. Blood 2021; 137:3507-3517. [PMID: 33651883 DOI: 10.1182/blood.2020008201] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2020] [Accepted: 01/14/2021] [Indexed: 12/15/2022] Open
Abstract
Autoimmune cytopenias (AICs) affect 5% to 9% of patients with chronic lymphocytic leukemia (CLL). Targeted drugs-ibrutinib, idelalisib, and venetoclax-have a prominent role in the treatment of CLL, but their impact on CLL-associated AICs is largely unknown. In this study, we evaluated the characteristics and outcome of preexisting AICs and described the incidence, quality, and management of treatment-emergent AICs during therapy with targeted drugs in patients with CLL. We collected data from 572 patients treated with ibrutinib (9% in combination with an anti-CD20 monoclonal antibody), 143 treated with idelalisib-rituximab, and 100 treated with venetoclax (12% in combination with an anti-CD20 monoclonal antibody). A history of preexisting AICs was reported in 104 (13%) of 815 patients. Interestingly, 80% of patients whose AICs had not resolved when treatment with a targeted drug was started experienced an improvement or a resolution during therapy. Treatment-emergent AICs occurred in 1% of patients during ibrutinib therapy, in 0.9% during idelalisib therapy, and in 7% during venetoclax therapy, with an estimated incidence rate of 5, 6, and 69 episodes per 1000 patients per year of exposure in the 3 treatment groups, respectively. The vast majority of patients who developed treatment-emergent AICs had unfavorable biological features such as an unmutated IGHV and a del(17p) and/or TP53 mutation. Notably, despite AICs, 83% of patients were able to continue the targeted drug, in some cases in combination with additional immunosuppressive agents. Overall, treatment with ibrutinib, idelalisib, or venetoclax seems to have a beneficial impact on CLL-associated AICs, inducing an improvement or even a resolution of preexisting AICs in most cases and eliciting treatment-emergent AICs in a negligible portion of patients.
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13
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Slager SL, Lanasa MC, Marti GE, Achenbach SJ, Camp NJ, Abbasi F, Kay NE, Vachon CM, Cerhan JR, Johnston JB, Call TG, Rabe KG, Kleinstern G, Boddicker NJ, Norman AD, Parikh SA, Leis JF, Banerji V, Brander DM, Glenn M, Ferrajoli A, Curtin K, Braggio E, Shanafelt TD, McMaster ML, Weinberg JB, Hanson CA, Caporaso NE. Natural history of monoclonal B-cell lymphocytosis among relatives in CLL families. Blood 2021; 137:2046-2056. [PMID: 33512457 PMCID: PMC8057266 DOI: 10.1182/blood.2020006322] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2020] [Accepted: 11/14/2020] [Indexed: 12/21/2022] Open
Abstract
Chronic lymphocytic lymphoma (CLL) has one of the highest familial risks among cancers. Monoclonal B-cell lymphocytosis (MBL), the precursor to CLL, has a higher prevalence (13%-18%) in families with 2 or more members with CLL compared with the general population (5%-12%). Although, the rate of progression to CLL for high-count MBLs (clonal B-cell count ≥500/µL) is ∼1% to 5%/y, no low-count MBLs have been reported to progress to date. We report the incidence and natural history of MBL in relatives from CLL families. In 310 CLL families, we screened 1045 relatives for MBL using highly sensitive flow cytometry and prospectively followed 449 of them. MBL incidence was directly age- and sex-adjusted to the 2010 US population. CLL cumulative incidence was estimated using Kaplan-Meier survival curves. At baseline, the prevalence of MBL was 22% (235/1045 relatives). After a median follow-up of 8.1 years among 449 relatives, 12 individuals progressed to CLL with a 5-year cumulative incidence of 1.8%. When considering just the 139 relatives with low-count MBL, the 5-year cumulative incidence increased to 5.7%. Finally, 264 had no MBL at baseline, of whom 60 individuals subsequently developed MBL (2 high-count and 58 low-count MBLs) with an age- and sex-adjusted incidence of 3.5% after a median of 6 years of follow-up. In a screening cohort of relatives from CLL families, we reported progression from normal-count to low-count MBL to high-count MBL to CLL, demonstrating that low-count MBL precedes progression to CLL. We estimated a 1.1% annual rate of progression from low-count MBL, which is in excess of that in the general population.
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Affiliation(s)
- Susan L Slager
- Department of Health Sciences Research, Mayo Clinic, Rochester, MN
| | - Mark C Lanasa
- Department of Medicine, Duke University, Duke Cancer Institute, Durham, NC
| | - Gerald E Marti
- Lymphoid Malignancies Section, Hematology Branch, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD
| | - Sara J Achenbach
- Department of Health Sciences Research, Mayo Clinic, Rochester, MN
| | - Nicola J Camp
- Department of Internal Medicine, Huntsman Cancer Institute, University of Utah School of Medicine, Salt Lake City, UT
| | - Fatima Abbasi
- Center for Biologics Research and Evaluation, Food and Drug Administration, Silver Springs, MD
| | - Neil E Kay
- Division of Hematology, Department of Medicine, Mayo Clinic, Rochester, MN
| | - Celine M Vachon
- Department of Health Sciences Research, Mayo Clinic, Rochester, MN
| | - James R Cerhan
- Department of Health Sciences Research, Mayo Clinic, Rochester, MN
| | - James B Johnston
- Department of Internal Medicine, Max Rady College of Medicine, University of Manitoba, Winnipeg, MB, Canada
- Research Institute in Oncology and Hematology, CancerCare Manitoba, Winnipeg, MB, Canada
| | - Timothy G Call
- Division of Hematology, Department of Medicine, Mayo Clinic, Rochester, MN
| | - Kari G Rabe
- Department of Health Sciences Research, Mayo Clinic, Rochester, MN
| | | | | | - Aaron D Norman
- Department of Health Sciences Research, Mayo Clinic, Rochester, MN
| | - Sameer A Parikh
- Division of Hematology, Department of Medicine, Mayo Clinic, Rochester, MN
| | - Jose F Leis
- Department of Hematology and Oncology, Mayo Clinic, Phoenix, AZ
| | - Versha Banerji
- Department of Internal Medicine, Max Rady College of Medicine, University of Manitoba, Winnipeg, MB, Canada
- Research Institute in Oncology and Hematology, CancerCare Manitoba, Winnipeg, MB, Canada
- Department of Biochemistry and Medical Genetics, Max Rady College of Medicine, University of Manitoba, Winnipeg, MB, Canada
| | - Danielle M Brander
- Department of Medicine, Duke University, Duke Cancer Institute, Durham, NC
| | - Martha Glenn
- Department of Internal Medicine, Huntsman Cancer Institute, University of Utah School of Medicine, Salt Lake City, UT
| | - Alessandra Ferrajoli
- Department of Leukemia, University of Texas MD Anderson Cancer Center, Houston, TX
| | - Karen Curtin
- Department of Internal Medicine, Huntsman Cancer Institute, University of Utah School of Medicine, Salt Lake City, UT
| | - Esteban Braggio
- Department of Hematology and Oncology, Mayo Clinic, Phoenix, AZ
| | - Tait D Shanafelt
- Division of Hematology, Department of Medicine, Stanford University School of Medicine, Palo Alto, CA
| | - Mary L McMaster
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, National Institutes of Health, Bethesda, MD
| | - J Brice Weinberg
- Department of Medicine, Duke University, Duke Cancer Institute, Durham, NC
- Department of Immunology, Duke University Medical Center, Durham, NC
- Durham Veterans Affairs Medical Center, Durham, NC; and
| | - Curtis A Hanson
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN
| | - Neil E Caporaso
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, National Institutes of Health, Bethesda, MD
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14
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Michel M, Lega JC, Terriou L. [Secondary ITP in adults]. Rev Med Interne 2020; 42:50-57. [PMID: 33139079 DOI: 10.1016/j.revmed.2020.08.004] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2020] [Accepted: 08/07/2020] [Indexed: 12/13/2022]
Abstract
Secondary forms of immune thrombocytopenia (ITP) represent approximately 20% of all ITP cases in adulthood and this rate increases with age. Since some causes may influence both the prognosis and outcome but also the management of ITP, a minimal workup must be performed at ITP diagnosis to look for an associated or underlying cause. Among adults, B-cell lymphomas and mainly chronic lymphocytic leukemia, systemic auto-immune diseases such as systemic lupus or primary immunodeficiencies mainly represented by common variable immunodeficiency are the most frequent causes of secondary ITP. Whereas first-line therapy used for secondary ITP is usually similar to the one commonly used in primary ITP and relies mostly on corticosteroids±intravenous immunoglobulin according to the severity of bleeding, second and third-line treatments must take into account the type and degree of activity of the underlying disease.
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Affiliation(s)
- M Michel
- Service de médecine interne, centre de référence pour les cytopénies auto-immunes de l'adulte, CHU Henri-Mondor, université Paris Est Créteil, Assistance publique-Hôpitaux de Paris, Créteil, France.
| | - J-C Lega
- Service de médecine interne et vasculaire, centre de compétences cytopénies auto-immunes, hôpital Lyon Sud, Lyon, France
| | - L Terriou
- Département de médecine interne et immunologie clinique, CHU de Lille, Lille, France
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15
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Ringelstein-Harlev S. Immune dysfunction complexity in chronic lymphocytic leukemia ‒ an issue to consider when designing novel therapeutic strategies. Leuk Lymphoma 2020; 61:2050-2058. [PMID: 32336174 DOI: 10.1080/10428194.2020.1755857] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
A complex interplay between chronic lymphocytic leukemia (CLL) cells and different constituents of the immune system generally results in immune tolerance. As targeted therapies are gaining a critical role in the therapeutic landscape of this disease, their impact on the already perturbed immune milieu needs to be considered. This review addresses the issues of basic immune dysfunction in CLL which is further complicated by the effects of a number of novel targeted therapies used for this malignancy. These new approaches may simultaneously facilitate both anti- and pro-cancer activity, potentially compromising the depth of response to therapy. Current evidence suggests that exploiting combination therapy could potentially overcome at least part of these deleterious effects, thereby prolonging response to treatment and helping to restore immune activity.
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Affiliation(s)
- Shimrit Ringelstein-Harlev
- Department of Hematology and Bone Marrow Transplantation, Rambam Health Care Campus, Haifa, Israel.,The Ruth and Bruce Rappaport Faculty of Medicine, Technion, Haifa, Israel
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16
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Autoimmune Complications in Chronic Lymphocytic Leukemia in the Era of Targeted Drugs. Cancers (Basel) 2020; 12:cancers12020282. [PMID: 31979293 PMCID: PMC7072470 DOI: 10.3390/cancers12020282] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2019] [Revised: 01/19/2020] [Accepted: 01/21/2020] [Indexed: 12/21/2022] Open
Abstract
Autoimmune phenomena are frequently observed in patients with chronic lymphocytic leukemia (CLL) and are mainly attributable to underlying dysfunctions of the immune system. Autoimmune cytopenias (AIC) affect 4-7% of patients with CLL and mainly consist of autoimmune hemolytic anemia and immune thrombocytopenia. Although less common, non-hematological autoimmune manifestations have also been reported. Treatment of CLL associated AIC should be primarily directed against the autoimmune phenomenon, and CLL specific therapy should be reserved to refractory cases or patients with additional signs of disease progression. New targeted drugs (ibrutinib, idelalisib and venetoclax) recently entered the therapeutic armamentarium of CLL, showing excellent results in terms of efficacy and became an alternative option to standard chemo-immunotherapy for the management of CLL associated AIC. However, the possible role of these drugs in inducing or exacerbating autoimmune phenomena still needs to be elucidated. In this article, we review currently available data concerning autoimmune phenomena in patients with CLL, particularly focusing on patients treated with ibrutinib, idelalisib, or venetoclax, and we discuss the possible role of these agents in the management of AIC.
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17
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Haider MS, Khan SA, Nasiruddin, Shahid S. Autoimmune cytopenias in chronic lymphocytic leukemia. Pak J Med Sci 2019; 35:1334-1338. [PMID: 31489002 PMCID: PMC6717446 DOI: 10.12669/pjms.35.5.369] [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: 11/15/2022] Open
Abstract
Objective To determine the frequency of autoimmune cytopenias in chronic lymphocytic leukemia. Methods This cross sectional study was carried out at Department of Hematology, Army Medical College Rawalpindi, in collaboration with Military Hospital Rawalpindi and Armed Forces institute of Pathology Rawalpindi from 1st January 2018 to 1st October 2018. Sample size of 64 was calculated using WHO calculator. Age and gender of patients was noted. Frequency of autoimmune hemolytic anaemia, immune thrombocytopenic purpura, pure red cell aplasia and autoimmune agranulocytosis were determined in diagnosed patients of chronic lymphocytic leukemia by various laboratory tests in our study population. Results A total of 64 patients were included in the study, 53 (82.8%) were males and 11(17.2%) were females. Mean age of patients was 65 years. Autoimmune hemolytic anaemia was observed in 5/64 (7.8%) of patients. Immune thrombocytopenic purpura was seen in 2/64 (3.1%) patients. Autoimmune granuloytopenia and pure red cell aplasia were not seen in any patient. Conclusion Autoimmune hemolytic anaemia and immune thrombocytopenic purpura are the most common causes of immune cytopenias in patients of CLL. Immune cytopenias should always be identified by laboratory tests as their management differs from other cytopenias which occur due to various other causes.
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Affiliation(s)
- M Shabih Haider
- Dr. Mohammad Shabih Haider, MBBS, Department of Pathology (Haematology Section), Army Medical College, Rawalpindi, Pakistan
| | - Saleem Ahmed Khan
- Dr. Saleem Ahmed Khan, FCPS, Department of Pathology (Haematology Section), Army Medical College, Rawalpindi, Pakistan
| | - Nasiruddin
- Dr. Nasiruddin, FCPS, Department of Pathology (Haematology Section), Army Medical College, Rawalpindi, Pakistan
| | - Samra Shahid
- Dr. Samra Shahid FCPS, Department of Pathology (Haematology Section), Army Medical College, Rawalpindi, Pakistan
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18
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Crickx E, Poullot E, Moulis G, Goulabchand R, Fieschi C, Galicier L, Meignin V, Coppo P, Delarue R, Casasnovas O, Roos-Weil D, de Leval L, Parrens M, Michel M, Dupuis J, Le Bras F, Fataccioli V, Martin-Garcia N, Godeau B, Haïoun C, Gaulard P, Mahévas M. Clinical spectrum, evolution, and management of autoimmune cytopenias associated with angioimmunoblastic T-cell lymphoma. Eur J Haematol 2019; 103:35-42. [PMID: 30985955 DOI: 10.1111/ejh.13239] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2019] [Revised: 04/03/2019] [Accepted: 04/04/2019] [Indexed: 12/12/2022]
Abstract
OBJECTIVE Angioimmunoblastic T-cell lymphoma (AITL) is frequently associated with autoimmune cytopenia (AIC). Whether such patients have a particular phenotype and require particular management is unclear. METHOD Angioimmunoblastic T-cell lymphoma patients from the multicentric database of the Lymphoma Study Association presenting with AIC during disease course were included and matched to AITL patients without AIC (1/5 ratio). RESULTS At diagnosis, AIC patients (n = 28) had more spleen and bone marrow involvement (54% vs 19% and 71% vs 34%, P < 0.001), Epstein-Barr virus replication (89% vs 39%, P < 0.001), gamma globulin titers (median 23 vs 15 g/L, P = 0.002), and proliferating B cells and plasmablasts in biopsies, as compared to control patients (n = 136). The 28 AIC patients had 41 episodes of AIC, diagnosed concomitantly with AITL in 23 (82%) cases. After a median follow-up of 24 months (range 3-155), 10 patients relapsed, all associated with AITL relapse. CONCLUSION Our results provide new insight into AIC associated with AITL by highlighting the significant interplay between AITL and B-cell activation leading to subsequent autoimmunity.
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Affiliation(s)
- Etienne Crickx
- Service de médecine interne, Hôpital Henri-Mondor, Assistance Publique-Hôpitaux de Paris (AP-HP), Université Paris-Est, Créteil, France.,Institut Necker Enfants Malades, INSERM U1151/CNRS UMS 8253, Université Paris Descartes, Sorbonne Paris Cité, Paris Cedex, France
| | - Elsa Poullot
- Département de Pathologie, Hôpital Henri-Mondor (AP-HP), Créteil, France.,Faculté de Médecine, Université Paris-Est, Inserm U955, Créteil, France
| | - Guillaume Moulis
- Service de médecine Interne, CHU de Toulouse, Toulouse, France.,UMR 1027 Inserm-Université de Toulouse, Toulouse, France.,CIC 1436, CHU de Toulouse, Toulouse, France
| | - Radjiv Goulabchand
- Service de médecine interne, maladies multi-organiques, Hôpital Saint-Eloi, CHRU Montpellier, Montpellier, France
| | - Claire Fieschi
- Service d'immunologie clinique, Hôpital Saint-Louis, Assistance Publique-Hôpitaux de Paris, Université Paris Diderot, Sorbonne Paris Cité, Paris, France
| | - Lionel Galicier
- Service d'immunologie clinique, Hôpital Saint-Louis, Assistance Publique-Hôpitaux de Paris, Université Paris Diderot, Sorbonne Paris Cité, Paris, France
| | - Véronique Meignin
- Service d'anatomopathologie, Hôpital Saint-Louis (AP-HP), Paris, France
| | - Paul Coppo
- Service d'hématologie, Centre de référence des microangiopathies thrombotiques, Hôpital Saint-Antoine (AP-HP), Sorbonne Universités, Paris, France
| | - Richard Delarue
- Service d'hématologie, Hôpital Necker (AP-HP), Paris, France
| | - Olivier Casasnovas
- Service d'hématologie, Centre Hospitalier Universitaire de Dijon, Dijon, France
| | - Damien Roos-Weil
- Sorbonne Universités, UPMC Université Paris 06, AP-HP, GRC-11, Groupe de recherche clinique sur les hémopathies lymphoïdes (GRECHY), Hôpital Pitié-Salpétrière (APHP), Paris, France
| | - Laurence de Leval
- Institut de Pathologie, Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland
| | - Marie Parrens
- Département de Pathologie, Hôpital Pessac, Bordeaux, France
| | - Marc Michel
- Service de médecine interne, Hôpital Henri-Mondor, Assistance Publique-Hôpitaux de Paris (AP-HP), Université Paris-Est, Créteil, France
| | - Jehan Dupuis
- Unité Hémopathies Lymphoïdes, Hôpital Henri-Mondor (AP-HP), Créteil, France
| | - Fabien Le Bras
- Unité Hémopathies Lymphoïdes, Hôpital Henri-Mondor (AP-HP), Créteil, France
| | - Virginie Fataccioli
- Département de Pathologie, Hôpital Henri-Mondor (AP-HP), Créteil, France.,Faculté de Médecine, Université Paris-Est, Inserm U955, Créteil, France
| | - Nadine Martin-Garcia
- Département de Pathologie, Hôpital Henri-Mondor (AP-HP), Créteil, France.,Faculté de Médecine, Université Paris-Est, Inserm U955, Créteil, France
| | - Bertrand Godeau
- Service de médecine interne, Hôpital Henri-Mondor, Assistance Publique-Hôpitaux de Paris (AP-HP), Université Paris-Est, Créteil, France
| | - Corinne Haïoun
- Unité Hémopathies Lymphoïdes, Hôpital Henri-Mondor (AP-HP), Créteil, France
| | - Philippe Gaulard
- Département de Pathologie, Hôpital Henri-Mondor (AP-HP), Créteil, France.,Faculté de Médecine, Université Paris-Est, Inserm U955, Créteil, France
| | - Matthieu Mahévas
- Service de médecine interne, Hôpital Henri-Mondor, Assistance Publique-Hôpitaux de Paris (AP-HP), Université Paris-Est, Créteil, France.,Institut Necker Enfants Malades, INSERM U1151/CNRS UMS 8253, Université Paris Descartes, Sorbonne Paris Cité, Paris Cedex, France.,Unité Inserm U955, équipe 2, Hôpital Henri-Mondor, Assistance publique-hôpitaux de Paris, Créteil, France
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19
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Presence of serum antinuclear antibodies correlating unfavorable overall survival in patients with chronic lymphocytic leukemia. Chin Med J (Engl) 2019; 132:525-533. [PMID: 30741830 PMCID: PMC6415995 DOI: 10.1097/cm9.0000000000000114] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023] Open
Abstract
Background: Serum antinuclear antibodies (ANAs) are positive in some patients with chronic lymphocytic leukemia (CLL), but the prognostic value of ANAs remains unknown. The aim of this study was to evaluate the role of ANAs as a prognostic factor in CLL. Methods: This study retrospectively analyzed clinical data from 216 newly diagnosed CLL subjects with ANAs test from 2007 to 2017. Multivariate Cox regression analyses were used to screen the independent prognostic factors related to time to first treatment (TTFT), progression free survival (PFS) and overall survival (OS). Receiver operator characteristic curves and area under the curve (AUC) were utilized to assess the predictive accuracy of ANAs together with other independent factors for OS. Results: The incidence of ANAs abnormality at diagnosis was 13.9%. ANAs positivity and TP53 disruption were independent prognostic indicators for OS. The AUC of positive ANAs together with TP53 disruption was 0.766 (95% confidence interval [CI]: 0.697–0.826), which was significantly larger than that of either TP53 disruption (AUC: 0.706, 95% CI: 0.634–0.772, P = 0.034) or positive ANAs (AUC: 0.595, 95% CI: 0.520–0.668, P < 0.001) in OS prediction. Besides, serum positive ANAs as one additional parameter to CLL-international prognostic index (IPI) obtained superior AUCs in predicting CLL OS than CLL-IPI alone. Conclusion: This study identified ANAs as an independent prognostic factor for CLL, and further investigations are needed to validate this finding.
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20
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Chronic Lymphocytic Leukemia Presenting as a Subcortical Watershed Infarct. Case Rep Hematol 2019; 2019:2089359. [PMID: 30729050 PMCID: PMC6343168 DOI: 10.1155/2019/2089359] [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: 07/29/2018] [Revised: 11/14/2018] [Accepted: 12/20/2018] [Indexed: 11/24/2022] Open
Abstract
Internal watershed infarcts (WI) involve white matter between deep and superficial arterial systems of middle cerebral artery. These infarcts are considered to be either from low blood flow or microembolism. Anemia is an extremely rare cause of watershed infarcts. Very few cases of hemolytic anemia causing watershed cerebral infarcts have been reported. Chronic lymphocytic leukemia (CLL) is frequently complicated with secondary autoimmune cytopenia such as autoimmune hemolytic anemia (AIHA), immune thrombocytopenia (ITP), and pure red cell aplasia. AIHA is present in about 7–10% of patients with CLL. AIHA from CLL presenting as WI is an extremely rare phenomenon with no previously published case reports to the best of our knowledge.
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21
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Pleyer C, Wiestner A, Sun C. Immunological changes with kinase inhibitor therapy for chronic lymphocytic leukemia. Leuk Lymphoma 2018; 59:2792-2800. [PMID: 29764250 PMCID: PMC6237652 DOI: 10.1080/10428194.2018.1457147] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2018] [Revised: 03/07/2018] [Accepted: 03/13/2018] [Indexed: 01/10/2023]
Abstract
Ibrutinib and idelalisib are kinase inhibitors that have revolutionized the treatment of chronic lymphocytic leukemia (CLL). Capable of inducing durable remissions, these agents also modulate the immune system. Both ibrutinib and idelalisib abrogate the tumor-supporting microenvironment by disrupting cell-cell interactions, modulating the T-cell compartment, and altering the cytokine milieu. Ibrutinib also partially restores T-cell and myeloid defects associated with CLL. In contrast, immune-related adverse effects, including pneumonitis, colitis, hepatotoxicity, and infections are of particular concern with idelalisib. While opportunistic infections and viral reactivations occur with both ibrutinib and idelalisib, these complications are less common and less severe with ibrutinib, especially when used as monotherapy without additional immunosuppressive agents. This review discusses the impact of ibrutinib and idelalisib on the immune system, including infectious and auto-immune complications as well as their specific effects on the B-cell, T-cell, and myeloid compartment.
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Affiliation(s)
- Christopher Pleyer
- Hematology Branch, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD
| | - Adrian Wiestner
- Hematology Branch, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD
| | - Clare Sun
- Hematology Branch, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD
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22
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Hampel PJ, Larson MC, Kabat B, Call TG, Ding W, Kenderian SS, Bowen D, Boysen J, Schwager SM, Leis JF, Chanan-Khan AA, Muchtar E, Hanson CA, Slager SL, Kay NE, Chaffee KG, Shanafelt TD, Parikh SA. Autoimmune cytopenias in patients with chronic lymphocytic leukaemia treated with ibrutinib in routine clinical practice at an academic medical centre. Br J Haematol 2018; 183:421-427. [PMID: 30117139 DOI: 10.1111/bjh.15545] [Citation(s) in RCA: 34] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2018] [Accepted: 07/05/2018] [Indexed: 01/04/2023]
Abstract
The effects of ibrutinib on the natural history of autoimmune cytopenias (AIC) among chronic lymphocytic leukaemia (CLL) patients treated in routine clinical practice require further investigation. Using the Mayo Clinical CLL Database, 193 CLL patients treated with ibrutinib between November 2013 and January 2017 outside the context of a clinical trial were identified; complete review of their medical records was performed for details of past history of AIC and treatment-emergent AIC. We identified 29/193 (15%) patients with history of AIC prior to ibrutinib start. Of 12 patients requiring AIC therapy at ibrutinib start, 8 (67%) were able to discontinue or de-escalate AIC treatment, and no patient had worsening of their AIC after initiating ibrutinib. Eleven (6%) patients developed treatment-emergent AIC after a median of 59 (range, 6-319) days following the initiation of ibrutinib, 7 of whom (64%) were able to continue ibrutinib. Overall and event-free survival from time of ibrutinib start were not significantly different between patients with history of AIC and those with no history of AIC. Treatment-emergent AIC were seen exclusively in patients with unmutated IGHV and were associated with a shorter EFS. These results suggest a low rate of treatment-emergent AIC and improvement in patients with existing AIC.
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Affiliation(s)
- Paul J Hampel
- Department of Internal Medicine, Mayo Clinic, Rochester, MN, USA
| | - Melissa C Larson
- Division of Biomedical Statistics & Informatics, Department of Health Sciences Research, Mayo Clinic, Rochester, MN, USA
| | - Brian Kabat
- Division of Biomedical Statistics & Informatics, Department of Health Sciences Research, Mayo Clinic, Rochester, MN, USA
| | - Timothy G Call
- Division of Hematology, Department of Medicine, Mayo Clinic, Rochester, MN, USA
| | - Wei Ding
- Division of Hematology, Department of Medicine, Mayo Clinic, Rochester, MN, USA
| | - Saad S Kenderian
- Division of Hematology, Department of Medicine, Mayo Clinic, Rochester, MN, USA
| | - Deborah Bowen
- Division of Hematology, Department of Medicine, Mayo Clinic, Rochester, MN, USA
| | - Justin Boysen
- Division of Hematology, Department of Medicine, Mayo Clinic, Rochester, MN, USA
| | - Susan M Schwager
- Division of Hematology, Department of Medicine, Mayo Clinic, Rochester, MN, USA
| | - Jose F Leis
- Department of Hematology and Oncology, Mayo Clinic, Phoenix, AZ, USA
| | | | - Eli Muchtar
- Division of Hematology, Department of Medicine, Mayo Clinic, Rochester, MN, USA
| | - Curtis A Hanson
- Division of Hematopathology, Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, USA
| | - Susan L Slager
- Division of Biomedical Statistics & Informatics, Department of Health Sciences Research, Mayo Clinic, Rochester, MN, USA
| | - Neil E Kay
- Division of Hematology, Department of Medicine, Mayo Clinic, Rochester, MN, USA
| | - Kari G Chaffee
- Division of Biomedical Statistics & Informatics, Department of Health Sciences Research, Mayo Clinic, Rochester, MN, USA
| | - Tait D Shanafelt
- Department of Hematology, Stanford University Medical Center, Stanford, CA, USA
| | - Sameer A Parikh
- Division of Hematology, Department of Medicine, Mayo Clinic, Rochester, MN, USA
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De Back TR, Kater AP, Tonino SH. Autoimmune cytopenias in chronic lymphocytic leukemia: a concise review and treatment recommendations. Expert Rev Hematol 2018; 11:613-624. [DOI: 10.1080/17474086.2018.1489720] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Affiliation(s)
- Tim R. De Back
- Department of Hematology and Lymphoma and Myeloma Center (LYMMCARE), Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - Arnon P. Kater
- Department of Hematology and Lymphoma and Myeloma Center (LYMMCARE), Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - Sanne H. Tonino
- Department of Hematology and Lymphoma and Myeloma Center (LYMMCARE), Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
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Strati P, Gabutti C, Thompson PA, Kontoyiannis DP, Ferrajoli A. Cytomegalovirus reactivation can be a cause of DAT-negative hemolytic anemia in patients with chronic lymphocytic leukemia. Leuk Lymphoma 2018; 60:535-537. [PMID: 29911929 DOI: 10.1080/10428194.2018.1474527] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
Affiliation(s)
- Paolo Strati
- a Department of Leukemia , The University of Texas MD Anderson Cancer Center , Houston , TX , USA
| | - Cristina Gabutti
- a Department of Leukemia , The University of Texas MD Anderson Cancer Center , Houston , TX , USA
| | - Philip A Thompson
- a Department of Leukemia , The University of Texas MD Anderson Cancer Center , Houston , TX , USA
| | - Dimitrios P Kontoyiannis
- b Department of Infectious Diseases , The University of Texas MD Anderson Cancer Center , Houston , TX , USA
| | - Alessandra Ferrajoli
- a Department of Leukemia , The University of Texas MD Anderson Cancer Center , Houston , TX , USA
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Getta BM, Devlin S, Park JH, Tallman MS, Berman E. Disease characteristics and clinical outcomes in patients aged less than 40 with chronic lymphocytic leukemia. Leuk Res 2018; 65:80-85. [DOI: 10.1016/j.leukres.2017.12.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2017] [Revised: 12/04/2017] [Accepted: 12/31/2017] [Indexed: 10/18/2022]
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Sudulagunta SR, Kumbhat M, Sodalagunta MB, Settikere Nataraju A, Bangalore Raja SK, Thejaswi KC, Deepak R, Mohammed AH, Sunny SP, Visweswar A, Suvarna M, Nanjappa R. Warm Autoimmune Hemolytic Anemia: Clinical Profile and Management. J Hematol 2017; 6:12-20. [PMID: 32300386 PMCID: PMC7155818 DOI: 10.14740/jh303w] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/04/2017] [Indexed: 12/20/2022] Open
Abstract
Background Autoimmune hemolytic anemia (AIHA) is a rare autoimmune disease in which autoantibodies target red blood cells leading to marked decrease in their lifespan. The classification of AIHA is based on the immunochemical properties of the RBC autoantibody. Warm antibody AIHA (wAIHA) accounts for 75-80% of all adult AIHA cases. The treatment of wAIHA is mainly corticosteroids. Our retrospective study aimed to study the clinical profile and management of wAIHA. Methods Data of 75 patients admitted with wAIHA or presented to outpatient department (previous medical records) with wAIHA between January 2003 and January 2016 were analyzed. Results In our study, females constituted 12 and 26 patients of primary and secondary wAIHA, while males constituted 17 and 20 patients of primary and secondary wAIHA, respectively. Mean hemoglobin level at AIHA onset was found to be 7.1 ± 1.7 g/dL in primary wAIHA group and 6.3 ± 1.2 g/dL in secondary wAIHA group, which is statistically significant. Splenectomy was used as mode of treatment in one (3.4%) patient of primary wAIHA group and 15 (32.60%) patients of secondary wAIHA group, which is statistically significant. Mean age of wAIHA onset was 69.7 ± 21.5 years in wAIHA group secondary to lymphoma and 54.3 ± 25.7 years in other wAIHA group, which is statistically significant. Conclusion The most common causes of secondary wAIHA are B-cell lymphoma, systemic lupus erythematosus, rheumatoid arthritis, chronic lymphocytic leukemia (CLL), common variable immune deficiency, renal cell carcinoma and secondary to drug usage (alpha methyldopa and carbamazepine), respectively. Reducing the cumulative dose of corticosteroids with second line treatment whenever possible and therefore reducing the risk of sepsis, specifically in older patients with comorbidities will reduce morbidity and mortality.
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Affiliation(s)
| | - Monica Kumbhat
- Department of Pathology, Sri Ramachandra Medical College, Chennai, India
| | | | | | | | | | - Raj Deepak
- Department of General Medicine, Dr.B.R.Ambedkar Medical College, Bangalore, India
| | | | - Sony P Sunny
- Department of General Medicine, Dr.B.R.Ambedkar Medical College, Bangalore, India
| | - Amulya Visweswar
- Department of General Medicine, Dr.B.R.Ambedkar Medical College, Bangalore, India
| | - Mikita Suvarna
- Department of General Medicine, Dr.B.R.Ambedkar Medical College, Bangalore, India
| | - Rashmi Nanjappa
- Department of General Medicine, Dr.B.R.Ambedkar Medical College, Bangalore, India
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Abstract
Chronic lymphocytic leukemia (CLL) is frequently associated with autoimmune complications such as autoimmune hemolytic anemia, immune thrombocytopenia, pure red cell aplasia, and autoimmune granulocytopenia. It is critical to diagnose cytopenias from these secondary complications of CLL accurately, since prognosis and therapy are substantially different from patients who have cytopenias due to extensive bone marrow infiltration by CLL. The pathogenesis of autoimmune cytopenias in CLL is complex; and it involves antigen presentation by CLL cells to polyclonal B cells resulting in production of autoantibody, and alteration of the T cell milieu tilting the balance in favor of an autoimmune response. Traditional therapy of autoimmune complications in CLL consists of immunosuppression with corticosteroids and/or anti-CD20 monoclonal antibodies. In patients who have a suboptimal response, treating the underlying CLL is generally effective in ameliorating secondary cytopenias. Although novel oral therapies such as ibrutinib, idelalisib, and venetoclax have been shown to be extremely effective in the management of CLL, prospective data from larger numbers of patients with longer follow-up are needed prior to recommending their routine use in the management of autoimmune cytopenias in CLL.
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MESH Headings
- Agranulocytosis/complications
- Agranulocytosis/drug therapy
- Agranulocytosis/epidemiology
- Anemia, Hemolytic, Autoimmune/complications
- Anemia, Hemolytic, Autoimmune/diagnosis
- Anemia, Hemolytic, Autoimmune/drug therapy
- Anemia, Hemolytic, Autoimmune/epidemiology
- Antineoplastic Combined Chemotherapy Protocols/therapeutic use
- Humans
- Immunosuppressive Agents/therapeutic use
- Leukemia, Lymphocytic, Chronic, B-Cell/complications
- Leukemia, Lymphocytic, Chronic, B-Cell/drug therapy
- Leukemia, Lymphocytic, Chronic, B-Cell/pathology
- Protein Kinase Inhibitors/therapeutic use
- Red-Cell Aplasia, Pure/complications
- Red-Cell Aplasia, Pure/drug therapy
- Red-Cell Aplasia, Pure/epidemiology
- Rituximab/administration & dosage
- Thrombocytopenia/complications
- Thrombocytopenia/drug therapy
- Thrombocytopenia/epidemiology
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Affiliation(s)
- Mazie Tsang
- Division of Hematology, Department of Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - Sameer A Parikh
- Division of Hematology, Department of Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA.
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Galinier A, Delwail V, Puyade M. Ibrutinib Is Effective in the Treatment of Autoimmune Haemolytic Anaemia in Mantle Cell Lymphoma. Case Rep Oncol 2017; 10:127-129. [PMID: 28203175 PMCID: PMC5301091 DOI: 10.1159/000456002] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2017] [Accepted: 01/11/2017] [Indexed: 01/19/2023] Open
Abstract
Autoimmune haemolytic anaemia (AIHA) in mantle cell lymphoma (MCL) is a rare but life-threatening complication. To date, there are no relevant data for treatment of AIHA in MCL. Ibrutinib, which has been approved for relapse/refractory MCL, is an immunomodulatory drug inhibiting Th2 activation and consequently the production of autoantibodies. We report a case of MCL with AIHA in which this form of anaemia was not controlled with the usual chemotherapy. Ibrutinib was used when MCL with AIHA relapsed, and it allowed rapid remission of AIHA and rapid discontinuation of steroid therapy.
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Affiliation(s)
- Aliénor Galinier
- CHU de Poitiers, Service d'Onco-Hématologie et Thérapie Cellulaire, Poitiers, France
| | - Vincent Delwail
- CHU de Poitiers, Service d'Onco-Hématologie et Thérapie Cellulaire, Poitiers, France
| | - Mathieu Puyade
- CHU de Poitiers, Service d'Onco-Hématologie et Thérapie Cellulaire, Poitiers, France
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31
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Carli G, Visco C, Falisi E, Perbellini O, Novella E, Giaretta I, Ferrarini I, Sandini A, Alghisi A, Ambrosetti A, Rodeghiero F. Evans syndrome secondary to chronic lymphocytic leukaemia: presentation, treatment, and outcome. Ann Hematol 2016; 95:863-70. [PMID: 27001309 DOI: 10.1007/s00277-016-2642-x] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2015] [Accepted: 03/08/2016] [Indexed: 11/30/2022]
Abstract
Evans syndrome (ES) is defined by the combination (either simultaneous or sequential) of immune thrombocytopenia (ITP) and autoimmune haemolytic anaemia (AIHA). When related to secondary conditions, ES may arise in patients with chronic lymphocytic leukaemia (CLL), which is frequently associated to autoimmune cytopenias (AIC). We analysed 25 patients with ES secondary to CLL, which were identified from a large series of consecutive patients with CLL, diagnosed and followed up in two institutions. They represented 2.9 % of the whole series. Thirteen patients presented with concurrent ITP and AIHA (simultaneous ES), while others developed the two AIC sequentially. Occurrence of ES was associated with unfavourable biological prognostic factors like ZAP-70 expression, unmutated immunoglobulin heavy chain variable region gene status, 17-p13 deletion and TP53 gene mutations. Of note, the majority of patients with ES (66 %) had stereotyped B cell receptor configuration. Most patients had short-lasting remissions and required second-line treatments to control the autoimmune manifestations of ES. Patients with ES were associated with inferior survival compared to patients not developing AIC, especially when ES developed early in the course of CLL, although the reduced survival was not confirmed by multivariate analysis. In conclusion, ES secondary to CLL is a difficult-to-treat complication, characterised by adverse biological features and clinical outcome.
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Affiliation(s)
- Giuseppe Carli
- Department of Cell Therapy and Haematology, San Bortolo Hospital, Via Rodolfi 37, 36100, Vicenza, Italy
| | - Carlo Visco
- Department of Cell Therapy and Haematology, San Bortolo Hospital, Via Rodolfi 37, 36100, Vicenza, Italy.
| | - Erika Falisi
- Department of Cell Therapy and Haematology, San Bortolo Hospital, Via Rodolfi 37, 36100, Vicenza, Italy
| | - Omar Perbellini
- Department of Cell Therapy and Haematology, San Bortolo Hospital, Via Rodolfi 37, 36100, Vicenza, Italy
| | - Elisabetta Novella
- Department of Cell Therapy and Haematology, San Bortolo Hospital, Via Rodolfi 37, 36100, Vicenza, Italy
| | - Ilaria Giaretta
- Department of Cell Therapy and Haematology, San Bortolo Hospital, Via Rodolfi 37, 36100, Vicenza, Italy
| | - Isacco Ferrarini
- Department of Medicine, Section of Haematology, University of Verona, Verona, Italy
| | - Alessandra Sandini
- Department of Immunohaematology, Transfusion Medicine and Human Genetics, San Bortolo Hospital, Vicenza, Italy
| | - Alberta Alghisi
- Department of Immunohaematology, Transfusion Medicine and Human Genetics, San Bortolo Hospital, Vicenza, Italy
| | - Achille Ambrosetti
- Department of Medicine, Section of Haematology, University of Verona, Verona, Italy
| | - Francesco Rodeghiero
- Department of Cell Therapy and Haematology, San Bortolo Hospital, Via Rodolfi 37, 36100, Vicenza, Italy
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32
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Abstract
Chronic lymphocytic leukemia/small lymphocytic lymphoma (CLL) is usually diagnosed in asymptomatic patients with early-stage disease. The standard management approach is careful observation, irrespective of risk factors unless patients meet the International Workshop on CLL (IWCLL) criteria for "active disease," which requires treatment. The initial standard therapy for most patients combines an anti-CD20 antibody (such as rituximab, ofatumumab, or obinutuzumab) with chemotherapy (fludarabine/cyclophosphamide [FC], bendamustine, or chlorambucil) depending on multiple factors including the physical fitness of the patient. However, patients with very high-risk CLL because of a 17p13 deletion (17p-) with or without mutation of TP53 (17p-/TP53mut) have poor responses to chemoimmunotherapy and require alternative treatment regimens containing B-cell receptor (BCR) signaling pathway inhibitors. The BCR signaling pathway inhibitors (ibrutinib targeting Bruton's tyrosine kinase [BTK] and idelalisib targeting phosphatidyl-inositol 3-kinase delta [PI3K-delta], respectively) are currently approved for the treatment of relapsed/refractory CLL and all patients with 17p- (ibrutinib), and in combination with rituximab for relapsed/refractory patients (idelalisib). These agents offer great efficacy, even in chemotherapy refractory CLL, with increased tolerability, safety, and survival. Ongoing studies aim to determine the best therapy combinations with the goal of achieving long-term disease control and the possibility of developing a curative regimen for some patients. CLL is associated with a wide range of infectious, autoimmune, and malignant complications. These complications result in considerable morbidity and mortality that can be minimized by early detection and aggressive management. This active monitoring requires ongoing patient education, provider vigilance, and a team approach to patient care.
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Affiliation(s)
- Stephan Stilgenbauer
- From Ulm University, Ulm, Germany; Weill Cornell Medical College, New York, NY; University of Rochester, Rochester, NY
| | - Richard R Furman
- From Ulm University, Ulm, Germany; Weill Cornell Medical College, New York, NY; University of Rochester, Rochester, NY
| | - Clive S Zent
- From Ulm University, Ulm, Germany; Weill Cornell Medical College, New York, NY; University of Rochester, Rochester, NY
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Abstract
Secondary autoimmune cytopenias in chronic lymphocytic leukemia are distinct clinical entities that require specific management. These autoimmune disorders have a complex pathogenesis that involves both the leukemic cells and the immune environment in which they exist. The mechanism is not the same in all cases, and to varying degrees involves the chronic lymphocytic leukemia (CLL) cells in antibody production, antigen presentation, and stimulation of T cells and bystander polyclonal B cells. Diagnosis of autoimmune cytopenias can be challenging as it is difficult to differentiate between autoimmunity and bone marrow failure due to disease progression. There is a need to distinguish these causes, as prognosis and treatment are not the same. Evidence regarding treatment of secondary autoimmune cytopenias is limited, but many effective options exist and treatment can be selected with severity of disease and patient factors in mind. With new agents to treat CLL coming into widespread clinical use, it will be important to understand how these will change the natural history and treatment of autoimmune cytopenias.
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Affiliation(s)
- Kerry A Rogers
- Division of Hematology, Department of Internal Medicine, The Ohio State University, Columbus, OH
| | - Jennifer A Woyach
- Division of Hematology, Department of Internal Medicine, The Ohio State University, Columbus, OH.
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Incidence and description of autoimmune cytopenias during treatment with ibrutinib for chronic lymphocytic leukemia. Leukemia 2015; 30:346-50. [PMID: 26442611 DOI: 10.1038/leu.2015.273] [Citation(s) in RCA: 67] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2015] [Revised: 09/03/2015] [Accepted: 09/25/2015] [Indexed: 02/07/2023]
Abstract
Chronic lymphocytic leukemia (CLL) is frequently complicated by secondary autoimmune cytopenias (AICs). Ibrutinib is an irreversible inhibitor of Bruton's tyrosine kinase approved for the treatment of relapsed CLL and CLL with del(17p). The effect of ibrutinib treatment on the incidence of AIC is currently unknown. We reviewed medical records of 301 patients treated with ibrutinib, as participants in therapeutic clinical trials at The Ohio State University Comprehensive Cancer Center between July 2010 and July 2014. Subjects were reviewed with respect to past history of AIC, and treatment-emergent AIC cases were identified. Before starting ibrutinib treatment, 26% of patients had experienced AIC. Information was available for a total of 468 patient-years of ibrutinib exposure, during which there were six cases of treatment-emergent AIC. This corresponds to an estimated incidence rate of 13 episodes for every 1000 patient-years of ibrutinib treatment. We further identified 22 patients receiving therapy for AIC at the time ibrutinib was started. Of these 22 patients, 19 were able to discontinue AIC therapy. We found that ibrutinib treatment is associated with a low rate of treatment-emergent AIC. Patients with an existing AIC have been successfully treated with ibrutinib and subsequently discontinued AIC therapy.
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35
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Manda S, Dunbar N, Marx-Wood CR, Danilov AV. Ibrutinib is an effective treatment of autoimmune haemolytic anaemia in chronic lymphocytic leukaemia. Br J Haematol 2015; 170:734-6. [DOI: 10.1111/bjh.13328] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Affiliation(s)
- Sudhir Manda
- Dartmouth-Hitchcock Medical Center; Lebanon NH USA
| | - Nancy Dunbar
- Dartmouth-Hitchcock Medical Center; Lebanon NH USA
| | | | - Alexey V. Danilov
- Dartmouth-Hitchcock Medical Center; Lebanon NH USA
- Knight Cancer Institute; Oregon Health and Science University; Portland OR USA
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36
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Visco C, Barcellini W, Maura F, Neri A, Cortelezzi A, Rodeghiero F. Autoimmune cytopenias in chronic lymphocytic leukemia. Am J Hematol 2014; 89:1055-62. [PMID: 24912821 DOI: 10.1002/ajh.23785] [Citation(s) in RCA: 76] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2014] [Revised: 05/28/2014] [Accepted: 06/06/2014] [Indexed: 12/20/2022]
Abstract
Chronic lymphocytic leukemia (CLL) is frequently complicated by secondary autoimmune cytopenias (AIC) represented by autoimmune hemolytic anemia (AIHA), immune thrombocytopenia (ITP), pure red cell aplasia, and autoimmune granulocytopenia. The distinction of immune cytopenias from cytopenias due to bone marrow infiltration, usually associated with a worse outcome and often requiring a different treatment, is mandatory. AIHA and ITP are more frequently found in patients with unfavorable biological risk factors for CLL. AIC secondary to CLL respond less favorably to standard treatments than their primary forms, and treating the underlying CLL with chemotherapy or monoclonal antibodies may ultimately be necessary.
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Affiliation(s)
- Carlo Visco
- Department of Cell Therapy and Hematology; Ospedale San Bortolo Vicenza
| | - Wilma Barcellini
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico; Milan
| | - Francesco Maura
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico; Milan
- Department of Clinical Sciences and Community Health; University of Milan; Milan
| | - Antonino Neri
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico; Milan
- Department of Clinical Sciences and Community Health; University of Milan; Milan
| | - Agostino Cortelezzi
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico; Milan
- Department of Clinical Sciences and Community Health; University of Milan; Milan
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37
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Tandra P, Krishnamurthy J, Bhatt VR, Newman K, Armitage JO, Akhtari M. Autoimmune cytopenias in chronic lymphocytic leukemia, facts and myths. Mediterr J Hematol Infect Dis 2013; 5:e2013068. [PMID: 24363883 PMCID: PMC3867225 DOI: 10.4084/mjhid.2013.068] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2013] [Accepted: 10/31/2013] [Indexed: 12/21/2022] Open
Abstract
CLL has been defined as presence of more than 5000 small mature appearing monoclonal B lymphocytes with a specific immunophenotype in peripheral blood. It is a well-known fact that CLL is associated with autoimmune cytopenias. CLL cells are CD5(+) B lymphocytes, and usually are not the "guilty" cells which produce autoantibodies. T cell defect is another characteristic of CLL and the total number of T cells is increased, and there is inversion of the CD4/CD8 ratio. Autoimmune hemolytic anemia (AIHA) is the most common autoimmune complication of CLL and has been reported in 10-25% of CLL patients. However, the stage-adjusted estimated rate of AIHA in CLL is about 5%. Conversely, CLL is three times more common in patients who present with AIHA. Direct agglutinin test (DAT) is positive in 7-14% of CLL patients but AIHA may also occur in DAT negative patients. Autoimmune thrombocytopenia (AIT) is the second most common complication of CLL and has been reported in 2-3% of patients. DAT is positive in AIT but presence of antiplatelet antibodies is neither diagnostic nor reliable. Autoimmune neutropenia (AIN) and pure red cell aplasia (PRCA) are very rare complications of CLL and like other autoimmune complications of CLL may occur at any clinical stage. It is believed that most case reports of AIN and PRCA in CLL actually belong to large granular lymphocytic leukemia (LGL). Non-hematologic autoimmune complications of CLL including cold agglutinin disease (CAD), paraneoplastic pemphigus (PNP), acquired angioedema, and anti-myelin associated globulin are rare. Before starting any treatment, clinicians should distinguish between autoimmune cytopenias and massive bone marrow infiltration since autoimmune complications of CLL are not necessarily equal to advanced disease with poor prognosis. According to IWCLL guideline, steroids are the mainstay of treatment of simple autoimmunity. Intravenous immunoglobulin (IVIg), cyclosporine, and rituximab are used in complex, steroid refractory cases. Monotherapy with purine analogues and alkylating agents should be avoided as they may increase CLL associated autoimmune complications.
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Affiliation(s)
- Pavankumar Tandra
- Division of Hematology and Oncology, University of Nebraska Medical Center, Omaha, NE 68198, USA
| | - Jairam Krishnamurthy
- Division of Hematology and Oncology, University of Nebraska Medical Center, Omaha, NE 68198, USA
| | - Vijaya Raj Bhatt
- Division of Hematology and Oncology, University of Nebraska Medical Center, Omaha, NE 68198, USA
| | - Kam Newman
- Dr. Kam Newman, Section of Transfusion Medicine, Cleveland Clinic Foundation, 9500 Euclid Avenue 6-1, Cleveland, OH 44195, USA
| | - James O Armitage
- Division of Hematology and Oncology, University of Nebraska Medical Center, Omaha, NE 68198, USA
| | - Mojtaba Akhtari
- Division of Hematology and Oncology, University of Nebraska Medical Center, Omaha, NE 68198, USA
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Aryal MR, Bhatt VR, Tandra P, Krishnamurthy J, Yuan J, Greiner TC, Akhtari M. Autoimmune neutropenia in multiple myeloma and the role of clonal T-cell expansion: evidence of cross-talk between B-cell and T-cell lineages? CLINICAL LYMPHOMA MYELOMA & LEUKEMIA 2013; 14:e19-23. [PMID: 24183500 DOI: 10.1016/j.clml.2013.08.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/21/2013] [Revised: 08/21/2013] [Accepted: 08/28/2013] [Indexed: 11/30/2022]
Affiliation(s)
- Madan Raj Aryal
- Department of Medicine, Reading Health System, West Reading, PA
| | - Vijaya Raj Bhatt
- Department of Internal Medicine, Division of Hematology-Oncology, University of Nebraska Medical Center, Omaha, NE
| | - Pavankumar Tandra
- Department of Internal Medicine, Division of Hematology-Oncology, University of Nebraska Medical Center, Omaha, NE
| | - Jairam Krishnamurthy
- Department of Internal Medicine, Division of Hematology-Oncology, University of Nebraska Medical Center, Omaha, NE
| | - Ji Yuan
- Department of Pathology and Microbiology, University of Nebraska Medical Center, Omaha, NE
| | - Timothy C Greiner
- Department of Pathology and Microbiology, University of Nebraska Medical Center, Omaha, NE
| | - Mojtaba Akhtari
- Department of Internal Medicine, Division of Hematology-Oncology, University of Nebraska Medical Center, Omaha, NE.
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A matter of debate in chronic lymphocytic leukemia: is the occurrence of autoimmune disorders an indicator of chronic lymphocytic leukemia therapy? Curr Opin Oncol 2013; 23:455-60. [PMID: 21681094 DOI: 10.1097/cco.0b013e328348c683] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW Autoimmune cytopenia is a noninfrequent complication of chronic lymphocytic leukemia (CLL) classified into simple and complex autoimmunity, on the basis of the absence or the concomitance of disease progression. Simple-refractory and complex autoimmunity indicate the need of treatment. Here, we review the epidemiology and the biological mechanisms that account for CLL-associated autoimmune disorders and discuss their prognostic relevance and the indication of treatment. RECENT FINDINGS Autoimmune disorders can complicate CLL at any stage and even occur in the preleukemic monoclonal B lymphocytosis. CLL cells can act as antigen-presenting cells, possibly inducing the formation of autoreactive T helper cells (through the production of B-cell activator factor and a proliferation-inducing ligand) and nonfunctional T regulatory cells (via CD27-CD70 interaction). Further, nonmalignant lymphocytes may stimulate via CD154-mediated mechanism both tumor growth and the development of autoimmunity, especially after fludarabine-based regimens of therapy. CLL cells tend to produce monoclonal polyreactive autoantibodies suggesting that autoantigen stimulation via B-cell receptor signaling may affect the natural history of CLL. Though the results of multivariate analysis do not allow to separate autoimmune disorders developing in CLL from conventional prognostic factors, the pathogenetic intertwining between autoimmunity and malignant transformation indicates the importance of defining whether the occurrence of autoimmunity in CLL might be considered an autonomous prognostic indicator that influences treatment decisions. SUMMARY Simple-refractory and complex autoimmunity are independent indicators of therapy for CLL. Further, epidemiological and biological studies will help clarifying the prognostic and possibly also the pathogenetic significance of simple autoimmunity.
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40
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Visco C, Cortelezzi A, Moretta F, Falisi E, Maura F, Finotto S, Barcellini W, Ambrosetti A, Neri A, Ruggeri M, Rodeghiero F. Autoimmune cytopenias in chronic lymphocytic leukemia at disease presentation in the modern treatment era: is stage C always stage C? Leuk Lymphoma 2013; 55:1261-5. [DOI: 10.3109/10428194.2013.834054] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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41
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Barr PM, Zent CS. The ABC of chronic lymphocytic leukemia: etiology of cytopenias is important in staging and management. Leuk Lymphoma 2013; 55:1219-20. [PMID: 24047480 DOI: 10.3109/10428194.2013.844343] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Affiliation(s)
- Paul M Barr
- James P. Wilmot Cancer Center, University of Rochester , Rochester, NY , USA
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Abstract
Chronic lymphocytic leukemia (CLL) is the most common leukemia in the Western world, characterized by peripheral blood B-cell lymphocytosis as well as lymphadenopathy, organomegaly, cytopenias, and systemic symptoms. Chronic lymphocytic leukemia cells have a distinctive immunophenotype, and the disease has a characteristic pattern of histological infiltration in the lymph node and bone marrow. The clinical course of CLL is heterogeneous, with some patients presenting with very indolent disease and other patients having a more aggressive malignancy. It is known that genetic abnormalities underlie this difference in clinical presentation. Some patients may present solely with lymphadenopathy, organomegaly, and presence of infiltrating monoclonal B cells with the same immunophenotype as CLL cells, but lacking peripheral blood lymphocytosis. This disease is called small lymphocytic lymphoma (SLL) and has been considered for almost 2 decades to be the tissue equivalent of CLL. Both CLL and SLL are currently considered different manifestations of the same entity by the fourth edition of the World Health Organization Classification of Tumours of Haematopoietic and Lymphoid Tissues. It is suspected that differential expression of chemokine receptors (e.g., reduced expression of R1 and CCR3 in SLL cells), integrins (e.g., CLL cells have lower expression of integrin αLβ2), and genetic abnormalities (a higher incidence of trisomy 12 and lower incidence of del(13q) is found in SLL) may explain some of the clinical differences between these 2 disorders. However, there is still a lack of knowledge on the precise biological basis underlying the different clinical presentations of CLL and SLL. It is expected that future studies will shed light on the pathophysiology of both disorders.
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Ghielmini M, Vitolo U, Kimby E, Montoto S, Walewski J, Pfreundschuh M, Federico M, Hoskin P, McNamara C, Caligaris-Cappio F, Stilgenbauer S, Marcus R, Trneny M, Dreger P, Montserrat E, Dreyling M. ESMO Guidelines consensus conference on malignant lymphoma 2011 part 1: diffuse large B-cell lymphoma (DLBCL), follicular lymphoma (FL) and chronic lymphocytic leukemia (CLL). Ann Oncol 2013; 24:561-76. [PMID: 23175624 PMCID: PMC6267877 DOI: 10.1093/annonc/mds517] [Citation(s) in RCA: 166] [Impact Index Per Article: 15.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2012] [Revised: 08/26/2012] [Accepted: 08/29/2012] [Indexed: 12/29/2022] Open
Abstract
To complete the existing treatment guidelines for all tumor types, ESMO organizes consensus conferences to better clarify open issues in each disease. In this setting, a consensus conference on the management of lymphoma was held on 18 June 2011 in Lugano, immediately after the end of the 11th International Conference on Malignant Lymphoma. The consensus conference convened ∼45 experts from all around Europe and selected six lymphoma entities to be addressed; for each of them three to five open questions were to be discussed by the experts. For each question, a recommendation should be given by the panel, supported by the strength of the recommendation based on the level of evidence. This consensus report focuses on the three most common lymphoproliferative malignancies: diffuse large B-cell lymphoma, follicular lymphoma and chronic lymphocytic leukemia. A second report will concentrate on mantle cell lymphoma, marginal zone lymphoma and T-cell lymphomas.
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MESH Headings
- Antineoplastic Combined Chemotherapy Protocols/therapeutic use
- Combined Modality Therapy
- Disease Management
- Humans
- Leukemia, Lymphocytic, Chronic, B-Cell/immunology
- Leukemia, Lymphocytic, Chronic, B-Cell/pathology
- Leukemia, Lymphocytic, Chronic, B-Cell/therapy
- Lymphoma, Follicular/drug therapy
- Lymphoma, Follicular/pathology
- Lymphoma, Follicular/radiotherapy
- Lymphoma, Large B-Cell, Diffuse/drug therapy
- Lymphoma, Large B-Cell, Diffuse/pathology
- Neoplasm Staging
- Positron-Emission Tomography
- Practice Guidelines as Topic
- Stem Cell Transplantation
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Affiliation(s)
- M Ghielmini
- Department of Medical Oncology, Oncology Institute of Southern Switzerland, Ospedale San Giovanni, Bellinzona, Switzerland.
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Frasier LL, Malani PN, Diehl KM. Splenectomy in older adults: indications and clinical outcomes. Int J Hematol 2013; 97:480-4. [PMID: 23443974 DOI: 10.1007/s12185-013-1300-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2012] [Revised: 01/29/2013] [Accepted: 02/14/2013] [Indexed: 12/01/2022]
Abstract
The aim of this study was to improve the understanding of the indications and associated outcomes among older adults undergoing splenectomy. Data regarding patients of age ≥60 years treated between 1998 and 2008 were reviewed. Fifty patients (age 71.6 ± 8) were identified. Common indications for splenectomy included idiopathic thrombotic purpura (26.0 %) and lymphoma (28.0 %). Patient co-morbidities included hypertension (54 %), coronary artery disease (24 %) and diabetes mellitus (20 %). Twenty-seven patients (54 %) underwent laparoscopic surgery; 23 (46 %) had open procedures; more than half of open splenectomies were conversions from attempted laparoscopy. Mean post-operative length of stay (LOS) was 5.9 ± 5 days (range 1-21). Two patients died in hospital; an additional three died within 6 months. Five patients were discharged to an extended care facility (ECF). Three patients required readmission within 30 days. Increased age was associated with need for ECF (p = 0.01). Increasing LOS, but not age, was associated with 6-month mortality (p = 0.04). Although we noted a 10 % in hospital mortality rate, splenectomy appears to be safe for carefully selected older adults.
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Affiliation(s)
- Lane L Frasier
- University of Michigan Medical School, Ann Arbor, MI, USA
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Shvidel L, Tadmor T, Braester A, Bairey O, Rahimi-Levene N, Herishanu Y, Klepfish A, Shtalrid M, Berrebi A, Polliack A. Pathogenesis, prevalence, and prognostic significance of cytopenias in chronic lymphocytic leukemia (CLL): a retrospective comparative study of 213 patients from a national CLL database of 1,518 cases. Ann Hematol 2012; 92:661-7. [PMID: 23274356 DOI: 10.1007/s00277-012-1663-3] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2012] [Accepted: 12/17/2012] [Indexed: 11/25/2022]
Abstract
Utilizing the database of the Israeli CLL Study Group, we investigated the prevalence and prognostic significance of anemia and thrombocytopenia in patients with chronic lymphocytic leukemia (CLL). Of 1,477 patients, 113 had anemia and thrombocytopenia associated with "infiltrative" marrow failure, median survival of 41 and 86 months, respectively. Autoimmune cytopenias were diagnosed in 100 patients, autoimmune hemolytic anemia (AIHA) in 80, and immune thrombocytopenia (ITP) in 31, while 11 had both co-existent. Median survival of patients with AIHA and ITP, from CLL diagnosis, was 96 and 137 months, respectively, but 29 and 75 months from onset of cytopenia. Patients with AIHA from the time of CLL diagnosis had a significantly shorter survival than those without anemia (p < .0001). Survival was similar for patients with AIHA or anemia due to "infiltrative" bone marrow failure (p = .44). The presence of positive antiglobulin test even without hemolysis was associated with worse outcome. Overall survival of patients with ITP and those without cytopenias (p = 0.94) were similar. In conclusion, laboratory or clinical evidence of AIHA has a significant negative impact on the survival of patients with CLL. Outcome for cases with ITP and patients without cytopenias was similar.
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MESH Headings
- Adult
- Aged
- Aged, 80 and over
- Algorithms
- Cytogenetic Analysis
- Databases, Factual/statistics & numerical data
- Female
- Humans
- Leukemia, Lymphocytic, Chronic, B-Cell/complications
- Leukemia, Lymphocytic, Chronic, B-Cell/diagnosis
- Leukemia, Lymphocytic, Chronic, B-Cell/epidemiology
- Leukemia, Lymphocytic, Chronic, B-Cell/mortality
- Leukopenia/complications
- Leukopenia/diagnosis
- Leukopenia/epidemiology
- Male
- Middle Aged
- Pancytopenia/complications
- Pancytopenia/diagnosis
- Pancytopenia/epidemiology
- Prevalence
- Prognosis
- Registries/statistics & numerical data
- Retrospective Studies
- Survival Analysis
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Affiliation(s)
- Lev Shvidel
- Kaplan Medical Center, Rehovot, affiliated with Hebrew University Medical School, Jerusalem, Israel.
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Lad DP, Varma S, Varma N, Sachdeva MUS, Bose P, Malhotra P. Regulatory T-cells in B-cell chronic lymphocytic leukemia: their role in disease progression and autoimmune cytopenias. Leuk Lymphoma 2012; 54:1012-9. [DOI: 10.3109/10428194.2012.728287] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Chen LP, Lin SJ, Yu MS. Prognostic value of platelet count in diffuse large B-cell lymphoma. CLINICAL LYMPHOMA MYELOMA & LEUKEMIA 2011; 12:32-7. [PMID: 22138101 DOI: 10.1016/j.clml.2011.09.215] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/29/2011] [Revised: 06/12/2011] [Accepted: 09/02/2011] [Indexed: 12/29/2022]
Abstract
BACKGROUND Besides International Prognostic Index, many parameters have proven prognostic significance in aggressive lymphoma. However, the most appropriate system of risk stratification in diffuse large B-cell lymphoma (DLBCL) is not yet clear. In this study, we attempt to clarify the prognostic value of platelet count at the onset of lymphoma. MATERIALS AND METHODS Between January 2000 and December 2009, 100 patients with DLBCL receiving R-CEOP (rituximab, cyclophosphamide, epirubicin, vincristine, and prednisolone) in a single institution were enrolled. Patient characteristics and survival outcomes were retrospectively analyzed. RESULTS Before front-line treatment, 17 patients with thrombocytopenia (< 150 × 10(9)/L) and 83 patients without thrombocytopenia were enrolled. Thrombocytopenic patients initially presented with more B symptoms (P = .040), more bone marrow involvement (P = .001), later staging (P = .001), and higher International Prognostic Index (P < .001). Thrombocytopenia was shown to be an independently poor prognostic factor in the multivariate analysis of overall survival (hazard ratio [HR], 3.405; 95% confidence interval [CI], 1.431-8.101; P = .006) and progression-free survival (HR, 4.299; 95% CI, 1.786-10.343; P = .001). CONCLUSION Platelet count at diagnosis is a simple but useful indicator for predicting survival outcomes of DLBCL. Although the mechanisms of thrombocytopenia may be complex in lymphoma, further investigations are warranted to illustrate the predictive merit.
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Affiliation(s)
- Ling-Ping Chen
- Division of Hematology and Oncology, Department of Internal Medicine, Kaohsiung Veterans General Hospital, 386 Ta-Chung 1st Road, Kaohsiung, Taiwan, R.O.C.
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Al-Nawakil C, Park S, Chapuis N, Dreyfus F, Szwebel TA, Gibault L, Molina T, Hermine O, Bouscary D, Tamburini J. Salvage therapy of autoimmune thrombocytopenic purpura revealing non-Hodgkin lymphoma by the thrombopoietin receptor agonist romiplostim. Br J Haematol 2011; 156:145-7. [PMID: 21848881 DOI: 10.1111/j.1365-2141.2011.08825.x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
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Baek SW, Lee MW, Ryu HW, Lee KS, Song IC, Lee HJ, Yun HJ, Kim S, Jo DY. Clinical features and outcomes of autoimmune hemolytic anemia: a retrospective analysis of 32 cases. THE KOREAN JOURNAL OF HEMATOLOGY 2011; 46:111-7. [PMID: 21747883 PMCID: PMC3128891 DOI: 10.5045/kjh.2011.46.2.111] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/05/2011] [Revised: 06/13/2011] [Accepted: 06/13/2011] [Indexed: 11/25/2022]
Abstract
Background There has been no report on the clinical features or natural history of autoimmune hemolytic anemia (AIHA) in the Korean adult population. This study retrospectively analyzed the clinical characteristics and long-term outcomes of AIHA in the Korean adults. Methods Patients newly diagnosed with AIHA between January 1994 and December 2010 at Chungnam National University Hospital were enrolled. Patient characteristics at diagnosis, response to treatment, and the natural course of the disease were documented. Results Thirty-two patients (31 females and 1 male) with a median age of 48 years (range, 17-86) were enrolled. Of these, 21.9% were initially diagnosed with secondary AIHA. Thirteen patients (40.6%) were initially diagnosed with Evans' syndrome. Of the 29 patients who were placed on therapy, 27 (93.1%) showed a partial response or better. Nevertheless, 1 year after initiating treatment, 80% of the patients were still treatment-dependent. During follow-up (median length 14 months; range, 0.5-238), 14 of 25 patients (56.0%) who were initially diagnosed with primary warm antibody AIHA were found to have systemic lupus erythematosus (SLE). Median time to conversion to SLE was 8.0 months (95% CI, 4.3-11.7), and the probabilities of conversion at 12 and 24 months were 63% and 91%, respectively. Younger age (<60 years) and a positive fluorescent anti-nuclear antibody test were associated with a higher probability of SLE conversion (P=0.01 and P<0.001, respectively). Conclusion Primary AIHA is rare. Regular, vigilant testing for SLE is required in patients initially diagnosed with AIHA.
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Affiliation(s)
- Seung-Woo Baek
- Department of Internal Medicine, School of Medicine, Chungnam National University, Daejeon, Korea
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Hodgson K, Ferrer G, Pereira A, Moreno C, Montserrat E. Autoimmune cytopenia in chronic lymphocytic leukaemia: diagnosis and treatment. Br J Haematol 2011; 154:14-22. [DOI: 10.1111/j.1365-2141.2011.08707.x] [Citation(s) in RCA: 66] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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