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Petley E, Yule A, Alexander S, Ojha S, Whitehouse WP. The natural history of ataxia-telangiectasia (A-T): A systematic review. PLoS One 2022; 17:e0264177. [PMID: 35290391 PMCID: PMC9049793 DOI: 10.1371/journal.pone.0264177] [Citation(s) in RCA: 25] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2021] [Accepted: 02/06/2022] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Ataxia-telangiectasia is an autosomal recessive, multi-system, and life-shortening disease caused by mutations in the ataxia-telangiectasia mutated gene. Although widely reported, there are no studies that give a comprehensive picture of this intriguing condition. OBJECTIVES Understand the natural history of ataxia-telangiectasia (A-T), as reported in scientific literature. SEARCH METHODS 107 search terms were identified and divided into 17 searches. Each search was performed in PubMed, Ovid SP (MEDLINE) 1946-present, OVID EMBASE 1980 -present, Web of Science core collection, Elsevier Scopus, and Cochrane Library. SELECTION CRITERIA All human studies that report any aspect of A-T. DATA COLLECTION AND ANALYSIS Search results were de-duplicated, data extracted (including author, publication year, country of origin, study design, population, participant characteristics, and clinical features). Quality of case-control and cohort studies was assessed by the Newcastle-Ottawa tool. Findings are reported descriptively and where possible data collated to report median (interquartile range, range) of outcomes of interest. MAIN RESULTS 1314 cases reported 2134 presenting symptoms. The most common presenting symptom was abnormal gait (1160 cases; 188 studies) followed by recurrent infections in classical ataxia-telangiectasia and movement disorders in variant ataxia-telangiectasia. 687 cases reported 752 causes of death among which malignancy was the most frequently reported cause. Median (IQR, range) age of death (n = 294) was 14 years 0 months (10 years 0 months to 23 years 3 months, 1 year 3 months to 76 years 0 months). CONCLUSIONS This review demonstrates the multi-system involvement in A-T, confirms that neurological symptoms are the most frequent presenting features in classical A-T but variants have diverse manifestations. We found that most individuals with A-T have life limited to teenage or early adulthood. Predominance of case reports, and case series demonstrate the lack of robust evidence to determine the natural history of A-T. We recommend population-based studies to fill this evidence gap.
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Affiliation(s)
- Emily Petley
- School of Medicine, University of Nottingham, Nottingham, United
Kingdom
| | - Alexander Yule
- United Lincolnshire Hospitals NHS Trust, Lincoln, United
Kingdom
| | - Shaun Alexander
- School of Medicine, University of Nottingham, Nottingham, United
Kingdom
| | - Shalini Ojha
- School of Medicine, University of Nottingham, Nottingham, United
Kingdom
- Children’s Hospital, University Hospitals of Derby and Burton, NHS
Foundation Trust, Derby, United Kingdom
| | - William P. Whitehouse
- School of Medicine, University of Nottingham, Nottingham, United
Kingdom
- Nottingham Children’s Hospital, Nottingham University Hospital NHS Trust,
Nottingham, United Kingdom
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Lymphoma Secondary to Congenital and Acquired Immunodeficiency Syndromes at a Turkish Pediatric Oncology Center. J Clin Immunol 2016; 36:667-76. [PMID: 27492260 DOI: 10.1007/s10875-016-0324-z] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2016] [Accepted: 07/26/2016] [Indexed: 12/19/2022]
Abstract
The prevalence of lymphoma in primary immunodeficiency cases and autoimmune diseases, as well as on a background of immunodeficiency following organ transplants, is increasing. The lymphoma treatment success rate is known to be a low prognosis. Our study aimed to emphasize the low survival rates in immunodeficient vs. immunocompetent lymphoma patients and also to investigate the effect of rituximab in patients with ataxia telangiectasia and other immunodeficiencies. We summarized the clinical characteristics and treatment results of 17 cases with primary immunodeficiency that developed non-Hodgkin lymphoma (NHL) and Hodgkin lymphoma (HL) retrospectively. Seven patients were diagnosed with ataxia-telangiectasia, two with common variable immunodeficiency, two with selective IgA deficiency, one with X-related lymphoproliferative syndrome, one with Wiskott-Aldrich syndrome, one with Epstein-Barr virus-related lymphoproliferative syndrome, one with interleukin-2-inducible T-cell kinase (ITK) deficiency, and one with lymphoma developing after autoimmune lymphoproliferative syndrome (ALPS). One patient underwent a renal transplant. Of the nine males and eight females (aged 3-12 years, median = 7) that developed lymphoma, seven were diagnosed with HL and ten with NHL (seven B-cell, three T-cell). The NHL patients were started on the Berlin-Frankfurt-Münster, POG9317, LMB-96, or R-CHOP treatment protocols with reduced chemotherapy dosages. HL cases were started on the doxorubicin, bleomycin, vinblastine, and dacarbazine (ABVD) and/or cyclophosphamide, vincristine, procarbazine, and prednisone (COPP) protocol, also with modified dosages. Importantly, all seven cases of HL are alive and in remission, while six of the ten NHL patients have died. Primary immunodeficiency is a strong predisposing factor for developing lymphoma. Low treatment success rates relative to other lymphomas and difficulties encountered during treatment indicate that new treatment agents are needed. While some success has been achieved by combining rituximab with lymphoma treatment protocols in B-NHL cases with primary immunodeficiency, the need for new treatment approaches for these patients remains critical.
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Schoenaker MHD, Suarez F, Szczepanski T, Mahlaoui N, Loeffen JL. Treatment of acute leukemia in children with ataxia telangiectasia (A-T). Eur J Med Genet 2016; 59:641-646. [PMID: 27238889 DOI: 10.1016/j.ejmg.2016.05.012] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2015] [Revised: 05/03/2016] [Accepted: 05/23/2016] [Indexed: 01/23/2023]
Abstract
Early onset ataxia telangiectasia (A-T) is a neurodegenerative DNA-instability disorder, which presents early in childhood. Hallmarks of A-T are progressive ataxia and a dramatic increased risk of developing malignancies (25%), especially of hematological origin. In children these malignancies mainly concern aggressive Non-Hodgkin lymphoma, acute leukemias and Hodgkin lymphoma. Of the acute leukemias, T-cell lymphoblastic leukemia (T-ALL) is by far the most common. Since patients with A-T experience increased toxicity to radio- and chemotherapeutic treatment, the optimal treatment strategy of acute leukemia remains subject of debate. Review of literature of treatment of T-ALL in patients with A-T (n = 18) showed that many patients are not diagnosed with A-T at time of presentation of T-ALL. This implicates that physicians must be aware of symptoms of A-T in young patients presenting with T-ALL. Complete remission rates are high following upfront modified as well as unmodified treatment strategies. Treatment of ALL in children with A-T is feasible and should be performed. Definitive treatment strategy must be determined by shared decision making with patient, caretakers and medical team. Future prospective studies are needed to elucidate optimal treatment strategy.
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Affiliation(s)
- M H D Schoenaker
- Department of Pediatrics, Amalia Children's Hospital, Radboud University Medical Center, Nijmegen, Netherlands
| | - F Suarez
- Department of Hematology and French National Reference Center for Primary Immune Deficiencies (CEREDIH), Necker-Enfants Malades University Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France; Laboratory of Molecular Mechanisms of Hematologic Disorders and Therapeutic Implication, INSERM UMR 1163 & CNRS ERL 8254, France; Institut Imagine, Sorbonne Paris Cité, Paris Descartes University, France
| | - T Szczepanski
- Department of Pediatric Hematology and Oncology, Zabrze, Medical University of Silesia, Katowice, Poland
| | - N Mahlaoui
- Pediatric Immuno-Haematology and Rheumatology Unit and French National Reference Center for Primary Immune Deficiencies (CEREDIH), Necker-Enfants Malades University Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France; Laboratory of Human Genetics of Infectious Diseases, Necker Branch, INSERM U1163, Necker Enfants Malades University Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France; Paris Descartes University, Sorbonne Paris Cité, Imagine Institute, Paris, France
| | - J L Loeffen
- Department of Pediatric Oncology and Hematology, Sophia Children's Hospital, Erasmus MC, Postbox 2040, 3000CA Rotterdam, Netherlands.
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Abstract
A 20-month-old girl diagnosed with T-cell acute lymphoblastic leukemia was treated according to the Nordic NOPHO ALL2000 protocol. The patient developed severe immunosuppression and experienced life-threatening adenovirus infection, which was treated with ribavirin and cidofovir. α-fetoprotein was 20- to 30-fold elevated, and genetic analysis confirmed the diagnosis of ataxia telangiectasia. Despite receiving only 7 weeks of anti-leukemic therapy, she has stayed in first remission now 8 years after the diagnosis. We speculate that this could be because of increased chemosensitivity of ATM-mutated leukemic cells, adenovirus causing a direct oncolytic effect, and/or high levels of endogenous cortisol during her severe infection.
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Keklik M, Koker MY, Sivgin S, Camlica D, Pala C, Cetin M, Kaynar L, Unal A, Eser B. Detection of acute lymphoblastic leukemia involvement in pleural fluid in an adult patient with ataxia telangiectasia by flow cytometry method. Indian J Hematol Blood Transfus 2014; 30:73-6. [PMID: 25332541 PMCID: PMC4192193 DOI: 10.1007/s12288-013-0253-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2012] [Accepted: 03/29/2013] [Indexed: 02/08/2023] Open
Abstract
Ataxia-telangiectasia (AT) is a rare multisystem, neurodegenerative genetic disorder. Patients should be closely monitored due to risk of malignancy development. Due to its wide clinical heterogeneity, it often leads physicians to an inaccurate or missed diagnosis, and insight into this rare disease is important. Pediatric patients may develop lymphomas and acute lymphoblastic leukemia (ALL). However, in adults, there are limited numbers of reports regarding association of AT and ALL. Rarely, ALL cases may present with pleural fluid involvement. In our study, we presented an adult case with AT, in which ALL involvement was detected in pleural fluid by flow cytometry (FC). A 20-years old male presented to emergency department with fever, shortness of breath and cough, as he had been followed with a diagnosis of AT. The following findings were detected in laboratory tests: Hb, 11.5 g/L; WBC, 36 × 10(9)/L; Plt: 140 × 10(9)/L. Blastic cells were observed in peripheral blood smear. On chest radiography, pleural fluid appearance was observed. On thorax CT, pleural fluid was detected in both hemithorax. Cytoplasmic CD3(+) and superficial CD3 (+), CD45 (+), CD5 (+), CD7 (+) and CD38 (+) was found in the flow cytometric evaluation of peripheral blood. Superficial CD3 (+), CD2 (+), CD5 (+) and CD7 (+) were found in flow cytometric evaluation of pleural fluid. These findings were considered as consistent with pleural involvement of T-ALL. FC is a potentially useful diagnostic tool for clinical practice and it is a convenience method which has an important role in detection of ALL in patients with pleural fluid.
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Affiliation(s)
- Muzaffer Keklik
- Department of Hematology, Faculty of Medicine, Erciyes Stem Cell Transplantation Hospital, Erciyes University, Kayseri, 38039 Turkey
| | - M. Yavuz Koker
- Flow Cytometry Unit, Department of Hematology, Faculty of Medicine, Erciyes University, Kayseri, Turkey
| | - Serdar Sivgin
- Department of Hematology, Faculty of Medicine, Erciyes Stem Cell Transplantation Hospital, Erciyes University, Kayseri, 38039 Turkey
| | - Demet Camlica
- Flow Cytometry Laboratory, Faculty of Medicine, Erciyes University, Kayseri, Turkey
| | - Cigdem Pala
- Department of Hematology, Faculty of Medicine, Erciyes Stem Cell Transplantation Hospital, Erciyes University, Kayseri, 38039 Turkey
| | - Mustafa Cetin
- Department of Hematology, Faculty of Medicine, Erciyes Stem Cell Transplantation Hospital, Erciyes University, Kayseri, 38039 Turkey
| | - Leylagul Kaynar
- Department of Hematology, Faculty of Medicine, Erciyes Stem Cell Transplantation Hospital, Erciyes University, Kayseri, 38039 Turkey
| | - Ali Unal
- Department of Hematology, Faculty of Medicine, Erciyes Stem Cell Transplantation Hospital, Erciyes University, Kayseri, 38039 Turkey
| | - Bulent Eser
- Department of Hematology, Faculty of Medicine, Erciyes Stem Cell Transplantation Hospital, Erciyes University, Kayseri, 38039 Turkey
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Onoda T, Kanno M, Meguro T, Sato H, Takahashi N, Kawakami T, Mitsui T, Hayasaka K. Successful treatment of acute myeloid leukaemia in a patient with ataxia telangiectasia. Eur J Haematol 2013; 91:557-60. [PMID: 23952578 DOI: 10.1111/ejh.12186] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/10/2013] [Indexed: 11/29/2022]
Abstract
Ataxia telangiectasia (AT) is a rare autosomal recessive multisystem disorder characterised by cerebellar degeneration, immunodeficiency and cancer predisposition. Around 10% of AT patients develop lymphoid malignancies, but the development of myeloid leukaemia with AT (AT-AML) is extremely rare, and there have been no previous publications regarding suitable therapies. Here, we first describe a successful therapeutic experience in a patient with AT-AML (FAB-M1) who attained remission after induction therapy and maintained stable disease for a year. To minimise therapy-induced toxicity, low-dose induction was applied first, though this was obviously insufficient and the patient subsequently responded well to dose-intensified short-term chemotherapy. In this report, we suggest a curative therapeutic approach for AT-AML, though the issue of how best to manage patients with cancer complicated by immunodeficiency remains undecided.
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Affiliation(s)
- Tadashi Onoda
- Department of Paediatrics, Yamagata University Faculty of Medicine, Yamagata, Japan
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Emir S, Vezir E, Azkur D, Demir HA, Metin A. Characteristics of children with non-hodgkin lymphoma associated with primary immune deficiency diseases: descriptions of five patients. Pediatr Hematol Oncol 2013; 30:544-53. [PMID: 23647505 DOI: 10.3109/08880018.2013.792893] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
BACKGROUND An increased incidence of non-Hodgkin lymphoma (NHL) has been seen in various primary immune deficiency (PID) cases. The present study aimed to evaluate the clinical characteristics and treatment outcomes of five cases with NHL associated with primary immunodeficiency. METHODS We retrospectively evaluated five patients with primary immunodeficiency who developed NHL. Two patients had ataxia-telangiectasia (A-T), one patient had common variable immunodeficiency (CVID), one patient had Bloom's Syndrome, and one patient had Wiskott-Aldrich syndrome (WAS). RESULTS All patients were male (median age, 8 years). Stage distribution was stage III in three patients and stage IV in two patients. Three patients had B-cell lymphoma and two had T-cell lymphoma. Reduced doses of Berlin-Frankfurt-Münster (BFM) and French Society of Pediatric Oncology (SFOP) regimens were used in four patients according to histopathological subtype. The two patients with ataxia and one patient with Bloom's Syndrome died of progressive/relapsed disease at months 5, 19, and 6, respectively. The patient with CVID associated with T-cell lymphoma has been in remission for 7 years. A full-dosage regimen of rituximab plus cyclophosphamide, doxorubicin, vincristine, and prednisone (R-CHOP) was successfully used in the patient with WAS and B-cell lymphoma; he was still in remission after 3 years. CONCLUSION Primary immunodeficiency diseases are one of the strongest known risk factors for the development of NHL. Management of these patients remains problematic. There is a great need to develop new therapeutic approaches in this group. The use of rituximab in combination with CHOP may provide a promising treatment option for B-cell lymphomas associated with immunodeficiency.
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Affiliation(s)
- Suna Emir
- Department of Pediatric Hematology Oncology, SB Ankara Children's Hematology Oncology Education and Research Hospital, Ankara, Turkey.
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Abstract
Ataxia-telangiectasia (A-T) is an autosomal recessive disease characterized by progressive cerebellar ataxia, oculocutaneous telangiectasia, immunodeficiency, a high incidence of lymphoreticular tumors, and an increased sensitivity to chemoradiotherapy-induced DNA damage. The appropriate cancer therapy remains unknown because of high toxicity rates with full-dose conventional protocols. We present a patient with A-T and nephroblastoma, who received an adapted treatment regimen. To our knowledge this is the second report on nephroblastoma in a patient with A-T but the first with confirmed premortem studies. Although the patient tolerated the chemotherapy regimen well, the patient relapsed and died a year after initial diagnosis.
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Borte S, Janzi M, Pan-Hammarström Q, von Döbeln U, Nordvall L, Winiarski J, Fasth A, Hammarström L. Placental transfer of maternally-derived IgA precludes the use of guthrie card eluates as a screening tool for primary immunodeficiency diseases. PLoS One 2012; 7:e43419. [PMID: 22916257 PMCID: PMC3420892 DOI: 10.1371/journal.pone.0043419] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2012] [Accepted: 07/20/2012] [Indexed: 11/19/2022] Open
Abstract
There is a need for neonatal screening tools to improve the long-term clinical outcome of patients with primary immunodeficiency diseases (PID). Recently, a PCR-based screening method for both TRECs and KRECs using Guthrie card samples has been developed. However, the applicability of these excision circle assays is limited to patients with severe T or B cell lymphopenia (SCID, XLA and A-T), whereas the most common forms of PID are not detected. Absence of serum IgA is seen in a major fraction of patients with immunological defects. As serum IgA in newborns is considered to be of fetal origin, eluates from routinely collected dried blood spot samples might thus be suitable for identification of children with PID. To assess the applicability of such screening assays, stored Guthrie card samples were obtained from 47 patients with various forms of primary immunodeficiency diseases (SCID, XLA, A-T, HIGM and IgAD), 20 individuals with normal serum IgA levels born to IgA-deficient mothers and 51 matched healthy newborns. Surprisingly, normal serum IgA levels were found in all SCID, XLA, A-T and HIGM patients and, additionally, in all those IgAD patients born to IgA-sufficient mothers. Conversely, no serum IgA was found in any of the 16 IgAD patients born by IgA-deficient mothers. Moreover, half of the IgA-sufficient individuals born by IgA-deficient mothers also lacked IgA at birth whereas no IgA-deficient individuals were found among the controls. IgA in neonatal dried blood samples thus appears to be of both maternal and fetal origin and precludes its use as a reliable marker for neonatal screening of primary immunodeficiency diseases.
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Affiliation(s)
- Stephan Borte
- Division of Clinical Immunology and Transfusion Medicine, Department of Laboratory Medicine, Karolinska Institutet at Karolinska University Hospital Huddinge, Stockholm, Sweden
- Translational Centre for Regenerative Medicine (TRM), University of Leipzig, Leipzig, Germany
- ImmunoDeficiencyCenter Leipzig (IDCL) at Hospital St. Georg gGmbH Leipzig, Jeffrey Modell Diagnostic and Research Center for Primary Immunodeficiencies Leipzig, Leipzig, Germany
- * E-mail: (SB); (LH)
| | - Magdalena Janzi
- Division of Clinical Immunology and Transfusion Medicine, Department of Laboratory Medicine, Karolinska Institutet at Karolinska University Hospital Huddinge, Stockholm, Sweden
| | - Qiang Pan-Hammarström
- Division of Clinical Immunology and Transfusion Medicine, Department of Laboratory Medicine, Karolinska Institutet at Karolinska University Hospital Huddinge, Stockholm, Sweden
| | - Ulrika von Döbeln
- Division of Metabolic Diseases, Department of Laboratory Medicine, Karolinska Institutet at Karolinska University Hospital Huddinge, Stockholm, Sweden
| | - Lennart Nordvall
- Department of Women’s and Children’s Health, Uppsala University, Academic Hospital, Uppsala, Sweden
| | - Jacek Winiarski
- Division of Pediatrics (CLINTEC), Karolinska Institutet at Karolinska University Hospital Huddinge, Stockholm, Sweden
| | - Anders Fasth
- Department of Pediatrics, The Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Lennart Hammarström
- Division of Clinical Immunology and Transfusion Medicine, Department of Laboratory Medicine, Karolinska Institutet at Karolinska University Hospital Huddinge, Stockholm, Sweden
- * E-mail: (SB); (LH)
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