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How does transfusion-associated graft-versus-host disease compare to hematopoietic cell transplantation-associated graft-versus-host disease? Transfus Apher Sci 2022; 61:103405. [DOI: 10.1016/j.transci.2022.103405] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
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Van Den Neste E, Letestu R, Aurran-Schleinitz T, Ysebaert L, Feugier P, Leprêtre S, Dartigeas C. Post-remission intervention with alemtuzumab or rituximab to eradicate minimal residual disease in chronic lymphocytic leukemia: where do we stand? Leuk Lymphoma 2011; 53:362-70. [PMID: 21854093 DOI: 10.3109/10428194.2011.608450] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
The introduction of purine nucleoside analogs, later in combination with alkylating moieties and anti-CD20 immunotherapy, has profoundly improved the response rate and response duration in patients with chronic lymphocytic leukemia (CLL). The quality of clinical response following treatment may be improved to a level where residual leukemic cells become undetectable. As patients with this type of response appear to have extended survival rates, minimal residual disease (MRD) eradication is considered a new objective in CLL treatment with the aim of improving progression-free survival (PFS) and potentially overall survival (OS). This review therefore aims to overview the prognostic value of MRD eradication in CLL, the role of post-remission intervention with "passive" immunotherapy (alemtuzumab or rituximab) so as to eliminate persistent MRD or prevent MRD relapse, the impact of these strategies on disease-free survival and their possible adverse consequences. The data indicate a potential for post-remission alemtuzumab or rituximab to prolong PFS in CLL, although more investigations and longer follow-up are required before MRD-guided strategies can be recommended outside of clinical trials.
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Affiliation(s)
- Eric Van Den Neste
- Service d'Hématologie, Cliniques universitaires UCL Saint-Luc, Brussels, Belgium.
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3
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Lim SH, Pathapati S, Langevin J, Hoot A. Severe CMV reactivation and gastritis during treatment of follicular lymphoma with bendamustine. Ann Hematol 2011; 91:643-4. [PMID: 21811782 DOI: 10.1007/s00277-011-1307-z] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2011] [Accepted: 07/26/2011] [Indexed: 10/17/2022]
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Phelippeau M, Bonnet D, Laurenty AP, Meyer N, Apoil PA, Selves J, Alric L, Saadoun D. Blanc ou rouge, il fallait choisir…. Rev Med Interne 2011; 32:120-3. [DOI: 10.1016/j.revmed.2010.12.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2010] [Accepted: 12/02/2010] [Indexed: 11/17/2022]
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Bacher U, Klyuchnikov E, Wiedemann B, Kroeger N, Zander AR. Safety of conditioning agents for allogeneic haematopoietic transplantation. Expert Opin Drug Saf 2009; 8:305-15. [DOI: 10.1517/14740330902918273] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
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Alter HJ, Klein HG. The hazards of blood transfusion in historical perspective. Blood 2008; 112:2617-26. [PMID: 18809775 PMCID: PMC2962447 DOI: 10.1182/blood-2008-07-077370] [Citation(s) in RCA: 216] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2008] [Accepted: 07/10/2008] [Indexed: 12/21/2022] Open
Abstract
The beginning of the modern era of blood transfusion coincided with World War II and the resultant need for massive blood replacement. Soon thereafter, the hazards of transfusion, particularly hepatitis and hemolytic transfusion reactions, became increasingly evident. The past half century has seen the near eradication of transfusion-associated hepatitis as well as the emergence of multiple new pathogens, most notably HIV. Specific donor screening assays and other interventions have minimized, but not eliminated, infectious disease transmission. Other transfusion hazards persist, including human error resulting in the inadvertent transfusion of incompatible blood, acute and delayed transfusion reactions, transfusion-related acute lung injury (TRALI), transfusion-associated graft-versus-host disease (TA-GVHD), and transfusion-induced immunomodulation. These infectious and noninfectious hazards are reviewed briefly in the context of their historical evolution.
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Affiliation(s)
- Harvey J Alter
- Department of Transfusion Medicine, National Institutes of Health, Bethesda, MD, USA.
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Heidary N, Naik H, Burgin S. Chemotherapeutic agents and the skin: An update. J Am Acad Dermatol 2008; 58:545-70. [PMID: 18342708 DOI: 10.1016/j.jaad.2008.01.001] [Citation(s) in RCA: 140] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2007] [Revised: 01/07/2008] [Accepted: 01/10/2008] [Indexed: 12/17/2022]
Abstract
UNLABELLED Chemotherapeutic agents give rise to numerous well described adverse effects that may affect the skin, hair, mucous membranes, or nails. The mucocutaneous effects of longstanding agents have been extensively studied and reviewed. Over the last 2 decades, a number of new molecular entities for the treatment of cancer have been approved by the United States Food and Drug Administration (FDA). This article reviews the cutaneous toxicity patterns of these agents. It also reviews one drug that has not received FDA approval but is in use outside the United States and is important dermatologically. Particular emphasis is placed on the novel signal transduction inhibitors as well as on newer literature pertaining to previously described reactions. LEARNING OBJECTIVES At the completion of this learning activity, participants should able to list the newer chemotherapeutic agents that possess significant mucocutaneous side effects and describe the range of reactions that are seen with each drug. In addition, they should be able to formulate appropriate management strategies for these reactions.
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Affiliation(s)
- Noushin Heidary
- Ronald O. Perelman Department of Dermatology, New York University, New York, USA
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Williamson LM, Stainsby D, Jones H, Love E, Chapman CE, Navarrete C, Lucas G, Beatty C, Casbard A, Cohen H. The impact of universal leukodepletion of the blood supply on hemovigilance reports of posttransfusion purpura and transfusion-associated graft-versus-host disease. Transfusion 2007; 47:1455-67. [PMID: 17655590 DOI: 10.1111/j.1537-2995.2007.01281.x] [Citation(s) in RCA: 71] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND The pathogenesis of posttransfusion purpura (PTP) and transfusion-associated graft-versus-host disease (TA-GVHD) involves patient exposure to donor platelets (PLTs) and T lymphocytes, respectively, which are removed during blood component leukodepletion (LD). STUDY DESIGN AND METHODS Reports of PTP and TA-GVHD to the UK hemovigilance scheme Serious Hazards of Transfusion (SHOT) from 1996 to 2005 were compared before and after implementation of universal LD during 1999. RESULTS There were 45 reports of PTP, with a mean of 10.3 per year before universal LD and 2.3 per year afterward (p < 0.001). All patients had received red cells, but before universal LD, only 1 of 31 (3%) cases had also received PLTs, compared to 8 of 14 (57%) afterward (p < 0.001). Thirty-four cases (76%) had human platelet antigen (HPA)-1a antibodies, whereas 11 had antibodies to other HPA specificities, only 1 of which occurred after LD. Two cases reported before LD also had heparin-dependent PLT antibodies. There were 13 reports of TA-GVHD, all fatal, of which only 2 cases of undiagnosed immunodeficiency met current UK criteria for irradiated components. Eight others had one or more risk factors: B-cell malignancy (6), steroids (1), fresh blood (1), and donor-recipient HLA haplotype share (4). Eleven cases were due to non-LD and 2 to LD components (p < 0.001). No cases have been reported since 2001. In an additional 405 cases, nonirradiated components were transfused in error to high-risk recipients, mainly on fludarabine, but none developed TA-GVHD. CONCLUSIONS These findings suggest that universal LD has further reduced the already low risk of TA-GVHD in immunocompetent recipients and has altered the profile of PTP cases.
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Affiliation(s)
- Lorna M Williamson
- Department of Haematology, University of Cambridge, and NHS Blood and Transplant, Long Road, Cambridge, United Kingdom.
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11
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Yildiz O, Ozguroglu M, Yanmaz MT, Turna H, Kursunoglu SG, Antonov M, Serdaroglu S, Demirkesen C, Buyukunal E. Paraneoplastic pemphigus associated with fludarabine use. Med Oncol 2007; 24:115-8. [PMID: 17673821 DOI: 10.1007/bf02685912] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2006] [Revised: 11/30/1999] [Accepted: 07/17/2006] [Indexed: 11/28/2022]
Abstract
Paraneoplastic pemphigus is a severe mucocutaneous disease associated with B-cell lymphoproliferative disorders. A 51-yr-old man presented to the oncology clinic with mucocutaneous skin lesions after six cycles of fludarabine for non-Hodgkin's lymphoma. A punch biopsy from the skin showed suprabasal acantholysis and blister formation in the epidermis and upper dermis. Direct immunofluorescence demonstrated intercellular IgG deposition in all epidermal layers and complement (C3) at the basement membrane. The indirect immunofluorescence on rat bladder showed intercellular binding of IgG. These findings were consistent with paraneoplastic pemphigus associated with fludarabine use. The temporal association between fludarabine use and paraneoplastic pemphigus suggests there is an etiopathological link between these two entities.
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Affiliation(s)
- Ozcan Yildiz
- Istanbul University, Cerrahpasa Medical Faculty, Department of Internal Medicine, Division of Medical Oncology, Istanbul, Turkey
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12
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Aydogdu I, Kaya E, Karadag N, Erkurt MA, Kuku I, Ozhan O, Oner RI, Bayindir Y. Transfusion-Associated Graft-versus-Host Disease in Patients with and without Immunodeficiency: Report of Six Cases. Transfus Med Hemother 2007. [DOI: 10.1159/000098105] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
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13
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Abstract
This article reviews transfusion risks with particular emphasis on the critically ill. It describes the various types of noninfectious,infectious, and mild-to-severe reactions that can occur in a trans-fused patient. The article describes differential diagnosis of these reactions and the handling and treatment of the patient. Diagnosis of the type of transfusion reaction by laboratory tests is detailed. Finally, the article discusses the dangers of human error with possible strategies to combat this problem using new technologies.
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Affiliation(s)
- Mercy Kuriyan
- Transfusion Medicine Services, Department of Pathology, University of Medicine and Dentistry of New Jersey, Robert Wood Johnson Medical School, 232 MEB, One Robert Wood Place, New Brunswick, NJ 08903, USA.
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Leitman SF, Tisdale JF, Bolan CD, Popovsky MA, Klippel JH, Balow JE, Boumpas DT, Illei GG. Transfusion-associated GVHD after fludarabine therapy in a patient with systemic lupus erythematosus. Transfusion 2004; 43:1667-71. [PMID: 14641861 DOI: 10.1046/j.0041-1132.2003.00579.x] [Citation(s) in RCA: 36] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
BACKGROUND Fludarabine, a purine antimetabolite with potent immunosuppressive properties, has previously been associated with the development of transfusion-associated GVHD (TA-GVHD) in patients with hematologic malignancies. Its role as a risk factor for TA-GVHD in patients without underlying leukemia or lymphoma is uncertain. STUDY DESIGN AND METHODS A 42-year-old female with refractory lupus nephritis received three monthly cycles of fludarabine (30 mg/m2/day on Days 1-3) and cyclophosphamide (500 mg/m2 on Day 1). Three months after the last dose of fludarabine, she received 2 units of packed RBCs and 6 units of pooled random platelets, none of which were irradiated. Two weeks later, fever, rash, aminotransferase elevations, hyperbilirubinemia, and pancytopenia developed. RESULTS Marrow biopsy showed severe aplasia and skin biopsy was consistent with GVHD. Allele-level HLA typing on circulating lymphocytes revealed extra HLA alleles not present in her pretreatment sample, but identical to the HLA haplotypes of an unrelated platelet donor. Treatment with antithymocyte globulin, cyclosporine, and prednisone was followed by preparatory conditioning for a PBPC transplant from an HLA-identical sibling, but the patient died of disseminated candidiasis before transplant. CONCLUSIONS Fludarabine and other purine analogs are increasingly used in the treatment of disorders other than hematologic malignancy, such as autoimmune disease. The occurence of TA-GVHD after fludarabine therapy in a patient with lupus strongly suggests that this drug is sufficiently immunoablative to be an independent risk factor for TA-GVHD. Irradiation of blood components should be considered in all patients who receive fludarabine therapy.
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Affiliation(s)
- Susan F Leitman
- Department of Transfusion Medicine, National Institute of Muscuoloskeletal and Skin Disease, National Institute of Health, Bethesda, MD 20892, USA.
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15
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Anderson K. Broadening the spectrum of patient groups at risk for transfusion-associated GVHD: implications for universal irradiation of cellular blood components. Transfusion 2003; 43:1652-4. [PMID: 14641857 DOI: 10.1111/j.0041-1132.2003.00631.x] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
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Hutchinson K, Kopko PM, Muto KN, Tuscano J, O'Donnell RT, Holland PV, Richman C, Paglieroni TG, Wun T. Early diagnosis and successful treatment of a patient with transfusion-associated GVHD with autologous peripheral blood progenitor cell transplantation. Transfusion 2002; 42:1567-72. [PMID: 12473136 DOI: 10.1046/j.1537-2995.2002.00253.x] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
BACKGROUND Transfusion-associated GVHD (TA-GVHD) is an uncommon complication of blood transfusion. Diagnosis of TA-GVHD is difficult, and it is usually rapidly fatal. There are few documented sur- vivors of TA-GVHD. CASE REPORT A 61-year-old woman with chronic lymphocytic leukemia (CLL) was treated with fludarabine followed by combination chemotherapy and high-dose radioimmunotherapy and peripheral blood progenitor cell (PBPC) rescue. She was transfused with nonirradiated blood components at an outside hospital and presented 10 days later with rash, elevated liver enzymes, and progressive pancytopenia. Skin biopsy was consistent with GVHD, and HLA typing of lymphocytes from the patient demonstrated mixed chimerism. The patient was treated with solumedrol and cyclosporin A, followed by high-dose cyclophosphamide and antithymocyte globulin and autologous PBPC infusion. She had rapid engraftment, resolution of skin rash, and normalization of liver function abnormalities. She is in good health with normal blood counts and no evidence of CLL 34 months after transplantation. CONCLUSION TA-GVHD occurs in the setting of an immunocompromised recipient receiving nonirradiated blood components. A typical presentation includes skin rash, liver function abnormalities, and pancytopenia. Demonstration of mixed chimerism by HLA typing facilitated diagnosis in this patient. High-dose immunosuppression, facilitated by the availability of autologous PBPCs, resulted in a successful outcome.
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Affiliation(s)
- Kendra Hutchinson
- Division of Hematology Oncology, University of California-Davis School of Medicine, USA
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17
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Affiliation(s)
- Marlis L Schroeder
- Department of Pediatrics and Child Health, University of Manitoba, 2011-675 McDermot Avenue, Winnipeg, Manitoba, Canada R3E 0V9.
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Gooptu C, Littlewood TJ, Frith P, Lyon CC, Carmichael AJ, Oliwiecki S, MacWhannell A, Amagai M, Hashimoto T, Dean D, Allen J, Wojnarowska F. Paraneoplastic pemphigus: an association with fludarabine? Br J Dermatol 2001; 144:1255-61. [PMID: 11422053 DOI: 10.1046/j.1365-2133.2001.04244.x] [Citation(s) in RCA: 43] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Paraneoplastic pemphigus is a relatively recently described immunobullous disease with characteristic features. We report three cases of paraneoplastic pemphigus in adult men with chronic lymphocytic leukaemia arising within a week of completion of treatment with fludarabine. In all cases, withdrawal of fludarabine and treatment of the blistering was associated with marked cutaneous improvement. Fludarabine, a synthetic nucleoside analogue, which has only been available in Britain since 1994, is known to be associated with autoimmune phenomena and may have been involved in the development of paraneoplastic pemphigus in these cases.
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Affiliation(s)
- C Gooptu
- Department of Dermatology, The Oxford Radcliffe Hospital, Oxford, UK
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19
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Affiliation(s)
- P M Ness
- Transfusion Medicine Division, Department of Pathology, Johns Hopkins Medical Institutions, Baltimore, MD, USA.
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Van Den Neste E, Delannoy A, Feremans W, Ferrant A, Michaux L. Second primary tumors and immune phenomena after fludarabine or 2-chloro-2'-deoxyadenosine treatment. Leuk Lymphoma 2001; 40:541-50. [PMID: 11426527 DOI: 10.3109/10428190109097653] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
The purine nucleoside analogs fludarabine and 2-chloro-2'-deoxyadenosine display substantial activity in the treatment of various chronic lymphoproliferative disorders. Their major toxicities are primarily immunosuppression and myelosuppression. The profound influence of these drugs on the immune system has raised questions as to the emergence of secondary neoplasms or auto-immune disorders after their use. Based on a literature review and on personal observations, this article reviews the potential clinical importance of these concerns.
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Affiliation(s)
- E Van Den Neste
- Department of Hematology, Cliniques universitaires Saint-Luc, Université catholique de Louvain, Brussels, Belgium.
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21
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Abstract
Chronic lymphocytic leukaemia (CLL) is a disease of late middle age and older. The majority of patients are diagnosed because of a lymphocytosis of at least 5 x 10(9)/L on an incidental blood count. It needs to be distinguished from mantle cell lymphoma and splenic marginal zone lymphoma by lymphocyte markers. The immunophenotype of CLL is sparse surface immunoglobulin, CD5+, CD19+, CD23+, CD79b-, and FMC7-. The disease is staged according to the presence of lymphadenopathy and/or splenomegaly and the features of bone marrow suppression. Most patients have an early stage of disease when diagnosed and perhaps 50% will never progress. This group of patients have a normal life expectancy and do not require treatment beyond reassurance. Progression involves an increasing white cell count, enlarging lymph nodes and spleen, anaemia and thrombocytopenia. Complications of progression include autoimmune haemolytic anaemia and thrombocytopenia, immunodeficiency, and the development of a more aggressive lymphoma. A range of prognostic factors is available to predict progression, but most haematologists rely on close observation of the patient. Intermittent chlorambucil remains the first choice treatment for the majority of patients. Combination chemotherapy offers no advantage. Intravenous fludarabine is probably more effective than chlorambucil, but no trial has yet shown a survival advantage for using it first rather than as a salvage treatment in patients not responding to chlorambucil. It is at least 40 times as expensive as chlorambucil. Cladribine may be as effective as fludarabine, although it has been used less and is even more expensive. Patients who relapse after chlorambucil should be offered retreatment with the same agent and if refractory should be switched to fludarabine, which may also be offered for retreatment on relapse. For patients refractory to both drugs, a variety of options are available. High dose corticosteroids, high dose chlorambucil, CHOP (cyclophosphamide, prednisolone, vincristine and doxorubicin), anti-CD52, anti-CD20 and a range of experimental drugs which are being evaluated in clinical trials. Younger patients should be offered the chance of treatment with curative intent, preferably in the context of a clinical trial. Autologous stem cell transplantation after achieving a remission with fludarabine has relative safety and may produce molecular complete remissions. Only time will tell whether some of these patients are cured but it seems unlikely. Standard allogeneic bone marrow transplant is probably too hazardous for most patients, but non-myeloablative regimens hold out the hope of invoking a graft-versus-leukaemia effect without a high tumour-related mortality. Trials of immunotherapy are exciting options for a few patients in specialised centres.
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Affiliation(s)
- T J Hamblin
- Department of Haematology, Royal Bournemouth Hospital, England.
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Affiliation(s)
- J Barrett
- Bone Marrow Transplant Unit, Hematology Branch, National Heart, Lung and Blood Institute, National Institutes of Health, Bethesda, MD 20892, USA.
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Tiplady CW, Hamilton PJ, Galloway MJ. Acquired haemophilia complicating the remission of a patient with high grade non-Hodgkin's lymphoma treated by fludarabine. CLINICAL AND LABORATORY HAEMATOLOGY 2000; 22:163-5. [PMID: 10931166 DOI: 10.1046/j.1365-2257.2000.00308.x] [Citation(s) in RCA: 21] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
We report the development of a high titre antibody to factor VIII in a patient with previous high grade B cell non-Hodgkin's lymphoma treated with fludarabine. Unlike previous reports of factor VIII inhibitors and lymphoproliferative disease this patient's lymphoma was in remission. We speculate that the occurrence of the inhibitor is another manifestation of the increasingly recognized autoimmune side-effects of fludarabine.
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Affiliation(s)
- C W Tiplady
- Department of Haematology, Royal Victoria Infirmary, Newcastle Upon Tyne, UK.
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Reich K, Brinck U, Letschert M, Blaschke V, Dames K, Braess J, Wörmann B, Rünger TM, Neumann C. Graft-versus-host disease-like immunophenotype and apoptotic keratinocyte death in paraneoplastic pemphigus. Br J Dermatol 1999; 141:739-46. [PMID: 10583130 DOI: 10.1046/j.1365-2133.1999.03123.x] [Citation(s) in RCA: 48] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Paraneoplastic pemphigus (PP) is an autoimmune disease, which is frequently associated with non-Hodgkin's lymphoma. Autoantibodies against components of the cytoplasmic plaque of epithelial desmosomes are usually present in the sera and are believed to play a major pathogenic part in acantholysis and suprabasal epidermal blistering. However, another typical histological feature of PP, interface dermatitis with keratinocyte dyskeratosis, is shared with skin diseases that involve epithelial damage mediated by T cells. Here, we present the detailed characterization of the cutaneous T-cell response in a patient with PP and demonstrate a selective epidermal accumulation of activated CD8+ T cells together with an increased local production of interferon-gamma and tumour necrosis factor-alpha, and a strong expression of HLA-DR and ICAM-1 on keratinocytes. Apoptosis was identified as a key mechanism of keratinocyte death, and appeared independent of the FAS/FAS ligand (FAS-L) pathway, as epidermal expression of FAS was not increased compared with normal skin, and FAS-L was undetectable on the protein and mRNA level. Triple therapy with high-dose corticosteroids, cyclophosphamide and intravenous immunoglobulins reduced levels of pemphigus-like autoantibodies and reversed the cutaneous inflammatory reaction leading to long-standing clinical remission. Our findings support the concept of a major contribution of cytotoxic T lymphocytes to the immunopathology of paraneoplastic pemphigus.
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Affiliation(s)
- K Reich
- Department of Dermatology, Georg-August-University, Göttingen, Germany.
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26
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Schonewille H, Haak HL, van Zijl AM. Alloimmunization after blood transfusion in patients with hematologic and oncologic diseases. Transfusion 1999; 39:763-71. [PMID: 10413286 DOI: 10.1046/j.1537-2995.1999.39070763.x] [Citation(s) in RCA: 103] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
BACKGROUND Because of intensive marrow depression and improved survival, patients with hematologic and oncologic malignancies are dependent on transfusion for a longer period. It has been advocated that these patients should receive blood that is matched for blood group antigens other than ABO and D. A retrospective study was performed on the rate of alloimmunization against red cell antigens in 564 patients with malignant hematologic diseases over a period of 10 years. STUDY DESIGN AND METHODS Records of transfusion and immunohematologic studies of all patients (n = 1066) with malignant myeloproliferative and lymphoproliferative diseases diagnosed between 1987 and 1996 at one hospital were collected from the hospital computer blood bank files. Transfusions were correlated with antibody formation. Factors affecting this correlation were analyzed. RESULTS Seventy-one antibodies were found in 51 patients. The overall immunization rate was 9.0 percent. Fifty percent of antibodies were formed after 13 units had been transfused. Once a patient had formed an antibody, the probability of additional antibodies increased 3.3-fold. Anti-c, anti-E, and anti-K composed the majority of antibodies found. Four patients formed Rh system antibodies after incompatible platelet transfusions. Patients who underwent intensive chemotherapy formed antibodies at a much lower rate than other patients. More than 40 percent of antibodies became undetectable after the first detection. No difficulty was encountered in finding compatible blood for these patients. CONCLUSIONS Antibody formation in hematologic malignancies is comparable to that in other diseases requiring multiple blood transfusions. Extensive antigen matching before transfusion of patients with hematologic and oncologic malignancies is not necessary and leads to increased costs.
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Affiliation(s)
- H Schonewille
- Department of Hematology, Leyenburg Hospital, The Hague, The Netherlands.
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27
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Chasty RC, Myint H, Oscier DG, Orchard JA, Bussutil DP, Hamon MD, Prentice AG, Copplestone JA. Autoimmune haemolysis in patients with B-CLL treated with chlorodeoxyadenosine (CDA). Leuk Lymphoma 1998; 29:391-8. [PMID: 9684936 DOI: 10.3109/10428199809068575] [Citation(s) in RCA: 23] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
We have treated 19 B-chronic lymphocytic leukaemia (B-CLL) patients with CDA (Leustat, Janssen-Cilag). Four patients developed severe autoimmune haemolytic anaemia, and 2 of these had severe reticulocytopenia due to red cell aplasia/hypoplasia. Two patients died as a complication of the haemolysis one during the primary episode, with a clinical course suggestive of transfusion associated graft-versus-host disease (taGVHD), and one following a relapse of haemolysis. The onset of haemolysis occurs within 4 cycles of CDA therapy and is temporally related to the T-lymphocyte nadir induced by CDA. The presence of a positive DAT prior to therapy in 3 of 4 patients developing haemolysis suggests that the CDA induced T-lymphocytopenia may exacerbate the tendency of certain CLL patients to autoimmune haemolysis.
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Affiliation(s)
- R C Chasty
- Department of Haematology, Derriford Hospital, Plymouth, UK
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28
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Affiliation(s)
- L M Williamson
- Division of Transfusion Medicine, University of Cambridge, United Kingdom
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Montserrat E, Bosch F, Rozman C. B-cell chronic lymphocytic leukemia: Recent progress in biology, diagnosis, and therapy. Ann Oncol 1997. [DOI: 10.1093/annonc/8.suppl_1.s93] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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Williamson LM, Heptonstall J, Soldan K. A SHOT in the arm for safer blood transfusion. BMJ (CLINICAL RESEARCH ED.) 1996; 313:1221-2. [PMID: 8939097 PMCID: PMC2352538 DOI: 10.1136/bmj.313.7067.1221] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
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Williamson LM, Wimperis JZ, Wood ME, Woodcock B. Fludarabine treatment and transfusion-associated graft-versus-host disease. Lancet 1996; 348:472-3. [PMID: 8709796 DOI: 10.1016/s0140-6736(05)64563-1] [Citation(s) in RCA: 20] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
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Montserrat E, Lopez-Lorenzo JL, Manso F, Martin A, Prieto E, Arias-Sampedro J, Fernandez MN, Oyarzabal FJ, Odriozola J, Alcala A, Garcia-Conde J, Guardia R, Bosch F. Fludarabine in resistant or relapsing B-cell chronic lymphocytic leukemia: the Spanish Group experience. Leuk Lymphoma 1996; 21:467-72. [PMID: 9172812 DOI: 10.3109/10428199609093445] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Fludarabine produces high response rates in patients with B-cell chronic lymphocytic leukemia (CLL). Nevertheless, response to fludarabine of patients with previously treated CLL varies from 17% to 74% (0% to 38% CR). In 68 patients with heavily pretreated and advanced CLL, an overall response rate to fludarabine of 28% (4% CR) was observed. Response correlated with sensitivity of the disease to previous treatments (relapsing vs. refractory disease) (62% vs. 20%; p = 0.005) and, albeit not significantly, with the number of cycles of fludarabine (>3 vs. < or = 3) that patients could receive (36% vs. 15%; p = NS). Responding patients had a longer survival (median, not reached) than those not responding (median, 11 months) (p = 0.03). Severe toxicity was observed in some cases. It is concluded that fludarabine is a highly useful agent in CLL. However, in order to improve its effectiveness and decrease its toxicity, fludarabine should be given as soon as a lack of response to front-line therapy is observed and before the disease becomes completely resistant to therapy.
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MESH Headings
- Anemia, Hemolytic, Autoimmune/chemically induced
- Anemia, Hemolytic, Autoimmune/therapy
- Antimetabolites, Antineoplastic/adverse effects
- Antimetabolites, Antineoplastic/therapeutic use
- Cause of Death
- Drug Evaluation
- Fever/etiology
- Graft vs Host Disease/etiology
- Hematologic Diseases/chemically induced
- Humans
- Infections/etiology
- Leukemia, Lymphocytic, Chronic, B-Cell/drug therapy
- Leukemia, Lymphocytic, Chronic, B-Cell/mortality
- Life Tables
- Remission Induction
- Retrospective Studies
- Salvage Therapy
- Spain/epidemiology
- Survival Analysis
- Transfusion Reaction
- Treatment Outcome
- Vidarabine/adverse effects
- Vidarabine/analogs & derivatives
- Vidarabine/therapeutic use
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Affiliation(s)
- E Montserrat
- Postgraduate School of Hematology "Farreras-Valenti", Department of Medicine, University of Barcelona, Spain
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Affiliation(s)
- I W Flinn
- Johns Hopkins Oncology Center, Division of Hematologic Malignancies, Baltimore, MD 21287-8985, USA
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Abstract
Three analogues of the purine 2-deoxyadenosine are available for the treatment of low grade lymphoproliferative disorders: pentostatin, cladribine and fludarabine. They have some common features in their mode of action, but differ both in their detailed pharmacology and the extent to which they have activity against specific lymphoid malignancies. Studies defining the scope of these drugs as single agents are now being followed by plans to exploit their potential synergy with other agents and clinically to define useful combination therapies.
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Abstract
Transfusion-associated graft-versus-host disease is a rare but usually fatal complication of transfusion of cellular blood components, caused by multiorgan engraftment and proliferation of donor T lymphocytes. The classical features of skin rash, diarrhoea and hepatitis, along with striking bone-marrow failure, are seen 1-2 weeks after transfusion. Although early reports described the condition only in immunosuppressed individuals, sharing of an HLA haplotype between donor and an immunocompetent recipient can also result in transfusion-associated graft-versus-host disease. The condition is entirely preventable by gamma irradiation of cellular blood components to 25 Gy, although this results in some reduction of red-cell viability and increased loss of red-cell potassium. The major indications for irradiated blood components include bone marrow/stem cell auto- or allografting, Hodgkin's disease, intrauterine transfusions, and transfusions from relatives or HLA-selected platelet donors.
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Affiliation(s)
- L M Williamson
- Division of Transfusion Medicine, University of Cambridge and East Anglian Blood Centre, UK
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Briz M, Cabrera R, Sanjuán I, Forés R, Díez JL, Herrero M, Regidor C, Algora M, Fernández MN. Diagnosis of transfusion-associated graft-versus-host disease by polymerase chain reaction in fludarabine-treated B-chronic lymphocytic leukaemia. Br J Haematol 1995; 91:409-11. [PMID: 8547083 DOI: 10.1111/j.1365-2141.1995.tb05311.x] [Citation(s) in RCA: 21] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Transfusion-associated graft-versus-host disease (TA-GVHD), has rarely been reported associated with B-chronic lymphocytic leukaemia (B-CLL). We report a patient diagnosed with B-CLL, previously treated with fludarabine, who developed TA-GVHD after being transfused during surgery for splenectomy. Diagnosis was confirmed by polymerase chain reaction (PCR) detection of donor DNA in the patient, by amplification of Y-chromosome sequence and analysis of minisatellite polymorphisms. B-CLL patients treated with fludarabine appear to be at risk for TA-GVHD and should be regarded as candidates for transfusions with irradiated blood products. This case illustrates that PCR is a rapid technique for the early diagnosis of TA-GVHD.
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Affiliation(s)
- M Briz
- Department of Haematology, Hospital Puerta de Hierro, Universidad Autónoma de Madrid, Spain
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