1
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Iori E, Mazzoli M, Ariatti A, Salviato T, Rispoli V, Valzania F, Galassi G. Myasthenia Gravis crossing Parkinson's disease: a 20 year study from single Italian center. Int J Neurosci 2024; 134:429-435. [PMID: 35917141 DOI: 10.1080/00207454.2022.2107517] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2022] [Revised: 07/10/2022] [Accepted: 07/15/2022] [Indexed: 10/16/2022]
Abstract
PURPOSE The concomitant diagnosis of Parkinson's disease (PD) and Myasthenia Gravis (MG) is rare. The aim of the study was to report our experience of patients with both diagnoses. MATERIAL AND METHODS We performed a retrospective analysis of patients with MG and PD, seen at Neurology Department, Modena, Italy from 2000 to 2020. We encountered 12 patients with both diagnoses. All had late onset MG (LOMG) and low Myasthenia Gravis Foundation of America (MGFA) severity scores at baseline. In respect of PD assessement, clinical signs were followed and summarized with modified Hoehn and Yahr staging (mHY). Patients were ranked as progressive or non-progressive, according to any change in mHY staging. We compared characteristics and outcome of the patients with age matched myasthenic subjects without PD. RESULTS The male gender significantly prevailed (p < 0.01) as well as the presence of multiple comorbidities (p < 0.001) in patients with MG associated with PD. In respect of clinical course, MG was benign as most of cases remained stable (66.7%). Six cases showed worsening of mHY scores; only one subject became wheelchair bound by the end of follow up. This uneven progression, at least in our hands, might suggest that MG and PD can evolve independently. CONCLUSION Clinicians should be alert about the association of PD and MG since early diagnosis and treatment are essential.
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Affiliation(s)
- Erika Iori
- Department of Biomedical, Metabolic Neural Sciences, University of Modena, Modena, Italy
| | - Marco Mazzoli
- Department of Biomedical, Metabolic Neural Sciences, University of Modena, Modena, Italy
| | - Alessandra Ariatti
- Department of Biomedical, Metabolic Neural Sciences, University of Modena, Modena, Italy
| | - Tiziana Salviato
- Department of Anatomy Pathology and Legal Medicine, University of Modena, Modena, Italy
| | - Vittorio Rispoli
- Department of Biomedical, Metabolic Neural Sciences, University of Modena, Modena, Italy
| | - Franco Valzania
- Neuro-Motor Department, S. Maria Nuova Hospital, AUSL-IRCSS, Reggio Emilia, Italy
| | - Giuliana Galassi
- Department of Biomedical, Metabolic Neural Sciences, University of Modena, Modena, Italy
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2
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Zhang T, Zhao YH, Li LJ, Wang HQ, Song J, Wu YH, Xing LM, Qu W, Wang GJ, Guan J, Liu H, Wang XM, Shao ZH, Fu R. [Clinical characteristics and prognosis of 21 patients with thymoma-associated pure red cell aplasia]. ZHONGHUA XUE YE XUE ZA ZHI = ZHONGHUA XUEYEXUE ZAZHI 2023; 44:1031-1034. [PMID: 38503528 PMCID: PMC10834874 DOI: 10.3760/cma.j.issn.0253-2727.2023.12.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Subscribe] [Scholar Register] [Received: 05/17/2023] [Indexed: 03/21/2024]
Affiliation(s)
- T Zhang
- Department of Hematology, Tianjin Medical University General Hospital, Tianjin 300052, China
| | - Y H Zhao
- Department of Hematology, Tianjin Medical University General Hospital, Tianjin 300052, China
| | - L J Li
- Department of Hematology, Tianjin Medical University General Hospital, Tianjin 300052, China
| | - H Q Wang
- Department of Hematology, Tianjin Medical University General Hospital, Tianjin 300052, China
| | - J Song
- Department of Hematology, Tianjin Medical University General Hospital, Tianjin 300052, China
| | - Y H Wu
- Department of Hematology, Tianjin Medical University General Hospital, Tianjin 300052, China
| | - L M Xing
- Department of Hematology, Tianjin Medical University General Hospital, Tianjin 300052, China
| | - W Qu
- Department of Hematology, Tianjin Medical University General Hospital, Tianjin 300052, China
| | - G J Wang
- Department of Hematology, Tianjin Medical University General Hospital, Tianjin 300052, China
| | - J Guan
- Department of Hematology, Tianjin Medical University General Hospital, Tianjin 300052, China
| | - H Liu
- Department of Hematology, Tianjin Medical University General Hospital, Tianjin 300052, China
| | - X M Wang
- Department of Hematology, Tianjin Medical University General Hospital, Tianjin 300052, China
| | - Z H Shao
- Department of Hematology, Tianjin Medical University General Hospital, Tianjin 300052, China
| | - R Fu
- Department of Hematology, Tianjin Medical University General Hospital, Tianjin 300052, China
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3
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Lobbes H, Lega JC, Le Guenno G, Ruivard M, Mainbourg S. Treatment strategy for acquired pure red cell aplasia: a systematic review and meta-analysis. Blood Adv 2023; 7:6451-6465. [PMID: 37624775 PMCID: PMC10632686 DOI: 10.1182/bloodadvances.2023010587] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2023] [Revised: 07/22/2023] [Accepted: 08/14/2023] [Indexed: 08/27/2023] Open
Abstract
The treatment of autoimmune acquired pure red cell aplasia (aPRCA) is challenging. Guidelines are based on expert recommendations in the absence of controlled trials. We assessed the efficacy of the main treatment strategy through a systematic review and meta-analysis using MEDLINE, EMBASE, and the Cochrane Library up to September 2022. The overall response rate (ORR) was pooled using random-effects models. In total, 24 observational studies (19 retrospective, median follow-up of 48 months) encompassing 753 patients (49% male) were included. Primary aPRCA represented 57% of the cases. The risk of bias was moderate to high using the ROBINS-I tool. Substantial heterogeneity (I2 > 50%) was retrieved. Corticosteroids as monotherapy as first-line treatment (186 patients, 13 studies) provided an ORR of 47% (95% confidence interval [CI], 34-60). Cyclosporine A was the most frequently used immunosuppressant agent (384 patients, 18 studies), providing an ORR of 74% (95% CI, 66-82) with a similar ORR in first- (73%) and second-line (76%) treatment and when cyclosporin was used as monotherapy (83%) or with corticosteroids (77%). A total of 112 patients (10 studies) received cyclophosphamide, with an ORR of 49% (95% CI, 35-64), which was higher when cyclophosphamide was combined with corticosteroids (48%) and used in second-line treatment (58%) than in monotherapy (31%), and in first-line treatment (44%). Sirolimus use was reported only after cyclosporine A failure and provided an ORR of 87% (95% CI, 68-100; 64 patients, 3 studies). Substantial uncertainty remains regarding the best treatment strategy in the absence of high-quality evidence. This study was registered on the PROPERO database as #CRD42022360452.
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Affiliation(s)
- Hervé Lobbes
- Service de Médecine Interne, Hôpital Estaing, Centre Hospitalier Universitaire de Clermont-Ferrand, Centre de Compétence des cytopénies autoimmunes de l’adulte, Clermont-Ferrand, France
- Institut Pascal, Centre Hospitalier Universitaire de Clermont-Ferrand, Université Clermont Auvergne, Centre National de la Recherche Scientifique, Clermont-Ferrand, France
| | - Jean-Christophe Lega
- Lyon Immunopathology Federation, Hospices Civils de Lyon, Lyon, France
- Service de Rhumatologie, Centre Hospitalier Lyon Sud, Hospices Civils de Lyon, Pierre-Bénite, France
- Equipe Evaluation et Modélisation des Effets Thérapeutiques, Unité Mixte de Recherche 5558, Laboratoire de Biométrie et Biologie évolutive, Centre National de la Recherche Scientifique, Université Claude Bernard Lyon 1, Villeurbanne, France
| | - Guillaume Le Guenno
- Service de Médecine Interne, Hôpital Estaing, Centre Hospitalier Universitaire de Clermont-Ferrand, Centre de Compétence des cytopénies autoimmunes de l’adulte, Clermont-Ferrand, France
| | - Marc Ruivard
- Service de Médecine Interne, Hôpital Estaing, Centre Hospitalier Universitaire de Clermont-Ferrand, Centre de Compétence des cytopénies autoimmunes de l’adulte, Clermont-Ferrand, France
- Institut Pascal, Centre Hospitalier Universitaire de Clermont-Ferrand, Université Clermont Auvergne, Centre National de la Recherche Scientifique, Clermont-Ferrand, France
| | - Sabine Mainbourg
- Lyon Immunopathology Federation, Hospices Civils de Lyon, Lyon, France
- Equipe Evaluation et Modélisation des Effets Thérapeutiques, Unité Mixte de Recherche 5558, Laboratoire de Biométrie et Biologie évolutive, Centre National de la Recherche Scientifique, Université Claude Bernard Lyon 1, Villeurbanne, France
- Département de Médecine Interne, Centre Hospitalier Lyon Sud, Hospices Civils de Lyon, Pierre-Bénite, France
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4
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Means RT. Pure red cell aplasia: The second hundred years. Am J Med Sci 2023; 366:160-166. [PMID: 37327996 DOI: 10.1016/j.amjms.2023.06.009] [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: 04/29/2023] [Revised: 06/05/2023] [Accepted: 06/13/2023] [Indexed: 06/18/2023]
Abstract
Pure red cell aplasia (PRCA) is a rare hematologic syndrome, characterized by an isolated normocytic anemia with severe reticulocytopenia, and defined by absence or near absence of erythroid precursors in the bone marrow. First described in 1922, PRCA may be a primary autoimmune or clonal myeloid or lymphoid disorder, but may also be secondary to other disorders of immune dysregulation/autoimmunity, to infections, to neoplasms, or to drugs. Insights from the study of PRCA have helped illuminate the understanding of the regulation of erythropoiesis. This review summarizes the classification, diagnostic, and therapeutic approach to PRCA as it begins its second century, with a particular focus on opportunities and challenges provided by new developments in the role of T-cells and T-cell regulatory mutations; the role of clonal hematopoiesis; and new developments in therapy for refractory PRCA and PRCA associated with ABO incompatible stem cell transplantation.
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Affiliation(s)
- Robert T Means
- Departments of Internal Medicine, Medical Education, and Pathology, James H. Quillen College of Medicine, Johnson City, TN, USA.
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5
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Xue Y, Wu Q, Pu D, Xu F, Li Y. Radiation‑induced pure red cell aplasia combined with acquired amegakaryocytic thrombocytopenia in a thymoma after rapid response to radiotherapy: A case report and literature review. Exp Ther Med 2023; 25:237. [PMID: 37114181 PMCID: PMC10126795 DOI: 10.3892/etm.2023.11936] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2022] [Accepted: 02/16/2023] [Indexed: 04/29/2023] Open
Abstract
Thymoma combined with pure red cell aplasia (PRCA) and acquired amegakaryocytic thrombocytopenia (AAMT) has been rarely reported, often occurring in the initial stage of treatment and after chemotherapy or thymectomy, while PRCA and AAMT occurring after radiotherapy for thymoma has not been reported. The present study describes the case of a 42-year-old female patient with thymoma complicated by radiation-induced PRCA and AAMT after a rapid response to radiotherapy, who was in complete remission without recurrence after adjustment of initial symptomatic therapy to cyclosporine combined with prednisone. After 1 month, the patient underwent complete resection of mediastinal tumor. Next-generation sequencing revealed that the DNA damage repair pathway-related gene MSH3 was mutated, with p.A57P in abundance of 9.21%. To the best of our knowledge, the present study is the first to report that PRCA and AAMT secondary to thymoma after radiotherapy may be associated with increased sensitivity to radiotherapy caused by a mutation in the MSH3 gene.
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Affiliation(s)
- Yinyin Xue
- Lung Cancer Center and Institute, West China Hospital, Sichuan University, Chengdu, Sichuan 610041, P.R. China
| | - Qiang Wu
- Lung Cancer Center and Institute, West China Hospital, Sichuan University, Chengdu, Sichuan 610041, P.R. China
| | - Dan Pu
- Lung Cancer Center and Institute, West China Hospital, Sichuan University, Chengdu, Sichuan 610041, P.R. China
| | - Feng Xu
- Lung Cancer Center and Institute, West China Hospital, Sichuan University, Chengdu, Sichuan 610041, P.R. China
| | - Yan Li
- Lung Cancer Center and Institute, West China Hospital, Sichuan University, Chengdu, Sichuan 610041, P.R. China
- Correspondence to: Professor Yan Li, Lung Cancer Center and Institute, West China Hospital, Sichuan University, 37 Guoxue Lane, Wuhou, Chengdu, Sichuan 610041, P.R. China
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6
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Thangatorai R. Pure Red Cell Aplasia Associated With Thymoma. Cureus 2023; 15:e39387. [PMID: 37362458 PMCID: PMC10286678 DOI: 10.7759/cureus.39387] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/22/2023] [Indexed: 06/28/2023] Open
Abstract
A 27-year-old male with thymoma presented with recurrent severe anemia which required multiple transfusions. Bone marrow biopsy showed pure red cell aplasia with normal other cell lineages. He was diagnosed with pure red cell aplasia associated with thymoma and treatment with cyclosporine A was begun. After 12 weeks of treatment, his hemoglobin improved to 11.3 g/dL and the patient remained transfusion independent.
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7
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Sakata R, Chu PS, Kawaida M, Emoto K, Sakurai M, Nishida R, Asakura K, Morikawa R, Taniki N, Kataoka K, Kanai T, Nakamoto N. Concurrent de novo Thymoma-associated Paraneoplastic Type 1 Autoimmune Hepatitis and Pure Red Cell Aplasia after Thymectomy: A Case Report and Literature Review. Intern Med 2023; 62:243-249. [PMID: 35705275 PMCID: PMC9908397 DOI: 10.2169/internalmedicine.9743-22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/18/2023] Open
Abstract
The precise manipulation of immune tolerance is the holy grail of immunotherapies for both autoimmunity and cancer immunity. Thymomas are well known to be associated with autoimmune diseases. The exact mechanism by which autoreactivity is induced after thymectomy remains to be elucidated. We herein present the case of a 50-year-old lady with concurrent de novo type 1 autoimmune hepatitis (AIH) and pure red cell aplasia (PRCA), 1 month after undergoing a successful total thymectomy for combined squamous cell carcinoma and thymoma (Masaoka stage II). Corticosteroids yielded short-term effects for both AIH and PRCA. Literature on thymoma-associated AIH, an extremely rare immune-related comorbidity, was also reviewed.
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Affiliation(s)
- Rie Sakata
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Keio University School of Medicine, Japan
- Postgraduate Medical Education Center, Keio University Hospital, Japan
| | - Po-Sung Chu
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Keio University School of Medicine, Japan
| | - Miho Kawaida
- Division of Diagnostic Pathology, Keio University School of Medicine, Japan
| | - Katsura Emoto
- Division of Diagnostic Pathology, Keio University School of Medicine, Japan
| | - Masatoshi Sakurai
- Division of Hematology, Department of Internal Medicine, Keio University School of Medicine, Japan
| | - Risa Nishida
- Division of Thoracic Surgery, Department of Surgery, Keio University School of Medicine, Japan
| | - Keisuke Asakura
- Division of Thoracic Surgery, Department of Surgery, Keio University School of Medicine, Japan
| | - Rei Morikawa
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Keio University School of Medicine, Japan
| | - Nobuhito Taniki
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Keio University School of Medicine, Japan
| | - Keisuke Kataoka
- Division of Hematology, Department of Internal Medicine, Keio University School of Medicine, Japan
| | - Takanori Kanai
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Keio University School of Medicine, Japan
| | - Nobuhiro Nakamoto
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Keio University School of Medicine, Japan
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8
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Quah C, Srinivasan S, Zaheer S, Banumukala VP. Clinics in diagnostic imaging (215). Singapore Med J 2022; 63. [PMID: 36573656 PMCID: PMC9815172 DOI: 10.4103//singaporemedj.smj-2021-231] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Affiliation(s)
- Colin Quah
- Department of Diagnostic Radiology, Khoo Teck Puat Hospital, Singapore,Correspondence: Dr Colin Quah, Department of Diagnostic Radiology, Khoo Teck Puat Hospital, 90 Yishun Central, 768828, Singapore. E-mail:
| | | | - Sheeba Zaheer
- Department of Diagnostic Radiology, Khoo Teck Puat Hospital, Singapore
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9
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Clinical characteristics and outcomes of 100 adult patients with pure red cell aplasia. Ann Hematol 2022; 101:1493-1498. [PMID: 35460389 DOI: 10.1007/s00277-022-04847-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2021] [Accepted: 04/17/2022] [Indexed: 02/06/2023]
Abstract
Adult pure red cell aplasia (PRCA) is a rare syndrome characterized by a severe normocytic anemia, reticulocytopenia, and absence of erythroblasts from bone marrow. The standard treatment has not yet been established for PRCA, although cyclosporine (CsA), corticosteroids (CS) showed a response in PRCA. We retrospectively analyzed the clinical data of 60 primary and 40 secondary adult patients with acquired PRCA. The proportion of secondary PRCA is relatively high and commonly associated with large granular lymphocyte leukemia (LGLL) (28 cases, 70.0%). The remission-induced regimens included CS, CsA, or other agents, and the response rate was 66.7%, 71.4%, and 50%, respectively (P = 0.336). When treating with CsA, the response rate of LGLL-associated PRCA was lower than primary PRCA (42.1% vs 85.7%, P = 0.001). Logistic regression analysis showed that ORR was inversely related to LGLL-associated PRCA. LGLL-associated PRCA had poor therapeutic efficacy to CsA.
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10
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Lindahl JP, Barlinn R, Abrahamsen IW, Spetalen S, Midtvedt K, Jenssen T. Case Report: Pure Red Cell Aplasia Caused by Refractory Parvovirus B19 Infection After Pancreas Transplantation Alone. Front Med (Lausanne) 2022; 9:849783. [PMID: 35372384 PMCID: PMC8966125 DOI: 10.3389/fmed.2022.849783] [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: 01/06/2022] [Accepted: 02/22/2022] [Indexed: 11/25/2022] Open
Abstract
A multidisciplinary team of doctors is in charge or is involved in the follow-up of patients who undergo solid organ transplantation (SOT). Immunosuppressive drugs are required after SOT, some potential unwanted side effects can be difficult to detect, and physicians must be aware of potential pitfalls. We report a case of a recipient with brittle type 1 diabetes who experienced severe and refractory anemia after pancreas transplantation alone (PTA). Despite a broad diagnostic approach for anemia, the diagnosis was delayed. The patient had normocytic normochromic anemia with severe reticulocytopenia and marked reduction or absence of erythroid precursors in the bone marrow, compatible with pure red cell aplasia (PRCA). Analyses of serological parvovirus B19 anti-IgM and anti-IgG antibodies, including PCR, were initially inconclusive/negative. The diagnosis of parvovirus B19 infection was confirmed after bone marrow biopsy with immunohistochemical staining for parvovirus B19. A retrospective analysis revealed an early post-transplant primary parvovirus B19 infection. The patient was successfully treated with intravenous immunoglobulin (IVIg) therapy. There is a risk of diagnostic delay for the less common types of anemia following SOT. Parvovirus B19 infection-associated PRCA is curable in SOT recipients and should be actively considered in patients with persistent anemia and low reticulocytes.
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Affiliation(s)
- Jørn Petter Lindahl
- Department of Transplantation Medicine, Oslo University Hospital, Rikshospitalet, Oslo, Norway
| | - Regine Barlinn
- Department of Microbiology, Oslo University Hospital, Rikshospitalet, Oslo, Norway
| | | | - Signe Spetalen
- Department of Pathology, Oslo University Hospital, Radiumhospitalet, Oslo, Norway
| | - Karsten Midtvedt
- Department of Transplantation Medicine, Oslo University Hospital, Rikshospitalet, Oslo, Norway
| | - Trond Jenssen
- Department of Transplantation Medicine, Oslo University Hospital, Rikshospitalet, Oslo, Norway.,Institute of Clinical Medicine, University of Oslo, Oslo, Norway
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Ao YQ, Jiang JH, Gao J, Wang HK, Ding JY. Recent thymic emigrants as the bridge between thymoma and autoimmune diseases. Biochim Biophys Acta Rev Cancer 2022; 1877:188730. [DOI: 10.1016/j.bbcan.2022.188730] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2022] [Revised: 04/14/2022] [Accepted: 04/15/2022] [Indexed: 11/27/2022]
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12
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Kosaka T, Nakahashi H, Nakazawa S, Ibe T, Yajima T, Shirabe K. Taste disorder in a patient with invasive thymoma without myasthenia gravis: a rare case report. MEDIASTINUM (HONG KONG, CHINA) 2022; 6:9. [PMID: 35340830 PMCID: PMC8841547 DOI: 10.21037/med-21-28] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/21/2021] [Accepted: 10/15/2021] [Indexed: 06/14/2023]
Abstract
Taste disorder has been reported as a non-motor symptom caused by myasthenia gravis (MG)-related autoimmune mechanism. Taste disorder in some cases recovered along with MG treatment, such as thymothymectomy or immunosuppressive treatment. However, symptom of taste disorder in thymoma patients without MG is very rare. Here, we reported a case of invasive thymoma without MG which had concurrent taste disorder. The taste disorder was successfully treated with cyclosporine. A female in her seventies had an anterior mediastinal tumor of 78-mm in diameter and pleural dissemination. She also had taste disorder, limited to sweet taste, and pure red cell aplasia (PRCA). Symptoms and physical findings showed no feature of MG. Pre-operative blood examination revealed no elevation of anti-acetylcholine receptor antibody . Extended total thymothymectomy and resection of all detectable pleural disseminations was performed. Pathological examination showed type B3 thymoma. Clinical stage was Masaoka stage IVa. After operation, there was no improvement in taste disorder and PRCA. Six months after operation, cyclosporine was administered for PRCA. In parallel with gradual improvement of anemia, taste disorder also gradually improved. Three months after the first administration of cyclosporine, taste disorder had completely recovered. This is the first case of taste disorder without any myasthenic status, which recovered with immunosuppressive drug. Our case suggested the potency of immunosuppressive treatment for taste disorder associate with thymoma without MG.
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Affiliation(s)
- Takayuki Kosaka
- Department of Thoracic Surgery, National Hospital Organization Takasaki General Medical Center, Takasaki, Japan
- Department of General Surgical Science, Gunma University Graduate School of Medicine, Maebashi, Japan
| | | | - Seshiru Nakazawa
- Department of General Surgical Science, Gunma University Graduate School of Medicine, Maebashi, Japan
| | - Takashi Ibe
- Department of Thoracic Surgery, National Hospital Organization Takasaki General Medical Center, Takasaki, Japan
- Department of General Surgical Science, Gunma University Graduate School of Medicine, Maebashi, Japan
| | - Toshiki Yajima
- Department of General Surgical Science, Gunma University Graduate School of Medicine, Maebashi, Japan
| | - Ken Shirabe
- Department of General Surgical Science, Gunma University Graduate School of Medicine, Maebashi, Japan
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Wagh AN, Bhagvat SR, Bhandarwar AH, Harivelam C, Ganesan B, Sawardekar VM. Minimally invasive extended thymectomy for thymoma associated with pure red cell aplasia. Indian J Thorac Cardiovasc Surg 2022; 38:199-203. [PMID: 35221558 PMCID: PMC8857358 DOI: 10.1007/s12055-021-01273-3] [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: 05/14/2021] [Revised: 09/13/2021] [Accepted: 09/14/2021] [Indexed: 12/01/2022] Open
Abstract
Anaemia characterised by near absence of red cell precursors in the bone marrow is referred to as "pure red cell aplasia (PRCA)." It has an unusual and intriguing association with thymoma and auto-immunity. Here, we report such a case which was successfully treated with extended thymectomy by minimally invasive approach. A 68-year-old anaemic lady presented to our institute with weakness and exertional dyspnoea for almost a year. She was transfused with blood for the same periodically but remained transfusion dependent. Apart from pallor, her systemic examination was unremarkable. Peripheral smear showed reduced haemoglobin (Hb) mass and reduced reticulocytes. Bone marrow biopsy implied PRCA. High-resolution computed tomography (HRCT) of thorax revealed a well-defined soft tissue lesion in the anterior mediastinum suggesting thymoma. Biopsy showed lymphocyte-rich type thymoma. Thymus along with fibrofatty tissue was resected completely using video-assisted thoracoscopic surgery (VATS) approach. Histopathological examination of the resected specimen revealed World Health Organisation (WHO) type B1-thymoma. Immediate post-operative period was uneventful. However, a fall in Hb which required blood transfusions necessitated initiation of immunosuppression with corticosteroids. Patient was given 6 weeks of adjuvant immunosuppression with corticosteroids. After 8 months post-thymectomy, she was leading a symptom-free life and no longer in need for blood transfusions. VATS thymectomy is a safe and feasible approach for the treatment of thymoma-induced PRCA with added advantage of minimal invasive approach. Long-term complete remission is possible with adjuvant immunosuppression.
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Affiliation(s)
- Amol N. Wagh
- Department of General Surgery, Grant Medical College and Sir JJ Group of Hospitals, Mumbai, India
| | - Shirish R. Bhagvat
- Department of General Surgery, Grant Medical College and Sir JJ Group of Hospitals, Mumbai, India
| | - Ajay H. Bhandarwar
- Department of General Surgery, Grant Medical College and Sir JJ Group of Hospitals, Mumbai, India
| | - Chidananda Harivelam
- Department of General Surgery, Grant Medical College and Sir JJ Group of Hospitals, Mumbai, India
| | - Balamurugan Ganesan
- Department of General Surgery, Grant Medical College and Sir JJ Group of Hospitals, Mumbai, India
| | - Vinayak M. Sawardekar
- Department of General Medicine, Grant Medical College and Sir JJ Group of Hospitals, Mumbai, India
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14
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Yen CC, Huang WL, Li SS, Chen YP, Tseng YL, Yen YT, Chu CY, Hsu YT, Chen TY. Pure Red Cell Aplasia and Other Haematological Diseases Associated With Thymoma: A Case Series and Systematic Review. Front Med (Lausanne) 2021; 8:759914. [PMID: 34966753 PMCID: PMC8710742 DOI: 10.3389/fmed.2021.759914] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2021] [Accepted: 11/18/2021] [Indexed: 11/20/2022] Open
Abstract
Background: Thymoma-associated haematological diseases (HDs), such as pure red cell aplasia (PRCA) and Good's syndrome, are extremely rare, and due to the paucity of large-scale studies, the characteristics, remission after thymectomy, and long-term evaluation remain undetermined. Methods: We retrospectively assessed patients with thymoma and associated HDs from Jan 2005 to Dec 2020. All patients received thymectomy and/or additional treatments for HDs. A comparison with thymoma-associated myasthenic gravis (MG), and a systematic review from PubMed/MEDLINE and Embase were conducted. Results: In the median follow-up of 56 months, 130 patients were enrolled. Patients with thymoma-associated MG (n = 46) and HDs [n = 8; PRCA (n = 5), PRCA and Good's syndrome (n = 2) and autoimmune haemolytic anaemia (n = 1)] were evaluated. Patients with MG had a significantly higher remission rate after thymectomy (50 vs. 17%; p = 0.0378) as compared to those with other autoimmune diseases. Two of seven patients with PRCA experienced remission with thymectomy alone, and an additional two patients achieved remission with thymectomy plus immunosuppressive therapy (IST). In the systematic review, 60 studies (case reports, n = 46; case series including the present study, n = 14) were evaluated. Forty-four percent of patients were diagnosed with PRCA after thymoma, and 61% achieved remission with thymectomy plus IST; however, Good's syndrome was unaffected. Conclusions: Our study indicates that patients with thymoma-associated autoimmune diseases other than MG have a lower remission rate than those with MG. Remission of thymoma-associated PRCA can be achieved by thymectomy and IST. This study provides insight into extremely rare but puzzling autoimmune manifestations.
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Affiliation(s)
- Chih-Chieh Yen
- Division of Haematology/Oncology, Department of Internal Medicine, National Cheng Kung University Hospital Douliou Branch, Yunlin, Taiwan
- Institute of Clinical Medicine, School of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Wei-Li Huang
- Division of Thoracic Surgery, Department of Surgery, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Sin-Syue Li
- Division of Haematology, Department of Internal Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Ya-Ping Chen
- Division of Haematology, Department of Internal Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Yau-Lin Tseng
- Division of Thoracic Surgery, Department of Surgery, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Yi-Ting Yen
- Division of Thoracic Surgery, Department of Surgery, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Chang-Yao Chu
- Department of Pathology, Chi-Mei Medical Center, Tainan, Taiwan
| | - Ya-Ting Hsu
- Division of Haematology, Department of Internal Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
- *Correspondence: Ya-Ting Hsu
| | - Tsai-Yun Chen
- Division of Haematology, Department of Internal Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
- Tsai-Yun Chen
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15
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Lesire B, Durieux V, Grigoriu B, Girard N, Berghmans T. Management of thymoma associated autoimmune pure red cell aplasia: Case report and systematic review of the literature. Lung Cancer 2021; 157:131-146. [PMID: 34049719 DOI: 10.1016/j.lungcan.2021.05.010] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2021] [Revised: 05/07/2021] [Accepted: 05/09/2021] [Indexed: 10/21/2022]
Abstract
Pure red cell aplasia (PRCA) is a rare paraneoplastic syndrome observed in 2-5 % of thymomas. Literature reports great variability in its management. Based on an illustrative clinical case, we present a systematic literature review whose main objective is to evaluate the therapeutic management of PRCA. The literature search was performed based on the PICO method in the Medline and Scopus databases. The reference clinical case concerns a 51-year-old woman with stage IVa thymoma. After initial response to chemotherapy, a locoregional progression occurred with PRCA development that responded favorably under second line chemotherapy. The patient finally died in a context of bicytopenia with febrile neutropenia. The systematic review covers 135 articles published between 1950 and 2019. Thymectomy alone or in combination with other therapies showed a 31 % complete remission (CR) rate for PRCA of, whereas none was reported with anti-tumor treatments without thymectomy. Among immunomodulatory therapies, cyclosporin gave the highest percentage of CR (74 %). Finally, the combination of thymectomy and immunomodulatory treatments showed a CR rate of 45 %. Thymectomy appeared to be the most effective anti-tumor treatment for PRCA. Immunomodulatory therapies, particularly cyclosporine, are shown effective, but the risk of infectious complications must be considered. The optimal place of anti-tumor and immunomodulatory therapies against PRCA has yet to be determined.
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Affiliation(s)
- Bastien Lesire
- Department of Internal Medecine, Institut Jules Bordet, Université Libre de Bruxelles, Brussels, Belgium.
| | - Valérie Durieux
- Bibliothèque des Sciences de la Santé, Université libre de Bruxelles, Belgium.
| | - Bogdan Grigoriu
- Department of Intensive Care and Oncological Emergencies & Thoracic Oncology, Institut Jules Bordet, Université Libre de Bruxelles, Brussels, Belgium.
| | - Nicolas Girard
- Institut du Thorax Curie Montsouris, Institut Curie, Paris, France.
| | - Thierry Berghmans
- Department of Medical Oncology, Institut Jules Bordet, Université Libre de Bruxelles, Brussels, Belgium; Laboratoire Facultaire de Médecine Factuelle de l'Université Libre de Bruxelles, Belgium.
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16
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Gurnari C, Maciejewski JP. How I manage acquired pure red cell aplasia in adults. Blood 2021; 137:2001-2009. [PMID: 33657207 PMCID: PMC8057257 DOI: 10.1182/blood.2021010898] [Citation(s) in RCA: 28] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2021] [Accepted: 02/18/2021] [Indexed: 12/19/2022] Open
Abstract
Pure red cell aplasia (PRCA) is a rare hematological disorder with multiple etiologies. The multifaceted nature of this disease is emphasized by the variety of concomitant clinical features. Classic idiopathic presentation aside, prompt recognition of pathogenetic clues is important because of their diagnostic and therapeutic implications. As a consequence, treatment of PRCA is diverse and strictly dependent on the presented clinical scenario. Here, we propose a series of clinical vignettes that showcase instructive representative situations derived from our routine clinical practice. Using these illustrative clinical cases, we review the diagnostic workup needed for a precise diagnosis and the currently available therapeutic options, discussing their applications in regard to the various PRCA-associated conditions and individual patients' characteristics. Finally, we propose a treatment algorithm that may offer guidance for personalized therapeutic recommendations.
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Affiliation(s)
- Carmelo Gurnari
- Translational Hematology and Oncology Research Department, Taussig Cancer Center, Cleveland Clinic, Cleveland, OH; and
- Department of Biomedicine and Prevention, Molecular Medicine and Applied Biotechnology, University of Rome Tor Vergata, Rome, Italy
| | - Jaroslaw P Maciejewski
- Translational Hematology and Oncology Research Department, Taussig Cancer Center, Cleveland Clinic, Cleveland, OH; and
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17
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Hishida T, Asamura H, Yoshida K, Tsuboi M, Yokoi K, Toyooka S, Matsumura A, Tagawa T, Okumura M. Clinical features and prognostic impact of coexisting autoimmune disease other than myasthenia gravis in resected thymomas: analysis of a Japanese multi-institutional retrospective database. Eur J Cardiothorac Surg 2021; 59:641-649. [PMID: 33188679 DOI: 10.1093/ejcts/ezaa362] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2019] [Revised: 08/20/2020] [Accepted: 08/29/2020] [Indexed: 12/27/2022] Open
Abstract
OBJECTIVES The purpose of this study was to clarify the prevalence, clinical features and survival of patients with thymoma and non-myasthenia gravis autoimmune disease (NMAD) using a nationwide cohort. METHODS The Japanese Association for Research on the Thymus nationwide database, which includes data from 32 institutions, was examined to clarify the prevalence and characteristics of NMAD associated with thymomas and elucidate the prognostic impact of NMAD for thymoma patients. RESULTS Among the 2423 patients with thymomas who were surgically treated between 1991 and 2010, 114 (4.7%) were identified with NMAD. The most frequently observed NMAD was pure red cell aplasia (PRCA) in 44 (1.8%), followed by hypogammaglobulinaemia (0.5%) and rheumatic arthritis (0.5%). Twenty-eight percent of patients with NMAD had concomitant myasthenia gravis. The presence of NMAD was not an independent prognostic factor for overall survival (OS) irrespective of the type of NMAD [PRCA+: hazard ratio (HR) 1.99, 95% confidence interval 0.74-4.47; PRCA- NMAD: HR 1.28, 0.30-3.56]; however, there were more cases with advanced age and disease of the thymoma amongst PRCA+ patients and these showed a worse OS than patients with PRCA- NMAD (P < 0.001), who had an OS similar to those without NMAD (P = 0.489). The 10-year OS rates in PRCA+, PRCA- NMAD and NMAD- groups were 45.5%, 97.4% and 89.5%, respectively. The main causes of death in PRCA+ patients were the progression of thymoma and other diseases including pneumonia. CONCLUSIONS Although the presence of NMAD itself did not significantly affect survival after surgery for thymoma, the type of NMAD was associated with different clinical features and prognosis. The NMAD+ thymomas should be separately categorized according to the presence or absence of PRCA.
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Affiliation(s)
- Tomoyuki Hishida
- Division of Thoracic Surgery, Department of Surgery, Keio University School of Medicine, Tokyo, Japan
| | - Hisao Asamura
- Division of Thoracic Surgery, Department of Surgery, Keio University School of Medicine, Tokyo, Japan
| | - Kazuo Yoshida
- Department of Thoracic Surgery, Shinshu University School of Medicine, Nagano, Japan
| | - Masahiro Tsuboi
- Department of Thoracic Surgery, National Cancer Centre Hospital East, Chiba, Japan
| | - Kohei Yokoi
- Department of Thoracic Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Shinichi Toyooka
- Department of Thoracic, Breast and Endocrinological Surgery, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Akihide Matsumura
- Department of Surgery, National Hospital Organization Kinki-chuo Chest Medical Centre, Osaka, Japan
| | - Tetsuzo Tagawa
- Department of Surgery and Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Meinoshin Okumura
- Department of General Thoracic Surgery, National Hospital Organization Osaka Toneyama Medical Centre, Osaka, Japan
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18
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Xavier RD, Devaraj S, Sadasivam V, Prakasam O, Menon N, Hariharan A, Sundaramoorthi T. Thymoma associated with pure red cell aplasia: a case report and literature review. Indian J Thorac Cardiovasc Surg 2020; 36:404-408. [PMID: 33061149 DOI: 10.1007/s12055-019-00875-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2019] [Revised: 08/20/2019] [Accepted: 09/01/2019] [Indexed: 10/24/2022] Open
Abstract
Pure red cell aplasia (PRCA) is a rare hematological complication associated with thymoma. Remission of PRCA occurs after thymectomy but can reappear after a latency period even without recurrence of thymoma. We report a case and we have reviewed the literature of thymoma associated with PRCA. Because of less number of reported cases, there have been no clinical trials investigating the immunosuppression regimen following thymectomy for thymoma associated with PRCA. After reviewing the literature, we came to a conclusion that thymectomy followed by immumosuppression with the cyclosporin-containing regimen is currently the most effective treatment.
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Affiliation(s)
- Reenus Demel Xavier
- Department of Cardiothoracic Surgery, Sri Ramakrishna Hospital, Coimbatore, Tamilnadu 641044 India
| | - Sujith Devaraj
- Department of Cardiothoracic Surgery, Sri Ramakrishna Hospital, Coimbatore, Tamilnadu 641044 India
| | - Vijay Sadasivam
- Department of Cardiothoracic Surgery, Sri Ramakrishna Hospital, Coimbatore, Tamilnadu 641044 India
| | - Om Prakasam
- Department of Cardiothoracic Surgery, Sri Ramakrishna Hospital, Coimbatore, Tamilnadu 641044 India
| | - Narendra Menon
- Department of Cardiothoracic Surgery, Sri Ramakrishna Hospital, Coimbatore, Tamilnadu 641044 India
| | - Ashok Hariharan
- Department of Cardiothoracic Surgery, Sri Ramakrishna Hospital, Coimbatore, Tamilnadu 641044 India
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19
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Lee SY, Gill A, Jung SM. Pure red cell aplasia and seronegative myasthenia gravis in association with thymoma. J Community Hosp Intern Med Perspect 2020; 10:238-241. [PMID: 32864051 PMCID: PMC7431916 DOI: 10.1080/20009666.2020.1770019] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Pure red cell aplasia is an uncommon paraneoplastic syndrome of thymoma. Myasthenia gravis is the most common paraneoplastic syndrome associated with thymoma. We present a case of a 79-year-old Pacific Islander female who presented with profound fatigue, generalized weakness, significant unintentional weight loss, bilateral ptosis, and anemia. The bone marrow biopsy showed near absence of erythroid elements consistent with pure red cell aplasia. Ice-pack test was consistent with myasthenia gravis and computed tomography of the chest demonstrated a thymoma. The patient was started on immunosuppressive treatment with prednisone and cyclosporine. This case demonstrates a rare combination of paraneoplastic manifestations of thymoma: pure red cell aplasia and myasthenia gravis.
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Affiliation(s)
- Sun Yong Lee
- Internal Medicine, San Joaquin General Hospital (SJGH), French Camp, CA, USA
| | - Amandeep Gill
- Internal Medicine, San Joaquin General Hospital (SJGH), French Camp, CA, USA
| | - Syung Min Jung
- Internal Medicine, San Joaquin General Hospital (SJGH), French Camp, CA, USA
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20
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Etiologies and Treatment Burden in Adult Patients with Pure Red Cell Aplasia: A Single-Center Experience and Review of Literature. Anemia 2020; 2020:4812759. [PMID: 32257434 PMCID: PMC7102412 DOI: 10.1155/2020/4812759] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2019] [Accepted: 02/17/2020] [Indexed: 11/18/2022] Open
Abstract
Background Pure red cell aplasia (PRCA) is less common blood disorder; the causes and the treatments of PRCA are varied. Methods We conducted a retrospective study during January 2010-December 2017, to explore the etiologies and to evaluate the response and treatment burden in adult patients with PRCA. Results Of 32 PRCA patients, median age was 57 years (18-90 years). Median hemoglobin level and reticulocyte count at the time of diagnosis were 5.6 g/dL (3.3-7.3 g/dL) and 0.3% (0.1-0.7%), respectively. Median time to hematologic recovery was 12 weeks (3-72 weeks), and median number of red blood cell transfusion (RBC) was 20 units (4-100 units). Causes of PRCA were erythropoiesis-stimulating agent (ESA) (47%), parvovirus B19 infection (19%), thymoma (13%), zidovudine (6%), primary autoimmune PRCA (6%), Kaposi's sarcoma (3%), systemic lupus erythematosus (3%), and ABO-mismatched stem cell transplantation (3%). Only 9 out of 24 treated patients achieved hematologic response within 8 weeks of treatment. Intravenous immunoglobulin therapy provided 100% response rate in patients with parvovirus B19-associated PRCA and primary autoimmune PRCA. Low response rate was found in patients receiving immunosuppressants and chemotherapy for the treatment of ESA and thymoma-associated PRCA, respectively. Conclusions Treatment outcome of PRCA depended upon the causes and the types of treatment, and the burden of RBC transfusion was very high in patients with ESA and thymoma-associated PRCA.
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21
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[How I diagnose and treat pure red cell aplasia]. ZHONGHUA XUE YE XUE ZA ZHI = ZHONGHUA XUEYEXUE ZAZHI 2020; 41:5-9. [PMID: 32023747 PMCID: PMC7357908 DOI: 10.3760/cma.j.issn.0253-2727.2020.01.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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22
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Rubinstein MM, Goss C, Avecilla ST, Dubé GP, Riely GJ, Mones JV. Management of thymoma-associated pure red cell aplasia: A novel use of blood substitute HBOC-201 in a Jehovah's Witness. Clin Case Rep 2020; 8:289-292. [PMID: 32128175 PMCID: PMC7044386 DOI: 10.1002/ccr3.2626] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2019] [Revised: 11/12/2019] [Accepted: 11/16/2019] [Indexed: 11/11/2022] Open
Abstract
Pure red cell aplasia (PRCA) is a rare paraneoplastic syndrome occasionally associated with thymomas. Here, we report on the first ever use of a bovine hemoglobin-based oxygen carrier, HBOC-201 (HbO2 Therapeutics LLC; Hemopure®, Waltham, MA) for the supportive management of pure red cell aplasia in a Jehovah Witness patient.
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Affiliation(s)
- Maria M. Rubinstein
- Department of MedicineMemorial Sloan Kettering Cancer CenterNew YorkNew York
| | - Cheryl Goss
- Department of Laboratory MedicineMemorial Sloan Kettering Cancer CenterNew YorkNew York
| | - Scott T. Avecilla
- Department of Laboratory MedicineMemorial Sloan Kettering Cancer CenterNew YorkNew York
| | | | - Gregory J. Riely
- Department of MedicineMemorial Sloan Kettering Cancer CenterNew YorkNew York
| | - Jodi V. Mones
- Department of MedicineMemorial Sloan Kettering Cancer CenterNew YorkNew York
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23
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Gendron N, de Fontbrune FS, Guyard A, Fadlallah J, Chantepie S, D'Aveni M, Le Calloch R, Garnier A, Couturier MA, Morel V, Bernard C, Terriou L, Lazaro E, Socié G, de Latour RP. Aplastic anemia related to thymoma: a survey on behalf of the French reference center of aplastic anemia and a review of the literature. Haematologica 2019; 105:e333-e336. [PMID: 31727769 DOI: 10.3324/haematol.2019.226134] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Affiliation(s)
- Nicolas Gendron
- Laboratoire d'Hématologie, Hôpital Bichat - Claude Bernard, AP-HP, Paris.,Université de Paris, Paris
| | - Flore Sicre de Fontbrune
- Université de Paris, Paris.,Service d'Hématologie Greffe, Centre de référence des aplasies médullaires acquises et constitutionnelles, Hôpital Saint Louis, AP-HP, Paris
| | - Alice Guyard
- Université de Paris, Paris.,Service d'Anatomo-Pathologie, Hôpital Bichat - Claude Bernard, AP-HP, Paris
| | - Jehane Fadlallah
- Université de Paris, Paris.,Service d'Immunologie Clinique, Hôpital Saint Louis, AP-HP, Paris
| | | | | | - Ronan Le Calloch
- Service de Médecine Interne - Maladies du sang - Maladies Infectieuses, Centre Hospitalier de Cornouaille, Quimper
| | | | | | | | - Claire Bernard
- Service de Médecine Interne, Hôpital de la Croix-Rousse, Hospices civils de Lyon, Lyon
| | | | | | - Gérard Socié
- Université de Paris, Paris.,Service d'Hématologie Greffe, Centre de référence des aplasies médullaires acquises et constitutionnelles, Hôpital Saint Louis, AP-HP, Paris
| | - Régis Peffault de Latour
- Université de Paris, Paris.,Service d'Hématologie Greffe, Centre de référence des aplasies médullaires acquises et constitutionnelles, Hôpital Saint Louis, AP-HP, Paris
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24
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Lo Iacono G, Gigli F, Gherzi L, Avenoso D, Fiori S, Sedda G, Tarella C, Spaggiari L. Thymoma and pure red cell aplasia with hypoplasia of megakaryocytopoiesis: A rare and life-treating condition. Transfus Apher Sci 2019; 59:102656. [PMID: 31606335 DOI: 10.1016/j.transci.2019.09.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2019] [Revised: 09/26/2019] [Accepted: 09/27/2019] [Indexed: 11/17/2022]
Abstract
Thymic tumors are rare diseases with an incidence of 0.15 cases per 100,000 person-years. They can be associated with a variety of other syndromes, such as Myasthenia Gravis or autoimmune disorders. Among them, pure red cell aplasia is a hemato-pathological condition characterized by anemia, reticulocytopenia and erythroid cell hypoplasia of bone marrow. Here, we reported a case of a 62-year-old female with a long history of neurologic symptoms due to Myasthenia Gravis. She was diagnosed with thymoma, with mediastinal mass and pleural thickening. After chemoradiotherapy treatment, she was surgically resected successfully, but she developed anemia and severe thrombocytopenia, worsening in respiratory failure requiring intubation. A bone marrow biopsy was performed resulting in a red-cell aplasia with marked hypoplasia of megakaryocytopoiesis compatible with pure red cell aplasia with acquired thrombocytopenia. Considering that there are no standard treatments, clinical condition improvement was achieved only after some lines of medical treatment. Our data, together with the few already published, help to raise the attention towards acquired cytopenias and the need to optimize the treatment for a potentially life-threatening condition.
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Affiliation(s)
- Giorgio Lo Iacono
- Department of Thoracic Surgery, IEO, European Institute of Oncology IRCCS, Milan, Italy.
| | - Federica Gigli
- Department of Oncohematology, IEO, European Institute of Oncology IRCCS, Milan, Italy
| | - Lorenzo Gherzi
- Department of Thoracic Surgery, IEO, European Institute of Oncology IRCCS, Milan, Italy
| | - Daniele Avenoso
- Department of Oncohematology, IEO, European Institute of Oncology IRCCS, Milan, Italy
| | - Stefano Fiori
- Department of Pathology, IEO, European Institute of Oncology IRCCS, Milan, Italy
| | - Giulia Sedda
- Department of Thoracic Surgery, IEO, European Institute of Oncology IRCCS, Milan, Italy
| | - Corrado Tarella
- Department of Oncohematology, IEO, European Institute of Oncology IRCCS, Milan, Italy; Department of Health Sciences, Università degli Studi di Milano, Milan, Italy
| | - Lorenzo Spaggiari
- Department of Thoracic Surgery, IEO, European Institute of Oncology IRCCS, Milan, Italy; Department of Oncology and Hemato-Oncology, Università degli Studi di Milano, Milan, Italy
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25
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Frequent STAT3 mutations in CD8 + T cells from patients with pure red cell aplasia. Blood Adv 2019; 2:2704-2712. [PMID: 30337298 DOI: 10.1182/bloodadvances.2018022723] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2018] [Accepted: 09/20/2018] [Indexed: 12/12/2022] Open
Abstract
Dysregulation of T-cell-mediated immunity is responsible for acquired pure red cell aplasia (PRCA). Although STAT3 mutations are frequently detected in patients with T-cell large granular lymphocytic leukemia (T-LGLL), which is often complicated by PRCA and which is also reported to be associated with acquired aplastic anemia (AA) and myelodysplastic syndrome (MDS), whether STAT3-mutated T cells are involved in the pathophysiology of PRCA and other types of bone marrow failure remains unknown. We performed STAT3 mutation analyses of the peripheral blood mononuclear cells from PRCA patients (n = 42), AA (n = 54), AA-paroxysmal nocturnal hemoglobinuria (AA-PNH; n = 7), and MDS (n = 21) using an allele-specific polymerase chain reaction and amplicon sequencing. STAT3 mutations were not detected in any of the 82 patients with AA/PNH/MDS but were detected in 43% of the 42 PRCA patients. In all 7 STAT3-mutation-positive patients who were studied, the STAT3 mutations were restricted to sorted CD8+ T cells. The prevalence of STAT3 mutation in idiopathic, thymoma-associated, autoimmune disorder-associated, and T-LGLL-associated PRCA was 33% (5 of 15), 29% (2 of 7), 20% (1 of 5), and 77% (10 of 13), respectively. The STAT3-mutation-positive patients were younger (median age, 63 vs 73 years; P= .026) and less responsive to cyclosporine (46% [6 of 13] vs 100% [8 of 8]; P= .0092) in comparison with STAT3-mutation-negative patients. The data suggest that STAT3-mutated CD8+ T cells may be closely involved in the selective inhibition of erythroid progenitors in PRCA patients.
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26
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Petrenko AA, Pivnik AV, Dudina GA, Dubnitskaya MG. [Pure red cell aplasia of the bone marrow in combination with thymoma. A literature review and own data]. TERAPEVT ARKH 2019; 91:121-126. [PMID: 32598745 DOI: 10.26442/00403660.2019.07.000326] [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: 04/16/2020] [Indexed: 11/22/2022]
Abstract
Eight patients were observed with a rare combination of thymoma and pure red cell aplasia of bone marrow (PRCA), of which seven women were between 44 to 68 years old. The diagnosis of PRCA was established before the detection of thymoma in 1 patient, simultaneously in 3, after - in 4. Seven patients underwent timomectomy. The weight of removed thymomas was from 200 to 780 grams. Morphological type A thymoma variant (spindle cell) was installed in 2 patients, type B1 - in 2, type B2 - in 2, type B3 - in 2. Complete remissions were obtained using cyclophosphamide and cyclosporin in 5 patients, lasting from 6 months to 7 years. The results of immunological studies with the identification of non - hemolytic antibodies to the proteolytic antigen (Pr1d) on the erythrocyte membrane in 4 patients are presented. Of these, two studied patients simultaneously detected antibodies to the Pr1d antigen and the interspecific antigen of mammalian erythroblasts (IAME). It is shown that the lifespan of red blood cells are not changed. The direct Coombs test was negative in 5 patients, but with the help of aggregate hemaglutination test and enzyme immunoassay, antibodies were detected on the surface of erythrocytes. The pathogenesis of this combination of diseases remains unclear and needs to be elucidated.
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Affiliation(s)
| | - A V Pivnik
- Loginov Moscow Clinical Scientific Center.,Peoples' Friendship University of Russia (RUDN University)
| | - G A Dudina
- Loginov Moscow Clinical Scientific Center
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27
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Shi TY, Wen XH, Shi XH, Lu YW. Thymic epithelial tumor complicated by immunological abnormalities: results from a single-center retrospective study in China. J Thorac Dis 2019; 11:1580-1588. [PMID: 31179102 DOI: 10.21037/jtd.2019.02.90] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Background To describe the clinical manifestations, immunological features, treatments, and outcomes of patients with thymic epithelial tumor (TET) complicated by immunological abnormalities, and to improve knowledge on immunological abnormalities in this rare disease. Methods Patients with pathologically confirmed TET at Beijing Chaoyang Hospital between January 2013 and May 2018 were included in this study, and clinical data were analyzed retrospectively. Immunological abnormalities were classified into two groups as follows: Good syndrome (GS) and autoimmune disease (AD). Results Fifty-nine TET patients were enrolled; twenty-two patients (37.3%) had immune dysfunction. There were no gender, age, or histological type differences between groups with or without immunological abnormalities. Six patients had GS, of whom four patients were diagnosed after thymectomy. Recurrent respiratory infections, particularly opportunistic infections, were the most common manifestation. Three GS patients developed a second cancer (50%; P=0.011). Anti-infective therapy and immunoglobulin supplements effectively treated GS. Seventeen patients developed ADs, including myasthenia gravis (MG) (n=13), Hashimoto's thyroiditis (n=4), Sjogren's syndrome (n=1), rheumatoid arthritis (n=1), pemphigus (n=1), and Evans syndrome (n=1). One patient developed both MG and GS and 4 patients presented with two ADs. Three AD cases occurred after thymectomy. Pemphigus and 80% (8/10) of MG cases were resolved following thymectomy. Conclusions There is a strong association between immunological abnormalities and TET, which may present at any time point during the disease, even after thymectomy. In addition to infection, GS patients are more likely to develop a second cancer. Thymectomy may produce favorable outcomes for MG in this study, while surgery does not improve immunodeficiency in GS patients.
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Affiliation(s)
- Tian-Yan Shi
- Department of Rheumatology and Clinical Immunology, Beijing Chaoyang Hospital, Capital Medical University, Beijing 100020, China
| | - Xiao-Hong Wen
- Department of Rheumatology and Clinical Immunology, Beijing Chaoyang Hospital, Capital Medical University, Beijing 100020, China
| | - Xu-Hua Shi
- Department of Rheumatology and Clinical Immunology, Beijing Chaoyang Hospital, Capital Medical University, Beijing 100020, China
| | - Yue-Wu Lu
- Department of Rheumatology and Clinical Immunology, Beijing Chaoyang Hospital, Capital Medical University, Beijing 100020, China
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Wightman SC, Shrager JB. Non-Myasthenia Gravis Immune Syndromes and the Thymus: Is There a Role for Thymectomy? Thorac Surg Clin 2019; 29:215-225. [PMID: 30928003 DOI: 10.1016/j.thorsurg.2018.12.008] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Thymectomy has long been considered, performed, and discussed for many different nonmyasthenic immune syndromes. Thymectomy is now an established treatment for MG, and has been performed for other immune syndromes with varying degrees of improvement. Although numerous reports document immune syndromes' association with thymoma, few address the role of thymectomy in symptom resolution. This review assesses thymectomy in the various nonmyasthenic immune syndromes for which it has been tried. Based on this review, it seems appropriate to revisit a more active role for thymectomy in pure red cell aplasia, pemphigus, rheumatoid arthritis, autoimmune hemolytic anemia, and ulcerative colitis.
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Affiliation(s)
- Sean C Wightman
- Division of Thoracic Surgery, Department of Cardiothoracic Surgery, Stanford University Hospitals and Clinics, 300 Pasteur Drive, Stanford, CA 94305, USA
| | - Joseph B Shrager
- Division of Thoracic Surgery, Department of Cardiothoracic Surgery, Stanford University Hospitals and Clinics, 300 Pasteur Drive, Stanford, CA 94305, USA.
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29
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Yoon JK, Jang HR, Park JH, Kim KH, Roh EY, Byun JM. A case of immune thrombocytopenia associated with invasive thymoma successfully treated with eltrombopag. Blood Res 2019; 54:74-79. [PMID: 30956967 PMCID: PMC6439297 DOI: 10.5045/br.2019.54.1.74] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2018] [Revised: 08/30/2018] [Accepted: 10/12/2018] [Indexed: 11/21/2022] Open
Affiliation(s)
- Jung-Ki Yoon
- Department of Internal Medicine, Seoul National University Boramae Medical Center, Seoul, Korea
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul National University Hospital, Seoul, Korea
| | - Hee Ryeong Jang
- Department of Internal Medicine, Kangwon National University Hospital, Chuncheon, Korea
| | - Jin Hyun Park
- Department of Internal Medicine, Seoul National University Boramae Medical Center, Seoul, Korea
| | - Ki Hwan Kim
- Department of Internal Medicine, Seoul National University Boramae Medical Center, Seoul, Korea
| | - Eu Youn Roh
- Department of Laboratory Medicine, Seoul National University Boramae Medical Center, Seoul, Korea
| | - Ja Min Byun
- Department of Internal Medicine, Seoul National University Boramae Medical Center, Seoul, Korea
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul National University Hospital, Seoul, Korea
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Cui X, Wan Z, Ma Z, Liu L, Yang Y. Occurrence of acute pulmonary embolism induced by recombinant erythropoietin during treatment of pure red cell aplasia associated with thymoma: A case report. Medicine (Baltimore) 2019; 98:e14789. [PMID: 30855492 PMCID: PMC6417601 DOI: 10.1097/md.0000000000014789] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
RATIONALE Thymoma is a type of rare tumor in the thymus gland, and among patients with thymoma, less than 10% will develop pure red cell aplasia (PRCA), whereas less than 5% of patients with PRCA have a thymoma. The optimal approach for PRCA in thymoma is immunosuppressive therapy, such as steroids, cyclosporine, and human antithymocyte globulin. PATIENT CONCERNS A sixty-one-year-old male was diagnosed with thymoma with PRCA after he complained fatigue, tinnitus, and weakness for 1 month, he received therapy with recombinant erythropoietin (rhEPO) for 1 month after the tumor was totally resected and readmitted with pulmonary embolism and received anticoagulation therapy with enoxaparin for 3 months. DIAGNOSES Thymoma, pure red cell aplasia, pulmonary embolism. INTERVENTION He received cyclosporine A, prednisone and rhEPO treatment. Two months after the thymectomy and postoperative radiation, he was readmitted with pulmonary embolism. OUTCOMES Thymoma and pulmonary embolism become complete response (CR), PRCA become partial response (PR). LESSONS Clinicians should be alert to the possibility of the increased risk of thrombosis induced by rhEPO when it used to treat PRCA associated with thymoma. If other medication is effective for managing PRCA, rhEPO should be avoided.
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Affiliation(s)
| | | | | | | | - Yuanhua Yang
- Department of Respiratory and Critical Care Medicine, Beijing Chaoyang Hospital, Capital Medical University, Beijing, China
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31
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Noronha SA. Aplastic and Hypoplastic Anemias. Pediatr Rev 2018; 39:601-611. [PMID: 30504252 DOI: 10.1542/pir.2017-0250] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Affiliation(s)
- Suzie A Noronha
- Division of Pediatric Hematology/Oncology, University of Rochester, Rochester, NY
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Pure Red Cell Aplasia Associated with Thymolipoma: Complete Anaemia Resolution following Thymectomy. Case Rep Hematol 2018; 2018:8627145. [PMID: 30402302 PMCID: PMC6198544 DOI: 10.1155/2018/8627145] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2018] [Accepted: 09/16/2018] [Indexed: 11/17/2022] Open
Abstract
Pure red cell aplasia is an uncommon cause of anaemia rarely associated with thymoma. A combination of immunosuppressive therapy and thymectomy offers a potential cure. Thymectomy alone rarely results in anaemia resolution. A seventy-three-year-old male with Klinefelter syndrome presented with progressively increasing shortness of breath and anaemia. Serological testing supported primary bone marrow pathology, and a bone marrow biopsy was performed. A pure red cell aplasia was seen on bone marrow examination, and computed tomography of the chest demonstrated a thymoma. Thymectomy was performed, and histology revealed a thymolipoma. Complete anaemia resolution was achieved following thymectomy alone. This suggests that thymomas may directly mediate immune dysregulation resulting in erythroid precursor destruction.
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Moriyama S, Yano M, Haneda H, Okuda K, Kawano O, Sakane T, Oda R, Watanabe T, Nakanishi R. Pure red cell aplasia associated with thymoma: a report of a single-center experience. J Thorac Dis 2018; 10:5066-5072. [PMID: 30233881 DOI: 10.21037/jtd.2018.07.14] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Background Pure red cell aplasia (PRCA) associated with thymoma is relatively rare, and relevant reports are limited. We investigated the clinical features and outcomes of PRCA associated with thymoma in this study. Methods A retrospective review of all PRCA patients who underwent surgical resection of thymoma from April 1, 2004, to December 31, 2015, was performed. Results We experienced eight patients with PRCA among 146 patients who underwent surgical resection of thymoma. Extended thymectomy (n=4) and thymectomy (n=4) were performed for thymoma. Regarding the WHO classification of thymoma, the subtypes were type B2 or B3 in seven patients, and the stage of thymoma was advanced in seven patients. Complete resection was achieved macroscopically in only five patients. Recurrence of thymoma occurred in four patients who underwent complete resection. PRCA was diagnosed after surgical resection of thymoma in six patients (range 1-101 months, median 56.5 months). Cyclosporine was used for PRCA in six patients. Pneumonia of treatment-related complications due to cyclosporine occurred in all patients. The follow-up period ranged from 13-147 months (median 54.5 months) after the PRCA diagnosis. Three patients obtained complete remission of anemia by cyclosporine. Although one patient was able to stop taking cyclosporine because of complete remission of anemia, transfusion was needed due to relapse of PRCA. Five patients died, with the main causes of death diagnosed as pneumonia (n=4) and cardiac failure (n=1). Conclusions PRCA associated with thymoma was diagnosed postoperatively in three-quarter of patients. We should be alert for the occurrence of PRCA even after resection of thymoma, especially in patients with incomplete resection or advanced disease. Cyclosporine was effective for PRCA, but treatment-related complications occurred, particularly pneumonia. As treatment for PRCA associated with thymoma and its complications were combined in a complex manner, treating PRCA associated with thymoma can be quite difficult.
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Affiliation(s)
- Satoru Moriyama
- Department of Oncology, Immunology and Surgery, Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan
| | - Motoki Yano
- Division of Chest Surgery, Department of Surgery, Aichi Medical University, Nagakute, Japan
| | - Hiroshi Haneda
- Department of Oncology, Immunology and Surgery, Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan
| | - Katsuhiro Okuda
- Department of Oncology, Immunology and Surgery, Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan
| | - Osamu Kawano
- Department of Oncology, Immunology and Surgery, Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan
| | - Tadashi Sakane
- Department of Oncology, Immunology and Surgery, Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan
| | - Risa Oda
- Department of Oncology, Immunology and Surgery, Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan
| | - Takuya Watanabe
- Department of Oncology, Immunology and Surgery, Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan
| | - Ryoichi Nakanishi
- Department of Oncology, Immunology and Surgery, Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan
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Acquired Amegakaryocytic Thrombocytopenia and Pure Red Cell Aplasia in Thymoma. Case Rep Hematol 2018; 2018:5034741. [PMID: 29713553 PMCID: PMC5866878 DOI: 10.1155/2018/5034741] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2018] [Revised: 02/15/2018] [Accepted: 02/18/2018] [Indexed: 11/24/2022] Open
Abstract
Association of thymoma with myasthenia gravis, pure red cell aplasia, and aplastic anemia is well documented. However, thymoma complicated by acquired amegakaryocytic thrombocytopenia (AAMT) is rarely reported. Here, we present a case of a 60-year-old male with past medical history of recurrent invasive thymoma who presented with cough and blood in sputum. He was found to have severe normocytic normochromic anemia and thrombocytopenia that did not improve with intravenous steroids or multiple transfusions of red cells and platelets. Subsequent bone marrow biopsy showed severely depleted megakaryocytes and erythroid precursor cells with relative myeloid hyperplasia suggestive of amegakaryocytic thrombocytopenia and red cell aplasia. He was started on oral cyclosporine but subsequently developed leukopenia and refused any further treatment or diagnostic procedures and left the hospital against medical advice. AAMT, thus, may be a very early presentation of impending aplastic anemia, and treating physicians need to be aware of this entity.
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35
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Simkins A, Maiti A, Short NJ, Jain N, Popat U, Patel KP, Oo TH. Acquired amegakaryocytic thrombocytopenia and red cell aplasia in a patient with thymoma progressing to aplastic anemia successfully treated with allogenic stem cell transplantation. Hematol Oncol Stem Cell Ther 2018; 12:115-118. [PMID: 29409729 DOI: 10.1016/j.hemonc.2017.09.001] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2017] [Revised: 09/14/2017] [Accepted: 09/25/2017] [Indexed: 10/18/2022] Open
Abstract
Association of pure red-cell aplasia with thymoma is well documented. However, acquired amegakaryocytic thrombocytopenia (AAMT) has been rarely associated with thymoma with only five reported cases in literature. We report a patient with thymoma complicated by pure red cell aplasia (PRCA) and AAMT who progressed to develop aplastic anemia (AA). The patient was refractory to 10-months of immunosuppressive therapy with cyclosporine, prednisone, and antithymocyte globulin. She was eventually treated with allogeneic stem cell transplantation (allo-SCT). On Day +323 the patient continues to be transfusion-independent. This case illustrates how in patients with thymoma and AAMT may herald development of AA. This is also the first report of a patient with AAMT progressing to thymoma-associated AA being successfully treated with allo-SCT. The successful outcome suggests allo-SCT as a feasible option similar to other AA patients.
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Affiliation(s)
- Aron Simkins
- Department of Internal Medicine, The University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Abhishek Maiti
- Department of Internal Medicine, The University of Texas Health Science Center at Houston, Houston, TX, USA.
| | - Nicholas J Short
- Division of Cancer Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Nitin Jain
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Uday Popat
- Department of Stem Cell Transplantation, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Keyur P Patel
- Department of Hematopathology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Thein H Oo
- Section of Benign Hematology, Division of Internal Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
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36
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Aquilina A, Camilleri DJ, Aquilina J. Pure red cell aplasia and myasthenia gravis: a patient having both autoimmune conditions in the absence of thymoma. BMJ Case Rep 2017; 2017:bcr-2017-220188. [PMID: 28893803 DOI: 10.1136/bcr-2017-220188] [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] [Indexed: 11/04/2022] Open
Abstract
This is a patient who was presented initially with symptoms of malaise, tiredness and exertional dyspnoea and found to have a severe normocytic normochromic anaemia with low reticulocyte counts. Bone marrow confirmed the diagnosis of pure red cell aplasia (PRCA) and at the time serology for recent parvovirus infection was positive. He was successfully treated with transfusions and intravenous Ig. Six years later, he had a mild relapse of his PRCA and subsequently developed severe dysphagia and dysarthria which were fatigable. Positive antiacetylcholine receptor antibodies confirmed the diagnosis of myasthenia gravis. The two conditions are both known to be associated with thymoma. Imaging and resection of the thymus gland showed only the presence of a thymic cyst. Treatment with pyrdistogmine and intravenous Ig have kept the patient asymptomatic and in remission. The rare association of the two autoimmune conditions associated in the same patient without thymoma is discussed.
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Abstract
Pure red cell aplasia (PRCA) is a syndrome defined by a normocytic normochromic anemia with severe reticulocytopenia and marked reduction or absence of erythroid precursors from the bone marrow. Diamond-Blackfan anemia is a congenital form of PRCA. Acquired PRCA may be either a primary disorder or secondary to some other disorder or agent. Primary acquired PRCA is an autoimmune disorder that is frequently antibody-mediated. Myelodysplastic syndromes may also present with the morphologic appearance of PRCA. Secondary acquired PRCA may be associated with collagen vascular/autoimmune disorders such as systemic lupus erythematosus; lymphoproliferative disorders such as chronic lymphocytic leukemia or large granular lymphocyte leukemia; infections, particularly B19 parvovirus; thymoma and other solid tumors; or a variety of other disorders, drugs, or toxic agents. The therapeutic approach to PRCA typically involves immunosuppression, but specific pathogenic subtypes are associated with specific therapeutic approaches. Cyclosporine A, with or without concurrent corticosteroids, appears to be the single most effective immunosuppressive agent.
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38
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Feinsilber D, Mears KA, Pettiford BL. Polyparaneoplastic Manifestations of Malignant Thymoma: A Unique Case of Myasthenia, Autoimmune Hepatitis, Pure Red Cell Aplasia, and Keratoconjunctivitis Sicca. Cureus 2017; 9:e1374. [PMID: 28744421 PMCID: PMC5519314 DOI: 10.7759/cureus.1374] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2017] [Accepted: 06/20/2017] [Indexed: 12/03/2022] Open
Abstract
Thymomas are relatively uncommon malignancies of the anterior mediastinum and present with four distinct histological types based on the specific epithelial to lymphocyte ratio: spindle cell, epithelial predominant, lymphocyte predominant, or mixed. Each histologic type of thymoma has a propensity for local invasion and metastasis and can have a wide variety of paraneoplastic manifestations, myasthenia being the most common. We present a unique case of a 34-year-old African-American female who initially presented with a history of profound weakness with repetitive motion, shortness of breath, horizontal nystagmus, persistent anemia, keratoconjunctivitis sicca, and what was initially thought to be azithromycin-induced hepatitis. Upon left anterior thoracotomy with biopsy of the mediastinal mass, pathology yielded a lymphocyte-predominant (B1), Masaoka stage IVA invasive thymoma with pericardial extension. This case illustrates the clinical significance of considering a multitude of extrathymic paraneoplastic manifestations, each with a unique physiological mechanism.
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Affiliation(s)
- Doron Feinsilber
- Hematology/Oncology, Medical College of Wisconsin/Froedert Cancer Center
| | - Katrina A Mears
- Department of Ophthalmology, Retina Consultants of Southwest Florida, National Ophthalmic Research Institute, Fort Myers, Fl
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Abstract
The association between thymoma and autoimmunity is well known. Besides myasthenia gravis, which is found in 15 to 20% of patients with thymoma, other autoimmune diseases have been reported: erythroblastopenia, systemic lupus erythematosus, inflammatory myopathies, thyroid disorders, Isaac's syndrome or Good's syndrome. More anecdotally, Morvan's syndrome, limbic encephalitis, other autoimmune cytopenias, autoimmune hepatitis, and bullous skin diseases (pemphigus, lichen) have been reported. Autoimmune diseases occur most often before thymectomy, but they can be discovered at the time of surgery or later. Two situations require the systematic investigation of a thymoma: the occurrence of myasthenia gravis or autoimmune erythroblastopenia. Nevertheless, the late onset of systemic lupus erythematosus or the association of several autoimmune manifestations should lead to look for a thymoma. Neither the characteristics of the patients nor the pathological data can predict the occurrence of an autoimmune disease after thymectomy. Thus, thymectomy usefulness in the course of the autoimmune disease, except myasthenia gravis, has not been demonstrated. This seems to indicate the preponderant role of self-reactive T lymphocytes distributed in the peripheral immune system prior to surgery. Given the high infectious morbidity in patients with thymoma, immunoglobulin replacement therapy should be considered in patients with hypogammaglobulinemia who receive immunosuppressive therapy, even in the absence of prior infection.
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40
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Muzamil J, Shiekh AA, Bhat GM, Lone AR, Bhat S, Nabi F. Thymoma masquerading as transfusion dependent anemia. Indian J Med Paediatr Oncol 2017; 37:296-299. [PMID: 28144099 PMCID: PMC5234169 DOI: 10.4103/0971-5851.195729] [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: 11/14/2022] Open
Abstract
Pure red cell aplasia (PRCA) is a known entity in clinical medicine. Patients are often transfusion dependent for their whole life. Ascertaining its etiology is always a herculean task. We received a similar transfusion-dependent patient, who on evaluation was found to have thymoma as an etiological factor. Thymoma presenting as PRCA is seen in 2%–5% patients and evaluating PRCA for thymoma is seen in 5%–13% patient. As per the WHO histopathological classification, thymoma has six types and Type A is associated with PRCA and Type B is associated with myasthenia gravis. This correlation was not seen in our patient, who had Type B thymoma. Surgical resection of thymus improves 30% of PRCA and rest needs immunosuppression. Our patient was not the surgical candidate, and hence he was put on chemotherapy.
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Affiliation(s)
- Javvid Muzamil
- Department of Medical Oncology, Sher-I-Kashmir Institute of Medical Sciences, Srinagar, Jammu and Kashmir, India
| | - Aejaz Aziz Shiekh
- Department of Medical Oncology, Sher-I-Kashmir Institute of Medical Sciences, Srinagar, Jammu and Kashmir, India
| | - Gull Mohammad Bhat
- Department of Medical Oncology, Sher-I-Kashmir Institute of Medical Sciences, Srinagar, Jammu and Kashmir, India
| | - Abdul Rashid Lone
- Department of Medical Oncology, Sher-I-Kashmir Institute of Medical Sciences, Srinagar, Jammu and Kashmir, India
| | - Shuaeb Bhat
- Department of Clinical Hematology, Sher-I-Kashmir Institute of Medical Sciences, Srinagar, Jammu and Kashmir, India
| | - Firdousa Nabi
- Department of Prosthodonsia, Government Dental College, Srinagar, Jammu and Kashmir, India
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41
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Abstract
Pure red cell aplasia (PRCA) is a syndrome defined by a normocytic normochromic anemia with severe reticulocytopenia and marked reduction or absence of erythroid precursors from the bone marrow. Diamond-Blackfan anemia is a congenital form of PRCA. Acquired PRCA may be either a primary disorder or secondary to some other disorder or agent. Primary acquired PRCA is an autoimmune disorder that is frequently antibody-mediated. Myelodysplastic syndromes may also present with the morphologic appearance of PRCA. Secondary acquired PRCA may be associated with collagen vascular/autoimmune disorders such as systemic lupus erythematosus; lymphoproliferative disorders such as chronic lymphocytic leukemia or large granular lymphocyte leukemia; infections, particularly B19 parvovirus; thymoma and other solid tumors; or a variety of other disorders, drugs, or toxic agents. The therapeutic approach to PRCA typically involves immunosuppression, but specific pathogenic subtypes are associated with specific therapeutic approaches. Cyclosporine A, with or without concurrent corticosteroids, appears to be the single most effective immunosuppressive agent.
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MESH Headings
- Adrenal Cortex Hormones/therapeutic use
- Anemia, Diamond-Blackfan/drug therapy
- Anemia, Diamond-Blackfan/immunology
- Anemia, Diamond-Blackfan/pathology
- Autoimmune Diseases/drug therapy
- Autoimmune Diseases/immunology
- Autoimmune Diseases/pathology
- Cyclosporine/therapeutic use
- Humans
- Immunosuppressive Agents/therapeutic use
- Leukemia, Large Granular Lymphocytic/drug therapy
- Leukemia, Large Granular Lymphocytic/immunology
- Leukemia, Large Granular Lymphocytic/pathology
- Leukemia, Lymphocytic, Chronic, B-Cell/drug therapy
- Leukemia, Lymphocytic, Chronic, B-Cell/immunology
- Leukemia, Lymphocytic, Chronic, B-Cell/pathology
- Myelodysplastic Syndromes/drug therapy
- Myelodysplastic Syndromes/etiology
- Myelodysplastic Syndromes/immunology
- Myelodysplastic Syndromes/pathology
- Parvoviridae Infections/drug therapy
- Parvoviridae Infections/immunology
- Parvoviridae Infections/pathology
- Parvovirus B19, Human/immunology
- Thymoma/drug therapy
- Thymoma/immunology
- Thymoma/pathology
- Vasculitis/drug therapy
- Vasculitis/immunology
- Vasculitis/pathology
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Affiliation(s)
- Robert T Means
- Office of the Dean, James H. Quillen College of Medicine, East Tennessee State University, Johnson City, TN
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Abstract
INTRODUCTION Blockade of the immune checkpoint programmed death receptor ligand-1 (PD-L1)/PD-1 pathway has well-established clinical activity across many tumor types. PD-L1 protein expression by immunohistochemistry is emerging as a predictive biomarker of response to these therapies. Here, we examine PD-L1 expression in a thymic epithelial tumor (TET) tissue microarray (TMA). METHODS The TMA contained 69 TETs and 17 thymic controls, with each case represented by triplicate cores. The TMA was stained with rabbit monoclonal antibody (clone 15; Sino Biological, Beijing, China) to human PD-L1. PD-L1 staining was scored based on intensity as follows: 0 = none, 1 = equivocal/uninterpretable, 2 = weak, and 3 = intermediate-strong. Those cases with all cores scoring three in the epithelial component were categorized as PD-L1 high and the remaining as PD-L1 low. RESULTS PD-L1 high scores were more frequent in TETs than in controls (68.1% versus 17.6%; p = 0.0036). PD-L1 scores and histology were significantly correlated, with higher intensity staining in World Health Organization (WHO). B2/B3/C TETs. Only 14.8% of TETs had PD-L1 staining of associated lymphocytes. In an adjusted analysis (age/sex), PD-L1 high TETs had a significantly worse overall survival (hazard ratio: 5.40, 95% confidence interval: 1.13-25.89; p = 0.035) and a trend for worse event-free survival (hazard ratio: 2.94, 95% confidence interval: 0.94-9.24; p = 0.064). CONCLUSIONS PD-L1 expression was present in all cases of TETs within the epithelial component but only in a minority in the lymphocytic component. TETs stained more intensely for PD-L1 than in controls, and PD-L1 high TETs were associated with more aggressive histology and worse prognosis. This study lends rationale to a clinical trial with anti-PD-1/PD-L1 therapy in this rare tumor type.
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Bernard C, Frih H, Pasquet F, Kerever S, Jamilloux Y, Tronc F, Guibert B, Isaac S, Devouassoux M, Chalabreysse L, Broussolle C, Petiot P, Girard N, Sève P. Thymoma associated with autoimmune diseases: 85 cases and literature review. Autoimmun Rev 2016; 15:82-92. [DOI: 10.1016/j.autrev.2015.09.005] [Citation(s) in RCA: 164] [Impact Index Per Article: 20.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2015] [Accepted: 09/20/2015] [Indexed: 11/30/2022]
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Fidias PM, Long AA, Fintelmann FJ, Zukerberg LR. CASE RECORDS of the MASSACHUSETTS GENERAL HOSPITAL. Case 31-2015. A 29-Year-Old Man with Thymoma, Diarrhea, and Weight Loss. N Engl J Med 2015; 373:1458-67. [PMID: 26444733 DOI: 10.1056/nejmcpc1406663] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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Abstract
Hypoproliferative anemia results from the inability of bone marrow to produce adequate numbers of red blood cells. The list of conditions that cause hypoproliferative anemia is long, starting from common etiologies as iron deficiency to rarer diagnoses of constitutional bone marrow failure syndromes. There is no perfect diagnostic algorithm, and clinical data may not always clearly distinguish "normal" from "abnormal", yet it is important for practicing clinicians to recognize each condition so that treatment can be initiated promptly. This review describes diagnostic approaches to hypoproliferative anemia, with particular emphasis on bone marrow failure syndromes.
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Affiliation(s)
- Kazusa Ishii
- Hematology Branch, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD.
| | - Neal S Young
- Hematology Branch, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD
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46
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Zhu W, Xu B. Association of Pretreatment Anemia with Pathological Response and Survival of Breast Cancer Patients Treated with Neoadjuvant Chemotherapy: A Population-Based Study. PLoS One 2015; 10:e0136268. [PMID: 26291454 PMCID: PMC4546363 DOI: 10.1371/journal.pone.0136268] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2015] [Accepted: 08/03/2015] [Indexed: 01/10/2023] Open
Abstract
Background Anemia related to adjuvant chemotherapy might predict compromised survival in patients with breast cancer. The present population-based study was to investigate the correlation of pretreatment anemia with pathological response and long-term prognosis of breast cancer patients receiving neoadjuvant chemotherapy (NCT). Methods From 1999 to 2011, a total of 655 patients with operable or locally advanced breast cancer who underwent NCT before definitive surgery were reviewed. The patients were subdivided into anemic (baseline hemoglobin (Hb)<12.0g/dL) and non-anemic (Hb≥12.0g/dL) groups. Comparison was made between anemic and non-anemic groups concerning the rate of pathological complete response (pCR), relapse-free survival (RFS), overall survival (OS) and cancer-specific survival (CSS). Logistic and Cox regression models were utilized to determine the predictive value of pretreatment anemia in outcomes of patients undergoing NCT. Results 166 women (25.3%) were anemic before treatment. Patients in the anemic group were less likely to achieve pCR in NCT than their non-anemic counterparts (odds ratio (OR) 0.428, 95% confidence interval (CI) 0.198–0.927, p = 0.031). Patients with baseline anemia displayed inferior 10-year RFS (59.1% vs 66.0%, p = 0.022 by log-rank), OS (75.3% vs 90.9%, p<0.001) and CSS (82.4% vs 94.4%, p<0.001) compared with those without. After adjustment for confounders, pretreatment anemia was demonstrated to correlate with elevated risk of relapse (hazard ratio (HR) 1.453, 95% CI 1.077–1.962, p = 0.015), cancer-specific mortality (HR 2.961, 95% CI 1.679–5.222, p<0.001) and all-cause mortality (HR 2.873, 95% CI 1.757–4.699, p<0.001). Conclusions Pretreatment anemia was associated with worse pathological response to NCT as well as survival status in breast cancer. Further studies are warranted to identify optimal interventions and improve the prognosis of this subgroup.
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Affiliation(s)
- Wenjie Zhu
- Department of Medical Oncology, Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, P. R. China
| | - Binghe Xu
- Department of Medical Oncology, Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, P. R. China
- * E-mail:
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47
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Antar AI, Otrock ZK, Kharfan-Dabaja MA, Mahfouz RA, Alameddine RS, El-Majzoub NMW, Salem ZM. Thymoma with Concomitant Pure Red Cell Aplasia, Good's Syndrome and Myasthenia Gravis Responding to Rituximab. Indian J Hematol Blood Transfus 2014; 32:219-22. [PMID: 27408396 DOI: 10.1007/s12288-014-0478-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2014] [Accepted: 11/19/2014] [Indexed: 11/27/2022] Open
Abstract
Thymomas are often associated with a variety of autoimmune diseases, mostly myasthenia gravis. The association of thymomas with both pure red cell aplasia (PRCA) and Good's syndrome is exceedingly rare. To the best of our knowledge, the combination of a thymoma with manifestations of myasthenia gravis, PRCA, and Good's syndrome, as in our case herein, has not been described before in the medical literature. We present a 90-year-old man initially diagnosed with an asymptomatic thymoma. Later, he developed generalized muscle weakness and was found to have severe anemia. He was diagnosed with PRCA, myasthenia gravis and Good's syndrome. He responded to rituximab with restoration of bone marrow erythroid maturation and stabilization of red blood cell counts.
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Affiliation(s)
- Ahmad I Antar
- Division of Hematology-Oncology, Department of Internal Medicine, American University of Beirut Medical Center, P.O. Box 11-0236, Beirut, Lebanon
| | - Zaher K Otrock
- Department of Pathology and Immunology, Barnes-Jewish Hospital, Washington University, St. Louis, MO USA
| | | | - Rami A Mahfouz
- Department of Pathology and Laboratory Medicine, American University of Beirut Medical Center, Beirut, Lebanon
| | - Raafat S Alameddine
- Division of Hematology-Oncology, Department of Internal Medicine, American University of Beirut Medical Center, P.O. Box 11-0236, Beirut, Lebanon
| | - Nadim M W El-Majzoub
- Department of Pathology and Laboratory Medicine, American University of Beirut Medical Center, Beirut, Lebanon
| | - Ziad M Salem
- Division of Hematology-Oncology, Department of Internal Medicine, American University of Beirut Medical Center, P.O. Box 11-0236, Beirut, Lebanon
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48
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Zhang Y, Chen Y, Chen D, Jiang Y, Huang W, Ouyang H, Xing W, Zeng M, Xie X, Zeng W. Impact of preoperative anemia on relapse and survival in breast cancer patients. BMC Cancer 2014; 14:844. [PMID: 25406979 PMCID: PMC4242544 DOI: 10.1186/1471-2407-14-844] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2014] [Accepted: 11/04/2014] [Indexed: 02/06/2023] Open
Abstract
Background Previous studies have shown that preoperative anemia is correlated with the
prognoses of various solid tumors. This study was performed to determine the
effect of preoperative anemia on relapse and survival in patients with breast
cancer. Methods A total of 2960 patients with breast cancer who underwent surgery between 2002
and 2008 at the Sun Yat-sen University Cancer Center (Guangzhou, PR China) were
evaluated in a retrospective analysis. A total of 2123 qualified patients were
divided into an anemic group [hemoglobin (Hb) < 12.0 g/dL, N = 535)] and a
nonanemic group (Hb ≥ 12.0 g/dL, N = 1588). The effects of anemia on local
relapse-free survival (LRFS), lymph node metastasis-free survival (LNMFS), distant
metastasis-free survival (DMFS), relapse-free survival (RFS), and overall survival
(OS) were assessed using Kaplan–Meier analysis. Independent prognostic factors
were identified in the final multivariate Cox proportional hazards regression
model. Results Among the 2123 women who qualified for the analysis, 535 (25.2%) had a Hb
level < 12.0 g/dL. The Kaplan–Meier curves showed that anemic patients had
worse LRFS, LNMFS, DMFS, RFS, and OS than nonanemic patients, even in the same
clinical stage of breast cancer. Cox proportional hazards regression model
indicated that preoperative anemia was an independent prognostic factor of LRFS,
LNMFS, DMFS, RFS, and OS for patients with breast cancer. Conclusions Preoperative anemia was independently associated with poor prognosis of
patients with breast cancer.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | - Weian Zeng
- Anesthesiology Department, State Key Laboratory in South China, Sun Yat-Sen University Cancer Center, 651 Dongfeng East Road, Guangzhou, PR China.
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Thymoma-associated pancytopenia: immunosuppressive therapy is the cornerstone for durable hematological remission. Ann Hematol 2014; 94:453-8. [DOI: 10.1007/s00277-014-2230-x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2014] [Accepted: 10/05/2014] [Indexed: 11/26/2022]
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50
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Gilreath JA, Stenehjem DD, Rodgers GM. Diagnosis and treatment of cancer-related anemia. Am J Hematol 2014; 89:203-12. [PMID: 24532336 DOI: 10.1002/ajh.23628] [Citation(s) in RCA: 135] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2013] [Revised: 10/25/2013] [Accepted: 10/31/2013] [Indexed: 01/04/2023]
Abstract
Cancer-related anemia (CRA) is due to multiple etiologies, including chemotherapy-induced myelosuppression, blood loss, functional iron deficiency, erythropoietin deficiency due to renal disease, marrow involvement with tumor as well as other factors. The most common treatment options for CRA include iron therapy, erythropoietic-stimulating agents (ESAs), and red cell transfusion. Safety concerns as well as restrictions and reimbursement issues surrounding ESA therapy for CRA have resulted in suboptimal treatment. Similarly, many clinicians are not familiar or comfortable using intravenous iron products to treat functional iron deficiency associated with CRA. This article summarizes our approach to treating CRA and discusses commonly encountered clinical scenarios for which current clinical guidelines do not apply.
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Affiliation(s)
- Jeffrey A. Gilreath
- Department of Pharmacy; Huntsman Cancer Institute; University of Utah Hospitals and Clinics; Salt Lake City Utah
| | - David D. Stenehjem
- Department of Pharmacy; Huntsman Cancer Institute; University of Utah Hospitals and Clinics; Salt Lake City Utah
- Department of Pharmacotherapy; Pharmacotherapy Outcomes Research Center, College of Pharmacy, University of Utah; Salt Lake City Utah
| | - George M. Rodgers
- Department of Medicine; University of Utah Hospitals and Clinics; Salt Lake City Utah
- Department of Pathology; University of Utah Hospitals and Clinics; Salt Lake City Utah
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