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Piekarska A, Pawelec K, Szmigielska-Kapłon A, Ussowicz M. The state of the art in the treatment of severe aplastic anemia: immunotherapy and hematopoietic cell transplantation in children and adults. Front Immunol 2024; 15:1378432. [PMID: 38646536 PMCID: PMC11026616 DOI: 10.3389/fimmu.2024.1378432] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2024] [Accepted: 03/22/2024] [Indexed: 04/23/2024] Open
Abstract
Acquired aplastic anemia (AA) is an immune-mediated bone marrow (BM) failure where marrow disruption is driven by a cytotoxic T-cell-mediated autoimmune attack against hematopoietic stem cells. The key diagnostic challenge in children, but also in adults, is to exclude the possible underlying congenital condition and myelodysplasia. The choice of treatment options, either allogeneic hematopoietic cell transplantation (alloHCT) or immunosuppressive therapy (IST), depends on the patient's age, comorbidities, and access to a suitable donor and effective therapeutic agents. Since 2022, horse antithymocyte globulin (hATG) has been available again in Europe and is recommended for IST as a more effective option than rabbit ATG. Therefore, an update on immunosuppressive strategies is warranted. Despite an improved response to the new immunosuppression protocols with hATG and eltrombopag, some patients are not cured or remain at risk of aplasia relapse or clonal evolution and require postponed alloHCT. The transplantation field has evolved, becoming safer and more accessible. Upfront alloHCT from unrelated donors is becoming a tempting option. With the use of posttransplant cyclophosphamide, haploidentical HCT offers promising outcomes also in AA. In this paper, we present the state of the art in the management of severe AA for pediatric and adult patients based on the available guidelines and recently published studies.
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Affiliation(s)
- Agnieszka Piekarska
- Department of Hematology and Transplantology, Medical University of Gdansk, Gdansk, Poland
| | - Katarzyna Pawelec
- Department of Oncology, Pediatric Hematology, Clinical Transplantology and Pediatrics, Medical University of Warsaw, Warsaw, Poland
| | | | - Marek Ussowicz
- Department of Pediatric Bone Marrow Transplantation, Oncology and Hematology, Wroclaw Medical University, Wroclaw, Poland
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Ciangola G, Santinelli E, McLornan DP, Pagliuca S, Gurnari C. Diagnostic evaluation in bone marrow failure disorders: what have we learnt to help inform the transplant decision in 2024 and beyond? Bone Marrow Transplant 2024; 59:444-450. [PMID: 38291125 DOI: 10.1038/s41409-024-02213-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2023] [Revised: 01/11/2024] [Accepted: 01/12/2024] [Indexed: 02/01/2024]
Abstract
Aplastic anemia (AA) is the prototypical bone marrow failure syndrome. In the current era of readily available 'molecular annotation', application of comprehensive next-generation sequencing panels has generated novel insights into underlying pathogenetic mechanisms, potentially leading to improvements in personalized therapeutic approaches. New evidence has emerged as to the role of somatic loss of HLA class I allele expression in 'immune-mediated' AA, associated molecular aberrations, and risk of clonal evolution. A deeper understanding has emerged regarding the role of 'myeloid' gene mutations in this context, translating patho-mechanistic insights derived from wider clinical and translational research within the myeloid disorder arena. Here, we review contemporary 'tools' which aid in confirmation of a diagnosis of AA, with an additional focus on their potential in guiding therapeutic options. A specific emphasis is placed upon interpretation and integration of this detailed diagnostic information and how this may inform optimal transplantation strategies.
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Affiliation(s)
- Giulia Ciangola
- Department of Biomedicine and Prevention, University of Rome Tor Vergata, Rome, Italy
| | - Enrico Santinelli
- Department of Biomedicine and Prevention, University of Rome Tor Vergata, Rome, Italy
| | | | - Simona Pagliuca
- Sérvice d'Hématologie Clinique, CHRU de Nancy, Nancy, France
- CNRS UMR 7365 IMoPa, Biopôle de l'Université de Lorraine, Vandœuvre-lès-Nancy, France
| | - Carmelo Gurnari
- Department of Biomedicine and Prevention, University of Rome Tor Vergata, Rome, Italy.
- Department of Translational Hematology and Oncology Research, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH, USA.
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Nakao S. Diagnosis of immune pathophysiology in patients with bone marrow failure. Int J Hematol 2024; 119:231-239. [PMID: 36609840 DOI: 10.1007/s12185-022-03519-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2022] [Revised: 12/14/2022] [Accepted: 12/14/2022] [Indexed: 01/09/2023]
Abstract
Differential diagnosis of pancytopenia with bone marrow (BM) hypoplasia represented by aplastic anemia (AA) is often challenging for physicians, because no laboratory tests have been established, until recently, to distinguish immune-mediated BM failure, which includes acquired AA (aAA) and a subset of low-risk myelodysplastic syndrome (MDS), from non-immune BM failure, which is primarily caused by genetic abnormalities in hematopoietic stem cells (HSCs). HSCs of healthy individuals often undergo somatic mutations, and some acquire phenotypic changes that allow them to escape immune attack against themselves. Once an immune attack against HSCs occurs, HSCs that undergo somatic mutations survive the immune attack and continue to produce their progenies with the same genetic or phenotypic changes. The presence of mature blood cells derived from mutated HSCs in the peripheral blood serves as evidence of the immune-mediated destruction of HSCs. Glycosylphosphatidylinositol-anchored protein-deficient (GPI[-]) blood cells and HLA class I allele-lacking (HLA[-]) leukocytes are two major aberrant cell types that represent the immune mechanism underlying BM failure. This review focuses on the importance of identifying immune mechanisms using laboratory markers, including GPI(-) cells and HLA(-) leukocytes, in the management of BM failure.
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Affiliation(s)
- Shinji Nakao
- Japanese Red Cross Ishikawa Blood Center, 4-445 Fujiekita, Kanazawa, Ishikawa, 920-0345, Japan.
- Department of Hematology, Faculty of Medicine, Institute of Medical Pharmaceutical and Health Sciences, Kanazawa University, 13-1 Takaramachi, Kanazawa, Ishikawa, 920-8641, Japan.
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Mizumaki H, Tran DC, Hosokawa K, Hosomichi K, Zaimoku Y, Takamatsu H, Yamazaki H, Ishiyama K, Yamazaki R, Fujiwara H, Tajima A, Nakao S. Minor GPI(-) granulocyte populations in aplastic anemia and healthy individuals derived from a few PIGA-mutated hematopoietic stem progenitor cells. Blood Cancer J 2023; 13:165. [PMID: 37938545 PMCID: PMC10632376 DOI: 10.1038/s41408-023-00932-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2023] [Revised: 09/08/2023] [Accepted: 09/15/2023] [Indexed: 11/09/2023] Open
Affiliation(s)
- Hiroki Mizumaki
- Department of Hematology, Faculty of Medicine, Institute of Medical Pharmaceutical and Health Sciences, Kanazawa University, Kanazawa, Japan
| | - Dung Cao Tran
- Department of Hematology, Faculty of Medicine, Institute of Medical Pharmaceutical and Health Sciences, Kanazawa University, Kanazawa, Japan
| | - Kohei Hosokawa
- Department of Hematology, Faculty of Medicine, Institute of Medical Pharmaceutical and Health Sciences, Kanazawa University, Kanazawa, Japan
| | - Kazuyoshi Hosomichi
- Department of Bioinformatics and Genomics, Graduate School of Advanced Preventive Medical Sciences, Kanazawa University, Kanazawa, Japan
| | - Yoshitaka Zaimoku
- Department of Hematology, Faculty of Medicine, Institute of Medical Pharmaceutical and Health Sciences, Kanazawa University, Kanazawa, Japan
| | - Hiroyuki Takamatsu
- Department of Hematology, Faculty of Medicine, Institute of Medical Pharmaceutical and Health Sciences, Kanazawa University, Kanazawa, Japan
| | - Hirohito Yamazaki
- Division of Transfusion Medicine, Kanazawa University Hospital, Kanazawa, Japan
| | - Ken Ishiyama
- Department of Hematology, Faculty of Medicine, Institute of Medical Pharmaceutical and Health Sciences, Kanazawa University, Kanazawa, Japan
| | - Rena Yamazaki
- Department of Obstetrics and Gynecology, Graduate School of Medical Sciences, Kanazawa University, Kanazawa, Japan
| | - Hiroshi Fujiwara
- Department of Obstetrics and Gynecology, Graduate School of Medical Sciences, Kanazawa University, Kanazawa, Japan
| | - Atsushi Tajima
- Department of Bioinformatics and Genomics, Graduate School of Advanced Preventive Medical Sciences, Kanazawa University, Kanazawa, Japan
| | - Shinji Nakao
- Department of Hematology, Faculty of Medicine, Institute of Medical Pharmaceutical and Health Sciences, Kanazawa University, Kanazawa, Japan.
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Rovó A, Gavillet M, Drexler B, Keller P, Schneider JS, Colucci G, Beauverd Y, van Dorland HA, Pollak M, Schmidt A, De Gottardi A, Bissig M, Lehmann T, Duchosal MA, Zeerleder S. Swiss Survey on current practices and opinions on clinical constellations triggering the search for PNH clones. Front Med (Lausanne) 2023; 10:1200431. [PMID: 37564039 PMCID: PMC10410560 DOI: 10.3389/fmed.2023.1200431] [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] [Received: 04/04/2023] [Accepted: 07/03/2023] [Indexed: 08/12/2023] Open
Abstract
This national survey investigated the current practice in Switzerland by collecting participants' opinions on paroxysmal nocturnal hemoglobinuria (PNH) clone assessment and clinical practice. Aim This study aimed to investigate clinical indications prompting PNH clones' assessment and physician's accessibility of a flow cytometry facility, and also to understand clinical attitudes on the follow-up (FU) of patients with PNH clones. Methods The survey includes 16 multiple-choice questions related to PNH and targets physicians with a definite level of experience in the topic using two screener questions. Opinion on clinical management was collected using hypothetical clinical situations. Each participant had the option of being contacted to further discuss the survey results. This was an online survey, and 264 physicians were contacted through email once a week for 5 weeks from September 2020. Results In total, 64 physicians (24.2%) from 23 institutions participated (81.3% hematologists and 67.2% from university hospitals). All had access to flow cytometry for PNH clone testing, with 76.6% having access within their own institution. The main reasons to assess for PNH clones were unexplained thrombosis and/or hemolysis, and/or aplastic anemia (AA). Patients in FU for PNH clones were more likely to be aplastic anemia (AA) and symptomatic PNH. In total, 61% of the participants investigated PNH clones repetitively during FU in AA/myelodysplastic syndromes patients, even when there was no PNH clone found at diagnosis, and 75% of the participants tested at least once a year during FU. Opinions related to clinical management were scattered. Conclusion The need to adhere to guidelines for the assessment, interpretation, and reporting of PNH clones emerges as the most important finding, as well as consensus for the management of less well-defined clinical situations. Even though there are several international guidelines, clear information addressing specific topics such as the type of anticoagulant to use and its duration, as well as the indication for treatment with complement inhibitors in some borderline situations are needed. The analysis and the discussion of this survey provide the basis for understanding the unmet needs of PNH clone assessment and clinical practice in Switzerland.
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Affiliation(s)
- Alicia Rovó
- Department of Hematology and Central Hematology Laboratory, Inselspital, Bern University Hospital, Bern, Switzerland
| | - Mathilde Gavillet
- Service and Central Laboratory of Hematology, Department of Oncology, Lausanne University Hospital (CHUV), Lausanne, Switzerland
- Department of Laboratory Medicine and Pathology, Lausanne University Hospital (CHUV), Lausanne, Switzerland
| | - Beatrice Drexler
- Division of Hematology, University Hospital Basel, Basel, Switzerland
| | | | - Jenny Sarah Schneider
- Department of Hematology and Central Hematology Laboratory, Inselspital, Bern University Hospital, Bern, Switzerland
| | | | - Yan Beauverd
- Division of Hematology, Geneva University Hospitals and Faculty of Medicine, Geneva, Switzerland
| | | | - Matthias Pollak
- Department of Hematology and Central Hematology Laboratory, Inselspital, Bern University Hospital, Bern, Switzerland
| | - Adrian Schmidt
- Department of Internal Medicine, Clinic of Medical Oncology and Hematology, Municipal Hospital Zurich Triemli, Zürich, Switzerland
| | - Andrea De Gottardi
- Servizio di Gastroenterología e Epatologia, Ente Ospedaliero Cantonale, Università della Svizzera Italiana, Lugano, Switzerland
| | - Marina Bissig
- Department of Medical Oncology and Hematology, University Hospital of Zürich, Zürich, Switzerland
| | - Thomas Lehmann
- Kantonsspital St. Gallen, Clinic for Medical Oncology and Hematology, St. Gallen, Switzerland
| | - Michel A. Duchosal
- Service and Central Laboratory of Hematology, Department of Oncology, Lausanne University Hospital (CHUV), Lausanne, Switzerland
| | - Sacha Zeerleder
- Department of Hematology, Kantonsspital Luzern, Lucerne and University of Bern, Bern, Switzerland
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Westers TM, Alhan C, Visser-Wisselaar HA, Chitu DA, van de Loosdrecht AA. Dysplasia and PNH-type cells in bone marrow aspirates of myelodysplastic syndromes. CYTOMETRY. PART B, CLINICAL CYTOMETRY 2023; 104:162-172. [PMID: 34806840 DOI: 10.1002/cyto.b.22038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/01/2021] [Revised: 10/01/2021] [Accepted: 11/01/2021] [Indexed: 11/07/2022]
Abstract
BACKGROUND Flow cytometry is increasingly applied in cytopenic patients suspected for myelodysplastic syndromes (MDS). Analysis includes evaluation of antigen expression patterns in granulocytes of which, for example, partial lack of CD16 may indicate dysplasia, but presence of paroxysmal nocturnal hemoglobinuria (PNH)-type cells should be considered. However, diagnostic bone marrow (BM) samples hamper PNH analysis because immature stages in the granulo-/monocytic compartment lack expression of certain glycophosphatidyl-inositol-anchored proteins. In this prospective study, we evaluated the presence of PNH-type cells in BM next to aberrancies from routine MDS immunophenotyping. METHODS We combined antibodies defining maturation trajectories with FLAER. Validation of the designed method against routine PNH analysis and parallel analysis of BM and blood samples revealed similar results (granulocytes: Wilcoxon p = 0.25 and p = 0.82, respectively). We analyzed BM samples from 134 MDS, 17 chronic myelomonocytic leukemia, 15 aplastic anemia (AA), 1 PNH, 51 non-clonal cytopenic controls, and 12 normal controls. RESULTS Most AA/PNH-BM samples showed clear PNH clones: median 1.1% (0%-35%); CD16 loss on mature neutrophils paralleled PNH-clone sizes. In MDS-BM, only 3.7% of cases showed ≥0.1% PNH-type cells, whereas partial CD16 loss was more frequent and abundant. CONCLUSIONS Our findings confirm that dysplastic features in MDS-BM may point to presence of PNH-type cells, though only few cases displayed FLAER-negative cells. We showed that identification of these cells in the granulocyte compartment of BM specimen is feasible, but-according to international guidelines-results need to be confirmed in peripheral blood.
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Affiliation(s)
- Theresia M Westers
- Department of Hematology, Amsterdam University Medical Centers, Location VU University Medical Center, Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - Canan Alhan
- Department of Hematology, Amsterdam University Medical Centers, Location VU University Medical Center, Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - Heleen A Visser-Wisselaar
- Department of Hematology, HOVON Data Center, Erasmus MC Cancer Institute, Rotterdam, The Netherlands
| | - Dana A Chitu
- Department of Hematology, HOVON Data Center, Erasmus MC Cancer Institute, Rotterdam, The Netherlands
| | - Arjan A van de Loosdrecht
- Department of Hematology, Amsterdam University Medical Centers, Location VU University Medical Center, Cancer Center Amsterdam, Amsterdam, The Netherlands
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Hosokawa K, Nakao S. Somatic mutations and clonal expansions in paroxysmal nocturnal hemoglobinuria. Semin Hematol 2022; 59:143-149. [DOI: 10.1053/j.seminhematol.2022.08.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2022] [Revised: 08/17/2022] [Accepted: 08/17/2022] [Indexed: 01/02/2023]
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The spectrum of paroxysmal nocturnal hemoglobinuria clinical presentation in a Brazilian single referral center. Ann Hematol 2022; 101:999-1007. [PMID: 35182190 PMCID: PMC8993788 DOI: 10.1007/s00277-022-04797-9] [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: 07/23/2021] [Accepted: 02/13/2022] [Indexed: 11/23/2022]
Abstract
Paroxysmal nocturnal hemoglobinuria (PNH) is a rare hematological disorder caused by the expansion of a hematopoietic clone harboring a somatic genetic variant in the PIG-A gene translating into a wide spectrum of clinical and laboratory changes, from intravascular hemolysis, thrombosis, and bone marrow failure to subclinical presentation. In this study, we retrospectively analyzed 87 consecutive cases (39 women; median follow-up, 18 months; range, 0–151 months) in whom a PNH clone was detected by flow cytometry between 2006 and 2019 seen at a single Brazilian referral center. The median age at diagnosis was 29 years (range, 8 to 83 years); 29 patients (33%) were initially classified as PNH/bone marrow failure, 13 (15%) as classic PNH, and 45 (52%) as subclinical PNH. The median overall survival (OS) of the entire cohort was not reached during follow-up, without significant differences between groups. At diagnosis, the median PNH clone size was 2.8% (range, 0 to 65%) in erythrocytes and 5.4% (range, 0 to 80%) in neutrophils. Fourteen patients experienced clone expansion during follow-up; in other 14 patients the clone disappeared, and in 18 patients it remained stable throughout the follow-up. A subclinical PNH clone was detected in three telomeropathy patients at diagnosis, but it was persistent and confirmed by DNA sequencing in only one case. In conclusion, PNH presentation was variable, and most patients had subclinical disease or associated with marrow failure and did not require specific anticomplement therapy. Clone size was stable or even disappeared in most cases.
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Kwoun WJ, Lee HT, Ahn JY. Frequencies of glycosylphosphatidylinositol (GPI)-deficient cells using high-sensitivity flow cytometry as per the 2018 ICCS/ESCCA consensus guideline in patients with hematologic malignancy, aplastic anemia, or cytopenia. Expert Rev Hematol 2022; 15:175-181. [PMID: 35119350 DOI: 10.1080/17474086.2022.2038561] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
OBJECTIVES We examined the frequencies and sizes of glycosylphosphatidylinositol(GPI)-deficient cells as per the International Clinical Cytometry Society/European Society for Clinical Cell Analysis(ICCS/ESCCA) consensus guidelines for the high-sensitivity detection of GPI-deficient cells. METHODS In 2018, the ICCS/ESCCA guidelines for the high-sensitivity detection of GPI-deficient cells were published. We evaluated frequencies and sizes of GPI-deficient red blood cells(RBCs), neutrophils, and monocytes as determined using the ICCS/ESCCA guidelines and Clinical and Laboratory Standards Institute(CLSI) guidelines in patients with a hematologic malignancy, aplastic anemia, or cytopenia. RESULTS A total of 106(38.7%) patients exhibited GPI deficiency in at least one blood cell lineage. GPI-deficient cells of one or more lineages were found in 62.7% of patients with a hematologic malignancy, 51.1% of patients with aplastic anemia, and 23.4% of patients with cytopenia. GPI-deficient monocytes were most frequently detected in all three groups. By population size, GPI-deficient clones (>1%) in monocytes were mostly detected in patients with a hematologic malignancy or aplastic anemia. Rare cells with GPI deficiency(<0.1%) in monocytes were most common among patients with cytopenia. CONCLUSION High-sensitive flow cytometry analysis including monocytes may be necessary for patients with a hematologic disorder.
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Affiliation(s)
- Woo-Jae Kwoun
- Department of Laboratory Medicine, Gachon University Gil Medical Center, Incheon, Republic of Korea.,Hamyang Public Health Center, Gyeongsangnam-do, Republic of Korea
| | - Hwan Tae Lee
- Department of Laboratory Medicine, BS Hospital, Incheon, Republic of Korea
| | - Jeong-Yeal Ahn
- Department of Laboratory Medicine, Gachon University Gil Medical Center, Incheon, Republic of Korea
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Colden MA, Kumar S, Munkhbileg B, Babushok DV. Insights Into the Emergence of Paroxysmal Nocturnal Hemoglobinuria. Front Immunol 2022; 12:830172. [PMID: 35154088 PMCID: PMC8831232 DOI: 10.3389/fimmu.2021.830172] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2021] [Accepted: 12/30/2021] [Indexed: 11/13/2022] Open
Abstract
Paroxysmal Nocturnal Hemoglobinuria (PNH) is a disease as simple as it is complex. PNH patients develop somatic loss-of-function mutations in phosphatidylinositol N-acetylglucosaminyltransferase subunit A gene (PIGA), required for the biosynthesis of glycosylphosphatidylinositol (GPI) anchors. Ubiquitous in eukaryotes, GPI anchors are a group of conserved glycolipid molecules responsible for attaching nearly 150 distinct proteins to the surface of cell membranes. The loss of two GPI-anchored surface proteins, CD55 and CD59, from red blood cells causes unregulated complement activation and hemolysis in classical PNH disease. In PNH patients, PIGA-mutant, GPI (-) hematopoietic cells clonally expand to make up a large portion of patients’ blood production, yet mechanisms leading to clonal expansion of GPI (-) cells remain enigmatic. Historical models of PNH in mice and the more recent PNH model in rhesus macaques showed that GPI (-) cells reconstitute near-normal hematopoiesis but have no intrinsic growth advantage and do not clonally expand over time. Landmark studies identified several potential mechanisms which can promote PNH clonal expansion. However, to what extent these contribute to PNH cell selection in patients continues to be a matter of active debate. Recent advancements in disease models and immunologic technologies, together with the growing understanding of autoimmune marrow failure, offer new opportunities to evaluate the mechanisms of clonal expansion in PNH. Here, we critically review published data on PNH cell biology and clonal expansion and highlight limitations and opportunities to further our understanding of the emergence of PNH clones.
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Affiliation(s)
- Melissa A. Colden
- Division of Hematology-Oncology, Department of Medicine, University of Pennsylvania, Philadelphia, PA, United States
- Comprehensive Bone Marrow Failure Center, Department of Pediatrics, Children’s Hospital of Philadelphia, Philadelphia, PA, United States
| | - Sushant Kumar
- Division of Hematology-Oncology, Department of Medicine, University of Pennsylvania, Philadelphia, PA, United States
- Comprehensive Bone Marrow Failure Center, Department of Pediatrics, Children’s Hospital of Philadelphia, Philadelphia, PA, United States
| | - Bolormaa Munkhbileg
- Division of Hematology-Oncology, Department of Medicine, University of Pennsylvania, Philadelphia, PA, United States
- Comprehensive Bone Marrow Failure Center, Department of Pediatrics, Children’s Hospital of Philadelphia, Philadelphia, PA, United States
| | - Daria V. Babushok
- Division of Hematology-Oncology, Department of Medicine, University of Pennsylvania, Philadelphia, PA, United States
- Comprehensive Bone Marrow Failure Center, Department of Pediatrics, Children’s Hospital of Philadelphia, Philadelphia, PA, United States
- *Correspondence: Daria V. Babushok,
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Babushok DV. When does a PNH clone have clinical significance? HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2021; 2021:143-152. [PMID: 34889408 PMCID: PMC8791108 DOI: 10.1182/hematology.2021000245] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/24/2023]
Abstract
Paroxysmal nocturnal hemoglobinuria (PNH) is an acquired blood disease caused by somatic mutations in the phosphatidylinositol glycan class A (PIGA) gene required to produce glycophosphatidyl inositol (GPI) anchors. Although PNH cells are readily identified by flow cytometry due to their deficiency of GPI-anchored proteins, the assessment of the clinical significance of a PNH clone is more nuanced. The interpretation of results requires an understanding of PNH pathogenesis and its relationship to immune-mediated bone marrow failure. Only about one-third of patients with PNH clones have classical PNH disease with overt hemolysis, its associated symptoms, and the highly prothrombotic state characteristic of PNH. Patients with classical PNH benefit the most from complement inhibitors. In contrast, two-thirds of PNH clones occur in patients whose clinical presentation is that of bone marrow failure with few, if any, PNH-related symptoms. The clinical presentations are closely associated with PNH clone size. Although exceptions occur, bone marrow failure patients usually have smaller, subclinical PNH clones. This review addresses the common scenarios that arise in evaluating the clinical significance of PNH clones and provides practical guidelines for approaching a patient with a positive PNH result.
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Affiliation(s)
- Daria V. Babushok
- Division of Hematology-Oncology, Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, PA; and Comprehensive Bone Marrow Failure Center, Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, PA
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12
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Fattizzo B, Ireland R, Dunlop A, Yallop D, Kassam S, Large J, Gandhi S, Muus P, Manogaran C, Sanchez K, Consonni D, Barcellini W, Mufti GJ, Marsh JCW, Kulasekararaj AG. Clinical and prognostic significance of small paroxysmal nocturnal hemoglobinuria clones in myelodysplastic syndrome and aplastic anemia. Leukemia 2021; 35:3223-3231. [PMID: 33664463 PMCID: PMC8550969 DOI: 10.1038/s41375-021-01190-9] [Citation(s) in RCA: 35] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2020] [Revised: 01/22/2021] [Accepted: 02/08/2021] [Indexed: 11/21/2022]
Abstract
In this large single-centre study, we report high prevalence (25%) of, small (<10%) and very small (<1%), paroxysmal nocturnal hemoglobinuria (PNH) clones by high-sensitive cytometry among 3085 patients tested. Given PNH association with bone marrow failures, we analyzed 869 myelodysplastic syndromes (MDS) and 531 aplastic anemia (AA) within the cohort. PNH clones were more frequent and larger in AA vs. MDS (p = 0.04). PNH clone, irrespective of size, was a good predictor of response to immunosuppressive therapy (IST) and to stem cell transplant (HSCT) (in MDS: 84% if PNH+ vs. 44.7% if PNH-, p = 0.01 for IST, and 71% if PNH+ vs. 56.6% if PNH- for HSCT; in AA: 78 vs. 50% for IST, p < 0.0001, and 97 vs. 77%, p = 0.01 for HSCT). PNH positivity had a favorable impact on disease progression (0.6% vs. 4.9% IPSS-progression in MDS, p < 0.005; and 2.1 vs. 6.9% progression to MDS in AA, p = 0.01), leukemic evolution (6.8 vs. 12.7%, p = 0.01 in MDS), and overall survival [73% (95% CI 68-77) vs. 51% (48-54), p < 0.0001], with a relative HR for mortality of 2.37 (95% CI 1.8-3.1; p < 0.0001) in PNH negative cases, both in univariate and multivariable analysis. Our data suggest systematic PNH testing in AA/MDS, as it might allow better prediction/prognostication and consequent clinical/laboratory follow-up timing.
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Affiliation(s)
- Bruno Fattizzo
- Department of Hematological medicine, King's College Hospital, London, UK
- Hematology, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico di Milano, Milan, Italy
- Department of Oncology and Onco-hematology, University of Milan, Milan, Italy
| | - Robin Ireland
- Department of Hematological medicine, King's College Hospital, London, UK
| | - Alan Dunlop
- Department of Hematological medicine, King's College Hospital, London, UK
| | - Deborah Yallop
- Department of Hematological medicine, King's College Hospital, London, UK
| | - Shireen Kassam
- Department of Hematological medicine, King's College Hospital, London, UK
| | - Joanna Large
- Department of Hematological medicine, King's College Hospital, London, UK
| | - Shreyans Gandhi
- Department of Hematological medicine, King's College Hospital, London, UK
| | - Petra Muus
- Department of Hematological medicine, King's College Hospital, London, UK
| | - Charles Manogaran
- Department of Hematological medicine, King's College Hospital, London, UK
| | - Katy Sanchez
- Department of Hematological medicine, King's College Hospital, London, UK
| | - Dario Consonni
- Hematology, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico di Milano, Milan, Italy
| | - Wilma Barcellini
- Hematology, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico di Milano, Milan, Italy
| | - Ghulam J Mufti
- Department of Hematological medicine, King's College Hospital, London, UK
- Hematological Medicine, King's College London, London, UK
| | - Judith C W Marsh
- Department of Hematological medicine, King's College Hospital, London, UK
- Hematological Medicine, King's College London, London, UK
| | - Austin G Kulasekararaj
- Department of Hematological medicine, King's College Hospital, London, UK.
- Hematological Medicine, King's College London, London, UK.
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13
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Nakagawa N, Ishiyama K, Tanabe M, Yoroidaka T, Mizumaki H, Imi T, Zaimoku Y, Maruyama H, Hosokawa K, Yamazaki H, Nakao S. The effectiveness of immunosuppressive therapy in patients with aplastic anaemia secondary to chemoradiotherapy for cancers. Br J Haematol 2021; 195:770-780. [PMID: 34476805 DOI: 10.1111/bjh.17802] [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: 05/15/2021] [Accepted: 08/14/2021] [Indexed: 11/28/2022]
Abstract
The outcome of immunosuppressive therapy (IST) and prognosis in patients with aplastic anaemia (AA) secondary to chemotherapy or radiotherapy for cancers remains unknown. A total of 43 of 2559 patients with AA referred to our hospital had previously received chemoradiotherapy for various types of solid tumours (n = 25) or haematological malignancies (n = 18). Their cancer status was complete remission (CR) in 27, non-CR in 13, and unknown in three. Small populations of glycosylphosphatidylinositol-anchored protein-deficient [GPI(-)] granulocytes were detected in 16 patients (37·2%). Of 18 patients who were treated with IST, 50% improved regardless of the presence of GPI(-) cells. The overall survival (OS) rate was significantly higher in patients with a history of solid tumours patients than in those of haematological malignancies (median OS, 87 vs. 11 months, P = 0·0003), and in patients treated with IST than in those of untreated patients (median OS, 115 vs. 20 months, P = 0·028). Cancer aggravation occurred in two of four patients who were treated with IST while in non-CR of their original cancers. Progression to myelodysplastic syndromes was observed in two patients not possessing GPI(-) cells. IST should thus be considered for patients with AA secondary to chemoradiotherapy for cancers, particularly when their original solid tumours are in CR.
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Affiliation(s)
- Noriharu Nakagawa
- Department of Hematology, Graduate School of Medical Sciences, Kanazawa University, Kanazawa, Japan.,Department of Hematology, Toyama Prefectural Central Hospital, Toyama, Japan
| | - Ken Ishiyama
- Department of Hematology, Graduate School of Medical Sciences, Kanazawa University, Kanazawa, Japan
| | - Mikoto Tanabe
- Department of Hematology, Graduate School of Medical Sciences, Kanazawa University, Kanazawa, Japan
| | - Takeshi Yoroidaka
- Department of Hematology, Graduate School of Medical Sciences, Kanazawa University, Kanazawa, Japan
| | - Hiroki Mizumaki
- Department of Hematology, Graduate School of Medical Sciences, Kanazawa University, Kanazawa, Japan
| | - Tatsuya Imi
- Department of Hematology, Graduate School of Medical Sciences, Kanazawa University, Kanazawa, Japan
| | - Yoshitaka Zaimoku
- Department of Hematology, Graduate School of Medical Sciences, Kanazawa University, Kanazawa, Japan
| | - Hiroyuki Maruyama
- Department of Hematology, Graduate School of Medical Sciences, Kanazawa University, Kanazawa, Japan
| | - Kohei Hosokawa
- Department of Hematology, Graduate School of Medical Sciences, Kanazawa University, Kanazawa, Japan
| | - Hirohito Yamazaki
- Department of Transfusion Medicine, Kanazawa University Hospital, Kanazawa, Japan
| | - Shinji Nakao
- Department of Hematology, Graduate School of Medical Sciences, Kanazawa University, Kanazawa, Japan
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14
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HLA class I allele-lacking leukocytes predict rare clonal evolution to MDS/AML in patients with acquired aplastic anemia. Blood 2021; 137:3576-3580. [PMID: 33754630 DOI: 10.1182/blood.2020010586] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2021] [Accepted: 03/03/2021] [Indexed: 12/27/2022] Open
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15
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Jeong D, Park HS, Kim SM, Im K, Yun J, Lee YE, Ryu S, Ahn YO, Yoon SS, Lee DS. Ultradeep Sequencing Analysis of Paroxysmal Nocturnal Hemoglobinuria Clones Detected by Flow Cytometry: PIG Mutation in Small PNH Clones. Am J Clin Pathol 2021; 156:72-85. [PMID: 33347536 DOI: 10.1093/ajcp/aqaa211] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVES We aimed to determine whether small paroxysmal nocturnal hemoglobinuria (PNH) clones detected by flow cytometry (FCM) harbor PIG gene mutations with quantitative correlation. METHODS We analyzed 89 specimens from 63 patients whose PNH clone size was ≥0.1% by FCM. We performed ultradeep sequencing for the PIGA, PIGM, PIGT, and PIGX genes in these specimens. RESULTS A strong positive correlation between PNH clone size by FCM and variant allele frequency (VAF) of PIG gene mutation was identified (RBCs: r = 0.77, P < .001; granulocytes: r = 0.68, P < .001). Granulocyte clone size of 2.5% or greater and RBCs 0.4% or greater by FCM always harbored PIG gene mutations. Meanwhile, in patients with clone sizes of less than 2.5% in granulocytes or less than 0.4% in RBCs, PIG gene mutations were present in only 15.9% and 12.2% of cases, respectively. In addition, there was not a statistically significant positive correlation between FCM clone size and VAF or the presence or absence of a PIG mutation. CONCLUSIONS Our results showed that in small PNH clones PIG gene mutations were present in only a small portion without significant correlation to VAF or the presence or absence of a PIG mutation.
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Affiliation(s)
- Dajeong Jeong
- Department of Laboratory Medicine, Seoul National University Hospital, Seoul, Korea
| | - Hee Sue Park
- Department of Laboratory Medicine, Chungbuk National University Hospital, Cheongju, Korea
| | - Sung-Min Kim
- Cancer Research Institute, Seoul National University College of Medicine, Seoul, Korea
| | - Kyongok Im
- Cancer Research Institute, Seoul National University College of Medicine, Seoul, Korea
| | - Jiwon Yun
- Department of Laboratory Medicine, Seoul National University Hospital, Seoul, Korea
| | - Young Eun Lee
- Department of Laboratory Medicine, Seoul National University Hospital, Seoul, Korea
| | - Sohee Ryu
- Department of Laboratory Medicine, Seoul National University Hospital, Seoul, Korea
| | - Yong-Oon Ahn
- Cancer Research Institute, Seoul National University College of Medicine, Seoul, Korea
| | - Sung-Soo Yoon
- Cancer Research Institute, Seoul National University College of Medicine, Seoul, Korea
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea
| | - Dong Soon Lee
- Department of Laboratory Medicine, Seoul National University Hospital, Seoul, Korea
- Cancer Research Institute, Seoul National University College of Medicine, Seoul, Korea
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16
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Mizumaki H, Hosomichi K, Hosokawa K, Yoroidaka T, Imi T, Zaimoku Y, Katagiri T, Anh Thi Nguyen M, Cao Tran D, Ibrahim Yousef Elbadry M, Chonabayashi K, Yoshida Y, Takamatsu H, Ozawa T, Azuma F, Kishi H, Fujii Y, Ogawa S, Tajima A, Nakao S. A frequent nonsense mutation in exon 1 across certain HLA-A and -B alleles in leukocytes of patients with acquired aplastic anemia. Haematologica 2021; 106:1581-1590. [PMID: 32439725 PMCID: PMC8168509 DOI: 10.3324/haematol.2020.247809] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2020] [Indexed: 12/24/2022] Open
Abstract
Leukocytes that lack HLA allelic expression are frequently detected in patients with acquired aplastic anemia (AA) who respond to immunosuppressive therapy (IST), although the exact mechanisms underlying the HLA loss and HLA allele repertoire likely to acquire loss-of-function mutations are unknown. We identified a common nonsense mutation at position 19 (c.19C>T, p.R7X) in exon 1 (Exon1mut) of different HLA-A and -B alleles in HLA-lacking granulocytes from AA patients. A droplet digital PCR (ddPCR) assay capable of detecting as few as 0.07% Exon1mut HLA alleles in total DNA revealed the mutation was present in 29% (101/353) of AA patients, with a median allele frequency of 0.42% (range, 0.071% to 21.3%). Exon1mut occurred in only 12 different HLA-A (n=4) and HLA-B (n=8) alleles, including B*40:02 (n=31) and A*02:06 (n=15), which correspond to 4 HLA supertypes (A02, A03, B07, and B44). The percentages of patients who possessed at least one of these 12 HLA alleles were significantly higher in the 353 AA patients (92%, P.
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Affiliation(s)
- Hiroki Mizumaki
- Department of Hematology, Kanazawa University, Kanazawa, Japan
| | - Kazuyoshi Hosomichi
- Graduate School of Advanced Preventive Medical Sciences, Kanazawa University, Japan
| | - Kohei Hosokawa
- Department of Hematology, Kanazawa University, Kanazawa, Japan
| | | | - Tatsuya Imi
- Department of Hematology, Kanazawa University, Kanazawa, Japan
| | | | - Takamasa Katagiri
- Clinical Laboratory Sciences, Kanazawa University Graduate School, Kanazawa, Japan
| | | | - Dung Cao Tran
- Department of Hematology, Kanazawa University, Kanazawa, Japan
| | | | | | - Yoshinori Yoshida
- Center for iPS Cell Research and Application, Kyoto University, Kyoto, Japan
| | | | - Tatsuhiko Ozawa
- Department of Immunology, University of Toyama, Toyama, Japan
| | - Fumihiro Azuma
- HLA Laboratory, Japanese Red Cross Kanto-Koshinetsu Block Blood Center, Kotoku, Japan
| | - Hiroyuki Kishi
- Department of Immunology, University of Toyama, Toyama, Japan
| | - Yoichi Fujii
- Dept. of Pathology and Tumor Biology, Graduate School of Medicine, Kyoto University, Japan
| | - Seishi Ogawa
- Dept. of Pathology and Tumor Biology, Graduate School of Medicine, Kyoto University, Japan
| | - Atsushi Tajima
- Graduate School of Advanced Preventive Medical Sciences, Kanazawa University, Kanazawa, Japan
| | - Shinji Nakao
- Department of Hematology, Kanazawa University, Kanazawa, Japan
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17
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Hematopoietic stem progenitor cells lacking HLA differ from those lacking GPI-anchored proteins in the hierarchical stage and sensitivity to immune attack in patients with acquired aplastic anemia. Leukemia 2021; 35:3257-3267. [PMID: 33824463 DOI: 10.1038/s41375-021-01202-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2020] [Revised: 01/27/2021] [Accepted: 02/18/2021] [Indexed: 12/21/2022]
Abstract
To characterize glycosylphosphatidylinositol-anchored protein-deficient (GPI[-]) and HLA-class I allele-lacking (HLA[-]) hematopoietic stem progenitor cells (HSPCs) in acquired aplastic anemia (AA), we studied the peripheral blood (PB) of 56 AA patients in remission who possessed both (n = 13, Group A) or either GPI(-) (n = 34, Group B) and HLA(-) (n = 9, Group C) cell populations. Seventy-seven percent (10/13) of Group A had HLA(-) cells in all lineages of PB cells, including platelets, while only 23% (3/13) had GPI(-) cells in all lineages, and the median percentage of HLA(-) granulocytes in the total granulocytes (21.2%) was significantly higher than that of GPI(-) granulocytes (0.28%, P < 0.05). The greater lineage diversity in HLA(-) cells than in GPI(-) cells was also seen when Group B and Group C were compared. Longitudinal studies of seven patients in Group A showed a gradual decrease in the percentage of HLA(-) granulocytes, with a reciprocal increase in the GPI(-) granulocytes in four patients responding to cyclosporine (CsA) and an increase in the HLA(-) granulocytes with a stable or declining GPI(-) granulocytes in three patients in sustained remission off CsA therapy. These findings suggest that HLA(-) HSPCs differ from GPI(-) HSPCs in the hierarchical stage and sensitivity to immune attack in AA.
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18
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Hosokawa K, Ishiyama K, Ikemoto T, Sugimori C, Noji H, Shichishima T, Obara N, Chiba S, Ninomiya H, Nguyen MAT, Shirasugi Y, Nakamura Y, Ando K, Ueda Y, Yonemura Y, Kawaguchi T, Nishimura JI, Kanakura Y, Nakao S. The clinical significance of PNH-phenotype cells accounting for < 0.01% of total granulocytes detected by the Clinical and Laboratory Standards Institute methods in patients with bone marrow failure. Ann Hematol 2020; 100:1975-1982. [PMID: 33095337 DOI: 10.1007/s00277-020-04314-w] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2020] [Accepted: 10/15/2020] [Indexed: 12/22/2022]
Abstract
Small populations of glycosylphosphatidylinositol-anchored protein-deficient (GPI[-]) cells accounting for up to 0.01% of total granulocytes can be accurately detected by a high-sensitivity flow cytometry (FCM) assay established by the Clinical and Laboratory Standards Institute (CLSI method) and have a prognostic value in bone marrow failure (BMF); however, the significance of GPI(-) granulocytes accounting for 0.001-0.009% of granulocytes remains unclear. To clarify this issue, we examined the peripheral blood of 21 BMF patients in whom minor (around 0.01%) populations of GPI(-) granulocytes had been previously detected by a different high-resolution FCM method (OPTIMA method, which defines ≥ 0.003% GPI(-) granulocytes as an abnormal increase) using both the CLSI and OPTIMA methods simultaneously. These two methods detected an "abnormal increase" in GPI(-) granulocytes in 10 patients (48%) and 17 patients (81%), respectively. CLSI detected 0.002-0.005% (median, 0.004%) GPI(-) granulocytes in 7 patients who were deemed positive for PNH-type cells according to the OPTIMA method, which detected 0.003-0.012% (median 0.006%) GPI(-) granulocytes. The clone sizes of GPI(-) cells detected by each assay were positively correlated (r = 0.994, p < 0.001). Of the seven patients who were judged positive for PNH-type cells by OPTIMA alone, five received immunosuppressive therapy, and all of them achieved a partial or complete response. GPI(-) granulocytes detected in BMF patients by the CLSI method should thus be considered significant, even at percentages of < 0.01%.
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Affiliation(s)
- Kohei Hosokawa
- Department of Hematology, Graduate School of Medical Sciences, Kanazawa University, 13-1 Takaramachi, Kanazawa, Ishikawa, 920-8641, Japan
- Japan PNH Study Group, Tokyo, Japan
| | - Ken Ishiyama
- Department of Hematology, Graduate School of Medical Sciences, Kanazawa University, 13-1 Takaramachi, Kanazawa, Ishikawa, 920-8641, Japan
- Japan PNH Study Group, Tokyo, Japan
| | - Toshiyuki Ikemoto
- Japan PNH Study Group, Tokyo, Japan
- Department of Clinical Laboratory, Shiga University of Medical Science Hospital, Ohtsu, Japan
| | - Chiharu Sugimori
- Japan PNH Study Group, Tokyo, Japan
- Department of Hematology, Ishikawa Prefectural Central Hospital, Kanazawa, Ishikawa, Japan
| | - Hideyoshi Noji
- Japan PNH Study Group, Tokyo, Japan
- Department of Hematology, Fukushima Medical University, Fukushima, Japan
| | - Tsutomu Shichishima
- Japan PNH Study Group, Tokyo, Japan
- Department of Hematology, Fukushima Medical University, Fukushima, Japan
| | - Naoshi Obara
- Japan PNH Study Group, Tokyo, Japan
- Department of Hematology, Faculty of Medicine, University of Tsukuba, Tsukuba, Japan
| | - Shigeru Chiba
- Japan PNH Study Group, Tokyo, Japan
- Department of Hematology, Faculty of Medicine, University of Tsukuba, Tsukuba, Japan
| | - Haruhiko Ninomiya
- Japan PNH Study Group, Tokyo, Japan
- Department of Medical Sciences, Faculty of Medicine, University of Tsukuba, Tsukuba, Japan
| | - Mai Anh Thi Nguyen
- Department of Hematology, Graduate School of Medical Sciences, Kanazawa University, 13-1 Takaramachi, Kanazawa, Ishikawa, 920-8641, Japan
- Japan PNH Study Group, Tokyo, Japan
| | - Yukari Shirasugi
- Japan PNH Study Group, Tokyo, Japan
- Department of Hematology and Oncology, Tokai University, Isehara, Japan
| | - Yoshihiko Nakamura
- Japan PNH Study Group, Tokyo, Japan
- Department of Hematology and Oncology, Tokai University, Isehara, Japan
| | - Kiyoshi Ando
- Japan PNH Study Group, Tokyo, Japan
- Department of Hematology and Oncology, Tokai University, Isehara, Japan
| | - Yasutaka Ueda
- Japan PNH Study Group, Tokyo, Japan
- Department of Hematology and Oncology, Osaka University, Osaka, Japan
| | - Yuji Yonemura
- Japan PNH Study Group, Tokyo, Japan
- Department of Hematology and Infectious Diseases, Kumamoto University, Kumamoto, Japan
| | - Tatsuya Kawaguchi
- Japan PNH Study Group, Tokyo, Japan
- Department of Hematology and Infectious Diseases, Kumamoto University, Kumamoto, Japan
| | - Jun-Ichi Nishimura
- Japan PNH Study Group, Tokyo, Japan
- Department of Hematology and Oncology, Osaka University, Osaka, Japan
| | - Yuzuru Kanakura
- Japan PNH Study Group, Tokyo, Japan
- Department of Hematology and Oncology, Osaka University, Osaka, Japan
| | - Shinji Nakao
- Department of Hematology, Graduate School of Medical Sciences, Kanazawa University, 13-1 Takaramachi, Kanazawa, Ishikawa, 920-8641, Japan.
- Japan PNH Study Group, Tokyo, Japan.
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19
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Lima M. Laboratory studies for paroxysmal nocturnal hemoglobinuria, with emphasis on flow cytometry. Pract Lab Med 2020; 20:e00158. [PMID: 32195308 PMCID: PMC7078534 DOI: 10.1016/j.plabm.2020.e00158] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2019] [Revised: 01/28/2020] [Accepted: 02/28/2020] [Indexed: 12/15/2022] Open
Abstract
Paroxysmal nocturnal hemoglobinuria (PNH) is a rare acquired clonal hematopoietic stem cell disorder caused by somatic mutations in the PIG-A gene, leading to the production of blood cells with absent or decreased expression of glycosylphosphatidylinositol-anchored proteins, including CD55 and CD59. Clinically, PNH is classified into three variants: classic (hemolytic), in the setting of another specified bone marrow disorder (such as aplastic anemia or myelodysplastic syndrome) and subclinical (asymptomatic). PNH testing is recommended for patients with intravascular hemolysis, acquired bone marrow failure syndromes and thrombosis with unusual features. Despite the availability of consensus guidelines for PNH diagnosis and monitoring, there are still discrepancies on how PNH tests are carried out, and these technical variations may lead to an incorrect diagnosis. Herein, we provide a brief historical overview of PNH, focusing on the laboratory tests available and on the current recommendations for PNH diagnosis and monitoring based in flow cytometry.
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Affiliation(s)
- Margarida Lima
- Laboratório de Citometria, Unidade de Diagnóstico Hematológico, Serviço de Hematologia Clínica, Hospital de Santo António (HSA), Centro Hospitalar Universitário do Porto (CHUP), Porto, Portugal
- Unidade Multidisciplinar de Investigação Biomédica, Instituto de Ciências Biomédicas da Universidade do Porto (UMIB/ICBAS/UP), Porto, Portugal
- Laboratório de Citometria, Hospital de Santo António (HSA), Centro Hospitalar Universitário do Porto (CHUP), Ex-CICAP, Rua D. Manuel II, s/n, 4099-001, Porto, Portugal.
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20
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Abstract
Paroxysmal nocturnal hemoglobinuria (PNH) is a rare but often debilitating disease which may lead to death in up to 35% of patients within 5 years if unrecognized and untreated. Detection of PNH and assessment of PNH clone size in RBC and WBC lineages by flow cytometric analysis has increased in importance due to the availability of novel therapies. These therapies typically block the hemolysis of red blood cells and thus significantly lower the morbidities and mortality associated with this disease. This chapter describes validated, state-of-the-art, high-sensitivity flow cytometric methodologies based on latest published testing guidelines for PNH.
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21
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Lian Y, Shi J, Nie N, Huang Z, Shao Y, Zhang J, Huang J, Li X, Ge M, Jin P, Wang M, Zheng Y. Evolution patterns of paroxysmal nocturnal hemoglobinuria clone and clinical implications in acquired bone marrow failure. Exp Hematol 2019; 77:41-50. [PMID: 31472171 DOI: 10.1016/j.exphem.2019.08.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2019] [Revised: 08/19/2019] [Accepted: 08/23/2019] [Indexed: 12/21/2022]
Abstract
The paroxysmal nocturnal hemoglobinuria (PNH) clone often presents in acquired bone marrow failure (aBMF), which is involved in more than half of aplastic anemia (AA) cases and about 10%-20% of myelodysplastic syndrome (MDS) cases. PNH clone expansion patterns and clinical implications, however, remain obscure. We conducted a large retrospective study of 457 aBMF patients with positive PNH clones to explore the wide spectrum of clone architecture, evolution patterns, and clinical implications. PNH clone size at diagnosis in AA or MDS was significantly smaller than that in clinical PNH (p < 0.001); the main clone patterns in AA and MDS were granulocyte dominant, with the remaining cases having a granulocyte-erythrocyte balance pattern in clinical PNH. In 131 AA patients at follow-up, there was no obvious difference in response rates between those with the aggressive pattern of clone evolution (73.7%) and those with the stable pattern (81.1%). A quarter of AA patients evolved into clinical hemolysis within a median interval of 11 months. AA cases progressing into clinical hemolysis after immunosuppressive therapy had significantly larger clones (granulocytes: 12.3% vs. 2.6%; erythrocytes: 5.7% vs. 1.3%) at diagnosis and presented mainly an aggressive pattern, especially the granulocyte-erythrocyte aggressive model. Clone sizes reaching 37% for erythrocytes and 28% for granulocytes were indicators of the onset of hemolysis in AA. In conclusion, aBMF patients presented significantly various PNH clone patterns at diagnosis. AA patients with either an aggressive or stable evolution pattern can achieve a response, but patients with an aggressive evolution pattern, especially the granulocyte-erythrocyte aggressive model, tend to evolve into clinical hemolysis.
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Affiliation(s)
- Yu Lian
- State Key Laboratory of Experimental Hematology, Institute of Hematology and Blood Diseases Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Tianjin, China
| | - Jun Shi
- State Key Laboratory of Experimental Hematology, Institute of Hematology and Blood Diseases Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Tianjin, China.
| | - Neng Nie
- State Key Laboratory of Experimental Hematology, Institute of Hematology and Blood Diseases Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Tianjin, China
| | - Zhendong Huang
- State Key Laboratory of Experimental Hematology, Institute of Hematology and Blood Diseases Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Tianjin, China
| | - Yingqi Shao
- State Key Laboratory of Experimental Hematology, Institute of Hematology and Blood Diseases Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Tianjin, China
| | - Jing Zhang
- State Key Laboratory of Experimental Hematology, Institute of Hematology and Blood Diseases Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Tianjin, China
| | - Jinbo Huang
- State Key Laboratory of Experimental Hematology, Institute of Hematology and Blood Diseases Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Tianjin, China
| | - Xingxin Li
- State Key Laboratory of Experimental Hematology, Institute of Hematology and Blood Diseases Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Tianjin, China
| | - Meili Ge
- State Key Laboratory of Experimental Hematology, Institute of Hematology and Blood Diseases Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Tianjin, China
| | - Peng Jin
- State Key Laboratory of Experimental Hematology, Institute of Hematology and Blood Diseases Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Tianjin, China
| | - Min Wang
- State Key Laboratory of Experimental Hematology, Institute of Hematology and Blood Diseases Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Tianjin, China
| | - Yizhou Zheng
- State Key Laboratory of Experimental Hematology, Institute of Hematology and Blood Diseases Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Tianjin, China
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22
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Features, reason for testing, and changes with time of 583 paroxysmal nocturnal hemoglobinuria clones from 529 patients: a multicenter Italian study. Ann Hematol 2019; 98:1083-1093. [PMID: 30868306 DOI: 10.1007/s00277-019-03644-8] [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] [Received: 11/03/2017] [Accepted: 02/24/2019] [Indexed: 10/27/2022]
Abstract
In this study, we aimed at disclosing the main features of paroxysmal nocturnal hemoglobinuria (PNH) clones, their association with presentation syndromes, and their changes during follow-up. A large-scale, cooperative collection (583 clones from 529 patients) of flow cytometric and clinical data was entered into a national repository. Reason for testing guidelines were provided to the 41 participating laboratories, which followed the 2010 technical recommendations for PNH testing by Borowitz. Subsequently, the 30 second-level laboratories adopted the 2012 guidelines for high-resolution PNH testing, both upon order by the local clinicians and as an independent laboratory initiative in selected cases. Type3 and Type2 PNH clones (total and partial absence of glycosyl-phosphatidyl-inositol-anchor, respectively) were simultaneously present in 54 patients. In these patients, Type3 component was sevenfold larger than Type2 (p < 0.001). Frequency distribution analysis of solitary Type3 clone size (N = 442) evidenced two discrete patterns: small (20% of peripheral neutrophils) and large (> 70%) clones. The first pattern was significantly associated with bone marrow failure and myelodysplastic syndromes, the second one with hemolysis, hemoglobinuria, and thrombosis. Pediatric patients (N = 34) showed significant preponderance of small clones and bone marrow failure. The majority of PNH clones involved neutrophils, monocytes, and erythrocytes. Nevertheless, we found clones made exclusively by white cells (N = 13) or erythrocytes (N = 3). Rare cases showed clonal white cells restricted only to monocytes (6 cases) or neutrophils (3 cases). Retesting over 1-year follow-up in 151 cases showed a marked clone size increase in 4 cases and a decrease in 13, demonstrating that early breaking-down of PNH clones is not a rare event (8.6% of cases). This collaborative nationwide study demonstrates a clear-cut difference in size between Type2 and Type3 clones, emphasizes the existence of just two classes of PNH presentations based on Type3 clone size, depicts an asymmetric cellular composition of PNH clones, and documents the possible occurrence of changes in clone size during the follow-up.
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23
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Sustained clonal hematopoiesis by HLA-lacking hematopoietic stem cells without driver mutations in aplastic anemia. Blood Adv 2019; 2:1000-1012. [PMID: 29720492 DOI: 10.1182/bloodadvances.2017013953] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2017] [Accepted: 04/07/2018] [Indexed: 11/20/2022] Open
Abstract
Clonal hematopoiesis by hematopoietic stem progenitor cells (HSPCs) that lack an HLA class I allele (HLA- HSPCs) is common in patients with acquired aplastic anemia (AA); however, it remains unknown whether the cytotoxic T lymphocyte (CTL) attack that allows for survival of HLA- HSPCs is directed at nonmutated HSPCs or HSPCs with somatic mutations or how escaped HLA- HSPC clones support sustained hematopoiesis. We investigated the presence of somatic mutations in HLA- granulocytes obtained from 15 AA patients in long-term remission (median, 13 years; range, 2-30 years). Targeted sequencing of HLA- granulocytes revealed somatic mutations (DNMT3A, n = 2; TET2, ZRSR2, and CBL, n = 1) in 3 elderly patients between 79 and 92 years of age, but not in 12 other patients aged 27 to 74 years (median, 51.5 years). The chronological and clonogenic analyses of the 3 cases revealed that ZRSR2 mutation in 1 case, which occurred in an HLA- HSPC with a DNMT3A mutation, was the only mutation associated with expansion of the HSPC clone. Whole-exome sequencing of the sorted HLA- granulocytes confirmed the absence of any driver mutations in 5 patients who had a particularly large loss of heterozygosity in chromosome 6p (6pLOH) clone size. Flow-fluorescence in situ hybridization analyses of sorted HLA+ and HLA- granulocytes showed no telomere attrition in HLA- granulocytes. The findings suggest that HLA- HSPC clones that escape CTL attack are essentially free from somatic mutations related to myeloid malignancies and are able to support long-term clonal hematopoiesis without developing driver mutations in AA patients unless HLA loss occurs in HSPCs with somatic mutations.
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Independent Paroxysmal Nocturnal Hemoglobinuria and Myelodysplastic Syndrome Clones in a Patient With Complete Bone Marrow Failure. Hemasphere 2018; 2:e142. [PMID: 30887006 PMCID: PMC6407802 DOI: 10.1097/hs9.0000000000000142] [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: 11/26/2022] Open
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25
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Hosokawa K, Sugimori C, Ishiyama K, Takamatsu H, Noji H, Shichishima T, Obara N, Chiba S, Ninomiya H, Shirasugi Y, Nakamura Y, Ando K, Ueda Y, Yonemura Y, Kawaguchi T, Nishimura JI, Kanakura Y, Nakao S. Establishment of a flow cytometry assay for detecting paroxysmal nocturnal hemoglobinuria-type cells specific to patients with bone marrow failure. Ann Hematol 2018; 97:2289-2297. [PMID: 30039297 DOI: 10.1007/s00277-018-3443-1] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2017] [Accepted: 07/13/2018] [Indexed: 10/28/2022]
Abstract
Minor populations of glycosylphosphatidylinositol-anchored protein-deficient (GPI[-]) cells in the peripheral blood may have a prognostic value in bone marrow failure (BMF). Our objective is to establish the optimal flow cytometry (FCM) assay that can discriminate GPI(-) populations specific to BMF from those of healthy individuals. To identify a cut-off that discriminates GPI(-) rare cells from GPI(+) cells, we determined a position of the borderline that separates the GPI(-) from GPI(+) cells on a scattergram by testing more than 30 healthy individuals, such that no GPI(-) dot fell into the upper left quadrant where fluorescein-labeled aerolysin (FLAER)-CD11b+ granulocytes and CD55-CD59- glycophorin A+ erythrocytes were positioned. This method allowed us to define ≥ 0.003% CD11b+FLAER- granulocytes and ≥ 0.005% glycophorin A+CD55-CD59- erythrocytes to be specific to BMF patients. Longitudinal cross-validation studies showed minimal (< 0.02%) inter-laboratory differences in the GPI(-) cell percentage. An analysis of 1210 patients with BMF revealed a GPI(-) cell population in 56.3% of patients with aplastic anemia and 18.5% of patients with myelodysplastic syndrome. The GPI(-) granulocyte percentages was 0.003-0.01% in 3.7% of patients. This FCM assay effectively identified an increase in the percentage of GPI(-) rare cells that are specific to BMF patients and allowed different laboratories to accurately detect 0.003-0.01% of pathological GPI(-) cells.
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Affiliation(s)
- Kohei Hosokawa
- Department of Hematology and Respirology, Kanazawa University, 13-1 Takaramachi, Kanazawa, Ishikawa, 920-8641, Japan.,Japan PNH Study Group, Tokyo, Japan
| | - Chiharu Sugimori
- Japan PNH Study Group, Tokyo, Japan.,Department of Hematology, Ishikawa Prefectural Central Hospital, Ishikawa, Japan
| | - Ken Ishiyama
- Department of Hematology and Respirology, Kanazawa University, 13-1 Takaramachi, Kanazawa, Ishikawa, 920-8641, Japan.,Japan PNH Study Group, Tokyo, Japan
| | - Hiroyuki Takamatsu
- Department of Hematology and Respirology, Kanazawa University, 13-1 Takaramachi, Kanazawa, Ishikawa, 920-8641, Japan.,Japan PNH Study Group, Tokyo, Japan
| | - Hideyoshi Noji
- Japan PNH Study Group, Tokyo, Japan.,Department of Hematology, Fukushima Medical University, Fukushima, Japan
| | - Tsutomu Shichishima
- Japan PNH Study Group, Tokyo, Japan.,Department of Hematology, Fukushima Medical University, Fukushima, Japan
| | - Naoshi Obara
- Japan PNH Study Group, Tokyo, Japan.,Department of Hematology, Faculty of Medicine, University of Tsukuba, Tsukuba, Japan
| | - Shigeru Chiba
- Japan PNH Study Group, Tokyo, Japan.,Department of Hematology, Faculty of Medicine, University of Tsukuba, Tsukuba, Japan
| | - Haruhiko Ninomiya
- Japan PNH Study Group, Tokyo, Japan.,Department of Medical Sciences, Faculty of Medicine, University of Tsukuba, Tsukuba, Japan
| | - Yukari Shirasugi
- Japan PNH Study Group, Tokyo, Japan.,Department of Hematology and Oncology, Tokai University, Tokai, Japan
| | - Yoshihiko Nakamura
- Japan PNH Study Group, Tokyo, Japan.,Department of Hematology and Oncology, Tokai University, Tokai, Japan
| | - Kiyoshi Ando
- Japan PNH Study Group, Tokyo, Japan.,Department of Hematology and Oncology, Tokai University, Tokai, Japan
| | - Yasutaka Ueda
- Japan PNH Study Group, Tokyo, Japan.,Department of Hematology and Oncology, Osaka University, Osaka, Japan
| | - Yuji Yonemura
- Japan PNH Study Group, Tokyo, Japan.,Department of Hematology and Infectious Diseases, Kumamoto University, Kumamoto, Japan
| | - Tatsuya Kawaguchi
- Japan PNH Study Group, Tokyo, Japan.,Department of Hematology and Infectious Diseases, Kumamoto University, Kumamoto, Japan
| | - Jun-Ichi Nishimura
- Japan PNH Study Group, Tokyo, Japan.,Department of Hematology and Oncology, Osaka University, Osaka, Japan
| | - Yuzuru Kanakura
- Japan PNH Study Group, Tokyo, Japan.,Department of Hematology and Oncology, Osaka University, Osaka, Japan
| | - Shinji Nakao
- Department of Hematology and Respirology, Kanazawa University, 13-1 Takaramachi, Kanazawa, Ishikawa, 920-8641, Japan. .,Japan PNH Study Group, Tokyo, Japan.
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Abstract
Aplastic anemia (AA) is an immune-mediated disorder that overlaps closely with clonal disorders, such as myelodysplastic syndrome and paroxysmal nocturnal hemoglobinuria (PNH). PIGA mutations in PNH clones and functional loss of HLA, including structural HLA mutations, likely represent immune escape clones and correlate with response to immunosuppressive therapy (IST). Somatic mutations typical for myeloid malignancies and age-related clonal hematopoiesis are detected in a proportion of AA patients, but their significance is unclear and seems to depend on whether patients are tested at diagnosis or after IST, patient age and ethnicity, and the methodology of molecular testing used.
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Affiliation(s)
- Ghulam J Mufti
- Department of Haematological Medicine, King's College Hospital, King's College London, Denmark Hill, London SE59RS, UK
| | - Judith C W Marsh
- Department of Haematological Medicine, King's College Hospital, King's College London, Denmark Hill, London SE59RS, UK.
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27
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Blaha J, Schwarz K, Fischer C, Schauwecker P, Höchsmann B, Schrezenmeier H, Anliker M. The Monoclonal Anti-CD157 Antibody Clone SY11B5, Used for High Sensitivity Detection of PNH Clones on WBCs, Fails to Detect a Common Polymorphic Variant Encoded byBST-1. CYTOMETRY PART B-CLINICAL CYTOMETRY 2018; 94:652-659. [DOI: 10.1002/cyto.b.21625] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/10/2017] [Revised: 12/28/2017] [Accepted: 01/08/2018] [Indexed: 12/27/2022]
Affiliation(s)
- Johanna Blaha
- Institute for Transfusion Medicine; University of Ulm; Ulm Germany
| | - Klaus Schwarz
- Institute for Transfusion Medicine; University of Ulm; Ulm Germany
- Institute for Clinical Transfusion Medicine and Immunogenetics Ulm; German Red Cross Blood Service Baden-Württemberg-Hessen; Ulm Germany
| | - Claudia Fischer
- Institute for Clinical Transfusion Medicine and Immunogenetics Ulm; German Red Cross Blood Service Baden-Württemberg-Hessen; Ulm Germany
| | - Peter Schauwecker
- Institute for Clinical Transfusion Medicine and Immunogenetics Ulm; German Red Cross Blood Service Baden-Württemberg-Hessen; Ulm Germany
| | - Britta Höchsmann
- Institute for Transfusion Medicine; University of Ulm; Ulm Germany
- Institute for Clinical Transfusion Medicine and Immunogenetics Ulm; German Red Cross Blood Service Baden-Württemberg-Hessen; Ulm Germany
| | - Hubert Schrezenmeier
- Institute for Transfusion Medicine; University of Ulm; Ulm Germany
- Institute for Clinical Transfusion Medicine and Immunogenetics Ulm; German Red Cross Blood Service Baden-Württemberg-Hessen; Ulm Germany
| | - Markus Anliker
- Institute for Clinical Transfusion Medicine and Immunogenetics Ulm; German Red Cross Blood Service Baden-Württemberg-Hessen; Ulm Germany
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28
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Manivannan P, Ahuja A, Pati HP. Diagnosis of Paroxysmal Nocturnal Hemoglobinuria: Recent Advances. Indian J Hematol Blood Transfus 2017; 33:453-462. [PMID: 29075054 PMCID: PMC5640555 DOI: 10.1007/s12288-017-0868-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2017] [Accepted: 08/21/2017] [Indexed: 11/29/2022] Open
Abstract
Paroxysmal nocturnal hemoglobinuria (PNH) is an acquired clonal hematopoietic stem cell disorder with its protean clinical manifestations. This is due to partial or complete absence of 'glycophosphatidyl-inositol-anchor proteins' (GPI-AP). The main aim of this review is to highlight various diagnostic modalities available, basic principle of each test and recent advances in the diagnosis of PNH. Recently among various tests available, the flow cytometry has become 'the gold standard' for PNH testing. In order to overcome the difficulties encountered by the testing and research laboratories throughout the world, International Clinical Cytometry Society has come up with guidelines regarding the indications for testing, protocol for sample collection, processing, panel of antibodies as well as gating strategies to be used, how to interpret the test and reporting format to be used. It is essential to test at least two GPI-linked markers on at least two different lineages particularly on red cells and granulocytes/monocytes. The fluorescent aerolysin combined with other monoclonal antibodies in multicolour flow cytometry offered an improved assay not only for diagnosis but also for monitoring of PNH clones. It is equally important to diagnose this rare entity with high index of suspicion.
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Affiliation(s)
| | - Ankur Ahuja
- Department of Laboratory Services, Army Hospital for Research and Referral, New Delhi, India
| | - Hara Prasad Pati
- Department of Hematology, All India Institute of Medical Sciences (AIIMS), New Delhi, India
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29
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Lee SE, Park SS, Jeon YW, Yoon JH, Cho BS, Eom KS, Kim YJ, Lee S, Min CK, Kim HJ, Cho SG, Kim DW, Min WS, Lee JW. Outcomes of allogeneic stem cell transplantation in patients with paroxysmal nocturnal hemoglobinuria with or without aplastic anemia. Eur J Haematol 2017; 99:336-343. [PMID: 28675769 DOI: 10.1111/ejh.12922] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/29/2017] [Indexed: 11/27/2022]
Abstract
OBJECTIVE The aim of this study was to evaluate the long-term outcomes of allogeneic stem cell transplantation (SCT) in patients with paroxysmal nocturnal hemoglobinuria (PNH) with or without aplastic anemia (AA). METHOD A total of 33 patients with PNH clones who underwent allogeneic SCT were analyzed. RESULTS After a median follow-up of 57 months (range, 6.0-151.3), the 5-year estimated overall survival rate was 87.9±5.7%. Four patients died of transplant-related mortality (TRM). With the exception of one patient with early TRM, 32 patients were engrafted. Two patients who had developed delayed GF received a second transplant and recovered. The cumulative incidences of acute graft-vs-host disease (GVHD) (≥grade II) and chronic GVHD (≥moderate) were 27.3±7.9% and 18.7±7.0%, respectively. Twenty-one patients receiving SCT with reduced-intensity conditioning (RIC) had available follow-up data for PNH cell population for the first 6 months post-transplant. Analysis of these data revealed that the PNH clones disappeared within approximately 2 months. CONCLUSION RIC regimen was sufficient to eradicate PNH clones with sustained donor-type engraftment after allogeneic SCT. Therefore, application of allogeneic SCT with RIC should be considered in patients with PNH, in accordance with the severity of the underlying bone marrow failure.
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Affiliation(s)
- Sung-Eun Lee
- Department of Hematology, Catholic Blood and Marrow Transplantation Center, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Sung Soo Park
- Department of Hematology, Catholic Blood and Marrow Transplantation Center, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Young-Woo Jeon
- Department of Hematology, Catholic Blood and Marrow Transplantation Center, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Jae-Ho Yoon
- Department of Hematology, Catholic Blood and Marrow Transplantation Center, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Byung-Sik Cho
- Department of Hematology, Catholic Blood and Marrow Transplantation Center, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Ki-Sung Eom
- Department of Hematology, Catholic Blood and Marrow Transplantation Center, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Yoo-Jin Kim
- Department of Hematology, Catholic Blood and Marrow Transplantation Center, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Seok Lee
- Department of Hematology, Catholic Blood and Marrow Transplantation Center, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Chang-Ki Min
- Department of Hematology, Catholic Blood and Marrow Transplantation Center, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Hee-Je Kim
- Department of Hematology, Catholic Blood and Marrow Transplantation Center, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Seok-Goo Cho
- Department of Hematology, Catholic Blood and Marrow Transplantation Center, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Dong-Wook Kim
- Department of Hematology, Catholic Blood and Marrow Transplantation Center, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Woo-Sung Min
- Department of Hematology, Catholic Blood and Marrow Transplantation Center, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Jong Wook Lee
- Department of Hematology, Catholic Blood and Marrow Transplantation Center, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
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30
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Narita A, Muramatsu H, Okuno Y, Sekiya Y, Suzuki K, Hamada M, Kataoka S, Ichikawa D, Taniguchi R, Murakami N, Kojima D, Nishikawa E, Kawashima N, Nishio N, Hama A, Takahashi Y, Kojima S. Development of clinical paroxysmal nocturnal haemoglobinuria in children with aplastic anaemia. Br J Haematol 2017. [PMID: 28643364 DOI: 10.1111/bjh.14790] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
The clinical significance of paroxysmal nocturnal haemoglobinuria (PNH) in children with aplastic anaemia (AA) remains unclear. We retrospectively studied 57 children with AA between 1992 and 2010. During the follow-up, five patients developed clinical PNH, in whom somatic PIGA mutations were detected by targeted sequencing. The 10-year probability of clinical PNH development was 10·2% (95% confidence interval, 3·6-20·7%). Furthermore, the detection of minor PNH clones by flow cytometry at AA diagnosis was a risk factor for the subsequent development of clinical PNH. These patients with PNH clones at AA diagnosis should undergo periodic monitoring for potential clinical PNH development.
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Affiliation(s)
- Atsushi Narita
- Department of Paediatrics, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Hideki Muramatsu
- Department of Paediatrics, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Yusuke Okuno
- Department of Paediatrics, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Yuko Sekiya
- Department of Paediatrics, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Kyogo Suzuki
- Department of Paediatrics, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Motoharu Hamada
- Department of Paediatrics, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Shinsuke Kataoka
- Department of Paediatrics, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Daisuke Ichikawa
- Department of Paediatrics, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Rieko Taniguchi
- Department of Paediatrics, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Norihiro Murakami
- Department of Paediatrics, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Daiei Kojima
- Department of Paediatrics, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Eri Nishikawa
- Department of Paediatrics, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Nozomu Kawashima
- Department of Paediatrics, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Nobuhiro Nishio
- Department of Paediatrics, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Asahito Hama
- Department of Paediatrics, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Yoshiyuki Takahashi
- Department of Paediatrics, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Seiji Kojima
- Department of Paediatrics, Nagoya University Graduate School of Medicine, Nagoya, Japan
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31
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Rahman K, Gupta R, Yadav G, Husein N, Singh MK, Nityanand S. Fluorescent Aerolysin (FLAER)-based paroxysmal nocturnal hemoglobinuria (PNH) screening: a single center experience from India. Int J Lab Hematol 2017; 39:261-271. [DOI: 10.1111/ijlh.12619] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2016] [Accepted: 11/21/2016] [Indexed: 01/19/2023]
Affiliation(s)
- K. Rahman
- Department of Hematology; SGPGI; Lucknow India
| | - R. Gupta
- Department of Hematology; SGPGI; Lucknow India
| | - G. Yadav
- Department of Hematology; SGPGI; Lucknow India
| | - N. Husein
- Department of Hematology; SGPGI; Lucknow India
| | - M. K. Singh
- Department of Hematology; SGPGI; Lucknow India
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32
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Glycosylphosphatidylinositol-specific T cells, IFN-γ-producing T cells, and pathogenesis of idiopathic aplastic anemia. Blood 2017; 129:388-392. [DOI: 10.1182/blood-2016-09-740845] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
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33
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Parker CJ. Update on the diagnosis and management of paroxysmal nocturnal hemoglobinuria. HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2016; 2016:208-216. [PMID: 27913482 PMCID: PMC6142517 DOI: 10.1182/asheducation-2016.1.208] [Citation(s) in RCA: 65] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/04/2023]
Abstract
Once suspected, the diagnosis of paroxysmal nocturnal hemoglobinuria (PNH) is straightforward when flow cytometric analysis of the peripheral blood reveals a population of glycosyl phosphatidylinositol anchor protein-deficient cells. But PNH is clinically heterogeneous, with some patients having a disease process characterized by florid intravascular, complement-mediated hemolysis, whereas in others, bone marrow failure dominates the clinical picture with modest or even no evidence of hemolysis observed. The clinical heterogeneity is due to the close, though incompletely understood, relationship between PNH and immune-mediated bone marrow failure, and that PNH is an acquired, nonmalignant clonal disease of the hematopoietic stem cells. Bone marrow failure complicates management of PNH because compromised erythropoiesis contributes, to a greater or lesser degree, to the anemia; in addition, the extent to which the mutant stem cell clone expands in an individual patient determines the magnitude of the hemolytic component of the disease. An understanding of the unique pathobiology of PNH in relationship both to complement physiology and immune-mediated bone marrow failure provides the basis for a systematic approach to management.
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Affiliation(s)
- Charles J Parker
- Division of Hematology and Hematologic Malignancies, Department of Medicine, University of Utah School of Medicine, Salt Lake City, UT
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34
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Nakao S. Diagnostic problems in acquired bone marrow failure syndromes. Int J Hematol 2016; 104:151-2. [DOI: 10.1007/s12185-016-2057-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2016] [Revised: 06/28/2016] [Accepted: 06/28/2016] [Indexed: 10/21/2022]
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35
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Saito C, Ishiyama K, Yamazaki H, Zaimoku Y, Nakao S. Hypomegakaryocytic thrombocytopenia (HMT): an immune-mediated bone marrow failure characterized by an increased number of PNH-phenotype cells and high plasma thrombopoietin levels. Br J Haematol 2016; 175:246-251. [PMID: 27351867 DOI: 10.1111/bjh.14210] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2016] [Accepted: 05/04/2016] [Indexed: 01/29/2023]
Abstract
Patients with mild hypomegakaryocytic thrombocytopenia (HMT) that does not meet the diagnostic criteria for a definite disease entity may potentially progress to aplastic anaemia (AA) that is refractory to therapy. To clarify the clinical picture of HMT, we prospectively followed 25 HMT patients with white blood cell count >3·0 × 109 /l, haemoglobin level >100 g/l and platelet count of <100·0 × 109 /l in the absence of morphological and karyotypic abnormalities in the bone marrow. Glycosylphosphatidylinositol-anchored protein-deficient blood cells [paroxysmal nocturnal haemoglobinuria (PNH)-type cells] were detected in 7 of the 25 (28%) patients and elevated plasma thrombopoietin (TPO, also termed THPO) levels (>320 pg/ml) were observed in 11 (44%) patients. Five (four PNH+ and one PNH-) of six TPOhigh patients who were treated with ciclosporin (CsA) showed improvement. Among the 21 patients who were followed without treatment, thrombocytopenia progressed in four of ten TPOlow patients and four of 11 TPOhigh patients. The 3-year failure-free survival rate of the CsA-treated TPOhigh patients (100%) was significantly higher than that of the untreated TPOhigh patients (20%). These results suggest that a significant population of HMT patients has an immune pathophysiology that is similar to AA and may be improved by early therapeutic intervention with CsA.
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Affiliation(s)
- Chizuru Saito
- Department of Haematology, Kanazawa University Hospital, Kanazawa, Japan
| | - Ken Ishiyama
- Department of Haematology, Kanazawa University Hospital, Kanazawa, Japan
| | - Hirohito Yamazaki
- Division of Transfusion Medicine, Kanazawa University Hospital, Kanazawa, Japan
| | - Yoshitaka Zaimoku
- Division of Transfusion Medicine, Kanazawa University Hospital, Kanazawa, Japan.,Cellular Transplantation Biology, Kanazawa University Graduate School of Medical Science, Kanazawa, Japan
| | - Shinji Nakao
- Cellular Transplantation Biology, Kanazawa University Graduate School of Medical Science, Kanazawa, Japan.
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36
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Damianaki A, Stagakis E, Mavroudi I, Spanoudakis M, Koutala H, Papadogiannis F, Kanellou P, Pontikoglou C, Papadaki HA. Minor populations of paroxysmal nocturnal hemoglobinuria-type cells in patients with chronic idiopathic neutropenia. Eur J Haematol 2016; 97:538-546. [PMID: 27124520 DOI: 10.1111/ejh.12766] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/25/2016] [Indexed: 12/21/2022]
Abstract
Chronic idiopathic neutropenia (CIN) is an acquired disorder of granulopoiesis characterized by increased apoptosis of the bone marrow (BM) granulocytic progenitor cells under the influence of pro-inflammatory mediators and oligoclonal/monoclonal T-lymphocytes. Because patients with immune-mediated BM failure display frequently paroxysmal nocturnal hemoglobinuria (PNH)-type cells in the peripheral blood (PB), we investigated the possible existence of PNH-type cells in 91 patients with CIN using flow cytometry. The patients displayed increased proportions of PNH-type glycophorin A+ /CD59dim and glycophorin A+ /CD59- red blood cells (RBCs), FLAER- /CD24- granulocytes, and FLAER- /CD14- monocytes, compared to controls (n = 55). A positive correlation was found between the proportions of PNH-type RBCs, granulocytes, and monocytes and an inverse correlation between the number of PB neutrophils and the proportions of PNH-type cell populations. The number of patients, displaying percentages of PNH-type cells above the highest percentage observed in the control group, was significantly increased among patients with skewed compared to those with normal T-cell receptor repertoire suggesting that T-cell-mediated immune processes underlie the emergence of PNH-type cells in CIN. Our findings suggest that patients with CIN display PNH-type cells in the PB at a high frequency corroborating the hypothesis that CIN belongs to the immune-mediated BM failure syndromes.
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Affiliation(s)
- Athina Damianaki
- Department of Hematology, University of Crete School of Medicine, Heraklion, Greece
| | - Elias Stagakis
- Department of Hematology, University of Crete School of Medicine, Heraklion, Greece
| | - Irene Mavroudi
- Department of Hematology, University of Crete School of Medicine, Heraklion, Greece
| | - Michael Spanoudakis
- Department of Hematology, University of Crete School of Medicine, Heraklion, Greece
| | - Helen Koutala
- Department of Hematology, University of Crete School of Medicine, Heraklion, Greece
| | - Fotios Papadogiannis
- Department of Hematology, University of Crete School of Medicine, Heraklion, Greece
| | - Peggy Kanellou
- Department of Hematology, University of Crete School of Medicine, Heraklion, Greece
| | | | - Helen A Papadaki
- Department of Hematology, University of Crete School of Medicine, Heraklion, Greece
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Clonal hematopoiesis in acquired aplastic anemia. Blood 2016; 128:337-47. [PMID: 27121470 DOI: 10.1182/blood-2016-01-636381] [Citation(s) in RCA: 124] [Impact Index Per Article: 15.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2016] [Accepted: 04/20/2016] [Indexed: 11/20/2022] Open
Abstract
Clonal hematopoiesis (CH) in aplastic anemia (AA) has been closely linked to the evolution of late clonal disorders, including paroxysmal nocturnal hemoglobinuria and myelodysplastic syndromes (MDS)/acute myeloid leukemia (AML), which are common complications after successful immunosuppressive therapy (IST). With the advent of high-throughput sequencing of recent years, the molecular aspect of CH in AA has been clarified by comprehensive detection of somatic mutations that drive clonal evolution. Genetic abnormalities are found in ∼50% of patients with AA and, except for PIGA mutations and copy-neutral loss-of-heterozygosity, or uniparental disomy (UPD) in 6p (6pUPD), are most frequently represented by mutations involving genes commonly mutated in myeloid malignancies, including DNMT3A, ASXL1, and BCOR/BCORL1 Mutations exhibit distinct chronological profiles and clinical impacts. BCOR/BCORL1 and PIGA mutations tend to disappear or show stable clone size and predict a better response to IST and a significantly better clinical outcome compared with mutations in DNMT3A, ASXL1, and other genes, which are likely to increase their clone size, are associated with a faster progression to MDS/AML, and predict an unfavorable survival. High frequency of 6pUPD and overrepresentation of PIGA and BCOR/BCORL1 mutations are unique to AA, suggesting the role of autoimmunity in clonal selection. By contrast, DNMT3A and ASXL1 mutations, also commonly seen in CH in the general population, indicate a close link to CH in the aged bone marrow, in terms of the mechanism for selection. Detection and close monitoring of somatic mutations/evolution may help with prediction and diagnosis of clonal evolution of MDS/AML and better management of patients with AA.
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Mohammed AA, El-Tanni H, Atiah TAM, Atiah AAM, Atiah MAM, Rasmy AA. Paroxysmal Nocturnal Hemoglobinuria: From Bench to Bed. Indian J Hematol Blood Transfus 2016; 32:383-391. [PMID: 27812245 DOI: 10.1007/s12288-016-0654-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2015] [Accepted: 02/02/2016] [Indexed: 12/30/2022] Open
Abstract
Paroxysmal nocturnal hemoglobinuria (PNH) is an acquired hemolytic anemia with highly variable clinical symptoms making the diagnosis and prediction of its outcome difficult. It is caused by the expansion of a hematopoietic progenitor cell that has acquired a mutation in the X-linked phosphatidylinositol glycan class A (PIGA) gene that results in deficiency of the glycosylphosphatidylinositol anchor structure responsible for fixing a wide spectrum of proteins particularly CD55 and CD59. The clinical features of this disease arise as a result of complement-mediated hemolysis in unprotected red cells, leukocytes, and platelets as well as the release of free hemoglobin. Patients may present with a variety of clinical manifestations, such as anemia, thrombosis, kidney disease, smooth muscle dystonias, abdominal pain, dyspnea, and extreme fatigue. PNH is an outstanding example of how an increased understanding of pathophysiology may directly improve clinical symptoms and treat disease-associated complications when we inhibit the terminal complement cascade. This topic will discuss PNH overview to assist specialists looking after PNH patients.
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Affiliation(s)
- Amrallah A Mohammed
- Medical Oncology Department, Faculty of Medicine, Zagazig University, Zagazig, Egypt ; Oncology Center, King Abdullah Medical City-Holy Capital, Makkah, Saudi Arabia ; Muzdallifa Street, P.O. Box 57657, Makkah, 21995 Saudi Arabia
| | - Hani El-Tanni
- Oncology Center, King Abdullah Medical City-Holy Capital, Makkah, Saudi Arabia
| | | | | | | | - Ayman A Rasmy
- Medical Oncology Department, Faculty of Medicine, Zagazig University, Zagazig, Egypt
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Sreedharanunni S, Sachdeva MUS, Bose P, Varma N, Bansal D, Trehan A. Frequency of Paroxysmal Nocturnal Hemoglobinuria Clones by Multiparametric Flow Cytometry in Pediatric Aplastic Anemia Patients of Indian Ethnic Origin. Pediatr Blood Cancer 2016; 63:93-7. [PMID: 26230286 DOI: 10.1002/pbc.25691] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2015] [Accepted: 07/13/2015] [Indexed: 11/06/2022]
Abstract
BACKGROUND The literature on paroxysmal nocturnal hemoglobinuria (PNH) in aplastic anemia (AA) is largely focused on adults with few studies in children. Moreover, large studies are conspicuously absent from developing countries. Knowledge of the prevalence and utility of their detection is required before widespread use of PNH screening in pediatric AA in resource-limited settings. METHODS We performed a retrospective audit over a period of 9 years to study the prevalence of PNH clones by flow cytometry (FCM) in children ≤12 years of age presenting with AA, and analyzed their response to immunosuppressant therapy. RESULTS Nine (12.9%) out of 70 patients had PNH clones comprising >1% of the target cell population, including five patients (7.14%) with PNH clone size >10%. The clone size in monocytes ranged from 3.7% to 95.2% (median 21.1%) and in neutrophils from 1.6% to 87.6% (median 19.5%). Fluorescent aerolysin (FLAER)-based FCM screening significantly improved the detection of PNH clones compared to non-FLAER based screening techniques (18.4% vs. 6.25%). One child showed chronic intravascular hemolysis and another developed arterial stroke during the course of illness. None of our PNH-positive AA patients tested for chromosome breakage studies (n = 8) showed increased clastrogen-induced breakage. CONCLUSIONS A lower frequency but moderate/large-sized PNH clones were seen in our pediatric AA population, compared to western data. FLAER-based FCM screening significantly improved the detection of PNH clones. We recommend routine FLAER-based screening of PNH in pediatric AA patients.
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Affiliation(s)
- Sreejesh Sreedharanunni
- Department of Hematology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Man Updesh Singh Sachdeva
- Department of Hematology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Parveen Bose
- Department of Hematology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Neelam Varma
- Department of Hematology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Deepak Bansal
- Hematology/Oncology Unit, Advanced Pediatric Center, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Amita Trehan
- Hematology/Oncology Unit, Advanced Pediatric Center, Postgraduate Institute of Medical Education and Research, Chandigarh, India
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Debliquis A, Wagner-Ballon O, Le Garff-Tavernier M, Fossat C, Chatelain B, Letestu R. Evaluation of paroxysmal nocturnal hemoglobinuria screening by flow cytometry through multicentric interlaboratory comparison in four countries. Am J Clin Pathol 2015; 144:858-68. [PMID: 26572992 DOI: 10.1309/ajcpwmwj7xdnq3sn] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022] Open
Abstract
OBJECTIVES Paroxysmal nocturnal hemoglobinuria (PNH) is currently diagnosed by flow cytometry; although highly sensitive, its interpretation and reporting appear as critical as its technique. Thus, we developed a quality control scheme for the French-speaking region based on the international recommendations for PNH screening. METHODS After a topical workshop, we proposed a 1-year, two-step survey program to any volunteering French-speaking clinical laboratory. The first survey consisted of sending raw data files to evaluate gating and the interpretation strategy of each center. The second stipulated sending fresh whole-blood samples to evaluate the whole process and its practice. RESULTS Forty-nine participants from voluntary centers returned results for each of the two successive surveys. On virtual survey, 27% reported false-positive PNH created by immature granulocytes, whereas the minor PNH clone was not detected by 9%. On fresh survey, 63% of centers used at least the same six-color combination (CD24, CD14, CD33, CD15, CD45, and fluorescent aerolysin), and nearly 70% of participants were able to perform a sensitivity test less than 0.1% on neutrophils. All participants detected the major PNH clone, yet 16% returned false-positive results for the non-PNH clone case. CONCLUSIONS We succeeded in rallying numerous French-speaking clinical laboratories for both surveys and in harmonizing the technical practice by highlighting common pitfalls.
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Hirokawa M, Fujishima N, Omokawa A, Ueki S. [Anemia: From Basic Knowledge to Up-to-Date Treatment. Topics: VI. Pathophysiology and management of aplastic anemia and pure red cell aplasia]. ACTA ACUST UNITED AC 2015; 104:1405-13. [PMID: 26513960 DOI: 10.2169/naika.104.1405] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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Hosokawa K, Sugimori N, Katagiri T, Sasaki Y, Saito C, Seiki Y, Mochizuki K, Yamazaki H, Takami A, Nakao S. Increased glycosylphosphatidylinositol-anchored protein-deficient granulocytes define a benign subset of bone marrow failures in patients with trisomy 8. Eur J Haematol 2015; 95:230-8. [PMID: 25404431 DOI: 10.1111/ejh.12484] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/13/2014] [Indexed: 01/23/2023]
Abstract
Trisomy 8 (+8), one of the most common chromosomal abnormalities found in patients with myelodysplastic syndromes (MDS), is occasionally seen in patients with otherwise typical aplastic anemia (AA). Although some studies have indicated that the presence of +8 is associated with the immune pathophysiology of bone marrow (BM) failure, its pathophysiology may be heterogeneous. We studied 53 patients (22 with AA and 31 with low-risk MDS) with +8 for the presence of increased glycosylphosphatidylinositol-anchored protein-deficient (GPI-AP(-) ) cells, their response to immunosuppressive therapy (IST), and their prognosis. A significant increase in the percentage of GPI-AP(-) cells was found in 14 (26%) of the 53 patients. Of the 26 patients who received IST, including nine with increased GPI-AP(-) cells and 17 without increased GPI-AP(-) cells, 14 (88% with increased GPI-AP(-) cells and 41% without increased GPI-AP(-) cells) improved. The overall and event-free survival rates of the +8 patients with and without increased GPI-AP(-) cells at 5 yr were 100% and 100% and 59% and 57%, respectively. Examining the peripheral blood for the presence of increased GPI-AP(-) cells may thus be helpful for choosing the optimal treatment for +8 patients with AA or low-risk MDS.
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Affiliation(s)
- Kohei Hosokawa
- Cellular Transplantation Biology, Kanazawa University Graduate School of Medical Science, Kanazawa, Japan
| | - Naomi Sugimori
- Cellular Transplantation Biology, Kanazawa University Graduate School of Medical Science, Kanazawa, Japan
| | - Takamasa Katagiri
- Clinical Laboratory Science, Kanazawa University Graduate School of Medical Science, Kanazawa, Japan
| | - Yumi Sasaki
- Cellular Transplantation Biology, Kanazawa University Graduate School of Medical Science, Kanazawa, Japan
| | - Chizuru Saito
- Cellular Transplantation Biology, Kanazawa University Graduate School of Medical Science, Kanazawa, Japan
| | - Yu Seiki
- Cellular Transplantation Biology, Kanazawa University Graduate School of Medical Science, Kanazawa, Japan
| | - Kanako Mochizuki
- Cellular Transplantation Biology, Kanazawa University Graduate School of Medical Science, Kanazawa, Japan
| | - Hirohito Yamazaki
- Cellular Transplantation Biology, Kanazawa University Graduate School of Medical Science, Kanazawa, Japan
| | - Akiyoshi Takami
- Cellular Transplantation Biology, Kanazawa University Graduate School of Medical Science, Kanazawa, Japan
| | - Shinji Nakao
- Cellular Transplantation Biology, Kanazawa University Graduate School of Medical Science, Kanazawa, Japan
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Liew M, Farley M, Andreasen J, Parker CJ, Wittwer CT. Rare event counting of CD59− red cells in human blood: A 47-month experience using PNH consensus guidelines for WBC and RBC testing in a reference lab. CYTOMETRY PART B-CLINICAL CYTOMETRY 2015; 88:261-9. [DOI: 10.1002/cyto.b.21225] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/01/2014] [Revised: 01/07/2015] [Accepted: 01/15/2015] [Indexed: 11/11/2022]
Affiliation(s)
- Michael Liew
- Institute for Clinical and Experimental Pathology, ARUP Laboratories; Salt Lake City Utah 84108
| | - Marjorie Farley
- Institute for Clinical and Experimental Pathology, ARUP Laboratories; Salt Lake City Utah 84108
| | - John Andreasen
- Institute for Clinical and Experimental Pathology, ARUP Laboratories; Salt Lake City Utah 84108
| | - Charles J. Parker
- Division of Hematology; Department of Internal Medicine; University of Utah School of Medicine; Salt Lake City Utah 84132
| | - Carl T. Wittwer
- Institute for Clinical and Experimental Pathology, ARUP Laboratories; Salt Lake City Utah 84108
- Department of Pathology; University of Utah School of Medicine; Salt Lake City Utah 84132
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Kahng J, Kim Y, Kim JO, Koh K, Lee JW, Han K. A novel marker for screening paroxysmal nocturnal hemoglobinuria using routine complete blood count and cell population data. Ann Lab Med 2015; 35:35-40. [PMID: 25553278 PMCID: PMC4272963 DOI: 10.3343/alm.2015.35.1.35] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2014] [Revised: 11/04/2014] [Accepted: 11/14/2014] [Indexed: 11/19/2022] Open
Abstract
Background Final diagnosis of paroxysmal nocturnal hemoglobinuria (PNH) may take years demanding a quick diagnosis measure. We used the facts that PNH cells are damaged in acid, and reagents for measuring reticulocytes in Coulter DxH800 (Beckman Coulter, USA) are weakly acidic and hypotonic, to create a new PNH screening marker. Methods We analyzed 979 complete blood counts (CBC) data from 963 patients including 57 data from 44 PNH patients. Standard criteria for PNH assay for population selection were followed: flow cytometry for CD55 and CD59 on red blood cells (RBCs) to a detection level of 1%; and fluorescent aerolysin, CD24 and CD15 in granulocytes to 0.1%. Twenty-four PNH minor clone-positive samples (minor-PNH+) were taken, in which the clone population was <5% of RBCs and/or granulocytes. Excluding PNH and minor-PNH+ patients, the population was divided into anemia, malignancy, infection, and normal groups. Parameters exhibiting a distinct demarcation between PNH and non-PNH groups were identified, and each parameter cutoff value was sought that includes the maximum [minimum] number of PNH [non-PNH] patients. Results Cutoff values for 5 selected CBC parameters (MRV, RDWR, MSCV, MN-AL2-NRET, and IRF) were determined. Positive rates were: PNH (86.0%), minor-PNH+ (33.3%), others (5.0%), anemia (13.4%), malignancy (5.3%), infection (3.7%), normal (0.0%); within anemia group, aplastic anemia (40.0%), immune hemolytic anemia (11.1%), iron deficiency anemia (1.6%). Sensitivity (86.0%), specificity (95.0%), PPV (52.1%), and NPV (99.1%) were achieved in PNH screening. Conclusion A new PNH screening marker is proposed with 95% specificity and 86% sensitivity. The flag identifies PNH patients, reducing time to final diagnosis by flow cytometry.
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Affiliation(s)
- Jimin Kahng
- Department of Laboratory Medicine, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Yonggoo Kim
- Department of Laboratory Medicine, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Jung Ok Kim
- Department of Laboratory Medicine, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Kwangsang Koh
- Department of Laboratory Medicine, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Jong Wook Lee
- Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Kyungja Han
- Department of Laboratory Medicine, College of Medicine, The Catholic University of Korea, Seoul, Korea
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Nakao S. [Recent progress of diagnosis and treatment for immune-mediated hematological diseases. Topics: III. Diagnosis and treatment; 6. Aplastic anemia]. ACTA ACUST UNITED AC 2014; 103:1631-8. [PMID: 25154258 DOI: 10.2169/naika.103.1631] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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Timeus F, Crescenzio N, Longoni D, Doria A, Foglia L, Pagliano S, Vallero S, Decimi V, Svahn J, Palumbo G, Ruggiero A, Martire B, Pillon M, Marra N, Dufour C, Ramenghi U, Saracco P. Paroxysmal nocturnal hemoglobinuria clones in children with acquired aplastic anemia: a multicentre study. PLoS One 2014; 9:e101948. [PMID: 25007335 PMCID: PMC4090189 DOI: 10.1371/journal.pone.0101948] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2013] [Accepted: 06/13/2014] [Indexed: 12/12/2022] Open
Abstract
A multicentre study evaluating the presence of glycosil phosphatidyl-inositol (GPI)-negative populations was performed in 85 children with acquired aplastic anemia (AA). A GPI-negative population was observed in 41% of patients at diagnosis, 48% during immune-suppressive therapy (IST), and 45% in patients off-therapy. No association was found between the presence of a GPI-negative population at diagnosis and the response to IST. In addition, the response rate to IST did not differ between the patients who were GPI-positive at diagnosis and later developed GPI-negative populations and the 11 patients who remained GPI-positive. Two patients with a GPI-negative population >10%, and laboratory signs of hemolysis without hemoglobinuria were considered affected by paroxysmal nocturnal hemoglobinuria (PNH) secondary to AA; no thrombotic event was reported. Excluding the 2 patients with a GPI-negative population greater than 10%, we did not observe a significant correlation between LDH levels and GPI-negative population size. In this study monitoring for laboratory signs of hemolysis was sufficient to diagnose PNH in AA patients. The presence of minor GPI-negative populations at diagnosis in our series did not influence the therapeutic response. As occasionally the appearance of a GPI-negative population was observed at cyclosporine (CSA) tapering or AA relapse, a possible role of GPI-negative population monitoring during IST modulation may need further investigation.
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Affiliation(s)
- Fabio Timeus
- Pediatric Onco-Hematology, Regina Margherita Children’s Hospital, Turin, Italy
- Pediatric Hematology, University of Turin, Turin, Italy
- * E-mail:
| | | | - Daniela Longoni
- Pediatric Department MBBM Foundation S. Gerardo Hospital, Monza, Italy
| | | | | | - Sara Pagliano
- Pediatric Hematology, University of Turin, Turin, Italy
| | - Stefano Vallero
- Pediatric Onco-Hematology, Regina Margherita Children’s Hospital, Turin, Italy
| | - Valentina Decimi
- Pediatric Department MBBM Foundation S. Gerardo Hospital, Monza, Italy
| | - Johanna Svahn
- Hematology Unit, G. Gaslini Children’s Hospital, Genoa, Italy
| | - Giuseppe Palumbo
- Pediatric Onco-Hematology Department, Bambin Gesù Children’s Hospital, Rome, Italy
| | | | | | - Marta Pillon
- Pediatric Onco-Hematology Unit, University Hospital of Padua, Padua, Italy
| | - Nicoletta Marra
- Department of Pediatric Haemato-Oncology, Santobono-Pausilipon Hospital, Naples, Italy
| | - Carlo Dufour
- Hematology Unit, G. Gaslini Children’s Hospital, Genoa, Italy
| | - Ugo Ramenghi
- Pediatric Hematology, University of Turin, Turin, Italy
| | - Paola Saracco
- Pediatric Hematology, University of Turin, Turin, Italy
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Nazha A, Jorgensen JL, Verstovsek S. Paroxysmal nocturnal hemoglobinuria is not a cause of anemia in patients with myelofibrosis. Leuk Lymphoma 2014; 55:2215-6. [PMID: 24359246 DOI: 10.3109/10428194.2013.876628] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Affiliation(s)
- Aziz Nazha
- Department of Leukemia, The University of Texas M. D. Anderson Cancer Center , Houston, TX , USA
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Kulagin A, Lisukov I, Ivanova M, Golubovskaya I, Kruchkova I, Bondarenko S, Vavilov V, Stancheva N, Babenko E, Sipol A, Pronkina N, Kozlov V, Afanasyev B. Prognostic value of paroxysmal nocturnal haemoglobinuria clone presence in aplastic anaemia patients treated with combined immunosuppression: results of two-centre prospective study. Br J Haematol 2013; 164:546-54. [DOI: 10.1111/bjh.12661] [Citation(s) in RCA: 71] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2013] [Accepted: 10/09/2013] [Indexed: 11/29/2022]
Affiliation(s)
- Alexander Kulagin
- First Pavlov State Medical University of St. Petersburg; St. Petersburg Novosibirsk Russia
| | - Igor Lisukov
- First Pavlov State Medical University of St. Petersburg; St. Petersburg Novosibirsk Russia
| | - Maria Ivanova
- First Pavlov State Medical University of St. Petersburg; St. Petersburg Novosibirsk Russia
| | - Irina Golubovskaya
- First Pavlov State Medical University of St. Petersburg; St. Petersburg Novosibirsk Russia
| | | | - Sergey Bondarenko
- First Pavlov State Medical University of St. Petersburg; St. Petersburg Novosibirsk Russia
| | - Vladimir Vavilov
- First Pavlov State Medical University of St. Petersburg; St. Petersburg Novosibirsk Russia
| | - Natalia Stancheva
- First Pavlov State Medical University of St. Petersburg; St. Petersburg Novosibirsk Russia
| | - Elena Babenko
- First Pavlov State Medical University of St. Petersburg; St. Petersburg Novosibirsk Russia
| | - Alexandra Sipol
- First Pavlov State Medical University of St. Petersburg; St. Petersburg Novosibirsk Russia
| | | | | | - Boris Afanasyev
- First Pavlov State Medical University of St. Petersburg; St. Petersburg Novosibirsk Russia
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Long-term outcome of immunosuppressive therapy for Japanese patients with lower-risk myelodysplastic syndromes. Int J Hematol 2013; 98:687-93. [PMID: 24254637 DOI: 10.1007/s12185-013-1468-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2013] [Revised: 11/05/2013] [Accepted: 11/06/2013] [Indexed: 10/26/2022]
Abstract
To investigate the long-term usefulness of immunosuppressive therapy (IST) for Japanese patients with lower-risk myelodysplastic syndromes, we retrospectively analyzed 29 MDS patients who were treated with cyclosporine A alone or with anti-thymocyte globulin at a single institute in Japan. A total of 58.6 % of patients showed hematological response to IST. Overall survival of all patients was 74.5 % at 5 years and 48.3 % at 10 years. The major adverse event was the elevation of creatinine level (grade 1 and 2). Eleven patients were still on IST at the time of analysis with, at least, some clinical benefits. Pneumonia was the most frequent cause of death (eight of 12 deaths), followed by bleeding (three of 12); most of the patients who died were non-responders. The presence of paroxysmal nocturnal hemoglobinuria-type cells was significantly associated with both response to IST and long-term survival by univariate analysis. The 10-year overall survival of responders (72.2 %) was significantly superior to that of non-responders (15.6 %, P < 0.0001). These results suggest that IST using cyclosporine A provides long-term benefit for Japanese patients with lower-risk MDS.
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Raza A, Ravandi F, Rastogi A, Bubis J, Lim SH, Weitz I, Castro-Malaspina H, Galili N, Jawde RA, Illingworth A. A prospective multicenter study of paroxysmal nocturnal hemoglobinuria cells in patients with bone marrow failure. CYTOMETRY PART B-CLINICAL CYTOMETRY 2013; 86:175-82. [PMID: 24227693 PMCID: PMC5594745 DOI: 10.1002/cyto.b.21139] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/07/2013] [Revised: 07/22/2013] [Accepted: 10/08/2013] [Indexed: 01/19/2023]
Abstract
Background Paroxysmal nocturnal hemoglobinuria (PNH), a rare clonal hematopoietic stem cell disorder, is characterized by chronic, uncontrolled complement activation leading to intravascular hemolysis and an inflammatory prothrombotic state. The EXPLORE study aimed to determine the prevalence of undiagnosed PNH in patients with aplastic anemia (AA), myelodysplastic syndrome (MDS), and/or other bone marrow failure (BMF) syndromes and the effect of PNH clone size on hemolysis. Methods Patients, selected from medical office chart reviews, had blood samples collected for hematologic panel testing and for flow cytometry detection of PNH clones. Results Granulocyte PNH clones ≥ 1% were detected in 199 of all 5,398 patients (3.7%), 93 of 503 AA patients (18.5%), 50 of 4,401 MDS patients (1.1%), and 3 of 130 other BMF patients (2.3%). Higher-sensitivity analyses detected PNH clones ≥ 0.01% in 167 of 1,746 patients from all groups (9.6%) and in 22 of 1,225 MDS patients (1.8%), 116 of 294 AA patients (39.5%), and four of 54 other BMF patients (7.8%). Among patients with PNH clones ≥ 1%, median clone size was smaller in patients with AA (5.1%) than in those with MDS (17.6%) or other BMF (24.4%), and the percentage of patients with lactate dehydrogenase levels (a marker for intravascular hemolysis) ≥ 1.5 × upper limit of normal was smaller in patients with AA (18.3%) than in those with MDS (42.0%). Conclusions These results confirm the presence of PNH clones in high-risk patient groups and suggest that screening of such patients may facilitate patient management and care.
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Affiliation(s)
- Azra Raza
- Department of Medicine, Columbia University, New York, New York
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