Antiphospholipid antibodies may be a new prognostic parameter in aggressive non-Hodgkin's lymphoma

Antiphospholipid Syndrome and Antibodies Associated With Malignancy and Older Age: A Retrospective Study

BACKGROUND

Antiphospholipid syndrome (APLS) is an established cause of thrombosis and hypercoagulability. However, the clinical characteristics of those with APLS or patients with positive antiphospholipid antibodies (APLA) in the embolic stroke of undetermined source (ESUS) have not been well studied.

METHODS

A retrospective analysis was conducted between January 1, 2010, and December 31, 2020, across all three Mayo Clinic sites. Patients who were included in the study were tested for APLA and had a diagnosis of ESUS. Baseline characteristics, radiographic parameters, and outcome data were collected and compared between those who tested positive for APLS or had positive APLA and those who were negative.

RESULTS

A total of 206 patients were included in the study. Eight (4%) patients were diagnosed with APLS, and 21 (10%) patients had positive APLA. On comparing those with a diagnosis of APLS and those without, patients with APLS were found to be significantly older (75 years old ± 9 vs. 58 years old ± 14, p = 0.001) and were more likely to have a history of cancer (50% vs. 13%, p = 0.012). Those with positive APLA had similar findings of being older (67 years old ±13 vs. 58 years old ± 14 p = 0.003) and more likely to have a history of cancer (29% vs. 8.4% p = 0.027). Radiographically, those with APLS had a higher white matter disease burden (Fazekas score median 2 (IQR 1.5-3) vs. median 1 (IQR 1-2), p = 0.028).

CONCLUSION

Both APLS and positive APLA are associated with older age and a history of malignancy. These findings highlight the importance of considering a hypercoagulable evaluation even in the elderly ESUS population.

Frequency of Autoantibodies on Non-Hodgkin Lymphoma

(1) Background: Non-Hodgkin Lymphoma is a neoplasm that can significantly compromise the immune system, but timely assessment can change the patient outcome. In cancer, the activation of the immune system could lead to the secretion of autoantibodies. (2) Methods: A retrospective cohort study was performed from 2017 to 2019 in patients with Non-Hodgkin Lymphoma diagnosed with a biopsy. (3) Results: We included 39 patients who were newly diagnosed, untreated, and without any autoimmune disease previously reported. Thirty patients had the presence of autoantibodies (antiphospholipid antibodies, anti-cytoplasmic neutrophils antibodies, antinuclear antibodies), and nine were without autoantibodies. There were no statistical differences among groups regarding clinical, demographic, staging, and prognosis characteristics. Also, there were no differences in the outcomes of the patients after finishing chemotherapy and one year after initiating treatment. (4) Conclusions: Further investigations must be conducted regarding an extended panel of autoantibodies because the panel of autoantibodies in this study did not show a relationship between the presence and the clinical outcome of the patients.

Positive antiphospholipid antibodies: observation or treatment?

Antiphospholipid antibodies (APLAs) are  primarily directed toward phospholipid-binding proteins and are responsible for thrombotic events. APLAs include anti-β2Glycoprotein I (anti-β2GPI), anticardiolipin (anti-CL) antibodies, and lupus anticoagulant. These antibodies are typical markers of antiphospholipid syndrome (APS) and are a part of its diagnostic criteria. Many data underline the presence of APLAs in other rheumatic diseases (e.g., systemic lupus erythematosus, systemic sclerosis, Sjögren's syndrome, rheumatoid arthritis and Behçet's disease). However, they are also detected in patients with cancer, infection, and neurological disorders. Furthermore, healthy individuals may be carriers of APLAs. Chronic asymptomatic APLAs presence is most common in the elderly and subjects with chronic diseases (including malignancies). Specific kinds of APLAs are considered markers of oncological progression. These antibodies occur in 6% of pregnant women (without diagnosed APS) and are related to many pregnancy complications. Of worth, various types of APLAs are reported to have different prothrombotic properties. The risk of thrombotic events in APLA-positive but clinically naïve patients raises many questions in clinical practice. This manuscript analyses various clinical situations and consequences of the APLAs' presence, particularly in patients without diagnosed APS. The prevalence, etiology, molecular background, and prothrombotic properties of numerous APLAs are broadly discussed. The new management approach in different clinical conditions and organ complications is present in the context of recent recommendations. Discussed data underlines that adequate and timely introduced thromboprophylaxis can decrease the risk of thrombus formation and prevent increased morbidity.

The prothrombotic state in cancer

Neoplasms result from changes in the mechanisms of growth, differentiation, and cellular death. Cancers are of high clinical relevance due to their prevalence and associated morbidity and mortality. The clinical and biological diversity of cancer depends mainly on cellular origin and degree of differentiation. These changes result from alterations in molecular expression that generate a complex clinical, biochemical, and morphologic phenotype. Although cancer is associated with a hypercoagulable state, few cancers result in a thrombotic event. Many factors influence thrombotic incidence, such as advanced disease, central catheter placement, chemotherapy, neoplasia, and surgery. The pro-coagulant state is associated with anomalies in the vascular wall, blood flow, blood constituents (tissue factor, thrombin), coagulation state, and cell growth factors. Tumor cells perpetuate this phenomenon by releasing tissue factor, inflammatory cytokines, and growth factors. These changes favor cellular activation that gives rise to actions involving coagulation, inflammation, thrombosis, tumor growth, angiogenesis, and tumor metastases. These, in turn, are closely linked to treatment response, tumor aggressiveness, and host survival. Activation of the coagulation cascade is related to these phenomena through molecules that interact in these processes. As such, it is necessary to identify these mediators to facilitate treatment and improve outcomes.

High Incidence of Antiphospholipid Antibodies in Newly Diagnosed Patients With Lymphoma and a Proposed aPL Predictive Score

Given that the presence of antiphospholipid (aPL) antibodies has been proposed to be associated with thrombosis in newly diagnosed patients with lymphoma, we conducted a prospective cohort study on these patients. In all, 154 patients were enrolled. More than half were advanced-stage diffuse large B-cell lymphoma. Approximately one-third (35.7%) of the patients had the presence of aPLs, with single-, double-, and triple-aPL positivities of 29.9%, 5.2%, and 0.6%, respectively. Of the 154 patients, 8 (5.19%) developed symptomatic thrombosis during follow-up. There were no significant differences in the incidences of thrombosis for the aPL-positive and aPL-negative groups (5.5% vs 5.1%; P = 1.000). In a multivariate analysis, patients with male sex and lymphoma stage IV were significant risk factors for aPL positivity, with odds ratio [OR] = 2.22 (95% CI: 1.11-4.45), P = .025, and OR: 2.34 (95% CI: 1.17-4.67), P = .016, respectively. An aPL predictive score of ≥−1 was predictive of aPL positivity, with a sensitivity of 83.6% and specificity of 34.3%.

Antiphospholipid Antibodies Are Not Associated with Clinical Parameters or Prognostic Outcomes in Patients with Non-Hodgkin's Lymphoma

BACKGROUND

 Antiphospholipid antibodies (APAs) are found quite frequently in patients with non-Hodgkin's lymphoma (NHL). However, the clinical significance of these antibodies is largely unknown. This study aims to delineate the clinical and prognostic role of APAs in NHL patients.

PATIENTS AND METHODS

  Consecutive patients of NHL were screened for lupus anticoagulant (LA), IgG/IgM anticardiolipin antibody, and IgG/IgM anti-β2-glycoprotein I at the time of diagnosis. Baseline investigations, staging, and treatment were done as per institutional protocol. Patients were followed up until the last known outpatient visit or death. All were screened at each visit for any thromboembolic event. The association of APA status with baseline NHL characteristics and treatment response was evaluated by univariate analysis. Kaplan-Meier survival analysis was used to compare the final outcome in patients with or without APAs. Patients who were initially APA positive were retested for the corresponding antibody at the end of chemotherapy.

RESULTS

 Twenty-four out of 105 patients (22.8%) were APA positive at diagnosis. The presence of APA was not significantly associated with NHL stage, histology, International Prognostic Index score, activated partial thromboplastin time, or treatment response. The median duration of follow-up was 15 months. Only four patients developed venous thrombosis; none was APA positive. There was no statistically significant difference in overall survival between the two groups (p = 0.471). Patients, who were APA positive initially, tested negative at the end of treatment, irrespective of treatment response.

CONCLUSION

 APAs are encountered more frequently in NHL patients than in the general population. However, APAs do not correlate with disease severity, thrombosis risk, treatment outcome, or overall survival.

Antiphospholipid antibodies and antiphospholipid syndrome in cancer: Uninvited guests in troubled times

Antiphospholipid antibodies (aPLs) are autoantibodies with laboratory significance in developing thrombosis and pregnancy morbidity in antiphospholipid syndrome (APS). High prevalence of aPLs namely - anticardiolipin, anti-β2-glycoprotein I, lupus anticoagulant, antiphosphatidylcholine, antiphosphatidylserine, antiphosphatidylinositol, antiphosphatidylethanolamine and antiprothrombin antibodies have been observed in patients with different types of haematological malignancies and solid tumours. Although cancer patients have high risk of developing thrombosis, the risk becomes even higher in aPLs carriers. Although the relationship between aPLs and cancer has to be further investigated, however, the presence of aPLs in neoplastic patients can possibly increase the risk of developing thrombosis. As the pathogenic role of aPLs in cancer is still a matter of debate, more researches should be conducted on the association between the aPLs and malignancies towards the potential impact on understanding the pathogenicity and treatment when cancer and APS coexists.

Marginal zone lymphoma-associated antiphospholipid antibodies successfully treated with bendamustine rituximab

A 46-year-old man presented with splenomegaly, abdominal adenopathy and profoundly elevated prothrombin time and partial thromboplastin time. He was diagnosed with marginal zone lymphoma (MZL) and small lymphocytic lymphoma, and the abnormal coagulation studies were secondary to the presence of a lupus anticoagulant. Optimal upfront therapy for MZL has not been established, and the incidence of antiphospholipid antibodies (APLA) in this patient population is rare. Following treatment with six cycles of bendamustine and rituximab with 2 years of rituximab maintenance, our patient remained in remission and his coagulation studies normalised. This report describes a case of successful treatment of APLA associated with MZL that resolved after treatment of the lymphoma.

Zonal cortical scarring and tubular thyroidization in kidney biopsies of patients with SLE-histologic indicator for antiphospholipid antibodies

Antiphospholipid antibody syndrome (APS) is an acquired prothrombotic autoimmune disease caused by the presence of antibodies against anionic phospholipids or plasma proteins bound to phospholipids on cell membranes. It can be a primary disease or secondary to other autoimmune diseases, most commonly systemic lupus erythematosus (SLE). Laboratory testing for antiphospholipid antibodies (aPL) may be only transiently positive, so APS could be missed until a catastrophic thrombotic episode or pregnancy morbidity occurs. In the kidneys, this manifests as thrombotic microangiopathy (TMA), and patients present with hypertensive urgency and acute kidney injury. However, APS may not always have a catastrophic presentation but instead a more smoldering course. Kidney biopsy may not show obvious active TMA lesions but rather only chronic injury in the form of zonal cortical scarring and tubular thyroidization. Still, it may warrant anticoagulation therapy. So it is important to recognize this pattern of injury in the biopsy. Herein, we retrospectively study the correlation between presence of this histologic feature in kidney biopsies of SLE patients and positive aPL testing results (anticardiolipin antibodies and/or lupus anticoagulant). Kidney biopsies of SLE patients from 2004 to 2015 ( n = 186) were screened for presence or absence of zonal cortical scarring. Their electronic medical records were reviewed for aPL results. Our study showed low sensitivity (33%) but higher positive predictive value (62%), specificity (89%) and negative predictive value (71%). This histologic finding is therefore not a sensitive screening tool, but if present, greatly increases the likelihood of underlying aPL. We want to emphasize that recognition of this histologic feature in the biopsies of SLE patients is important so as not to miss the opportunity to treat with anticoagulation therapy and possibly slow down the chronic renal damage.

Antiphospholipid antibodies associated with nodal marginal zone lymphoma and its progression to diffuse large B-cell lymphoma-A case report

An association between autoimmune events, as well as the development of antiphospholipid (aPL) antibodies and lymphoproliferative disorders is well recognized. We present the patient with coagulation abnormalities and non-Hodgkin lymphoma (NHL), primarily diagnosed as nodal marginal zone B-cell lymphoma (NMZL), and in relapse as diffuse large B-cell lymphoma (DLBCL). In the follow-up period, the patient simultaneously developed different aPL antibodies. The presence of aPL antibodies in NHL is frequent but it is not common in the NMZL. The aim of the present case report is to highlight the possible underlying increase of aPL antibodies in NMZL patients with coagulation tests abnormalities.

Fulminant phlegmasia cerulea dolens with concurrent cholangiocarcinoma and a lupus anticoagulant: a case report and review of the literature

Phlegmasia cerulea dolens (PCD) is an aggressive and life-threatening form of venous thrombosis complicated by ischemic necrosis. Massive thrombosis extends to collateral veins resulting in venous congestion with fluid sequestration in the interstitium causing collapse of arterioles, which progresses to ischemia and, if severe, circulatory collapse and shock. The mortality rate for PCD is as high as 40%, especially when gangrene develops. PCD has been associated with acquired thrombophilias, including malignancy and antiphospholipid syndrome (APS). We present a unique case of a patient with PCD refractory to anticoagulant and thrombolytic therapy, whose fulminant course was attributed to concurrent cholangiocarcinoma and antiphospholipid antibodies identified by a positive lupus anticoagulant assay. This case highlights the importance of uncovering precipitating causes of thromboembolism, which may offer prognostic information and may necessitate therapy beyond anticoagulation and thrombolysis to reduce the morbidity of PCD. The current literature on PCD and APS, along with their associations with malignancy, is reviewed.

Evaluation of significance of lymphocyte subpopulations and non-specific serologic markers in B-cell non-Hodgkin's lymphoma patients

The use of rituximab brought attention to the hosts' immune system and to the microenvironment in non-Hodgkin's lymphoma cases. Our aim was to identify prognostic factors that can be measured easily to indicate the current state of the patient's immune status and possible reaction against malignant cells. In the retrospective analysis (2000-2008), 66 patients diagnosed with B-cell non-Hodgkin's lymphomas were enrolled (40 women, 26 men; mean age: 51 years). White blood cells, lymphocytes, CD3 +; CD4 +; CD8 + T-cells, immunoglobulin types A; G; M, anti-cardiolipin antibody isotypes A; G; M; and levels of beta-2-microglobulin were measured before the initiation of the first cycle of chemotherapy, during and after 4-weeks treatment. As for CD 3+ T-lymphocytes, the absolute CD 3+ T -lymphocyte numbers were higher before (0.78 × 10(9)/L) versus during (0.27 × 10(9)/L) treatment, and increased percentages were detected in pre- (66.57 %) and post-treatment (75.32 %). Absolute numbers of CD 8+ T-lymphocyte levels showed reduction before (0.26 × 10(9)/L) versus during (0.10 × 10(9)/L) therapy, but were elevated after (0.28 × 10(9)/L) treatment, while increased percentage before (21.99 %) versus after (29.85 %), and during (24.56 %) versus after (29.85 %) therapy were seen. Average white blood cell numbers were increased before (9.71 × 10(9)/L) versus during (12.07 × 10(9)/L) treatment, while decreased numbers could be observed, after (5.47 × 10(9)/L) treatment. IgA levels were decreased before (2.51 g/L) versus after (1.63 g/L) therapy. IgG levels were higher before (12.25 g/L) vs. after (8.64 g/L) treatment. IgM levels were decreased before (1.76 g/L) and after (0.83 g/L) as well as before (1.76 g/L) versus during (0.73 g/L) treatment. Anti-cardiolipin antibody type A level were decreased before (2.76 U/ml) versus after (2.49 U/ml) treatment. Decreased level of beta-2-microglobulin could be observed before (2.91 mg/L) versus post (2.28 mg/L) chemotherapy. Findings may provide better insight into the effects of immuno-chemotherapy on the hosts' immune system.

Multiple autoimmune propensity and B-non-hodgkin lymphoma: cause or effect?

We report a case of multiple autoimmunity consisting of the presence of autoimmune haemolytic anaemia (AIHA), antimitochondrial antibodies (AMAs), and antiphospholipid antibodies (APLAbs) as the presenting manifestations of an extrahepatic B-non-Hodgkin lymphoma (B-NHL) in a 63-year-old woman. The patient presented with fatigue attributed to severe AIHA. Due to increased serum IgM and γ-GT levels, an investigation for AMA was performed, which proved positive with anti-M2 specificity. A prolongation of activated partial thromboplastin time (aPTT) led to the determination of APLAbs (lupus anticoagulant and other APLAbs) which were also positive. Bone marrow biopsy in combination with immmunohistochemical studies established the diagnosis of lymphoplasmacytic B-NHL. Ten months later, B-NHL was in remission while AMA and APLAbs were still positive. In conclusion, we documented the coexistence of multiple autoimmune reactions together with B-NHL highlighting the possible common pathogenetic pathways of the two entities.

Multiple thromboemboli associated to two occult tumors: a case mimicking catastrophic antiphospholipid syndrome

Thromboembolic events tend to arise during the natural lifetime of tumors. However, multiple thromboemboli mimicking catastrophic antiphospholipid syndrome is quite rare as a first manifestation of a tumor. Herein we describe the case of a 51-year old woman that presented with multiple thromboemboli affecting her brain, lung and kidneys. Despite bolus administration of corticosteroids, anticoagulant therapy and immunoglobulin infusion treatment, the patient died. She had suffered from two occult tumors, which could not be identified premortem: a lung adenocarcinoma and an intrahepatic cholangiocarcinoma. This case underscores the importance of determining the underlying etiology behind multiple thromboemboli. The most important prognostic factor is rapid initiation of treatment of the multiple thromboemboli, emphasizing treatment of their etiology.

Clotting, immune system, and venous thrombosis in lung adenocarcinoma patients: a prospective study

Thrombosis is highly prevalent in cancer patients, being accepted as a bad prognosis marker. The importance of various mechanisms involved in the thrombophilic state of lung cancer patients is not well understood. In this prospective study, involving 109 unselected patients with lung adenocarcinoma, thrombosis was present in 24% of patients and affected survival in a bivariable model. However, in a multivariable evaluation, considering all the factors under study, only LAC and IgM anti-beta(2) GP I modified thrombosis risk, whereas in a Kaplan-Meyer regression model, thrombosis, IL-6, LAC, factor VIII, and IgM anti-beta(2) GP I interfered with patient's survival.

Lung adenocarcinoma and antiphospholipid antibodies

Thrombosis is a frequent finding in cancer patients, being referred to as a poor prognostic factor. The mechanisms underlying the thrombophilic state in malignancy are not well elucidated but involve a complex interaction between tumor and host cells as well as the hemostatic system. A number of studies have demonstrated the presence of antiphospholipid antibodies (aPL) in cancer patients, suggesting a potential role in tumor-associated thrombosis. A prospective analysis has been performed in a group of lung adenocarcinoma patients in respect to the presence of aPL and thrombotic manifestations. Lupus anticoagulant (LAC) was identified in 61 out of 105 patients and it correlated highly with thrombosis (22/61, LAC positive vs 2/44, LAC negative RR=7.93; p<0.001). On the other hand, patients that displayed IgM anti-beta2-glycoprotein I (abeta2GPI) (22/80) showed an unexpected decrease in thrombosis risk (2/22, with IgM abeta2GPI vs 18/58, without IgM abeta2GPI RR=0.29; p=0.04). Considerations on the mechanisms that link cancer, thrombosis and aPL are discussed in this article.

Antiphospholipid antibodies and multiple organ failure in critically ill cancer patients

OBJECTIVES

To describe the clinical outcomes and thrombotic events in a series of critically ill cancer patients positive for antiphospholipid (aPL) antibodies.

DESIGN

Retrospective case series study.

SETTING

Medical-surgical oncologic intensive care unit (ICU).

PATIENTS AND PARTICIPANTS

Eighteen patients with SIRS/sepsis and multiple organ failure (MOF) and positive for aPL antibodies, included over a 10-month period.

INTERVENTIONS

None

MEASUREMENTS AND RESULTS

aPL antibodies and coagulation parameters were measured up to 48 hours after the occurrence of acrocyanosis or arterial/venous thrombotic events. When current criteria for the diagnosis of aPL syndrome were applied, 16 patients met the criteria for 'probable' and two patients had a definite diagnosis of APL syndrome in its catastrophic form (CAPS). Acrocyanosis, arterial events and venous thrombosis were present in eighteen, nine and five patients, respectively. Sepsis, cancer and major surgery were the main precipitating factors. All patients developed MOF during the ICU stay, with a hospital mortality rate of 72% (13/18). Five patients were discharged from the hospital. There were three survivors at 90 days of follow-up. New measurements of lupus anticoagulant (LAC) antibodies were performed in these three survivors and one patient still tested positive for these antibodies.

CONCLUSIONS

In this small series of patients, we observed a high frequency of auto-antibodies and micro- and macro-vascular thrombotic events in critically ill cancer patients. The coexistence of sepsis or SIRS and aPL antibodies was often associated with MOF and death. More studies are necessary to determine the pathophysiological significance of antiphospholipid antibodies in severely ill cancer patients.

Lupus Anticoagulant Activity as a Thrombosis Risk Factor in Lung Adenocarcinoma Patients

There is a high incidence of thrombosis in cancer patients. Retrospective studies indicate that lupus anticoagulant (LA) antibodies can be a thrombosis risk factor in cancer. In 77 patients with different forms of cancer LA and thrombosis incidence were retrospectively evaluated. In a prospective study, with 42 lung adenocarcinoma patients, we measured plasma LA, fibrinogen, factor VIII (FVIII), and thrombosis incidence. A high frequency of LA and thrombosis were observed in both studies. In isolation LA, increased levels of FVIII and fibrinogen could not be considered good markers for the development of thrombosis.

Display technologies: application for the discovery of drug and gene delivery agents

Recognition of molecular diversity of cell surface proteomes in disease is essential for the development of targeted therapies. Progress in targeted therapeutics requires establishing effective approaches for high-throughput identification of agents specific for clinically relevant cell surface markers. Over the past decade, a number of platform strategies have been developed to screen polypeptide libraries for ligands targeting receptors selectively expressed in the context of various cell surface proteomes. Streamlined procedures for identification of ligand-receptor pairs that could serve as targets in disease diagnosis, profiling, imaging and therapy have relied on the display technologies, in which polypeptides with desired binding profiles can be serially selected, in a process called biopanning, based on their physical linkage with the encoding nucleic acid. These technologies include virus/phage display, cell display, ribosomal display, mRNA display and covalent DNA display (CDT), with phage display being by far the most utilized. The scope of this review is the recent advancements in the display technologies with a particular emphasis on molecular mapping of cell surface proteomes with peptide phage display. Prospective applications of targeted compounds derived from display libraries in the discovery of targeted drugs and gene therapy vectors are discussed.