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Shomali W, Gotlib J. World Health Organization and International Consensus Classification of eosinophilic disorders: 2024 update on diagnosis, risk stratification, and management. Am J Hematol 2024; 99:946-968. [PMID: 38551368 DOI: 10.1002/ajh.27287] [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: 02/06/2024] [Accepted: 02/09/2024] [Indexed: 04/09/2024]
Abstract
DISEASE OVERVIEW The eosinophilias encompass a broad range of non-hematologic (secondary or reactive) and hematologic (primary or clonal) disorders with the potential for end-organ damage. DIAGNOSIS Hypereosinophilia (HE) has generally been defined as a peripheral blood eosinophil count greater than 1.5 × 109/L, and may be associated with tissue damage. After the exclusion of secondary causes of eosinophilia, diagnostic evaluation of primary eosinophilias relies on a combination of various tests. They include morphologic review of the blood and marrow, standard cytogenetics, fluorescence in situ hybridization, molecular testing and flow immunophenotyping to detect histopathologic or clonal evidence for an acute or chronic hematolymphoid neoplasm. RISK STRATIFICATION Disease prognosis relies on identifying the subtype of eosinophilia. After evaluation of secondary causes of eosinophilia, the 2022 World Health Organization and International Consensus Classification endorse a semi-molecular classification scheme of disease subtypes. This includes the major category "myeloid/lymphoid neoplasms with eosinophilia and tyrosine kinase gene fusions" (MLN-eo-TK), and the MPN subtype, "chronic eosinophilic leukemia" (CEL). Lymphocyte-variant HE is an aberrant T-cell clone-driven reactive eosinophila, and idiopathic hypereosinophilic syndrome (HES) is a diagnosis of exclusion. RISK-ADAPTED THERAPY The goal of therapy is to mitigate eosinophil-mediated organ damage. For patients with milder forms of eosinophilia (e.g., <1.5 × 109/L) without symptoms or signs of organ involvement, a watch and wait approach with close follow-up may be undertaken. Identification of rearranged PDGFRA or PDGFRB is critical because of the exquisite responsiveness of these diseases to imatinib. Pemigatinib was recently approved for patients with relapsed or refractory FGFR1-rearranged neoplasms. Corticosteroids are first-line therapy for patients with lymphocyte-variant HE and HES. Hydroxyurea and interferon-α have demonstrated efficacy as initial treatment and in steroid-refractory cases of HES. Mepolizumab, an interleukin-5 (IL-5) antagonist monoclonal antibody, is approved by the U.S Food and Drug Administration for patients with idiopathic HES. Cytotoxic chemotherapy agents, and hematopoietic stem cell transplantation have been used for aggressive forms of HES and CEL, with outcomes reported for limited numbers of patients. Targeted therapies such as the IL-5 receptor antibody benralizumab, IL-5 monoclonal antibody depemokimab, and various tyrosine kinase inhibitors for MLN-eo-TK, are under active investigation.
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Affiliation(s)
- William Shomali
- Division of Hematology, Stanford Cancer Institute/Stanford University School of Medicine, Stanford, California, USA
| | - Jason Gotlib
- Division of Hematology, Stanford Cancer Institute/Stanford University School of Medicine, Stanford, California, USA
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Jesenak M, Diamant Z, Simon D, Tufvesson E, Seys SF, Mukherjee M, Lacy P, Vijverberg S, Slisz T, Sediva A, Simon HU, Striz I, Plevkova J, Schwarze J, Kosturiak R, Alexis NE, Untersmayr E, Vasakova MK, Knol E, Koenderman L. Eosinophils-from cradle to grave: An EAACI task force paper on new molecular insights and clinical functions of eosinophils and the clinical effects of targeted eosinophil depletion. Allergy 2023; 78:3077-3102. [PMID: 37702095 DOI: 10.1111/all.15884] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2023] [Revised: 08/21/2023] [Accepted: 08/27/2023] [Indexed: 09/14/2023]
Abstract
Over the past years, eosinophils have become a focus of scientific interest, especially in the context of their recently uncovered functions (e.g. antiviral, anti-inflammatory, regulatory). These versatile cells display both beneficial and detrimental activities under various physiological and pathological conditions. Eosinophils are involved in the pathogenesis of many diseases which can be classified into primary (clonal) and secondary (reactive) disorders and idiopathic (hyper)eosinophilic syndromes. Depending on the biological specimen, the eosinophil count in different body compartments may serve as a biomarker reflecting the underlying pathophysiology and/or activity of distinct diseases and as a therapy-driving (predictive) and monitoring tool. Personalized selection of an appropriate therapeutic strategy directly or indirectly targeting the increased number and/or activity of eosinophils should be based on the understanding of eosinophil homeostasis including their interactions with other immune and non-immune cells within different body compartments. Hence, restoring as well as maintaining homeostasis within an individual's eosinophil pool is a goal of both specific and non-specific eosinophil-targeting therapies. Despite the overall favourable safety profile of the currently available anti-eosinophil biologics, the effect of eosinophil depletion should be monitored from the perspective of possible unwanted consequences.
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Affiliation(s)
- Milos Jesenak
- Department of Clinical Immunology and Allergology, University Teaching Hospital in Martin, Martin, Slovak Republic
- Department of Paediatrics, Jessenius Faculty of Medicine in Martin, Comenius University in Bratislava, University Teaching Hospital in Martin, Martin, Slovak Republic
- Department of Pulmonology and Phthisiology, Jessenius Faculty of Medicine in Martin, Comenius University in Bratislava, University Teaching Hospital in Martin, Martin, Slovak Republic
| | - Zuzana Diamant
- Department of Clinical Sciences Lund, Respiratory Medicine, Allergology and Palliative Medicine, Lund University, Lund, Sweden
- Department Microbiology Immunology & Transplantation, KU Leuven, Catholic University of Leuven, Leuven, Belgium
- Department of Respiratory Medicine, First Faculty of Medicine, Charles University and Thomayer Hospital, Prague, Czech Republic
| | - Dagmar Simon
- Department of Dermatology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Ellen Tufvesson
- Department of Clinical Sciences Lund, Respiratory Medicine, Allergology and Palliative Medicine, Lund University, Lund, Sweden
| | - Sven F Seys
- Laboratory of Clinical Immunology, Department of Microbiology and Immunology, KU Leuven, Leuven, Belgium
| | - Manali Mukherjee
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
- The Firestone Institute for Respiratory Health, Research Institute of St. Joe's Hamilton, Hamilton, Ontario, Canada
| | - Paige Lacy
- Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Susanne Vijverberg
- Amsterdam UMC Location University of Amsterdam, Pulmonary Diseases, Amsterdam, The Netherlands
| | - Tomas Slisz
- Department of Respiratory Medicine, First Faculty of Medicine, Charles University and Thomayer Hospital, Prague, Czech Republic
| | - Anna Sediva
- Department of Immunology, 2nd Faculty of Medicine, Charles University, Motol University Hospital, Prague, Czech Republic
| | - Hans-Uwe Simon
- Institute of Pharmacology, University of Bern, Bern, Switzerland
- Institute of Biochemistry, Brandenburg Medical School, Neuruppin, Germany
| | - Ilja Striz
- Department of Clinical and Transplant Immunology, Institute for Clinical and Experimental Medicine, Prague, Czech Republic
| | - Jana Plevkova
- Department of Pathophysiology, Jessenius Faculty of Medicine in Martin, Comenius University in Bratislava, Martin, Slovak Republic
| | - Jurgen Schwarze
- Child Life and Health and Centre for Inflammation Research, The Queen's Medical Research Institute, University of Edinburgh, Edinburgh, UK
| | - Radovan Kosturiak
- Department of Paediatrics, Jessenius Faculty of Medicine in Martin, Comenius University in Bratislava, University Teaching Hospital in Martin, Martin, Slovak Republic
- Outpatient Clinic for Clinical Immunology and Allergology, Nitra, Slovak Republic
| | - Neil E Alexis
- Center for Environmental Medicine, Asthma and Lung Biology, Department of Paediatrics, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Eva Untersmayr
- Institute of Pathophysiology and Allergy Research, Center for Pathophysiology, Infectiology and Immunology, Medical University of Vienna, Vienna, Austria
| | - Martina Koziar Vasakova
- Department of Respiratory Medicine, First Faculty of Medicine, Charles University and Thomayer Hospital, Prague, Czech Republic
| | - Edward Knol
- Department Center of Translational Immunology, University Medical Center Utrecht, Utrecht, The Netherlands
- Department Dermatology/Allergology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Leo Koenderman
- Department Center of Translational Immunology, University Medical Center Utrecht, Utrecht, The Netherlands
- Department Pulmonary Diseases, University Medical Center Utrecht, Utrecht, The Netherlands
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Srinivas SM, Chebbi PG, Shivappa SK. Idiopathic Hypereosinophilic Syndrome Presenting with Recalcitrant Oral and Genital Ulcers Responding Well to Thalidomide. Indian Dermatol Online J 2023; 14:676-678. [PMID: 37727572 PMCID: PMC10506822 DOI: 10.4103/idoj.idoj_632_22] [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: 11/23/2022] [Revised: 01/25/2023] [Accepted: 02/12/2023] [Indexed: 09/21/2023] Open
Abstract
Hypereosinophilic syndrome is a myeloproliferative disorder characterized by abnormal accumulation of eosinophils in the blood or peripheral tissues. It is uncommonly seen in children. We describe a 14-year-old girl diagnosed with idiopathic hypereosinophilic syndrome presenting with recurrent, painful oral and genital ulcers, hepatosplenomegaly along with consistently high eosinophil count and leucocytosis. Genetic studies showed negative for FIPIL-PDGFRA fusion gene. Mucosal ulcers were recalcitrant to conventional therapy and responded well to thalidomide.
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Affiliation(s)
- Sahana M. Srinivas
- Department of Pediatric Dermatology, Indira Gandhi Institute of Child Health, Bengaluru, Karnataka, India
| | - Pooja G. Chebbi
- Department of Pediatric Medicine, Indira Gandhi Institute of Child Health, Bengaluru, Karnataka, India
| | - Sanjay K. Shivappa
- Department of Pediatric Dermatology, Indira Gandhi Institute of Child Health, Bengaluru, Karnataka, India
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Wei X, Li X, Wei Z, Zhang H, Deng J, Xing S, Zhang J. Clinical analysis of hypereosinophilic syndrome first presenting with asthma-like symptoms. Ann Med 2022; 54:11-21. [PMID: 34935570 PMCID: PMC8725856 DOI: 10.1080/07853890.2021.2014555] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
INTRODUCTION Clinical manifestations of hypereosinophilic syndrome (HES) are diverse. This study aimed to summarise these clinical characteristics with asthma-like onset as the first symptom, and compare these characteristics and treatment strategies between idiopathic and parasitic HES. MATERIALS AND METHODS We retrospectively analysed 36 HES patients with asthma-like symptoms as the first episode, between January 2013 and October 2019. Data of patients with HES of an unknown cause (idiopathic HES) and parasitic infection (parasite HES) were analysed. RESULTS The idiopathic and parasite HES groups included 16 and 20 patients, respectively, with more males in the parasite HES group (p < .05). Wheezing and dry rales was the most common symptom and signs, with no significant differences in symptoms and signs between the groups. The most often misdiagnosed disease was bronchial asthma. The peripheral blood eosinophil count was significantly increased compared with normal counts in both groups (p > .05). Abnormal pulmonary function is mainly manifested as obstructive ventilatory disorder and mixed ventilatory disorder. Chest computed tomography showed extensive ground-glass exudation, patches, consolidation, nodules, and pleural effusion. Histopathological examination showed eosinophilic infiltration without vasculitis or granuloma. Glucocorticoids had a significant therapeutic effect, and the parasite HES group required combined deworming drugs. The duration of corticosteroids therapy in the idiopathic HES group was significantly longer than that in the parasite HES group (p < .05). The overall prognosis was good, and 81.25% of the patients were clinically cured in the parasite HES group; however, relapse occurred easily in the idiopathic HES group. CONCLUSIONS Asthma-like symptoms, obstructive ventilatory disorder or positive bronchial dilation test, and poor response to inhaled corticosteroids are not necessarily indicative of refractory asthma; HES should be considered. The clinical characteristics of HES of different aetiologies are similar. Systemic corticosteroid therapy is preferred for idiopathic and parasitic infections. Idiopathic HES is treated with prolonged corticosteroids and relapses easily.Key MessagesAsthma-like symptoms, obstructive ventilatory disorder or positive bronchial dilation tests, and poor responses to inhaled corticosteroids are not necessarily indicative of refractory asthma, and hypereosinophilic syndrome should be considered.The clinical characteristics of hypereosinophilic syndrome of different aetiologies are similar, and systemic glucocorticoid therapy is preferred for both idiopathic and parasitic infections.Idiopathic hypereosinophilic syndrome is treated with prolonged corticosteroids and relapses easily.
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Affiliation(s)
- Xuan Wei
- Department of Respiratory and Critical Care Medicine, The First Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi, China
| | - Xiaofeng Li
- Department of Respiratory and Critical Care Medicine, The First Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi, China
| | - Zuyou Wei
- Department of Respiratory and Critical Care Medicine, The First Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi, China
| | - Hui Zhang
- Department of Respiratory and Critical Care Medicine, The First Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi, China
| | - Jiehua Deng
- Department of Respiratory and Critical Care Medicine, The First Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi, China
| | - Suke Xing
- Department of Respiratory and Critical Care Medicine, The First Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi, China
| | - Jianquan Zhang
- Department of Respiratory and Critical Care Medicine, The First Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi, China.,Department of Respiratory Medicine, The Eighth Affiliated Hospital, Sun Yat Sen University, Shenzhen, Guangdong, China
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Chen MM, Roufosse F, Wang SA, Verstovsek S, Durrani SR, Rothenberg ME, Pongdee T, Butterfield J, Lax T, Wechsler ME, Stein ML, Ogbogu PU, Kahwash BM, Mathur SK, Simon D, Akuthota P, Holland N, Wetzler L, Ware JM, Guo C, Fay MP, Khoury P, Klion AD, Bochner BS. An International, Retrospective Study of Off-Label Biologic Use in the Treatment of Hypereosinophilic Syndromes. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2022; 10:1217-1228.e3. [PMID: 35181548 PMCID: PMC9086180 DOI: 10.1016/j.jaip.2022.02.006] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/20/2022] [Revised: 02/01/2022] [Accepted: 02/02/2022] [Indexed: 05/03/2023]
Abstract
BACKGROUND Treatment of hypereosinophilic syndrome (HES) often requires the use of immunomodulators with substantial side effect profiles. The emergence of biologics offers an alternative treatment modality. OBJECTIVE To examine real-world practice data to describe the safety and consequences of various biologics suspected to directly or indirectly affect eosinophilic inflammation for the treatment of HES. METHODS Retrospective data from 13 centers were collected via an online Research Electronic Data Capture repository. Inclusion criteria included (1) peripheral eosinophil count of 1,500/mm3 or greater without a secondary cause; (2) clinical manifestations attributable to the eosinophilia; and (3) having received mepolizumab (anti-IL-5), benralizumab (afucosylated anti-IL-5 receptor α), omalizumab (anti-IgE), alemtuzumab (anti-CD52), dupilumab (anti-IL-4 receptor α), or reslizumab (anti-IL-5) outside a placebo-controlled clinical trial. RESULTS Of the 151 courses of biologics prescribed for 121 patients with HES, 59% resulted in improved HES symptoms and 77% enabled tapering of other HES medications. Overall, 105 patients were receiving daily systemic glucocorticoids at the time of a biologic initiation and were able to reduce the glucocorticoid dose by a median reduction of 10 mg of daily prednisone equivalents. Biologics were generally safe and well-tolerated other than infusion reactions with alemtuzumab. Thirteen of 24 patients had clinical improvement after switching biologics and nine patients responded to increasing the dose of mepolizumab after a lack of response to a lower dose. CONCLUSIONS Biologics may offer a safer treatment alternative to existing therapies for HES, although the optimal dosing and choice for each subtype of HES remain to be determined. Limitations of this study include its retrospective nature and intersite differences in data collection and availability of each biologic.
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Affiliation(s)
- Michael M Chen
- Division of Allergy and Immunology, Northwestern University, Chicago, Ill
| | - Florence Roufosse
- Department of Internal Medicine, Hôpital Erasme, Université Libre de Bruxelles, Brussels, Belgium
| | - Sa A Wang
- Department of Leukemia, MD Anderson Cancer Center, Houston, Texas
| | - Srdan Verstovsek
- Department of Leukemia, MD Anderson Cancer Center, Houston, Texas
| | - Sandy R Durrani
- Division of Allergy and Immunology, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Marc E Rothenberg
- Division of Allergy and Immunology, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Thanai Pongdee
- Division of Allergic Diseases, Mayo Clinic, Rochester, Minn
| | | | - Timothy Lax
- Division of Allergy and Inflammation, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Mass
| | - Michael E Wechsler
- Division of Pulmonary, Critical Care and Sleep, Department of Medicine, National Jewish Health, Denver, Colo
| | - Miguel L Stein
- Allergy and Clinical Immunology Unit, Edith Wolfson Medical Center, Tel Aviv University, Holon, Israel
| | - Princess U Ogbogu
- Division of Allergy and Immunology, Department of Otolaryngology, Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Basil M Kahwash
- Division of Allergy and Immunology, Department of Otolaryngology, Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Sameer K Mathur
- Division of Allergy, Pulmonary and Critical Care, Department of Medicine, University of Wisconsin, Madison, Wis
| | - Dagmar Simon
- Department of Dermatology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Praveen Akuthota
- Division of Pulmonary, Critical Care & Sleep Medicine, Department of Medicine, University of California San Diego, La Jolla, CA
| | - Nicole Holland
- Laboratory of Parasitic Diseases, National Institutes of Health, Bethesda, Md
| | - Lauren Wetzler
- Laboratory of Parasitic Diseases, National Institutes of Health, Bethesda, Md
| | - JeanAnne M Ware
- Laboratory of Parasitic Diseases, National Institutes of Health, Bethesda, Md
| | - Canting Guo
- Division of Allergy and Immunology, Northwestern University, Chicago, Ill
| | - Michael P Fay
- Laboratory of Parasitic Diseases, National Institutes of Health, Bethesda, Md
| | - Paneez Khoury
- Laboratory of Parasitic Diseases, National Institutes of Health, Bethesda, Md
| | - Amy D Klion
- Laboratory of Parasitic Diseases, National Institutes of Health, Bethesda, Md
| | - Bruce S Bochner
- Division of Allergy and Immunology, Northwestern University, Chicago, Ill.
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Jain V, Bansal A, Aggarwal D, Chetrit M, Gupta M, Bhatia K, Thakkar S, Doshi R, Ghosh R, Bandopadhyay D, Barzilai B, Shiau CJ, Frishman WH, Aronow WS. Eosinophilic Myocarditis: When Allergies Attack the Heart! Cardiol Rev 2022; 30:70-74. [PMID: 34369408 DOI: 10.1097/crd.0000000000000373] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Eosinophilic myocarditis is a clinical condition whereby myocardial injury is mediated by eosinophilic infiltration. A number of underlying causes, including reactive, clonal, or idiopathic hypereosinophilic syndrome, may trigger eosinophilia. Disease presentation may vary from mild subclinical variants to fulminant myocarditis with thromboembolic complications, and in some cases, endomyocardial and valvular fibrosis may be seen. A detailed examination coupled with the use of multimodality imaging, and endomyocardial biopsy may help establish diagnosis. Treatment is aimed at symptomatic management and treating the underlying cause of eosinophilia, such as withdrawal of implicated drugs, antihelminthic therapy for infection, immunosuppression for autoimmune conditions, and targeted therapy with tyrosine kinase inhibitors in cases with clonal myeloid disorders.
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Affiliation(s)
- Vardhmaan Jain
- From the Department of Internal Medicine, Cleveland Clinic Foundation, Cleveland, OH
| | - Agam Bansal
- From the Department of Internal Medicine, Cleveland Clinic Foundation, Cleveland, OH
| | - Devika Aggarwal
- Department of Internal Medicine, Beaumont Hospital, Royal Oak, MI
| | - Michael Chetrit
- Department of Cardiovascular Medicine, Cleveland Clinic Foundation, Cleveland, OH
| | - Manasvi Gupta
- Department of Internal Medicine, University of Connecticut Health, Farmington, CT
| | - Kirtipal Bhatia
- Department of Internal Medicine, St. Luke Roosevelt Medical Centre/Mount Sinai, New York, NY
| | | | - Rajkumar Doshi
- Department of Internal Medicine, University of Nevada Reno School of Medicine, Reno, NV
| | - Raktim Ghosh
- Department of Cardiovascular Medicine, Medstar Heart and Vascular Institute, Baltimore, MD
| | | | - Benico Barzilai
- Department of Cardiovascular Medicine, Cleveland Clinic Foundation, Cleveland, OH
| | - Carolyn Jane Shiau
- Department of Pathology, Royal Columbian Hospital, New Westminster, BC, Canada
| | - William H Frishman
- Department of Medicine and Cardiology, New York Medical College/Westchester Medical Center, Valhalla, NY
| | - Wilbert S Aronow
- Department of Medicine and Cardiology, New York Medical College/Westchester Medical Center, Valhalla, NY
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7
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Shomali W, Gotlib J. World Health Organization-defined eosinophilic disorders: 2022 update on diagnosis, risk stratification, and management. Am J Hematol 2022; 97:129-148. [PMID: 34533850 DOI: 10.1002/ajh.26352] [Citation(s) in RCA: 59] [Impact Index Per Article: 29.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2021] [Accepted: 09/14/2021] [Indexed: 12/13/2022]
Abstract
DISEASE OVERVIEW The eosinophilias encompass a broad range of nonhematologic (secondary or reactive) and hematologic (primary or clonal) disorders with potential for end-organ damage. DIAGNOSIS Hypereosinophilia (HE) has generally been defined as a peripheral blood eosinophil count greater than 1.5 × 109 /L. After exclusion of secondary causes of eosinophilia, diagnostic evaluation of primary eosinophilias relies on morphologic review of the blood and marrow, standard cytogenetics, fluorescence in situ hybridization, next generation sequencing gene assays, and flow immunophenotyping to detect histopathologic or clonal evidence for an acute or chronic hematolymphoid neoplasm. RISK STRATIFICATION Disease prognosis relies on identifying the subtype of eosinophilia. After evaluation of secondary causes of eosinophilia, the 2016 World Health Organization endorses a semi-molecular classification scheme of disease subtypes. This includes the major category "myeloid/lymphoid neoplasms with eosinophilia and rearrangement of PDGFRA, PDGFRB, or FGFR1 or with PCM1-JAK2", and the myeloproliferative neoplasm subtype, "chronic eosinophilic leukemia, not otherwise specified" (CEL, NOS). Lymphocyte-variant HE is an aberrant T-cell clone-driven reactive eosinophila, and idiopathic hypereosinophilic syndrome (HES) is a diagnosis of exclusion. RISK-ADAPTED THERAPY The goal of therapy is to mitigate eosinophil-mediated organ damage. For patients with milder forms of eosinophilia (eg, < 1.5 × 109 /L) without symptoms or signs of organ involvement, a watch and wait approach with close follow-up may be undertaken. Identification of rearranged PDGFRA or PDGFRB is critical because of the exquisite responsiveness of these diseases to imatinib. Corticosteroids are first-line therapy for patients with lymphocyte-variant HE and HES. Hydroxyurea and interferon-α have demonstrated efficacy as initial treatment and in steroid-refractory cases of HES. Mepolizumab, an interleukin-5 (IL-5) antagonist monoclonal antibody, was recently approved by the US Food and Drug Administration for patients with idiopathic HES. The use of the IL-5 receptor antibody benralizumab, as well as other targeted therapies such as JAK2 and FGFR1 inhibitors, is under active investigation.
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Affiliation(s)
- William Shomali
- Division of Hematology, Stanford Cancer Institute Stanford University School of Medicine Stanford California USA
| | - Jason Gotlib
- Division of Hematology, Stanford Cancer Institute Stanford University School of Medicine Stanford California USA
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8
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Williams AK, Dou C, Chen LYC. Treatment of lymphocyte-variant hypereosinophilic syndrome (L-HES): what to consider after confirming the elusive diagnosis. Br J Haematol 2021; 195:669-680. [PMID: 34105142 DOI: 10.1111/bjh.17615] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2021] [Revised: 05/07/2021] [Accepted: 05/13/2021] [Indexed: 12/20/2022]
Abstract
Lymphocyte-variant hypereosinophilic syndrome (L-HES) is a rare disease driven by immunophenotypically aberrant T cells producing eosinophilopoetic cytokines such as interleukin-5 (IL-5). Treatment is challenging because L-HES is relatively steroid resistant and not amenable to tyrosine kinase inhibitors. We searched the literature for clinical trials and observational studies, including case reports, of patients treated for L-HES. In all, 25 studies were selected; two were randomised controlled trials of IL-5 blockade, which included some patients with L-HES, and the rest were observational studies. Corticosteroids are often used as first-line therapy, but patients with L-HES have lower response rates than other types of HES. Treatments that reduce symptoms and steroid dependence in some patients include interferon-alpha (IFN-α), anti-IL-5 monoclonal antibodies, cyclosporine and mycophenolate. These drugs target T-cell activation and proliferation, or IL-5 directly. Although effective, IFN-α and cyclosporine were commonly reported to cause side-effects resulting in discontinuation. Alemtuzumab can induce remissions, but these are generally short lived. The anti-IL-5 monoclonal antibodies mepolizumab and benralizumab are effective and well tolerated, but with a high rate of relapse once withdrawn. Hydroxyurea, methotrexate, imatinib were unsuccessful in most patients studied. More prospective clinical trials are needed for patients with L-HES.
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Affiliation(s)
| | - Carol Dou
- Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Luke Y C Chen
- Division of Hematology, University of British Columbia, Vancouver, BC, Canada
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9
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Mattei F, Andreone S, Marone G, Gambardella AR, Loffredo S, Varricchi G, Schiavoni G. Eosinophils in the Tumor Microenvironment. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2021; 1273:1-28. [PMID: 33119873 DOI: 10.1007/978-3-030-49270-0_1] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Eosinophils are rare blood-circulating and tissue-infiltrating immune cells studied for decades in the context of allergic diseases and parasitic infections. Eosinophils can secrete a wide array of soluble mediators and effector molecules, with potential immunoregulatory activities in the tumor microenvironment (TME). These findings imply that these cells may play a role in cancer immunity. Despite these cells were known to infiltrate tumors since many years ago, their role in TME is gaining attention only recently. In this chapter, we will review the main biological functions of eosinophils that can be relevant within the TME. We will discuss how these cells may undergo phenotypic changes acquiring pro- or antitumoricidal properties according to the surrounding stimuli. Moreover, we will analyze canonical (i.e., degranulation) and unconventional mechanisms (i.e., DNA traps, exosome secretion) employed by eosinophils in inflammatory contexts, which can be relevant for tumor immune responses. Finally, we will review the available preclinical models that could be employed for the study of the role in vivo of eosinophils in cancer.
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Affiliation(s)
- Fabrizio Mattei
- Department of Oncology and Molecular Medicine, Istituto Superiore di Sanità, Rome, Italy
| | - Sara Andreone
- Department of Oncology and Molecular Medicine, Istituto Superiore di Sanità, Rome, Italy
| | - Giancarlo Marone
- Department of Public Health, University of Naples Federico II, Naples, Italy.,Azienda Ospedaliera Ospedali dei Colli - Monaldi Hospital Pharmacy, Naples, Italy
| | | | - Stefania Loffredo
- Department of Translational Medical Sciences and Center for Basic and Clinical Immunology Research (CISI), University of Naples Federico II, Naples, Italy.,WAO Center of Excellence, Naples, Italy.,Institute of Experimental Endocrinology and Oncology "G. Salvatore" (IEOS), National Research Council (CNR), Naples, Italy
| | - Gilda Varricchi
- Department of Translational Medical Sciences and Center for Basic and Clinical Immunology Research (CISI), University of Naples Federico II, Naples, Italy. .,WAO Center of Excellence, Naples, Italy. .,Institute of Experimental Endocrinology and Oncology "G. Salvatore" (IEOS), National Research Council (CNR), Naples, Italy.
| | - Giovanna Schiavoni
- Department of Oncology and Molecular Medicine, Istituto Superiore di Sanità, Rome, Italy.
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Molecular Pathogenesis and Treatment Perspectives for Hypereosinophilia and Hypereosinophilic Syndromes. Int J Mol Sci 2021; 22:ijms22020486. [PMID: 33418988 PMCID: PMC7825323 DOI: 10.3390/ijms22020486] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2020] [Revised: 12/29/2020] [Accepted: 12/30/2020] [Indexed: 12/25/2022] Open
Abstract
Hypereosinophilia (HE) is a heterogeneous condition with a persistent elevated eosinophil count of >350/mm3, which is reported in various (inflammatory, allergic, infectious, or neoplastic) diseases with distinct pathophysiological pathways. HE may be associated with tissue or organ damage and, in this case, the disorder is classified as hypereosinophilic syndrome (HES). Different studies have allowed for the discovery of two major pathogenetic variants known as myeloid or lymphocytic HES. With the advent of molecular genetic analyses, such as T-cell receptor gene rearrangement assays and Next Generation Sequencing, it is possible to better characterize these syndromes and establish which patients will benefit from pharmacological targeted therapy. In this review, we highlight the molecular alterations that are involved in the pathogenesis of eosinophil disorders and revise possible therapeutic approaches, either implemented in clinical practice or currently under investigation in clinical trials.
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Shomali W, Gotlib J. World Health Organization-defined eosinophilic disorders: 2019 update on diagnosis, risk stratification, and management. Am J Hematol 2019; 94:1149-1167. [PMID: 31423623 DOI: 10.1002/ajh.25617] [Citation(s) in RCA: 115] [Impact Index Per Article: 23.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2019] [Accepted: 08/13/2019] [Indexed: 12/16/2022]
Abstract
DISEASE OVERVIEW The eosinophilias encompass a broad range of non-hematologic (secondary or reactive) and hematologic (primary, clonal) disorders with potential for end-organ damage. DIAGNOSIS Hypereosinophilia has generally been defined as a peripheral blood eosinophil count greater than 1.5 × 109 /L, and may be associated with tissue damage. After exclusion of secondary causes of eosinophilia, diagnostic evaluation of primary eosinophilias relies on a combination of various tests. They include morphologic review of the blood and marrow, standard cytogenetics, fluorescence in situ-hybridization, flow immunophenotyping, and T-cell clonality assessment to detect histopathologic or clonal evidence for an acute or chronic hematolymphoid neoplasm. RISK STRATIFICATION Disease prognosis relies on identifying the subtype of eosinophilia. After evaluation of secondary causes of eosinophilia, the 2016 World Health Organization endorses a semi-molecular classification scheme of disease subtypes. This includes the major category "myeloid/lymphoid neoplasms with eosinophilia and rearrangement of PDGFRA, PDGFRB, or FGFR1 or with PCM1-JAK2", and the MPN subtype, "chronic eosinophilic leukemia, not otherwise specified" (CEL, NOS). Lymphocyte-variant hypereosinophilia is an aberrant T-cell clone-driven reactive eosinophila, and idiopathic hypereosinophilic syndrome (HES) is a diagnosis of exclusion. RISK-ADAPTED THERAPY The goal of therapy is to mitigate eosinophil-mediated organ damage. For patients with milder forms of eosinophilia (eg, <1.5 × 109 /L) without symptoms or signs of organ involvement, a watch and wait approach with close-follow-up may be undertaken. Identification of rearranged PDGFRA or PDGFRB is critical because of the exquisite responsiveness of these diseases to imatinib. Corticosteroids are first-line therapy for patients with lymphocyte-variant hypereosinophilia and HES. Hydroxyurea and interferon-alfa have demonstrated efficacy as initial treatment and in steroid-refractory cases of HES. In addition to hydroxyurea, second line cytotoxic chemotherapy agents, and hematopoietic stem cell transplantation have been used for aggressive forms of HES and CEL, with outcomes reported for limited numbers of patients. The use of antibodies against interleukin-5 (IL-5) (mepolizumab), the IL-5 receptor (benralizumab), as well as other targets on eosinophils remains an active area of investigation.
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Affiliation(s)
- William Shomali
- Division of Hematology, Stanford Cancer Institute/Stanford University School of Medicine, Stanford, California
| | - Jason Gotlib
- Division of Hematology, Stanford Cancer Institute/Stanford University School of Medicine, Stanford, California
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Klion A. Hypereosinophilic syndrome: approach to treatment in the era of precision medicine. HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2018; 2018:326-331. [PMID: 30504328 PMCID: PMC6245960 DOI: 10.1182/asheducation-2018.1.326] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/06/2023]
Abstract
Hypereosinophilic syndromes (HESs) are a heterogeneous group of rare disorders characterized by peripheral eosinophilia and eosinophilic end organ complications. Conventional therapies, including glucocorticoids and cytotoxic and immunomodulatory agents, have variable efficacy and significant toxicity. Although the recent development of agents that target eosinophils, including tyrosine kinase inhibitors and monoclonal antibodies, provides the possibility of more effective, less toxic approaches to treatment of HES, there are little available data to guide their use in these conditions. In the following review, the controversies regarding the definition and classification of HES will be discussed, and a pragmatic approach to treatment based on clinically defined HES variants will be presented. An illustrative case will be used to highlight the complexities of treatment selection in HES patients.
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Affiliation(s)
- Amy Klion
- Human Eosinophil Section, Laboratory of Parasitic Diseases, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD
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13
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Biologic Agents for the Treatment of Hypereosinophilic Syndromes. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2018; 5:1502-1509. [PMID: 29122152 DOI: 10.1016/j.jaip.2017.08.001] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 06/23/2017] [Revised: 08/04/2017] [Accepted: 08/07/2017] [Indexed: 11/22/2022]
Abstract
Hypereosinophilic syndromes (HES) are a heterogeneous group of rare disorders defined by the presence of marked peripheral or tissue eosinophilia resulting in end-organ damage. Although conventional therapies, including glucocorticoids, hydroxyurea, and IFN-α, are initially effective in reducing eosinophilia and symptoms in a majority of patients with platelet-derived growth factor mutation-negative HES, the development of resistance and treatment-related toxicity are common. In contrast, targeted therapy with the tyrosine kinase inhibitor, imatinib, is well tolerated but effective only in the subset of patients with HES with a primary myeloid disorder. Eosinophil-targeted biotherapeutics offer the potential of improved efficacy with few, if any, adverse effects. The aims of this review are to provide an overview of current approaches to the use of conventional HES therapies and a discussion of existing biotherapeutics that target eosinophils and their potential use in the treatment of HES. With the continuing expansion of eosinophil-targeted biotherapeutics, the future for patients with eosinophilic disorders is promising.
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Dispenza MC, Bochner BS. Diagnosis and Novel Approaches to the Treatment of Hypereosinophilic Syndromes. Curr Hematol Malig Rep 2018; 13:191-201. [PMID: 29680938 PMCID: PMC6029712 DOI: 10.1007/s11899-018-0448-8] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
PURPOSE OF REVIEW Hypereosinophilic syndrome (HES) is characterized by persistent hypereosinophilia associated with end-organ damage. As our understanding of the pathogenesis of various forms of HES broadens, so does our ability to tailor steroid-sparing therapies for each subtype. The purpose of this review is to summarize recent literature related to the etiology, diagnosis, and management of HES. RECENT FINDINGS Mutations involved in subsets of HES can guide the choice of tyrosine kinase inhibitors beyond just imatinib. Several biologics that target interleukin-5 or its receptor have shown beneficial and selective eosinophil-reducing effects in clinical trials for asthma and other disorders including HES. Early clinical data with emerging therapies such as dexpramipexole and anti-Siglec-8 antibody show promise, but need to be confirmed in randomized trials. Several new biologics and tyrosine kinase inhibitors have been shown to lower eosinophil numbers, but more randomized trials are needed to confirm efficacy in HES.
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Affiliation(s)
- Melanie C Dispenza
- Division of Allergy and Immunology, Department of Medicine, Northwestern University Feinberg School of Medicine, 240 E. Huron Street, Room M306, Chicago, IL, 60611, USA
| | - Bruce S Bochner
- Division of Allergy and Immunology, Department of Medicine, Northwestern University Feinberg School of Medicine, 240 E. Huron Street, Room M306, Chicago, IL, 60611, USA.
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15
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Gotlib J. World Health Organization-defined eosinophilic disorders: 2017 update on diagnosis, risk stratification, and management. Am J Hematol 2017; 92:1243-1259. [PMID: 29044676 DOI: 10.1002/ajh.24880] [Citation(s) in RCA: 138] [Impact Index Per Article: 19.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2017] [Accepted: 08/03/2017] [Indexed: 12/20/2022]
Abstract
DISEASE OVERVIEW The eosinophilias encompass a broad range of nonhematologic (secondary or reactive) and hematologic (primary, clonal) disorders with potential for end-organ damage. DIAGNOSIS Hypereosinophilia has generally been defined as a peripheral blood eosinophil count greater than 1500/mm3 and may be associated with tissue damage. After exclusion of secondary causes of eosinophilia, diagnostic evaluation of primary eosinophilias relies on a combination of morphologic review of the blood and marrow, standard cytogenetics, fluorescent in situ-hybridization, flow immunocytometry, and T-cell clonality assessment to detect histopathologic or clonal evidence for an acute or chronic myeloid or lymphoproliferative disorder. RISK STRATIFICATION Disease prognosis relies on identifying the subtype of eosinophilia. After evaluation of secondary causes of eosinophilia, the 2016 World Health Organization endorses a semi-molecular classification scheme of disease subtypes which includes the major category "myeloid/lymphoid neoplasms with eosinophilia and rearrangement of PDGFRA, PDGFRB, or FGFR1 or with PCM1-JAK2," and the "MPN subtype, chronic eosinophilic leukemia, not otherwise specified" (CEL, NOS). Lymphocyte-variant hypereosinophilia is an aberrant T-cell clone-driven reactive eosinophila, and idiopathic hypereosinophilic syndrome (HES) is a diagnosis of exclusion. RISK-ADAPTED THERAPY The goal of therapy is to mitigate eosinophil-mediated organ damage. For patients with milder forms of eosinophilia (e.g., < 1500/mm3 ) without symptoms or signs of organ involvement, a watch and wait approach with close-follow-up may be undertaken. Identification of rearranged PDGFRA or PDGFRB is critical because of the exquisite responsiveness of these diseases to imatinib. Corticosteroids are first-line therapy for patients with lymphocyte-variant hypereosinophilia and HES. Hydroxyurea and interferon-alpha have demonstrated efficacy as initial treatment and steroid-refractory cases of HES. In addition to hydroxyurea, second line cytotoxic chemotherapy agents and hematopoietic cell transplant have been used for aggressive forms of HES and CEL with outcomes reported for limited numbers of patients. The use of antibodies against interleukin-5 (IL-5) (mepolizumab), the IL-5 receptor (benralizumab), and CD52 (alemtuzumab), as well as other targets on eosinophils remains an active area of investigation.
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Affiliation(s)
- Jason Gotlib
- Stanford Cancer Institute, Stanford, California 94305-5821
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17
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Chen H, Raza HK, Jing J, Shen D, Xu P, Zhou S, Zu J, Yang X, Zhang W, Zhang S, Hua F, Cui G. Hypereosinophilic syndrome with central nervous system involvement: Two case reports and literature review. Brain Inj 2017; 31:1695-1700. [PMID: 28945486 DOI: 10.1080/02699052.2017.1357835] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
OBJECTIVE To report two cases of hypereosinophilic syndrome (HES) with central nervous system involvement and explore its possible pathogenesis. METHODS We have analysed the clinical data and relevant features of two patients who presented themselves to The Affiliated Hospital of Xuzhou Medical University between 2012 and 2015. We have reviewed the relevant literature, elaborated the possible pathogenesis, and discussed the treatment options. RESULTS Both patients had consistently high levels of absolute eosinophil count which led to multiple cerebral infarcts in the arterial border zone and small-vessel disease. Blood tests were taken several times during their course of disease showing elevated eosinophils. Both patients underwent head computed tomography (CT), magnetic resonance imaging, and magnetic resonance angiography, which indicated small-vessel disease and watershed infarction. Glucocorticoids, improvement cycle, and neuro-nutrition treatments resulted in a significant improvement of their clinical state. CONCLUSION HES can involve central nervous system by causing small-vessel disease and watershed infarction, which can be its presenting features. Repeated blood tests should be done to rule out HES in central nervous system lesion.
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Affiliation(s)
- Hao Chen
- a Department of Neurology , The Affiliated Hospital of Xuzhou Medical University , Xuzhou , China
| | - Hafiz Khuram Raza
- a Department of Neurology , The Affiliated Hospital of Xuzhou Medical University , Xuzhou , China
| | - Jia Jing
- b Department of Biology , Georgia State University , Atlanta , USA
| | - Dayong Shen
- a Department of Neurology , The Affiliated Hospital of Xuzhou Medical University , Xuzhou , China
| | - Peng Xu
- a Department of Neurology , The Affiliated Hospital of Xuzhou Medical University , Xuzhou , China
| | - Su Zhou
- a Department of Neurology , The Affiliated Hospital of Xuzhou Medical University , Xuzhou , China
| | - Jie Zu
- a Department of Neurology , The Affiliated Hospital of Xuzhou Medical University , Xuzhou , China
| | - Xinxin Yang
- a Department of Neurology , The Affiliated Hospital of Xuzhou Medical University , Xuzhou , China
| | - Wei Zhang
- a Department of Neurology , The Affiliated Hospital of Xuzhou Medical University , Xuzhou , China
| | - Shenyang Zhang
- a Department of Neurology , The Affiliated Hospital of Xuzhou Medical University , Xuzhou , China
| | - Fang Hua
- a Department of Neurology , The Affiliated Hospital of Xuzhou Medical University , Xuzhou , China
| | - Guiyun Cui
- a Department of Neurology , The Affiliated Hospital of Xuzhou Medical University , Xuzhou , China
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Abstract
Eosinophils can regulate local and systemic inflammation, and their presence in higher numbers appears to play an important role in the pathology of various atopic and inflammatory diseases. Eosinophil maturation, recruitment, and survival depend on several cytokine regulators, including interleukin (IL)-5, IL-4, and IL-13 as well as growth factors such as GM-CSF. Over the last decade, the approach to treating eosinophilic diseases has changed greatly. A number of biologic modulators have been developed to target eosinophilic inflammatory pathways, and their usage has resulted in variable clinical improvement in the treatment of eosinophilic-associated conditions. Novel targeted therapies that are safe and effective for treating these disorders are being investigated. This review summarizes the clinical use of biologic agents that have been studied in clinical trials or approved for treating eosinophilic diseases.
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Affiliation(s)
- Panida Sriaroon
- Division of Allergy, Immunology, and Rheumatology, Department of Pediatrics, University of South Florida, 140 7th ave S, CRI 4008, St. Petersburg, FL, 33701, USA.
| | - Mark Ballow
- Division of Allergy, Immunology, and Rheumatology, Department of Pediatrics, University of South Florida, 140 7th ave S, CRI 4008, St. Petersburg, FL, 33701, USA
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Abstract
Current therapies for eosinophilic disorders are limited. Most treatment approaches remain empirical, are not supported by data from controlled clinical trials, involve the off-label use of agents developed for treatment of other diseases, and tend to rely heavily on the use of glucocorticoids and other agents with significant toxicity. Great progress has been made in the discovery, preclinical development, and clinical testing of a variety of biologics and small molecules that have the potential to directly or indirectly influence eosinophils, eosinophilic inflammation, and the consequences of eosinophil activation.
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Abstract
Eosinophilia in the peripheral blood can be the manifestation various medical conditions, including benign or malignant disorders. There are 3 main types of eosinophilia-associated myeloid neoplasms (MN-eos): myeloid and lymphoid neoplasms, chronic eosinophilic leukemia not otherwise specified, and idiopathic hypereosinophilic syndrome (HES). Imatinib mesylate has revolutionized the treatment of molecularly defined MN-eos, and novel agents have been successfully used to treat HES. The discovery of new, recurrent molecular alterations in patients with MN-eos may improve their diagnosis and therapy. This review focuses on the hematologist's approach to a patient with eosinophilia and treatment options for those with eosinophilic myeloid neoplasms.
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Affiliation(s)
- Lorenzo Falchi
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Boulevard, Houston, TX 77030, USA
| | - Srdan Verstovsek
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Boulevard, Houston, TX 77030, USA.
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21
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Gotlib J. World Health Organization-defined eosinophilic disorders: 2015 update on diagnosis, risk stratification, and management. Am J Hematol 2015; 90:1077-89. [PMID: 26486351 DOI: 10.1002/ajh.24196] [Citation(s) in RCA: 82] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2015] [Accepted: 09/15/2015] [Indexed: 12/19/2022]
Abstract
DISEASE OVERVIEW The eosinophilias encompass a broad range of non-hematologic (secondary or reactive) and hematologic (primary, clonal) disorders with potential for end-organ damage. DIAGNOSIS Hypereosinophilia has generally been defined as a peripheral blood eosinophil count greater than 1,500/mm(3) and may be associated with tissue damage. After exclusion of secondary causes of eosinophilia, diagnostic evaluation of primary eosinophilias relies on a combination of morphologic review of the blood and marrow, standard cytogenetics, fluorescent in situ-hybridization, flow immunocytometry, and T-cell clonality assessment to detect histopathologic or clonal evidence for an acute or chronic myeloid or lymphoproliferative disorder. RISK STRATIFICATION Disease prognosis relies on identifying the subtype of eosinophilia. After evaluation of secondary causes of eosinophilia, the 2008 World Health Organization establishes a semi-molecular classification scheme of disease subtypes including 'myeloid and lymphoid neoplasms with eosinophilia and abnormalities of PDGFRA, PDGFRB, or FGFR1', chronic eosinophilic leukemia, not otherwise specified, (CEL, NOS), lymphocyte-variant hypereosinophilia, and idiopathic hypereosinophilic syndrome (HES), which is a diagnosis of exclusion. RISK-ADAPTED THERAPY The goal of the therapy is to mitigate eosinophil-mediated organ damage. For patients with milder forms of eosinophilia (e.g. < 1,500/mm(3) ) without symptoms or signs of organ involvement, a watch and wait approach with close-follow-up may be undertaken. Identification of rearranged PDGFRA or PDGFRB is critical because of the exquisite responsiveness of these diseases to imatinib. Corticosteroids are first-line therapy for patients with lymphocyte-variant hypereosinophilia and HES. Hydroxyurea and interferon-alpha have demonstrated efficacy as initial treatment and steroid-refractory cases of HES. In addition to hydroxyurea, second line cytotoxic chemotherapy agents and hematopoietic cell transplant have been used for aggressive forms of HES and CEL with outcomes reported for limited numbers of patients. Although clinical trials have been performed with anti IL-5 (mepolizumab) and anti-CD52 (alemtuzumab) antibodies, their therapeutic role in primary eosinophilic diseases and HES has yet to be established.
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22
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Gotlib J. Tyrosine Kinase Inhibitors and Therapeutic Antibodies in Advanced Eosinophilic Disorders and Systemic Mastocytosis. Curr Hematol Malig Rep 2015; 10:351-61. [DOI: 10.1007/s11899-015-0280-3] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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23
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Boyman O, Kaegi C, Akdis M, Bavbek S, Bossios A, Chatzipetrou A, Eiwegger T, Firinu D, Harr T, Knol E, Matucci A, Palomares O, Schmidt-Weber C, Simon HU, Steiner UC, Vultaggio A, Akdis CA, Spertini F. EAACI IG Biologicals task force paper on the use of biologic agents in allergic disorders. Allergy 2015; 70:727-54. [PMID: 25819018 DOI: 10.1111/all.12616] [Citation(s) in RCA: 86] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/22/2015] [Indexed: 12/22/2022]
Abstract
Biologic agents (also termed biologicals or biologics) are therapeutics that are synthesized by living organisms and directed against a specific determinant, for example, a cytokine or receptor. In inflammatory and autoimmune diseases, biologicals have revolutionized the treatment of several immune-mediated disorders. Biologicals have also been tested in allergic disorders. These include agents targeting IgE; T helper 2 (Th2)-type and Th2-promoting cytokines, including interleukin-4 (IL-4), IL-5, IL-9, IL-13, IL-31, and thymic stromal lymphopoietin (TSLP); pro-inflammatory cytokines, such as IL-1β, IL-12, IL-17A, IL-17F, IL-23, and tumor necrosis factor (TNF); chemokine receptor CCR4; and lymphocyte surface and adhesion molecules, including CD2, CD11a, CD20, CD25, CD52, and OX40 ligand. In this task force paper of the Interest Group on Biologicals of the European Academy of Allergy and Clinical Immunology, we review biologicals that are currently available or tested for the use in various allergic and urticarial pathologies, by providing an overview on their state of development, area of use, adverse events, and future research directions.
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Affiliation(s)
- O. Boyman
- Department of Immunology; University Hospital Zurich; University of Zurich; Zurich Switzerland
| | - C. Kaegi
- Department of Immunology; University Hospital Zurich; University of Zurich; Zurich Switzerland
| | - M. Akdis
- Swiss Institute of Allergy and Asthma Research (SIAF); University of Zurich; Davos Switzerland
- Christine Kühne-Center for Allergy Research and Education (CK-CARE); Davos Switzerland
| | - S. Bavbek
- Division of Immunology and Allergy; Department of Pulmonary Disease; School of Medicine; Ankara University; Ankara Turkey
| | - A. Bossios
- Krefting Research Centre; Department of Internal Medicine and Nutrition; Institute of Medicine; Sahlgrenska Academy; University of Gothenburg; Gothenburg Sweden
| | - A. Chatzipetrou
- Allergy Unit ‘D. Kalogeromitros’; 2nd Department of Dermatology and Venereology; ‘Attikon’ University Hospital; Medical School; University of Athens; Athens Greece
| | - T. Eiwegger
- Department of Pediatrics and Adolescent Medicine; Medical University of Vienna; Vienna Austria
| | - D. Firinu
- Unit of Internal Medicine, Allergy and Clinical Immunology; Department of Medical Sciences ‘M. Aresu’; University of Cagliari; Monserrato Italy
| | - T. Harr
- Service d'Immunologie et d'Allergologie; Spécialités de Médecine; Hôpitaux Universitaires de Genève; Geneva Switzerland
| | - E. Knol
- Departments of Immunology and Dermatology/Allergology; University Medical Center Utrecht; Utrecht The Netherlands
| | - A. Matucci
- Immunoallergology Unit; Department of Biomedicine; Azienda Ospedaliero Universitaria Careggi; Florence Italy
| | - O. Palomares
- Department of Biochemistry and Molecular Biology; School of Chemistry; Complutense University of Madrid; Madrid Spain
| | - C. Schmidt-Weber
- Center of Allergy and Environment (ZAUM); Technische Universität and Helmholtz Center Munich; Member of the German Center for Lung Research (DZL); Munich Germany
| | - H.-U. Simon
- Institute of Pharmacology; University of Bern; Bern Switzerland
| | - U. C. Steiner
- Division of Allergology and Clinical Immunology; Spitalnetz Bern Tiefenau Ziegler; Bern Switzerland
| | - A. Vultaggio
- Immunoallergology Unit; Department of Biomedicine; Azienda Ospedaliero Universitaria Careggi; Florence Italy
| | - C. A. Akdis
- Swiss Institute of Allergy and Asthma Research (SIAF); University of Zurich; Davos Switzerland
- Christine Kühne-Center for Allergy Research and Education (CK-CARE); Davos Switzerland
| | - F. Spertini
- Division of Immunology and Allergy; Centre Hospitalier Universitaire Vaudois; Lausanne Switzerland
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Radonjic-Hoesli S, Valent P, Klion AD, Wechsler ME, Simon HU. Novel targeted therapies for eosinophil-associated diseases and allergy. Annu Rev Pharmacol Toxicol 2014; 55:633-56. [PMID: 25340931 DOI: 10.1146/annurev-pharmtox-010814-124407] [Citation(s) in RCA: 46] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
Eosinophil-associated diseases often present with life-threatening manifestations and/or chronic organ damage. Currently available therapeutic options are limited to a few drugs that often have to be prescribed on a lifelong basis to keep eosinophil counts under control. In the past 10 years, treatment options and outcomes in patients with clonal eosinophilic and other eosinophilic disorders have improved substantially. Several new targeted therapies have emerged, addressing different aspects of eosinophil expansion and inflammation. In this review, we discuss available and currently tested agents as well as new strategies and drug targets relevant to both primary and secondary eosinophilic diseases, including allergic disorders.
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25
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Landolina NAC, Levi-Schaffer F. Eosinophils as a pharmacological target for the treatment of allergic diseases. Curr Opin Pharmacol 2014; 17:71-80. [PMID: 25128782 DOI: 10.1016/j.coph.2014.07.014] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2014] [Revised: 07/08/2014] [Accepted: 07/23/2014] [Indexed: 01/21/2023]
Abstract
Eosinophils are innate immune cells and active players in inflammatory responses. Their activation and increased levels in the blood and at specific sites are associated with parasitic infections and several inflammatory conditions, notably allergic diseases in which eosinophils are considered to be damaging cells. Intervention targeting eosinophils is thought to prevent and/or limit irreversible organ damage and other eosinophil-associated disorders like hypereosinophilic syndromes, some cancers and autoimmune diseases. Several eosinophil-targeted therapeutic agents which block specific steps in eosinophil differentiation, migration and activation have recently been developed, showing encouraging results and new insights into their specific role in allergy. Here, we review some potentially effective drug compounds, their drawbacks and future prospective focusing on allergic diseases.
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Affiliation(s)
- Nadine Anna Caterina Landolina
- Institute for Drug Research, School of Pharmacy, Faculty of Medicine, The Hebrew University of Jerusalem, POB 12065, Jerusalem 91120, Israel
| | - Francesca Levi-Schaffer
- Institute for Drug Research, School of Pharmacy, Faculty of Medicine, The Hebrew University of Jerusalem, POB 12065, Jerusalem 91120, Israel.
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26
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Gotlib J. World Health Organization-defined eosinophilic disorders: 2014 update on diagnosis, risk stratification, and management. Am J Hematol 2014; 89:325-37. [PMID: 24577808 DOI: 10.1002/ajh.23664] [Citation(s) in RCA: 102] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2013] [Accepted: 01/03/2014] [Indexed: 12/27/2022]
Abstract
DISEASE OVERVIEW The eosinophilias encompass a broad range of nonhematologic (secondary or reactive) and hematologic (primary, clonal) disorders with potential for end-organ damage. DIAGNOSIS Hypereosinophilia (HE) has generally been defined as a peripheral blood eosinophil count greater than 1,500/mm(3) and may be associated with tissue damage. After exclusion of secondary causes of eosinophilia, diagnostic evaluation of primary eosinophilias relies on a combination of morphologic review of the blood and marrow, standard cytogenetics, fluorescent in situ hybridization, flow immunocytometry, and T-cell clonality assessment to detect histopathologic or clonal evidence for an acute or chronic myeloid or lymphoproliferative disorder. RISK STRATIFICATION Disease prognosis relies on identifying the subtype of eosinophilia. After evaluation of secondary causes of eosinophilia, the 2008 World Health Organization establishes a semimolecular classification scheme of disease subtypes including "myeloid and lymphoid neoplasms with eosinophilia and abnormalities of PDGFRA, PDGFRB, or FGFR1', chronic eosinophilic leukemia, not otherwise specified" (CEL, NOS), lymphocyte-variant HE, and idiopathic hypereosinophilic syndrome (HES), which is a diagnosis of exclusion. RISK-ADAPTED THERAPY The goal of therapy is to mitigate eosinophil-mediated organ damage. For patients with milder forms of eosinophilia (e.g., <1,500/mm(3)) without symptoms or signs of organ involvement, a watch and wait approach with close-follow-up may be undertaken. Identification of rearranged PDGFRA or PDGFRB is critical because of the exquisite responsiveness of these diseases to imatinib. Corticosteroids are first-line therapy for patients with lymphocyte-variant HE and HES. Hydroxyurea and interferon-alpha have demonstrated efficacy as initial treatment and steroid-refractory cases of HES. In addition to hydroxyurea, second-line cytotoxic chemotherapy agents and hematopoietic cell transplant have been used for aggressive forms of HES and CEL with outcomes reported for limited number of patients. Although clinical trials have been performed with anti-IL-5 (mepolizumab) and anti-CD52 (alemtuzumab) antibodies, their therapeutic role in primary eosinophilic diseases and HES has yet to be established.
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Affiliation(s)
- Jason Gotlib
- Division of Hematology; Stanford Cancer Center; Stanford California
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Fathi AT, Dec GW, Richter JM, Chen YB, Schwartzenberg SS, Holmvang G, Hasserjian RP. Case records of the Massachusetts General Hospital. Case 7-2014. A 27-year-old man with diarrhea, fatigue, and eosinophilia. N Engl J Med 2014; 370:861-72. [PMID: 24571759 DOI: 10.1056/nejmcpc1302331] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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Hochhaus A, le Coutre PD, Kantarjian HM, Baccarani M, Erben P, Reiter A, McCulloch T, Fan X, Novick S, Giles FJ. Effect of the tyrosine kinase inhibitor nilotinib in patients with hypereosinophilic syndrome/chronic eosinophilic leukemia: analysis of the phase 2, open-label, single-arm A2101 study. J Cancer Res Clin Oncol 2013; 139:1985-93. [PMID: 24057647 DOI: 10.1007/s00432-013-1529-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2013] [Accepted: 09/13/2013] [Indexed: 12/18/2022]
Abstract
PURPOSE Hypereosinophilic syndrome (HES) and chronic eosinophilic leukemia (CEL) are characterized by sustained overproduction of eosinophils and organ dysfunction. CEL involves the presence of clonal genetic markers, such as a fusion of FIP1-like 1 protein and platelet-derived growth factor receptor α (FIP1L1-PDGFRα, or F/P) or PDGFRα-activating mutations. METHODS Sixteen patients with HES/CEL were enrolled in the phase 2 nilotinib registration trial (NCT00109707) and treated with nilotinib 400 mg twice daily. The median duration of treatment was 95 days (range 3-1,079). RESULTS Twelve patients had HES: 1 achieved a complete hematologic response (CHR), 3 achieved stable disease, 3 had progressive disease, and 5 were not evaluable for response. Four patients had CEL: 2 with the F/P fusion and 2 with PDGFRα-activating mutations. Both patients with an F/P fusion achieved a CHR; 1 also achieved a complete molecular response (CMR). Of the 2 patients with PDGFRα-activating mutations, 1 had stable disease and the other achieved CMR. At 24 months, overall survival in the HES group was 75.0 % (95 % CI 50.5-100.0) and no patients in the CEL group died. Median survival was not yet reached after a median follow-up of 32 months. The most common grade 3/4 hematologic laboratory abnormalities were lymphocytopenia (31.3 %) and neutropenia (25.0 %). The most common drug-related nonhematologic grade 3/4 adverse event was pruritus, which occurred in 2 patients (12.5 %). CONCLUSIONS Nilotinib 400 mg twice daily was effective in some patients with HES/CEL regardless of F/P mutation status, and the safety profile was consistent with other nilotinib studies.
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Affiliation(s)
- Andreas Hochhaus
- Abteilung Hämatologie/Onkologie, Universitätsklinikum Jena, Jena, Germany,
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The conformational control inhibitor of tyrosine kinases DCC-2036 is effective for imatinib-resistant cells expressing T674I FIP1L1-PDGFRα. PLoS One 2013; 8:e73059. [PMID: 24009732 PMCID: PMC3756952 DOI: 10.1371/journal.pone.0073059] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2013] [Accepted: 07/16/2013] [Indexed: 11/19/2022] Open
Abstract
The cells expressing the T674I point mutant of FIP1-like-1-platelet-derived growth factor receptor alpha (FIP1L1-PDGFRα) in hypereosinophilics syndrome (HES) are resistant to imatinib and some second-generation tyrosine kinase inhibitors (TKIs). There is a desperate need to develop therapy to combat this acquired drug resistance. DCC-2036 has been synthesized as a third-generation TKI to combat especially the Bcr-Abl T315I mutant in chronic myeloid leukemia. This study evaluated the effect of DCC-2036 on FIP1L1-PDGFRα-positive cells, including the wild type (WT) and the T674I mutant. The in vitro effects of DCC-2036 on the PDGFRα signal pathways, proliferation, cell cycling and apoptosis of FIP1L1-PDGFRα-positive cells were investigated, and a nude mouse xenograft model was employed to assess the in vivo antitumor activity. We found that DCC-2036 decreased the phosphorylated levels of PDGFRα and its downstream targets without apparent effects on total protein levels. DCC-2036 inhibited proliferation, and induced apoptosis with MEK-dependent up-regulation of the pro-apoptotic protein Bim in FIP1L1-PDGFRα-positive cells. DCC-2036 also exhibited in vivo antineoplastic activity against cells with T674I FIP1L1-PDGFRα. In summary, FIP1L1-PDGFRα-positive cells are sensitive to DCC-2036 regardless of their sensitivity to imatinib. DCC-2036 may be a potential compound to treat imatinib-resistant HES.
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Clinical overview of cutaneous features in hypereosinophilic syndrome. Curr Allergy Asthma Rep 2013; 12:85-98. [PMID: 22359067 DOI: 10.1007/s11882-012-0241-z] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
The hypereosinophilic syndromes (HES) are a heterogeneous group of disorders defined as persistent and marked blood eosinophilia of unknown origin with systemic organ involvement. HES is a potentially severe multisystem disease associated with considerable morbidity. Skin involvement and cutaneous findings frequently can be seen in those patients. Skin symptoms consist of angioedema; unusual urticarial lesions; and eczematous, therapy-resistant, pruriginous papules and nodules. They may be the only obvious clinical symptoms. Cutaneous features can give an important hint to the diagnosis of this rare and often severe illness. Based on advances in molecular and genetic diagnostic techniques and on increasing experience with characteristic clinical features and prognostic markers, therapy has changed radically. Current therapies include corticosteroids, hydroxyurea, interferon-α, the tyrosine kinase inhibitor imatinib mesylate, and (in progress) the monoclonal anti-interleukin-5 antibodies. This article provides an overview of current concepts of disease classification, different skin findings, and therapy for HES.
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Montgomery ND, Dunphy CH, Mooberry M, Laramore A, Foster MC, Park SI, Fedoriw YD. Diagnostic Complexities of Eosinophilia. Arch Pathol Lab Med 2013; 137:259-69. [DOI: 10.5858/arpa.2011-0597-ra] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Context.— The advent of molecular tools capable of subclassifying eosinophilia has changed the diagnostic and clinical approach to what was classically called hypereosinophilic syndrome.Objectives.— To review the etiologies of eosinophilia and to describe the current diagnostic approach to this abnormality.Data Sources.— Literature review.Conclusions.— Eosinophilia is a common, hematologic abnormality with diverse etiologies. The underlying causes can be broadly divided into reactive, clonal, and idiopathic. Classically, many cases of eosinophilia were grouped together into the umbrella category of hypereosinophilic syndrome, a clinical diagnosis of exclusion. In recent years, an improved mechanistic understanding of many eosinophilias has revolutionized the way these disorders are understood, diagnosed, and treated. As a result, specific diagnoses can now be assigned in many cases that were previously defined as hypereosinophilic syndrome. Most notably, chromosomal rearrangements, such as FIP1L1-PDGFRA fusions caused by internal deletions in chromosome 4, are now known to be associated with many chronic eosinophilic leukemias. When present, these specific molecular abnormalities predict response to directed therapies. Although an improved molecular understanding is revolutionizing the treatment of patients with rare causes of eosinophilia, it has also complicated the approach to evaluating and treating eosinophilia. Here, we review causes of eosinophilia and present a framework by which the practicing pathologist may approach this diagnostic dilemma. Finally, we consider recent cases as clinical examples of eosinophilia from a single institution, demonstrating the diversity of etiologies that must be considered.
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Affiliation(s)
- Nathan D. Montgomery
- From the Departments of Pathology and Laboratory Medicine, Division of Hematopathology (Drs Montgomery, Dunphy, Laramore, and Fedoriw); and Medicine, Division of Hematology and Oncology (Drs Mooberry, Foster, and Park), University of North Carolina School of Medicine, Chapel Hill
| | - Cherie H. Dunphy
- From the Departments of Pathology and Laboratory Medicine, Division of Hematopathology (Drs Montgomery, Dunphy, Laramore, and Fedoriw); and Medicine, Division of Hematology and Oncology (Drs Mooberry, Foster, and Park), University of North Carolina School of Medicine, Chapel Hill
| | - Micah Mooberry
- From the Departments of Pathology and Laboratory Medicine, Division of Hematopathology (Drs Montgomery, Dunphy, Laramore, and Fedoriw); and Medicine, Division of Hematology and Oncology (Drs Mooberry, Foster, and Park), University of North Carolina School of Medicine, Chapel Hill
| | - Andrew Laramore
- From the Departments of Pathology and Laboratory Medicine, Division of Hematopathology (Drs Montgomery, Dunphy, Laramore, and Fedoriw); and Medicine, Division of Hematology and Oncology (Drs Mooberry, Foster, and Park), University of North Carolina School of Medicine, Chapel Hill
| | - Matthew C. Foster
- From the Departments of Pathology and Laboratory Medicine, Division of Hematopathology (Drs Montgomery, Dunphy, Laramore, and Fedoriw); and Medicine, Division of Hematology and Oncology (Drs Mooberry, Foster, and Park), University of North Carolina School of Medicine, Chapel Hill
| | - Steven I. Park
- From the Departments of Pathology and Laboratory Medicine, Division of Hematopathology (Drs Montgomery, Dunphy, Laramore, and Fedoriw); and Medicine, Division of Hematology and Oncology (Drs Mooberry, Foster, and Park), University of North Carolina School of Medicine, Chapel Hill
| | - Yuri D. Fedoriw
- From the Departments of Pathology and Laboratory Medicine, Division of Hematopathology (Drs Montgomery, Dunphy, Laramore, and Fedoriw); and Medicine, Division of Hematology and Oncology (Drs Mooberry, Foster, and Park), University of North Carolina School of Medicine, Chapel Hill
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Wechsler ME, Fulkerson PC, Bochner BS, Gauvreau GM, Gleich GJ, Henkel T, Kolbeck R, Mathur SK, Ortega H, Patel J, Prussin C, Renzi P, Rothenberg ME, Roufosse F, Simon D, Simon HU, Wardlaw A, Weller PF, Klion AD. Novel targeted therapies for eosinophilic disorders. J Allergy Clin Immunol 2012; 130:563-71. [PMID: 22935585 DOI: 10.1016/j.jaci.2012.07.027] [Citation(s) in RCA: 79] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2012] [Revised: 07/25/2012] [Accepted: 07/25/2012] [Indexed: 12/18/2022]
Abstract
Hypereosinophilic syndromes (HESs) are a diverse group of conditions characterized by clinical manifestations attributable to eosinophilia and eosinophilic infiltration of tissues. HESs are chronic disorders with significant morbidity and mortality. Although the availability of targeted chemotherapeutic agents, including imatinib, has improved quality of life and survival in some patients with HESs, additional agents with increased efficacy and decreased toxicity are sorely needed. The purpose of this review is to provide an overview of eosinophil biology with an emphasis on potential targets of pharmacotherapy and to provide a summary of potential eosinophil-targeting agents, including those in development, in clinical trials, or approved for other disorders.
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Cogan E, Roufosse F. Clinical management of the hypereosinophilic syndromes. Expert Rev Hematol 2012; 5:275-89; quiz 290. [PMID: 22780208 DOI: 10.1586/ehm.12.14] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
Hypereosinophilic syndromes (HESs) are rare disorders characterized by marked hypereosinophilia that is directly responsible for organ damage or dysfunction. Different pathogenic mechanisms have been discovered in patient subgroups leading to the characterization of myeloproliferative and lymphocytic disease variants. In the updated terminology, idiopathic HES is now restricted to patients with HES of undetermined etiology. The practical clinical approach of patients with the different HES variants is reviewed herein, focusing on specific diagnostic tools and therapeutic options. Corticosteroids, hydroxyurea and IFN-α remain the classical agents for treatment of most patients with HESs. The specific role of therapeutic compounds that have become available more recently, namely, tyrosine kinase inhibitors and IL-5 antagonists, is discussed.
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Affiliation(s)
- Elie Cogan
- Department of Internal Medicine, Hôpital Erasme, Université Libre de Bruxelles, B-1070 Brussels, Belgium.
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Strati P, Cortes J, Faderl S, Kantarjian H, Verstovsek S. Long-term follow-up of patients with hypereosinophilic syndrome treated with Alemtuzumab, an anti-CD52 antibody. CLINICAL LYMPHOMA MYELOMA & LEUKEMIA 2012; 13:287-91. [PMID: 23123105 DOI: 10.1016/j.clml.2012.09.018] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/02/2012] [Revised: 09/21/2012] [Accepted: 09/26/2012] [Indexed: 01/09/2023]
Abstract
BACKGROUND Relapsing, refractory patients with idiopathic hypereosinophilic syndrome (I-HES) and chronic eosinophilic leukemia-not otherwise specified (CEL-NOS) do not have many effective, durable therapeutic options. Alemtuzumab, an anti-CD52 antibody, has been reported to be an effective therapy due to inherent expression of CD52 on eosinophils. METHODS A retrospective chart review of 12 patients treated with alemtuzumab at our center until 2012. RESULTS Ten (83%) of 12 patients achieved complete hematologic response (CHR) after a median of 1 week for a median duration of 66 weeks, with the elimination of disease-related symptoms; 2 patients achieved partial hematologic remission hematologic remission (PHR). Patients with CHR who received alemtuzumab maintenance (n = 5) had a significantly longer time to progression than those patients who were only observed (n = 5) (P = .01). Eleven patients relapsed (only one while on maintenance), and 6 were rechallenged with alemtuzumab. Five (83%) achieved second CHR after a median of 3.5 weeks, for a median duration of 123 weeks. Again, those given maintenance (n = 3) had a longer time to progression than those who were only observed (P = .04). Adverse effects were mostly related to infusion reactions and lymphopenia-related viral infections (despite antibiotic prophylaxis). One patient developed Epstein-Barr virus-related lymphoma. CONCLUSIONS Alemtuzumab is an effective treatment for patients with relapsed, refractory idiopathic hypereosinophilic syndrome and chronic eosinophilic leukemia-not otherwise specified, in terms of both CHR achievement (even after repeated rechallenges) and duration (particularly if provided as a maintenance therapy). Common adverse effects are related to infusion reactions and immunosuppression.
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Affiliation(s)
- Paolo Strati
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
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35
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Gotlib J. World Health Organization-defined eosinophilic disorders: 2012 update on diagnosis, risk stratification, and management. Am J Hematol 2012; 87:903-14. [PMID: 22926771 DOI: 10.1002/ajh.23293] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
DISEASE OVERVIEW The eosinophilias encompass a broad range of nonhematologic (secondary or reactive) and hematologic (primary, clonal) disorders with potential for end-organ damage. DIAGNOSIS Hypereosinophilia has generally been defined as a peripheral blood eosinophil count greater than 1,500/mm(3) and may be associated with tissue damage. After exclusion of secondary causes of eosinophilia, diagnostic evaluation of primary eosinophilias relies on a combination of morphologic review of the blood and marrow, standard cytogenetics, fluorescent in situ-hybridization, flow immunocytometry, and T-cell clonality assessment to detect histopathologic or clonal evidence for an acute or chronic myeloid or lymphoproliferative disorder. RISK STRATIFICATION Disease prognosis relies on identifying the subtype of eosinophilia. After evaluation of secondary causes of eosinophilia, the 2008 World Health Organization establishes a semimolecular classification scheme of disease subtypes including "myeloid and lymphoid neoplasms with eosinophilia and abnormalities of PDGFRA, PDGFRB, or FGFR1," chronic eosinophilic leukemia, not otherwise specified' (CEL, NOS), lymphocyte-variant hypereosinophilia, and idiopathic hypereosinophilic syndrome (HES), which is a diagnosis of exclusion. RISK-ADAPTED THERAPY The goal of therapy is to mitigate eosinophil-mediated organ damage. For patients with milder forms of eosinophilia (e.g., <1,500/mm(3) ) without symptoms or signs of organ involvement, a watch and wait approach with close-follow-up may be undertaken. Identification of rearranged PDGFRA or PDGFRB is critical because of the exquisite responsiveness of these diseases to imatinib. Corticosteroids are first-line therapy for patients with lymphocyte-variant hypereosinophilia and HES. Hydroxyurea and interferon-alpha have demonstrated efficacy as initial treatment and steroid-refractory cases of HES. In addition to hydroxyurea, second line cytotoxic chemotherapy agents and hematopoietic cell transplant have been used for aggressive forms of HES and CEL with outcomes reported for limited numbers of patients. Although clinical trials have been performed with anti IL-5 (mepolizumab) and anti-CD52 (alemtuzumab) antibodies, their therapeutic role in primary eosinophilic diseases and HES has yet to be established.
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Affiliation(s)
- Jason Gotlib
- Division of Hematology, Stanford University Medical Center, Palo Alto, CA, USA.
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36
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Valent P, Gleich GJ, Reiter A, Roufosse F, Weller PF, Hellmann A, Metzgeroth G, Leiferman KM, Arock M, Sotlar K, Butterfield JH, Cerny-Reiterer S, Mayerhofer M, Vandenberghe P, Haferlach T, Bochner BS, Gotlib J, Horny HP, Simon HU, Klion AD. Pathogenesis and classification of eosinophil disorders: a review of recent developments in the field. Expert Rev Hematol 2012; 5:157-76. [PMID: 22475285 DOI: 10.1586/ehm.11.81] [Citation(s) in RCA: 112] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Eosinophils and their products play an essential role in the pathogenesis of various reactive and neoplastic disorders. Depending on the underlying disease, molecular defect and involved cytokines, hypereosinophilia may develop and may lead to organ damage. In other patients, persistent eosinophilia is accompanied by typical clinical findings, but the causative role and impact of eosinophilia remain uncertain. For patients with eosinophil-mediated organ pathology, early therapeutic intervention with agents reducing eosinophil counts can be effective in limiting or preventing irreversible organ damage. Therefore, it is important to approach eosinophil disorders and related syndromes early by using established criteria, to perform all appropriate staging investigations, and to search for molecular targets of therapy. In this article, we review current concepts in the pathogenesis and evolution of eosinophilia and eosinophil-related organ damage in neoplastic and non-neoplastic conditions. In addition, we discuss classifications of eosinophil disorders and related syndromes as well as diagnostic algorithms and standard treatment for various eosinophil-related disorders.
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Affiliation(s)
- Peter Valent
- Department of Medicine I, Division of Hematology and Hemostaseology, Medical University of Vienna, Vienna, Austria.
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Bleeker JS, Syed FF, Cooper LT, Weiler CR, Tefferi A, Pardanani A. Treatment-refractory idiopathic hypereosinophilic syndrome: pitfalls and progress with use of novel drugs. Am J Hematol 2012; 87:703-6. [PMID: 22367886 DOI: 10.1002/ajh.23120] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2011] [Revised: 01/09/2012] [Accepted: 01/10/2012] [Indexed: 12/13/2022]
Affiliation(s)
- Jonathan S Bleeker
- Division of Hematology, Department of Internal Medicine, Mayo Clinic, Rochester, Minnesota, USA.
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Abstract
Accurate diagnosis of eosinophilic lung diseases is essential to optimizing patient outcomes, but remains challenging. Signs and symptoms frequently overlap among the disorders, and because these disorders are infrequent, expertise is difficult to acquire. Still, these disorders are not rare, and most clinicians periodically encounter patients with one or more of the eosinophilic lung diseases and need to understand how to recognize, diagnose, and manage these diseases. This review focuses on the clinical features, general diagnostic workup, and management of the eosinophilic lung diseases.
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Affiliation(s)
- Evans R Fernández Pérez
- Interstitial Lung Disease Program, Autoimmune Lung Center, National Jewish Health, Denver, CO 80206, USA.
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Abstract
PURPOSE OF REVIEW The advent of molecular techniques has resulted in the ability to tailor medications to specific protein targets. This review will emphasize several biological therapies, specifically directed toward cytokine receptors and inhibitors, and their role in the treatment of atopic and autoinflammatory diseases. RECENT FINDINGS Translational research and the identification of the molecular pathophysiology of diseases have led to more targeted treatment approaches. The biologic modulators encompassing monoclonal antibodies as cytokine inhibitors, receptor blocking antibodies, and new fusion receptors are now being applied to diseases beyond their original application. SUMMARY The expanded use of biological therapies has experienced success in the treatment of numerous disorders, especially in subsets of patients with disease that has been refractory to conventional therapies.
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41
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Gotlib J. World Health Organization-defined eosinophilic disorders: 2011 update on diagnosis, risk stratification, and management. Am J Hematol 2011; 86:677-88. [PMID: 21761433 DOI: 10.1002/ajh.22062] [Citation(s) in RCA: 56] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
DISEASE OVERVIEW The eosinophilias encompass a broad range of non-hematologic (secondary or reactive) and hematologic (primary, clonal) disorders with potential for end-organ damage. DIAGNOSIS Hypereosinophilia has generally been defined as a peripheral blood eosinophil count greater than 1,500/mm(3) and may be associated with tissue damage. After exclusion of secondary causes of eosinophilia, diagnostic evaluation of primary eosinophilias relies on a combination of morphologic review of the blood and marrow, standard cytogenetics, fluorescent in situ-hybridization, flow immunocytometry, and T-cell clonality assessment to detect histopathologic or clonal evidence for an acute or chronic myeloid or lymphoproliferative disorder. RISK STRATIFICATION Disease prognosis relies on identifying the subtype of eosinophilia. After evaluation of secondary causes of eosinophilia, the 2008 World Health Organization establishes a semi-molecular classification scheme of disease subtypes including myeloid and lymphoid neoplasms with eosinophilia and abnormalities of PDGFRA, PDGFRB, or FGFR1, chronic eosinophilic leukemia, not otherwise specified (CEL, NOS), lymphocyte-variant hypereosinophilia, and idiopathic hypereosinophilic syndrome (HES), which is a diagnosis of exclusion. RISK-ADAPTED THERAPY The goal of therapy is to mitigate eosinophil-mediated organ damage. For patients with milder forms of eosinophilia (e.g. < 1,500/mm(3) ) without symptoms or signs of organ involvement, a watch and wait approach with close-follow-up may be undertaken. Identification of rearranged PDGFRA or PDGFRB is critical because of the exquisite responsiveness of these diseases to imatinib. Corticosteroids are first-line therapy for patients with lymphocyte-variant hypereosinophilia and HES. Hydroxyurea and interferon-alpha have demonstrated efficacy as initial treatment and steroid-refractory cases of HES. In addition to hydroxyurea, second line cytotoxic chemotherapy agents and hematopoietic cell transplant have been used for aggressive forms of HES and CEL with outcomes reported for limited numbers of patients. Although clinical trials have been performed with anti IL-5 (mepolizumab) and anti-CD52 (alemtuzumab) antibodies, their therapeutic niche in primary eosinophilic diseases and HES have yet to be established.
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Affiliation(s)
- Jason Gotlib
- Division of Hematology, Department of Medicine, Stanford University School of Medicine/Stanford Cancer Center, Stanford, California 94305-5821, USA.
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42
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Shahein AR, Gonzalez S, Carcao M, Abdelhaleem M, Hellmann J, McNamara PJ. A case of severe eosinophilia in a preterm infant. Pediatrics 2011; 127:e767-71. [PMID: 21357337 DOI: 10.1542/peds.2010-0260] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Eosinophilia of prematurity is commonly seen in premature infants as a result of many causes, although a sustained or progressive form is uncommon. Different pathophysiological hypotheses include decreased circulating adrenal steroids and foreign antigen exposure. We present here a case of prolonged extreme eosinophilia in a preterm infant complicated by thrombocytopenia. The patient's eosinophil count reached 91.48 × 10(9)/L and remitted with nonspecific treatment. A comprehensive clinical, laboratory, and radiologic assessment is usually required in the context of a hypereosinophilic preterm infant to recognize the triggering etiology. Nonspecific treatment was the modality of choice because of unclear etiology in our case. Preterm infants with blood eosinophilia might not need immunomodulatory treatment despite extremely high absolute eosinophil counts.
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Affiliation(s)
- Abdul R Shahein
- Division of aHematology/Oncology, Department of Pediatrics, Hospital for Sick Children, Toronto, Ontario, Canada
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Aldinucci D, Gloghini A, Pinto A, De Filippi R, Carbone A. The classical Hodgkin's lymphoma microenvironment and its role in promoting tumour growth and immune escape. J Pathol 2010; 221:248-63. [DOI: 10.1002/path.2711] [Citation(s) in RCA: 200] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
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44
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Eosinophilic myeloid disorders: new classification and novel therapeutic strategies. Curr Opin Hematol 2010; 17:117-24. [DOI: 10.1097/moh.0b013e3283366c70] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
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45
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Tefferi A, Gotlib J, Pardanani A. Hypereosinophilic syndrome and clonal eosinophilia: point-of-care diagnostic algorithm and treatment update. Mayo Clin Proc 2010; 85:158-64. [PMID: 20053713 PMCID: PMC2813824 DOI: 10.4065/mcp.2009.0503] [Citation(s) in RCA: 104] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Acquired eosinophilia is operationally categorized into secondary, clonal, and idiopathic types. Causes of secondary eosinophilia include parasite infections, allergic or vasculitis conditions, drugs, and lymphoma. Clonal eosinophilia is distinguished from idiopathic eosinophilia by the presence of histologic, cytogenetic, or molecular evidence of an underlying myeloid malignancy. The World Health Organization classification system for hematologic malignancies recognizes 2 distinct subcategories of clonal eosinophilia: chronic eosinophilic leukemia, not otherwise specified and myeloid/lymphoid neoplasms with eosinophilia and mutations involving platelet-derived growth factor receptor alpha/beta or fibroblast growth factor receptor 1. Clonal eosinophilia might also accompany other World Health Organization-defined myeloid malignancies, including chronic myelogenous leukemia, myelodysplastic syndromes, chronic myelomonocytic leukemia, and systemic mastocytosis. Hypereosinophilic syndrome, a subcategory of idiopathic eosinophilia, is defined by the presence of a peripheral blood eosinophil count of 1.5 x 10(9)/L or greater for at least 6 months (a shorter duration is acceptable in the presence of symptoms that require eosinophil-lowering therapy), exclusion of both secondary and clonal eosinophilia, evidence of organ involvement, and absence of phenotypically abnormal and/or clonal T lymphocytes. The presence of the latter defines lymphocytic variant hyper eosinophilia, which is best classified under secondary eosinophilia. In the current review, we provide a simplified algorithm for distinguishing the various causes of clonal and idiopathic eosinophilia and discuss current therapy, including new drugs (imatinib mesylate, alemtuzumab, and mepolizumab).
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MESH Headings
- Alemtuzumab
- Algorithms
- Antibodies, Monoclonal/therapeutic use
- Antibodies, Monoclonal, Humanized
- Antibodies, Neoplasm/therapeutic use
- Antineoplastic Agents/therapeutic use
- Benzamides
- Causality
- Decision Trees
- Diagnosis, Differential
- Eosinophilia/classification
- Eosinophilia/diagnosis
- Eosinophilia/drug therapy
- Eosinophilia/etiology
- Humans
- Hypereosinophilic Syndrome/classification
- Hypereosinophilic Syndrome/diagnosis
- Hypereosinophilic Syndrome/drug therapy
- Hypereosinophilic Syndrome/etiology
- Imatinib Mesylate
- Leukemia, Myelogenous, Chronic, BCR-ABL Positive/complications
- Leukemia, Myelomonocytic, Chronic/complications
- Mastocytosis/complications
- Mutation/genetics
- Myelodysplastic Syndromes/complications
- Piperazines/therapeutic use
- Pyrimidines/therapeutic use
- Receptor, Fibroblast Growth Factor, Type 1/genetics
- Receptors, Platelet-Derived Growth Factor/genetics
- mRNA Cleavage and Polyadenylation Factors/genetics
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Affiliation(s)
- Ayalew Tefferi
- Division of Hematology, Mayo Clinic, Rochester, MN 55905, USA.
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Chen LYC, Lai EJ, Collins DR, Ostrow DN, Sreenivasan GM. A young woman with episodic angioedema, papilledema, and eosinophilia. Am J Hematol 2010; 85:124-7. [PMID: 20029989 DOI: 10.1002/ajh.21584] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Luke Y C Chen
- Clinical Educator Fellow, Division of Hematology and Centre for Health Education Scholarship, University of British Columbia, British Columbia, Canada
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Lierman E, Cools J. Recent breakthroughs in the understanding and management of chronic eosinophilic leukemia. Expert Rev Anticancer Ther 2009; 9:1295-304. [PMID: 19761433 DOI: 10.1586/era.09.82] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
The term hypereosinophilic syndrome (HES) was initially introduced to describe a group of diseases all characterized by persistent unexplained hypereosinophilia. Additional names have subsequently been introduced to describe specific variants of HES, such as the myeloid variant and the lymphoid variant, or to indicate idiopathic HES, for which the cause of the eosinophilia is completely unknown. Molecular analysis led to the identification of the clonal origin of several subgroups of HES, clearly establishing these diseases as true leukemias. These cases of hypereosinophilia are now referred to as 'myeloid neoplasms associated with eosinophilia and abnormalities of PDGF receptor A and B (PDGFRA and PDGFRB), or FGF receptor 1 (FGFR1)'. In cases for which clonality is clear, but no PDGFRA, PDGFRB or FGFR1 rearrangement could be demonstrated, the term 'chronic eosinophilic leukemia, not otherwise specified' is preferred. Most importantly, patients with rearrangements of PDGFRA or PDGFRB can be efficiently treated with the kinase inhibitor imatinib. Additional potent kinase inhibitors have been identified, also including inhibitors that target FGFR1 and imatinib-resistant variants of PDGFRalpha. For treatment of unexplained hypereosinophilia and 'chronic eosinophilic leukemia, not otherwise specified; different therapeutic strategies are currently under investigation and promising results have been obtained using humanized anti-IL-5 antibodies. Further molecular understanding of the cause of these 'idiopathic' diseases may lead to the development of novel targeted therapies.
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Affiliation(s)
- Els Lierman
- Department of Molecular and Developmental Genetics VIB11, Center for Human Genetics, KULeuven, Campus Gasthuisberg O&N1, Herestraat 49-box 602, B-3000 Leuven, Belgium.
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Neutrophils express CD52 and exhibit complement-mediated lysis in the presence of alemtuzumab. Blood 2009; 114:3052-5. [PMID: 19638623 DOI: 10.1182/blood-2009-02-203075] [Citation(s) in RCA: 47] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Neutropenia is a recognized adverse event in patients treated with the humanized anti-CD52 monoclonal antibody alemtuzumab. However, as it is widely believed that neutrophils do not express CD52, the etiology of alemtuzumab-associated neutropenia is unclear. We have found that neutrophils express both mRNA coding for CD52 and the protein itself on the cell surface. We confirmed cell-surface expression using 3 different anti-CD52 antibodies, and note that neutrophils express lower levels of CD52 than lymphocytes and eosinophils. Further, incubation of alemtuzumab with neutrophils results in dose-dependent, complement-mediated lysis in the presence of both heterologous and autologous complement. These data offer an explanation for the etiology of alemtuzumab-associated neutropenia. In a climate of increased use of alemtuzumab in leukemia and other disease states, as well as in transplantation, these data highlight the need for increased vigilance of emerging neutropenia in patients treated with alemtuzumab.
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Valent P. Pathogenesis, classification, and therapy of eosinophilia and eosinophil disorders. Blood Rev 2009; 23:157-65. [PMID: 19246139 DOI: 10.1016/j.blre.2009.01.001] [Citation(s) in RCA: 56] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
Eosinophilia is a recurrent feature and diagnostic clue in several hematologic malignancies. In stem cell- and myelopoietic neoplasms, eosinophils are derived from the malignant clone, whereas in lymphoid neoplasms and reactive states, eosinophilia is usually triggered by eosinopoietic cytokines. Myeloid neoplasms typically presenting with eosinophilia include chronic myeloid leukemia, chronic eosinophilic leukemia (CEL), other myeloproliferative neoplasms, some acute leukemias, advanced mast cell disorders, and rare forms of myelodysplastic syndromes. Diagnostic evaluations in unexplained eosinophilia have to take these diagnoses into account. In such patients, a thorough hematologic work-up including bone marrow histology and immunohistochemistry, cytogenetics, molecular markers, and a complete staging of potentially affected organ systems has to be initiated. Endomyocardial fibrosis, the most dangerous cardiovascular complication of the hypereosinophilic state, is frequently detected in PDGFR-mutated neoplasms, specifically in FIP1L1/PDGFRA+ CEL, but is usually not seen in other myeloid neoplasms or reactive eosinophilia, even if eosinophilia is recorded for many years. Treatment of hypereosinophilic patients depends on the variant of disease, presence of end organ damage, molecular targets, and the overall situation in each case. In a group of patients, oncogenic tyrosine kinases (TK) such as FIP1L1/PDGFRA, can be employed as therapeutic targets by using imatinib or other TK-blocking agents.
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Affiliation(s)
- Peter Valent
- Department of Internal Medicine I, Division of Hematology and Hemostaseology, Medical University of Vienna, Vienna, Austria.
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