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Patnaik MM, Tefferi A. Chronic myelomonocytic leukemia: 2024 update on diagnosis, risk stratification and management. Am J Hematol 2024; 99:1142-1165. [PMID: 38450850 PMCID: PMC11096042 DOI: 10.1002/ajh.27271] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2024] [Accepted: 02/09/2024] [Indexed: 03/08/2024]
Abstract
DISEASE OVERVIEW Chronic myelomonocytic leukemia (CMML) is a clonal hematopoietic stem cell disorder with overlapping features of myelodysplastic syndromes and myeloproliferative neoplasms, characterized by prominent monocytosis and an inherent risk for leukemic transformation (~15%-20% over 3-5 years). DIAGNOSIS Newly revised diagnostic criteria include sustained (>3 months) peripheral blood (PB) monocytosis (≥0.5 × 109/L; monocytes ≥10% of leukocyte count), consistent bone marrow (BM) morphology, <20% BM or PB blasts (including promonocytes), and cytogenetic or molecular evidence of clonality. Cytogenetic abnormalities occur in ~30% of patients, while >95% harbor somatic mutations: TET2 (~60%), SRSF2 (~50%), ASXL1 (~40%), RAS pathway (~30%), and others. The presence of ASXL1 and DNMT3A mutations and absence of TET2 mutations negatively impact overall survival (ASXL1WT/TET2MT genotype being favorable). RISK STRATIFICATION Several risk models serve similar purposes in identifying high-risk patients that are considered for allogeneic stem cell transplant (ASCT) earlier than later. Risk factors in the Mayo Molecular Model (MMM) include presence of truncating ASXL1 mutations, absolute monocyte count >10 × 109/L, hemoglobin <10 g/dL, platelet count <100 × 109/L, and the presence of circulating immature myeloid cells; the resulting 4-tiered risk categorization includes high (≥3 risk factors), intermediate-2 (2 risk factors), intermediate-1 (1 risk factor), and low (no risk factors); the corresponding median survivals were 16, 31, 59, and 97 months. CMML is also classified as being "myeloproliferative (MP-CMML)" or "myelodysplastic (MD-CMML)," based on the presence or absence of leukocyte count of ≥13 × 109/L. TREATMENT ASCT is the only treatment modality that secures cure or long-term survival and is appropriate for MMM high/intermediate-2 risk disease. Drug therapy is currently not disease-modifying and includes hydroxyurea and hypomethylating agents; a recent phase-3 study (DACOTA) comparing hydroxyurea and decitabine, in high-risk MP-CMML, showed similar overall survival at 23.1 versus 18.4 months, respectively, despite response rates being higher for decitabine (56% vs. 31%). UNIQUE DISEASE ASSOCIATIONS These include systemic inflammatory autoimmune diseases, leukemia cutis and lysozyme-induced nephropathy; the latter requires close monitoring of renal function during leukocytosis and is a potential indication for cytoreductive therapy.
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Affiliation(s)
- Mrinal M Patnaik
- Division of Hematology, Department of Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Ayalew Tefferi
- Division of Hematology, Department of Medicine, Mayo Clinic, Rochester, Minnesota, USA
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Nasreddine GM, Farhat S, Hammoud ZM, Saad F, Saad W. Chronic Myelomonocytic Leukemia-Associated Immune Thrombocytopenic Purpura: A Report of a Rare Case and a Review of Literature. Cureus 2024; 16:e55904. [PMID: 38595873 PMCID: PMC11003726 DOI: 10.7759/cureus.55904] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/09/2024] [Indexed: 04/11/2024] Open
Abstract
Chronic myelomonocytic leukemia (CMML) presents as a complex hematologic malignancy with myelodysplastic and myeloproliferative features. Our case report explores the rare coexistence of CMML with immune thrombocytopenic purpura (ITP) in a 63-year-old female patient. CMML diagnosis followed World Health Organization criteria, and the patient was classified as having high-risk myelodysplastic syndrome (MDS)-CMML stage 2. Initial treatment with subcutaneous azacytidine for CMML proved partially effective, highlighting persistent severe thrombocytopenia. Subsequent investigations revealed secondary ITP associated with Crohn's disease. Conventional ITP therapies, including high-dose steroids and intravenous immunoglobulin, showed limited efficacy. Eltrombopag, a thrombopoietin receptor agonist, was initiated, resulting in the normalization of platelet counts within six weeks. Our case emphasizes the diagnostic challenges and intricate treatment landscape of CMML-associated ITP, suggesting eltrombopag as a potential therapeutic option in refractory cases. The study contributes to the evolving understanding of the complex interplay between myeloid disorders and immune-mediated hematological conditions, calling for personalized and multidisciplinary approaches to enhance patient outcomes.
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Affiliation(s)
- Ghadir M Nasreddine
- Department of Hematology and Oncology, Lebanese University, Faculty of Medical Sciences, Beirut, LBN
| | - Solay Farhat
- Department of Hematology and Oncology, Lebanese University, Faculty of Medical Sciences, Beirut, LBN
| | - Zeinab M Hammoud
- Department of Hematology and Oncology, Lebanese University, Faculty of Medical Sciences, Beirut, LBN
| | - Firas Saad
- Department of Hematology and Oncology, Morristown Medical Center, New Jersey, USA
| | - Wajih Saad
- Department of Hematology and Oncology, Al-Zahraa Hospital University Medical Center, Beirut, LBN
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3
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Osman AEG, Rets A, Patel AB. KRAS mutations, autoimmunity and female sex in chronic myelomonocytic leukemia. Leuk Res 2024; 138:107466. [PMID: 38430640 DOI: 10.1016/j.leukres.2024.107466] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2023] [Revised: 02/16/2024] [Accepted: 02/20/2024] [Indexed: 03/05/2024]
Affiliation(s)
- Afaf E G Osman
- Division of Hematology and Hematologic Malignancies, University of Utah, Salt Lake City, UT, United States
| | - Anton Rets
- Department of Pathology, University of Utah and ARUP Laboratories Inc., Salt Lake City, UT, United States
| | - Ami B Patel
- Division of Hematology and Hematologic Malignancies, University of Utah, Salt Lake City, UT, United States.
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Nathan DI, Dougherty M, Bhatta M, Mascarenhas J, Marcellino BK. Clonal hematopoiesis and inflammation: A review of mechanisms and clinical implications. Crit Rev Oncol Hematol 2023; 192:104187. [PMID: 37879493 DOI: 10.1016/j.critrevonc.2023.104187] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2023] [Revised: 09/21/2023] [Accepted: 10/16/2023] [Indexed: 10/27/2023] Open
Abstract
Clonal hematopoiesis (CH) is defined by the presence of somatic mutations in hematopoietic stem and progenitor cells (HSPC). CH is associated primarily with advancing age and confers an elevated risk of progression to overt hematologic malignancy and cardiovascular disease. Increasingly, CH is associated with a wide range of diseases driven by, and sequelae of, inflammation. Accordingly, there is great interest in better understanding the pathophysiologic and clinical relationship between CH, aging, and disease. Both observational and experimental findings support the concept that CH is a potential common denominator in the inflammatory outcomes of aging. However, there is also evidence that local and systemic inflammatory states promote the growth and select for CH clones. In this review, we aim to provide an up-to-date summary of the nature of the relationship between inflammation and CH, which is central to unlocking potential therapeutic opportunities to prevent progression to myeloid malignancy.
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Affiliation(s)
- Daniel I Nathan
- Tisch Cancer Institute, Division of Hematology and Medical Oncology, The Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Max Dougherty
- Tisch Cancer Institute, Division of Hematology and Medical Oncology, The Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Manasa Bhatta
- Department of Medicine, The Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - John Mascarenhas
- Tisch Cancer Institute, Division of Hematology and Medical Oncology, The Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Bridget K Marcellino
- Tisch Cancer Institute, Division of Hematology and Medical Oncology, The Icahn School of Medicine at Mount Sinai, New York, NY, USA.
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5
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Barge L, Gooch M, Hendle M, Simleit E. Real world implementation of flow cytometric monocyte subset partitioning for distinguishing chronic myelomonocytic leukaemia from other causes of monocytosis. Pathology 2023; 55:827-834. [PMID: 37541805 DOI: 10.1016/j.pathol.2023.05.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2023] [Revised: 04/21/2023] [Accepted: 05/05/2023] [Indexed: 08/06/2023]
Abstract
Monocyte subset partitioning by flow cytometry may be a useful tool in distinguishing chronic myelomonocytic leukaemia (CMML) from other causes of monocytosis, however there has been varying success in real world implementation. Additionally, current assays require an individual tube for analysis despite significant overlap in antibodies used in routine T and NK cell analysis. The objective of this study was to validate a flow cytometry assay for the enumeration of monocyte subsets in our community-based laboratory and compare this to a hybrid panel allowing analysis of monocytes, T cells and NK cells in a single tube. Monocyte subset analysis was performed on peripheral blood samples of patients with monocytosis at the time of bone marrow biopsy or transient monocytosis in the setting of bacteraemia. Cut-offs of >94% classical and <1.13% non-classical monocytes for distinguishing CMML were assessed. Classical monocytes were significantly higher, and non-classical monocytes significantly lower in CMML compared to other causes of monocytosis. The sensitivity and specificity of >94% classical monocytes were 73% [95% confidence interval (CI) 43-90%] and 89% (95% CI 75-96%) regardless of which panel was used. Non-classical monocytes of <1.13% had a sensitivity and specificity of 82% (95% CI 52-97%) and 83% (95% CI 68-92%) with the monocyte panel and 55% (95% CI 28-78%) and 89% (95% CI 75-96%) using the hybrid panel. We have found the estimation of the classical monocyte subset to be the most robust and repeatable variation of this assay with sensitivity and specificity that is clinically useful. A hybrid panel may provide an effective approach to implementing monocyte subsets into practice.
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Affiliation(s)
- Luani Barge
- Queensland Medical Laboratories, Murarrie, Qld, Australia; University of Queensland, St Lucia, Qld, Australia.
| | - Michael Gooch
- Queensland Medical Laboratories, Murarrie, Qld, Australia
| | | | - Erin Simleit
- Queensland Medical Laboratories, Murarrie, Qld, Australia
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Deng LJ, Dong Y, Li MM, Sun CG. Co-existing squamous cell carcinoma and chronic myelomonocytic leukemia with ASXL1 and EZH2 gene mutations: A case report. World J Clin Cases 2023; 11:3643-3650. [PMID: 37383892 PMCID: PMC10294182 DOI: 10.12998/wjcc.v11.i15.3643] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2023] [Revised: 04/07/2023] [Accepted: 04/19/2023] [Indexed: 05/25/2023] Open
Abstract
BACKGROUND Chronic myelomonocytic leukemia (CMML), a rare clonal hematopoietic stem cell disorder characterized by myelodysplastic syndrome and myeloproliferative neoplasms, has a generally poor prognosis, and easily progresses to acute myeloid leukemia. The simultaneous incidence of hematologic malignancies and solid tumors is extremely low, and CMML coinciding with lung malignancies is even rarer. Here, we report a case of CMML, with ASXL1 and EZH2 gene mutations, combined with non-small cell lung cancer (lung squamous cell carcinoma).
CASE SUMMARY A 63-year-old male, suffering from toothache accompanied by coughing, sputum, and bloody sputum for three months, was given a blood test after experiencing continuous bleeding resulting from a tooth extraction at a local hospital. Based on morphological results, the patient was diagnosed with CMML and bronchoscopy was performed in situ to confirm the diagnosis of squamous cell carcinoma in the lower lobe of the lung. After receiving azacitidine, programmed cell death protein 1, and platinum-based chemotherapy drugs, the patient developed severe myelosuppression and eventually fatal leukocyte stasis and dyspnea.
CONCLUSION During the treatment and observation of CMML and be vigilant of the growth of multiple primary malignant tumors.
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Affiliation(s)
- Lai-Jun Deng
- Department of Hematology, Weifang Hospital of Traditional Chinese Medicine, Weifang 261000, Shandong Province, China
| | - Yang Dong
- Department of Clinical Pharmacy, Weifang Hospital of Traditional Chinese Medicine, Weifang 261000, Shandong Province, China
| | - Mi-Mi Li
- Department of Pathology, Weifang Hospital of Traditional Chinese Medicine, Weifang 261000, Shandong Province, China
| | - Chang-Gang Sun
- Department of Hematology, Weifang Hospital of Traditional Chinese Medicine, Weifang 261000, Shandong Province, China
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Impact of Mutational Status and Prognostic Factors on Survival in Chronic Myelomonocytic Leukemia With Systemic Inflammation and Autoimmune Disorders. Hemasphere 2023; 7:e847. [PMID: 36844177 PMCID: PMC9953038 DOI: 10.1097/hs9.0000000000000847] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2022] [Accepted: 01/12/2023] [Indexed: 02/25/2023] Open
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Prakash S, Arber DA, Bueso-Ramos C, Hasserjian RP, Orazi A. Advances in myelodysplastic/myeloproliferative neoplasms. Virchows Arch 2023; 482:69-83. [PMID: 36469102 DOI: 10.1007/s00428-022-03465-7] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2022] [Revised: 11/22/2022] [Accepted: 11/23/2022] [Indexed: 12/07/2022]
Abstract
The myelodysplastic syndrome/myeloproliferative neoplasms (MDS/MPN) category includes a heterogeneous group of diseases characterized by the co-occurrence of clinical and pathologic features of both myelodysplastic and myeloproliferative neoplasms. The recently published International Consensus Classification of myeloid neoplasms revised the entities included in the MDS/MPN category as well as criteria for their diagnosis. In addition to the presence of one or more increased peripheral blood cell counts as evidence of myeloproliferative features, concomitant cytopenia as evidence of ineffective hematopoiesis is now an explicit requirement to diagnose the diseases included in this category. The increasing availability of modern gene sequencing has allowed better understanding of the biologic characteristics of these myeloid neoplasms. The presence of specific mutations in the appropriate clinicopathologic context is now included in the diagnostic criteria for some of MDS/MPN entities. In this review, we highlight what has changed in the diagnostic criteria of MDS/MPN from the WHO 2016 classification while providing practical guidance in diagnosing these diseases.
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Affiliation(s)
- Sonam Prakash
- Department of Laboratory Medicine, University of California, San Francisco, CA, USA
| | - Daniel A Arber
- Department of Pathology, University of Chicago, Chicago, IL, USA
| | - Carlos Bueso-Ramos
- Division of Pathology and Laboratory Medicine, Department of Hematopathology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Robert P Hasserjian
- Department of Pathology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Attilio Orazi
- Department of Pathology, Texas Tech University Health Sciences Center, El Paso, TX, USA.
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9
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Veeraballi S, Patel A, Are G, Ramahi A, Chittamuri S, Shaaban H. A Case of Chronic Myelomonocytic Leukemia Unmasked After Receiving J&J COVID-19 Vaccine. Cureus 2022; 14:e26070. [PMID: 35865440 PMCID: PMC9292133 DOI: 10.7759/cureus.26070] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/18/2022] [Indexed: 11/05/2022] Open
Abstract
Chronic myelomonocytic leukemia (CMML) is a clonal hematopoietic stem cell disease that comes under the overlap syndrome (myelodysplastic and myeloproliferative disorders). CMML is characterized by peripheral blood monocytosis and bone marrow dysplasia. The pathogenesis of CMML is poorly understood. Although cytogenetic and molecular abnormalities are common, they are not diagnostic. Herein, we present a rare case of CMML after receiving the J&J COVID-19 vaccine with the rare association of limited scleroderma. Based on the Surveillance, Epidemiology, and End Result (SEER) cancer statistics review 2014-2018, the five-year age-adjusted incidence rate of CMML in both sexes is 0.5/100,000, with greater incidence in males (0.7/100,000) compared to females (0.3/100,000). We emphasize the fact that, based on the previous studies reported, the association of scleroderma with CMML is very rare. Our patient had concomitant CMML and scleroderma, which were unmasked after the patient received the COVID-19 vaccine. Our case suggests the possibility of developing CMML after receiving the J&J COVID vaccine. Immunization has always been a life-saving intervention in history. As the world is foreseeing getting the COVID-19 vaccine, it is essential to report all the possible adverse events for safety monitoring. Physicians should be aware of this unusual complication of the vaccine, and more cases are needed to confirm the association between them.
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10
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Nachbor KM, Minkus CL. Sclerouveitis with exudative retinal detachment associated with chronic myelomonocytic leukemia. Am J Ophthalmol Case Rep 2022; 26:101573. [PMID: 35586153 PMCID: PMC9108460 DOI: 10.1016/j.ajoc.2022.101573] [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: 03/03/2022] [Revised: 04/27/2022] [Accepted: 04/28/2022] [Indexed: 11/03/2022] Open
Abstract
Purpose To describe a case of sclerouveitis with exudative retinal detachment in a patient with chronic myelomonocytic leukemia. Observations An 82-year-old woman with chronic myelomonocytic leukemia (CMML) presented with acute painful right eye redness and decreased visual acuity. Examination revealed right eye anterior and posterior scleritis with exudative retinal detachment, as well as 2+ anterior chamber cell in the right eye and 0.5+ in the left eye. Workup was negative for infectious etiologies and chest imaging revealed no pulmonary nodules. She was treated with prednisolone drops and a tapering course of oral prednisone as she started therapy with ruxolitinib for CMML. Inflammation resolved with treatment, and she remained quiet off steroids while on ruxolitinib. Conclusions and importance This is the first case report to specifically describe sclerouveitis associated with CMML, despite the known association of this cancer with various inflammatory manifestations. This case demonstrates that CMML may present with scleritis and uveitis, and should be considered as the underlying etiology of inflammatory eye disease in patients with a diagnosis of CMML.
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Affiliation(s)
- Kristine M Nachbor
- Department of Ophthalmology and Visual Neurosciences, University of Minnesota, Minneapolis, MN, USA
| | - Caroline L Minkus
- Department of Ophthalmology and Visual Neurosciences, University of Minnesota, Minneapolis, MN, USA
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Yu Y, Liu JL, Tian DS. Anti-N-methyl-D-aspartate receptor encephalitis associated with chronic myelogenous leukemia, causality or coincidence? A case report. BMC Neurol 2022; 22:153. [PMID: 35461209 PMCID: PMC9034597 DOI: 10.1186/s12883-022-02675-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2021] [Accepted: 04/12/2022] [Indexed: 11/10/2022] Open
Abstract
Background Anti-N-methyl-D-aspartate receptor (NMDAR) encephalitis is the most frequent autoimmune paraneoplastic encephalitis, and is primarily associated with ovarian teratomas. Here, we report the first case of a patient diagnosed with chronic myelogenous leukemia (CML) during the recovery phase of anti-NMDAR encephalitis. Case presentation The patient was admitted with fever, headache, and seizures. Brain MRI revealed a cerebrospinal fluid (CSF)-containing arachnoid cyst in the left temporal lobe with no other abnormal signals. EEG showed diffuse background slowing in the delta-theta range. The patient tested positive for anti-NMDAR antibodies in both the serum and CSF. One year after the onset of encephalitis, the patient was referred to the Department of Hematology for extreme leukocytosis. Karyotype analysis showed the presence of Philadelphia chromosome t(9;22)(q34;q11). Quantitative reverse transcriptase PCR analysis further identified BCR/ABL1 fusion transcripts; thus, CML was diagnosed. Conclusions To the best of our knowledge, this is the first case of anti-NMDAR encephalitis associated with CML. This report should alert clinicians to consider CML as a malignancy that is possibly associated with limbic encephalitis.
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Patnaik MM, Tefferi A. Chronic myelomonocytic leukemia: 2022 update on diagnosis, risk stratification, and management. Am J Hematol 2022; 97:352-372. [PMID: 34985762 DOI: 10.1002/ajh.26455] [Citation(s) in RCA: 37] [Impact Index Per Article: 18.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2021] [Accepted: 01/03/2022] [Indexed: 12/19/2022]
Abstract
DISEASE OVERVIEW Chronic myelomonocytic leukemia (CMML) is a clonal hematopoietic stem cell disorder with overlapping features of myelodysplastic syndromes and myeloproliferative neoplasms, with an inherent risk for leukemic transformation (~15% over 3-5 years). DIAGNOSIS Diagnosis is based on the presence of sustained (>3 months) peripheral blood monocytosis (≥1 × 109 /L; monocytes ≥10%), usually with accompanying bone marrow dysplasia. Clonal cytogenetic abnormalities occur in ~30% of patients, while >90% have somatic gene mutations. Mutations involving TET2 (~60%), SRSF2 (~50%), ASXL1 (~40%), and the oncogenic RAS pathway (~30%) are frequent, while the presence of ASXL1 and DNMT3A mutations and the absence of TET2 mutations negatively impact overall survival. RISK-STRATIFICATION Molecularly integrated prognostic models include the Groupe Français des Myélodysplasies, Mayo Molecular Model (MMM), and the CMML specific prognostic model. Risk factors incorporated into the MMM include presence of truncating ASXL1 mutations, absolute monocyte count >10 × 109 /L, hemoglobin <10 g/dL, platelet count <100 × 109 /L, and the presence of circulating immature myeloid cells. The MMM stratifies CMML patients into four groups: high (≥3 risk factors), intermediate-2 (2 risk factors), intermediate-1 (1 risk factor), and low (no risk factors), with median survivals of 16, 31, 59, and 97 months, respectively. RISK-ADAPTED THERAPY Hypomethylating agents such as 5-azacitidine and decitabine are commonly used, with overall response rates of ~40%-50% and complete remission rates of ~7%-17%; with no impact on mutational allele burdens. Allogeneic stem cell transplant is the only potentially curative option but is associated with significant morbidity and mortality.
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Affiliation(s)
- Mrinal M. Patnaik
- Division of Hematology, Department of Medicine Mayo Clinic Rochester Minnesota USA
| | - Ayalew Tefferi
- Division of Hematology, Department of Medicine Mayo Clinic Rochester Minnesota USA
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Kuendgen A, Kasprzak A, Germing U. Hybrid or Mixed Myelodysplastic/Myeloproliferative Disorders - Epidemiological Features and Overview. Front Oncol 2021; 11:778741. [PMID: 34869027 PMCID: PMC8635204 DOI: 10.3389/fonc.2021.778741] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2021] [Accepted: 10/25/2021] [Indexed: 11/25/2022] Open
Abstract
The WHO-category Myelodysplastic/Myeloproliferative neoplasms (MDS/MPNs) recognizes a unique group of clonal myeloid malignancies exhibiting overlapping features of myelodysplastic as well as myeloproliferative neoplasms. The group consists of chronic myelomonocytic leukemia (CMML), atypical chronic myeloid leukemia, BCR-ABL1-negative (aCML), juvenile myelomonocytic leukemia (JMML), myelodysplastic/myeloproliferative neoplasm with ringed sideroblasts and thrombocytosis (MDS/MPN-RS-T), and myelodysplastic/myeloproliferative neoplasms, unclassifiable (MDS/MPN-U). The most frequent entity in this category is CMML, while all other diseases are extremely rare. Thus, only very limited data on the epidemiology of these subgroups exists. An appropriate diagnosis and classification can be challenging since the diagnosis is still largely based on morphologic criteria and myelodysplastic as well as myeloproliferative features can be found in various occurrences. The diseases in this category share several features that are common in this specific WHO-category, but also exhibit specific traits for each disease. This review summarizes published data on epidemiological features and offers a brief overview of the main diagnostic criteria and clinical characteristics of the five MDS/MPN subgroups.
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Affiliation(s)
- Andrea Kuendgen
- Department of Hematology, Oncology, and Clinical Immunology, Heinrich-Heine-University Hospital Duesseldorf, Duesseldorf, Germany
| | - Annika Kasprzak
- Department of Hematology, Oncology, and Clinical Immunology, Heinrich-Heine-University Hospital Duesseldorf, Duesseldorf, Germany
| | - Ulrich Germing
- Department of Hematology, Oncology, and Clinical Immunology, Heinrich-Heine-University Hospital Duesseldorf, Duesseldorf, Germany
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14
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Chan O, Renneville A, Padron E. Chronic myelomonocytic leukemia diagnosis and management. Leukemia 2021; 35:1552-1562. [PMID: 33714974 DOI: 10.1038/s41375-021-01207-3] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2020] [Revised: 01/23/2021] [Accepted: 02/18/2021] [Indexed: 01/31/2023]
Abstract
Chronic myelomonocytic leukemia (CMML) is a rare, heterogeneous myeloid malignancy classified as a myelodysplastic syndromes/myeloproliferative neoplasm (MDS/MPN) overlap syndrome by the World Health Organization (WHO). Its initial presentation can be incidental or associated with myelodysplastic or myeloproliferative symptoms and up to 20% of patients harbor a concurrent inflammatory or autoimmune condition. Persistent monocytosis is the hallmark of CMML but diagnosis can be challenging. Increased understanding of human monocyte subsets, chromosomal abnormalities, and somatic gene mutations have led to more accurate diagnosis and improved prognostication. A number of risk stratification systems have been developed and validated but using those that incorporate molecular information such as CMML Prognostic Scoring System (CPSS)-Mol, Mayo Molecular, and Groupe Francophone des Myelodysplasies (GFM) are preferred. Symptom-directed approaches forms the basis of CMML management. Outcomes vary substantially depending on risk ranging from observation for a number of years to rapidly progressive disease and acute myeloid leukemia (AML) transformation. Patients who are low risk but with symptoms from cytopenias or proliferative features such as splenomegaly may be treated with hypomethylating agents (HMAs) or cytoreductive therapy, respectively, with the goal of durable symptoms control. Allogeneic hematopoietic cell transplantation should be considered for intermediate to high risk patients. The lack of effective pharmaceutical options has generated interest in novel therapeutics for this disease, and early phase clinical trial results are promising.
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Affiliation(s)
- Onyee Chan
- Department of Malignant Hematology, Moffitt Cancer Center, Tampa, FL, USA
| | | | - Eric Padron
- Department of Malignant Hematology, Moffitt Cancer Center, Tampa, FL, USA.
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Gauchy A, Hentzien M, Wynckel A, de Marcellus V, Rodier C, Delmer A, Quinquenel A. Efficacy of eculizumab in refractory life-threatening warm autoimmune hemolytic anemia associated with chronic myelomonocytic leukemia. Clin Case Rep 2020; 8:2641-2644. [PMID: 33363796 PMCID: PMC7752594 DOI: 10.1002/ccr3.3250] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2020] [Revised: 07/04/2020] [Accepted: 07/21/2020] [Indexed: 02/06/2023] Open
Abstract
Eculizumab may be considered as an emergency therapeutic option in refractory life-threatening warm autoimmune hemolytic anemia especially if direct antiglobulin test is positive for both IgG and C3d and after failure of all conventional treatments.
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Affiliation(s)
- Anne‐Cécile Gauchy
- Service d'Hématologie CliniqueHôpital Robert DebréCentre Hospitalier UniversitaireReimsFrance
- UFR Médecine Université Reims Champagne‐ArdenneReimsFrance
| | - Maxime Hentzien
- UFR Médecine Université Reims Champagne‐ArdenneReimsFrance
- Service de Médecine InterneMaladies Infectieuse et Immunologie CliniqueHôpital Robert DebréCentre Hospitalier UniversitaireReimsFrance
| | - Alain Wynckel
- Service de NéphrologieHôpital Robert DebréCentre Hospitalier UniversitaireReimsFrance
| | - Victoire de Marcellus
- Service d'Hématologie CliniqueHôpital Robert DebréCentre Hospitalier UniversitaireReimsFrance
- UFR Médecine Université Reims Champagne‐ArdenneReimsFrance
| | - Cyrielle Rodier
- Service d'Hématologie CliniqueHôpital Robert DebréCentre Hospitalier UniversitaireReimsFrance
- UFR Médecine Université Reims Champagne‐ArdenneReimsFrance
| | - Alain Delmer
- Service d'Hématologie CliniqueHôpital Robert DebréCentre Hospitalier UniversitaireReimsFrance
- UFR Médecine Université Reims Champagne‐ArdenneReimsFrance
| | - Anne Quinquenel
- Service d'Hématologie CliniqueHôpital Robert DebréCentre Hospitalier UniversitaireReimsFrance
- UFR Médecine Université Reims Champagne‐ArdenneReimsFrance
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16
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Krecak I, Medic MG, Gveric–Krecak V, Roncevic P, Bašić Kinda S, Babel J, Radonic R. Coombs-positive refractory acquired thrombotic thrombocytopenic purpura in a patient with chronic myelomonocytic leukemia successfully treated with rituximab. Acta Clin Belg 2020; 75:357-361. [PMID: 31007140 DOI: 10.1080/17843286.2019.1608395] [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] [Indexed: 01/08/2023]
Abstract
OBJECTIVES Acquired thrombotic thrombocytopenic purpura (aTTP) is a rare autoimmune disorder characterized by auto-antibodies to Willebrand factor (vWF) cleaving enzyme (ADAMTS13), resulting in unusually large vWF multimers that lead to platelet aggregation, microthrombi formation and microangiopathic hemolytic anemia. Hemolysis in aTTP is mechanical; thus, direct antiglobulin test (Coombs test) is usually negative. Multiple autoimmune conditions and various auto-antibodies have been described in the context of chronic myelomonocytic leukemia (CMML). In this paper, we describe the first case of CMML with auto-antibodies to ADAMTS13, presenting initially as plasmapheresis-refractory Coombs-positive aTTP. Results: Although our patient was not treated for CMML, a complete remission of aTTP was eventually achieved with rituximab. Conclusion; We propose that aTTP should be in the differential diagnosis of CMML patients with thrombocytopenia and anemia (Coombs positive or not) who develop signs of thrombotic microangiopathy. Further studies are much needed to decipher the immune-mediated processes in CMML.
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Affiliation(s)
- Ivan Krecak
- Department of Internal Medicine, General Hospital of Sibenik - Knin County, Sibenik, Croatia
| | - Marijana Grgic Medic
- Intensive Care Unit, Department of Internal Medicine, University Hospital Centre Zagreb, Zagreb, Croatia
| | - Velka Gveric–Krecak
- Department of Internal Medicine, General Hospital of Sibenik - Knin County, Sibenik, Croatia
| | - Pavle Roncevic
- Division of Hematology, Department of Internal Medicine, University Hospital Centre Zagreb, Zagreb, Croatia
| | - Sandra Bašić Kinda
- Division of Hematology, Department of Internal Medicine, University Hospital Centre Zagreb, Zagreb, Croatia
| | - Jaksa Babel
- Intensive Care Unit, Department of Internal Medicine, University Hospital Centre Zagreb, Zagreb, Croatia
| | - Radovan Radonic
- Intensive Care Unit, Department of Internal Medicine, University Hospital Centre Zagreb, Zagreb, Croatia
- School of Medicine, University of Zagreb, Zagreb, Croatia
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17
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The transcriptome of CMML monocytes is highly inflammatory and reflects leukemia-specific and age-related alterations. Blood Adv 2020; 3:2949-2961. [PMID: 31648319 DOI: 10.1182/bloodadvances.2019000585] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2019] [Accepted: 08/23/2019] [Indexed: 12/19/2022] Open
Abstract
Chronic myelomonocytic leukemia (CMML) is an aggressive myeloid neoplasm of older individuals characterized by persistent monocytosis. Somatic mutations in CMML are heterogeneous and only partially explain the variability in clinical outcomes. Recent data suggest that cardiovascular morbidity is increased in CMML and contributes to reduced survival. Clonal hematopoiesis of indeterminate potential (CHIP), the presence of mutated blood cells in hematologically normal individuals, is a precursor of age-related myeloid neoplasms and associated with increased cardiovascular risk. To isolate CMML-specific alterations from those related to aging, we performed RNA sequencing and DNA methylation profiling on purified monocytes from CMML patients and from age-matched (old) and young healthy controls. We found that the transcriptional signature of CMML monocytes is highly proinflammatory, with upregulation of multiple inflammatory pathways, including tumor necrosis factor and interleukin (IL)-6 and -17 signaling, whereas age per se does not significantly contribute to this pattern. We observed no consistent correlations between aberrant gene expression and CpG island methylation, suggesting that proinflammatory signaling in CMML monocytes is governed by multiple and complex regulatory mechanisms. We propose that proinflammatory monocytes contribute to cardiovascular morbidity in CMML patients and promote progression by selection of mutated cell clones. Our data raise questions of whether asymptomatic patients with CMML benefit from monocyte-depleting or anti-inflammatory therapies.
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18
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Moreno Berggren D, Kjellander M, Backlund E, Engvall M, Garelius H, Lorenz F, Nilsson L, Rasmussen B, Lehmann S, Hellström-Lindberg E, Jädersten M, Ungerstedt J, Ejerblad E. Prognostic scoring systems and comorbidities in chronic myelomonocytic leukaemia: a nationwide population-based study. Br J Haematol 2020; 192:474-483. [PMID: 32501529 DOI: 10.1111/bjh.16790] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2020] [Accepted: 05/04/2020] [Indexed: 01/07/2023]
Abstract
Outcomes in chronic myelomonocytic leukaemia (CMML) are highly variable and may be affected by comorbidity. Therefore, prognostic models and comorbidity indices are important tools to estimate survival and to guide clinicians in individualising treatment. In this nationwide population-based study, we assess comorbidities and for the first time validate comorbidity indices in CMML. We also compare the prognostic power of: the revised International Prognostic Scoring System (IPSS-R), CMML-specific prognostic scoring system (CPSS), MD Anderson Prognostic Scoring System (MDAPS) and Mayo score. In this cohort of 337 patients with CMML, diagnosed between 2009 and 2015, the median overall survival was 21·3 months. Autoimmune conditions were present in 25% of the patients, with polymyalgia rheumatica and Hashimoto's thyroiditis being most common. Of the tested comorbidity indices: the Charlson Comorbidity Index (CCI), Haematopoietic cell transplantation-specific Comorbidity Index (HCT-CI) and Myelodysplastic Syndrome-Specific Comorbidity Index (MDS-CI), CCI had the highest C-index (0·62) and was the only comorbidity index independently associated with survival in multivariable analyses. When comparing the prognostic power of the scoring systems, the CPSS had the highest C-index (0·69). In conclusion, using 'real-world' data we found that the CCI and CPSS have the best prognostic power and that autoimmune conditions are overrepresented in CMML.
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Affiliation(s)
- Daniel Moreno Berggren
- Department of Medical Science, Section of Hematology, Uppsala University, Uppsala, Sweden
| | - Matilda Kjellander
- Center for Hematology and Regenerative Medicine, Department of Medicine Huddinge, Karolinska Institutet, Karolinska University Hospital and PO Hematology, Karolinska University Hospital, Stockholm, Sweden
| | - Ellen Backlund
- Department of Medical Science, Section of Hematology, Uppsala University, Uppsala, Sweden
| | - Marie Engvall
- Department of Immunology, Genetics and Pathology, Uppsala University, Uppsala, Sweden
| | - Hege Garelius
- Section for Haematology and Coagulation, Department of Medicine, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Fryderyk Lorenz
- Department of Radiation Sciences, Oncology, Umeå University, Umeå, Sweden
| | - Lars Nilsson
- Department of Hematology, Oncology and Radiation Physics, Skåne University Hospital, Lund, Sweden
| | - Bengt Rasmussen
- School of Medical Sciences, Örebro University Hospital, Örebro, Sweden
| | - Sören Lehmann
- Department of Medical Science, Section of Hematology, Uppsala University, Uppsala, Sweden
| | - Eva Hellström-Lindberg
- Center for Hematology and Regenerative Medicine, Department of Medicine Huddinge, Karolinska Institutet, Karolinska University Hospital and PO Hematology, Karolinska University Hospital, Stockholm, Sweden
| | - Martin Jädersten
- Center for Hematology and Regenerative Medicine, Department of Medicine Huddinge, Karolinska Institutet, Karolinska University Hospital and PO Hematology, Karolinska University Hospital, Stockholm, Sweden
| | - Johanna Ungerstedt
- Center for Hematology and Regenerative Medicine, Department of Medicine Huddinge, Karolinska Institutet, Karolinska University Hospital and PO Hematology, Karolinska University Hospital, Stockholm, Sweden
| | - Elisabeth Ejerblad
- Department of Medical Science, Section of Hematology, Uppsala University, Uppsala, Sweden
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19
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Patnaik MM, Tefferi A. Chronic Myelomonocytic leukemia: 2020 update on diagnosis, risk stratification and management. Am J Hematol 2020; 95:97-115. [PMID: 31736132 DOI: 10.1002/ajh.25684] [Citation(s) in RCA: 89] [Impact Index Per Article: 22.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2019] [Accepted: 11/13/2019] [Indexed: 12/12/2022]
Abstract
DISEASE OVERVIEW Chronic myelomonocytic leukemia (CMML) is a clonal hematopoietic stem cell disorder with overlapping features of myelodysplastic syndromes and myeloproliferative neoplasms, with an inherent risk for leukemic transformation (~15% over 3-5 years). DIAGNOSIS Diagnosis is based on the presence of sustained (>3 months) peripheral blood monocytosis (≥1 × 109 /L; monocytes ≥10%), along with bone marrow dysplasia. Clonal cytogenetic abnormalities occur in ~ 30% of patients, while >90% have gene mutations. Mutations involving TET2 (~60%), SRSF2 (~50%), ASXL1 (~40%) and the oncogenic RAS pathway (~30%) are frequent; while the presence of ASXL1 and DNMT3A mutations and the absence of TET2 mutations negatively impact over-all survival. RISK STRATIFICATION Molecularly integrated prognostic models include; the Groupe Français des Myélodysplasies (GFM), Mayo Molecular Model (MMM) and the CMML specific prognostic model (CPSS-Mol). Risk factors incorporated into the MMM include presence of nonsense or frameshift ASXL1 mutations, absolute monocyte count>10 × 109 /L, hemoglobin <10 g/dL, platelet count <100 × 109 /L and the presence of circulating immature myeloid cells. The MMM stratifies CMML patients into four groups; high (≥3 risk factors), intermediate-2 (2 risk factors), intermediate-1 (1 risk factor) and low (no risk factors), with median survivals of 16, 31, 59 and 97 months, respectively. RISK-ADAPTED THERAPY Hypomethylating agents such as 5-azacitidine and decitabine are commonly used, with overall response rates of ~40%-50% and complete remission rates of ~7%-17%; with no impact on mutational allele burdens. Allogeneic stem cell transplant is the only potentially curative option, but is associated with significant morbidity and mortality.
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Affiliation(s)
- Mrinal M. Patnaik
- Division of Hematology, Department of MedicineMayo Clinic Rochester Minnesota
| | - Ayalew Tefferi
- Division of Hematology, Department of MedicineMayo Clinic Rochester Minnesota
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20
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Autoimmune disease in CMML-the chicken or the egg? Best Pract Res Clin Haematol 2019; 33:101136. [PMID: 32460986 DOI: 10.1016/j.beha.2019.101136] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2019] [Revised: 12/09/2019] [Accepted: 12/10/2019] [Indexed: 12/14/2022]
Abstract
Chronic myelomonocytic leukemia (CMML) is a clonal disorder that is associated with a wide range of systemic inflammatory and autoimmune diseases (SIADs). Approximately 20% of patients with CMML will have an associated SIAD and recognizing this association is critical to the evaluation, prognostication and management of patients with CMML. In this paper, we review the evidence supporting a causative link between these two entities as well as the direction of this relationship. We argue that the data favors CMML as the antecedent and causative disease state with a few notable exceptions. Better understanding of this relationship aids clinicians in the education of their patients and in determining the optimal management approach at the bedside. It is important to recognize opportunities to harmonize the treatments of these disease processes, which may enhance the effectiveness of treatment while reducing the burden of adverse effects from redundant therapies.
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21
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A Case of Acquired Haemophilia A in a Patient with Chronic Myelomonocytic Leukaemia. Case Rep Hematol 2019; 2019:8612031. [PMID: 30937199 PMCID: PMC6415290 DOI: 10.1155/2019/8612031] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2018] [Revised: 12/08/2018] [Accepted: 02/10/2019] [Indexed: 11/17/2022] Open
Abstract
A 67-year-old male, with a known diagnosis of myelodysplastic syndromes with multilineage dysplasia (MDS-MLD) was admitted to our hospital with a primary complaint of subcutaneous bleeding in his left thigh. Laboratory data showed anaemia and prolongation of activated partial thromboplastin time (85.8 s, normal range 24-39 s) without thrombocytopenia. Coagulation factor VIII (FVIII) activity was less than 1% (normal range 60-150%), and a FVIII inhibitor was identified and quantified at 166 BU/mL to indicate a diagnosis of acquired haemophilia A (AHA). A recent, but sustained circulating monocytosis (>1 × 109/L) was observed, which combined with elevated numbers of neutrophil and monocytic cells in the marrow, suggested evolution of MDS-MLD to chronic myelomonocytic leukaemia (CMML), coinciding with AHA. Further analysis revealed a karyotype of 46, XY, i(14) (q10), which was the same abnormality previously identified in the patient. To treat bleeding caused by AHA, steroid and activated prothrombin complex concentrate were administered. Azacitidine (AZA) was used to treat CMML. During the clinical course, bleeding partially improved; however, subsequent acute myocardial infarction occurred on day 87. Worsening bone marrow failure was observed 4 months after the original admission, despite administration of AZA therapy, and the patient died due to bleeding from AHA. This case suggests that the evolution of MDS to CMML status can be associated with AHA conferring a bleeding tendency.
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22
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Pophali P, Horna P, Lasho TL, Finke CM, Ketterling RP, Gangat N, Nagorney D, Tefferi A, Patnaik MM. Splenectomy in patients with chronic myelomonocytic leukemia: Indications, histopathological findings and clinical outcomes in a single institutional series of thirty-nine patients. Am J Hematol 2018; 93:1347-1357. [PMID: 30105755 PMCID: PMC6196105 DOI: 10.1002/ajh.25246] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2018] [Revised: 08/03/2018] [Accepted: 08/06/2018] [Indexed: 12/13/2022]
Abstract
In a 28-year period, 39 (7%) patients with chronic myelomonocytic leukemia (CMML) (median age 66 years, 64% male) underwent a splenectomy at our institution. Primary indications for splenectomy were refractory thrombocytopenia (36%), progressive spleen related symptoms (33%), emergent splenectomy for splenic rupture (21%), refractory anemia (8%), and prior to allogeneic stem cell transplant (3%). Eleven (28%) patients had anemia at the time of splenectomy, of which 3 (27%) were autoimmune. The median time to splenectomy from CMML diagnosis was 6 months (0-40); perioperative morbidity and mortality rates were 43% and 13%, while the median postsplenectomy survival was 25 months (11-38). Durable remission in spleen related symptoms, thrombocytopenia, complications from splenic rupture, and anemia were achieved in 85%, 50%, 62%, and 21% of patients, respectively. Perioperative morbidity (n = 30) included infections/sepsis in 6 (20%), intraabdominal bleeding in 4 (13%), venous thromboembolism (VTE) in 3 (10%), and acute lung injury in 2 (7%) patients. The median duration of hospital stay was 6 days (1-25), with 5 deaths occurring secondary to respiratory failure (n = 2), multiorgan dysfunction (n = 2) and hemorrhagic shock (n = 1). There was no difference in overall survival between CMML patients that underwent splenectomy, in comparison to those that did not. Unlike in myelofibrosis, portal hypertension was not an indication for splenectomy and no patients developed post-splenectomy thrombocytosis. In conclusion, apart from being a lifesaving emergent modality in the event of splenic rupture, splenectomy has an important palliative role in patients with CMML, with significant and durable improvements in spleen related symptoms and refractory cytopenias.
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Affiliation(s)
- Prateek Pophali
- Division of Hematology, Department of Internal Medicine,
Mayo Clinic, Rochester, MN
| | - Pedro Horna
- Division of Hematopathology, Department of Laboratory
Medicine, Mayo Clinic, Rochester, MN
| | - Terra L. Lasho
- Division of Hematology, Department of Internal Medicine,
Mayo Clinic, Rochester, MN
| | - Christy M. Finke
- Division of Hematology, Department of Internal Medicine,
Mayo Clinic, Rochester, MN
| | - Rhett P. Ketterling
- Division of Hematopathology, Department of Laboratory
Medicine, Mayo Clinic, Rochester, MN
| | - Naseema Gangat
- Division of Hematology, Department of Internal Medicine,
Mayo Clinic, Rochester, MN
| | - David Nagorney
- Department of General Surgery, Mayo Clinic, Rochester,
MN
| | - Ayalew Tefferi
- Division of Hematology, Department of Internal Medicine,
Mayo Clinic, Rochester, MN
| | - Mrinal M. Patnaik
- Division of Hematology, Department of Internal Medicine,
Mayo Clinic, Rochester, MN
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23
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Patnaik MM, Tefferi A. Chronic myelomonocytic leukemia: 2018 update on diagnosis, risk stratification and management. Am J Hematol 2018; 93:824-840. [PMID: 29878489 DOI: 10.1002/ajh.25104] [Citation(s) in RCA: 92] [Impact Index Per Article: 15.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2018] [Accepted: 04/02/2018] [Indexed: 12/20/2022]
Abstract
DISEASE OVERVIEW Chronic myelomonocytic leukemia (CMML) is a clonal hematopoietic stem cell disorder with overlapping features of myelodysplastic syndromes and myeloproliferative neoplasms, with an inherent risk for leukemic transformation (∼15%-20% over 3-5 years). DIAGNOSIS Diagnosis is based on the presence of sustained (>3 months) peripheral blood monocytosis (≥1 × 109 /L; monocytes ≥10%), along with bone marrow dysplasia. Clonal cytogenetic abnormalities occur in ∼ 30% of patients, while >90% have gene mutations. Mutations involving TET2 (∼60%), SRSF2 (∼50%), ASXL1 (∼40%) and the oncogenic RAS pathway (∼30%) are frequent; while the presence of ASXL1 and DNMT3A mutations and the absence of TET2 mutations negatively impact over-all survival. RISK STRATIFICATION Molecularly integrated prognostic models include; the Groupe Français des Myélodysplasies (GFM), Mayo Molecular Model (MMM), and the CMML specific prognostic model (CPSS-Mol). Risk factors incorporated into the MMM include presence of nonsense or frameshift ASXL1 mutations, absolute monocyte count > 10 × 109 /L, hemoglobin <10 gm/dL, platelet count <100 × 109 /L and the presence of circulating immature myeloid cells. The MMM stratifies CMML patients into 4 groups; high (≥3 risk factors), intermediate-2 (2 risk factors), intermediate-1 (1 risk factor), and low (no risk factors), with median survivals of 16, 31, 59, and 97 months, respectively. RISK-ADAPTED THERAPY Hypomethylating agents such as 5-azacitidine and decitabine are commonly used, with overall response rates of ∼30%-40% and complete remission rates of ∼7%-17%; with no impact on mutational allele burdens. Allogeneic stem cell transplant is the only potentially curative option, but is associated with significant morbidity and mortality.
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Affiliation(s)
- Mrinal M. Patnaik
- Division of Hematology, Department of MedicineMayo ClinicRochester Minnesota
| | - Ayalew Tefferi
- Division of Hematology, Department of MedicineMayo ClinicRochester Minnesota
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24
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Bernat AL, Priola SM, Elsawy A, Farrash F, Taslimi S, Gentili F. Chronic subdural collection overlying an intra-axial hemorrhagic lesion in chronic myelomonocytic leukemia: special report and review of the literature. Expert Rev Neurother 2018; 18:371-377. [PMID: 29658352 DOI: 10.1080/14737175.2018.1464391] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
Introduction: Chronic myelomonocytic leukaemia (CMML) is a clonal hematopoietic stem cell disorder characterized by the presence of an absolute monocytosis in the peripheral blood (>1 x 109/L) and the presence of myelodysplastic and myeloproliferative features in the bone marrow. Involvement of the central nervous system (CNS) is uncommon in CMML.Areas covered: Herein described is a case report of a CMML patient who presents with symptomatic chronic subdural collection overlying a haemorrhagic brain lesion, along with diffuse dural infiltration, after two cycles of azacytidine. Surgical intervention was performed to alleviate the mass effect on the brain, and obtain a tissue sample for diagnosis. Histopathological report confirmed brain infiltration with myeloid leukemic cells.Expert commentary: Despite its rarity, cerebral dissemination should be considered even in patients with CMML. A multidisciplinary approach, lead by a hematologist, is mandatory in order to correct the underlying haematological disorder, with specific attention to the coagulation profile. Surgical intervention is necessary for symptomatic patients, and should be performed once an improvement of clinical conditions has been achieved. Despite appropriate surgical and medical therapy, the prognosis remains poor with high risk of perioperative complications, such as rebleeding, and progressive systemic involvement.
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Affiliation(s)
- Anne-Laure Bernat
- Department of Neurosurgery, Toronto Western Hospital, University of Toronto, Toronto, Canada
| | - Stefano Maria Priola
- Department of Neurosurgery, Toronto Western Hospital, University of Toronto, Toronto, Canada
| | - Ahmad Elsawy
- Department of Neurosurgery, Toronto Western Hospital, University of Toronto, Toronto, Canada
| | - Faisal Farrash
- Department of Neurosurgery, Toronto Western Hospital, University of Toronto, Toronto, Canada
| | - Shervin Taslimi
- Department of Neurosurgery, Toronto Western Hospital, University of Toronto, Toronto, Canada
| | - Fred Gentili
- Department of Neurosurgery, Toronto Western Hospital, University of Toronto, Toronto, Canada
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25
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Chronic Myelomonocytic Leukemia following Multicentric Castleman Disease. Case Rep Hematol 2018; 2018:5895903. [PMID: 29607228 PMCID: PMC5828649 DOI: 10.1155/2018/5895903] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2017] [Accepted: 12/07/2017] [Indexed: 11/18/2022] Open
Abstract
Multicentric Castleman disease (MCD) is a rare nonmalignant lymphoproliferative disorder presenting systemic symptoms such as fever, night sweats, fatigue, anemia, effusions, and multifocal lymphadenopathy. The etiology of MCD has not been clarified to date. The coexistence of MCD with chronic myelomonocytic leukemia (CMML) has been rarely reported. Although the pathogenesis remains unclear, this association probably reflects an incidental and fortuitous finding rather than the alteration of a common pluripotent stem cell precursor. Herein, we report on one case of MCD coexisting with CMML and elucidate the underlying mechanism of pathology in some aspects.
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26
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Giat E, Ehrenfeld M, Shoenfeld Y. Cancer and autoimmune diseases. Autoimmun Rev 2017; 16:1049-1057. [DOI: 10.1016/j.autrev.2017.07.022] [Citation(s) in RCA: 101] [Impact Index Per Article: 14.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2017] [Accepted: 07/12/2017] [Indexed: 02/06/2023]
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27
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Abstract
Chronic myelomonocytic leukemia (CMML) is a clonal hematopoietic malignancy that may deserve specific management. Defined by a persistent peripheral blood monocytosis ≥1 × 109/L and monocytes accounting for ≥10% of the white blood cells, this aging-associated disease combines cell proliferation as a consequence of myeloid progenitor hypersensitivity to granulocyte-macrophage colony-stimulating factor with myeloid cell dysplasia and ineffective hematopoiesis. The only curative option for CMML remains allogeneic stem cell transplantation. When transplantation is excluded, CMML is stratified into myelodysplastic (white blood cell count <13 × 109/L) and proliferative (white blood cell count ≥13 × 109/L) CMML. In the absence of poor prognostic factors, the management of myelodysplastic CMML is largely inspired from myelodysplastic syndromes, relying on erythropoiesis-stimulating agents to cope with anemia, and careful monitoring and supportive care, whereas the management of proliferative CMML usually relies on cytoreductive agents such as hydroxyurea, although ongoing studies will help delineate the role of hypomethylating agents in this patient population. In the presence of excessive blasts and other poor prognostic factors, hypomethylating agents are the preferred option, even though their impact on leukemic transformation and survival has not been proved. The therapeutic choice is illustrated by 4 clinical situations among the most commonly seen. Although current therapeutic options can improve patient's quality of life, they barely modify disease evolution. Improved understanding of CMML pathophysiology will hopefully lead to the exploration of novel targets that potentially would be curative.
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28
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El-Fattah MA. Second malignancies in survivors of chronic myelomonocytic leukemia: a U.S. population-based study. Leuk Lymphoma 2017; 58:1-7. [DOI: 10.1080/10428194.2016.1276289] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Affiliation(s)
- Mohamed Abd El-Fattah
- Department of Internal Medicine, Faculty of Medicine, Suez Canal University, Ismailia, Egypt
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29
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Zahid MF, Barraco D, Lasho TL, Finke C, Ketterling RP, Gangat N, Hanson CA, Tefferi A, Patnaik MM. Spectrum of autoimmune diseases and systemic inflammatory syndromes in patients with chronic myelomonocytic leukemia. Leuk Lymphoma 2016; 58:1488-1493. [DOI: 10.1080/10428194.2016.1243681] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Affiliation(s)
- Mohammad Faizan Zahid
- Division of Hematology, Department of Internal Medicine, Mayo Clinic, Rochester, MN, USA
| | - Daniela Barraco
- Division of Hematology, Department of Internal Medicine, Mayo Clinic, Rochester, MN, USA
| | - Terra L. Lasho
- Division of Hematology, Department of Internal Medicine, Mayo Clinic, Rochester, MN, USA
| | - Christy Finke
- Division of Hematology, Department of Internal Medicine, Mayo Clinic, Rochester, MN, USA
| | - Rhett P. Ketterling
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, USA
| | - Naseema Gangat
- Division of Hematology, Department of Internal Medicine, Mayo Clinic, Rochester, MN, USA
| | - Curtis A. Hanson
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, USA
| | - Ayalew Tefferi
- Division of Hematology, Department of Internal Medicine, Mayo Clinic, Rochester, MN, USA
| | - Mrinal M. Patnaik
- Division of Hematology, Department of Internal Medicine, Mayo Clinic, Rochester, MN, USA
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30
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Grignano E, Mekinian A, Braun T, Liozon E, Hamidou M, Decaux O, Puéchal X, Kahn JE, Schoindre Y, Rossignol J, Lortholary O, Lioger B, Hermine O, Park S, Ades L, Montestruc F, Ricard L, Gardin C, Fenaux P, Fain O. Autoimmune and inflammatory diseases associated with chronic myelomonocytic leukemia: A series of 26 cases and literature review. Leuk Res 2016; 47:136-41. [DOI: 10.1016/j.leukres.2016.05.013] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/29/2016] [Revised: 05/13/2016] [Accepted: 05/19/2016] [Indexed: 12/26/2022]
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31
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Moura CA, Santiago M, Neto J, Gomes de Souza VH, Moura CG. Chronic myelomonocytic leukemia mimicking hematologic systemic lupus erythematosus. Lupus 2016; 26:204-207. [PMID: 27365372 DOI: 10.1177/0961203316657436] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
The relationship between primary hematologic disease and rheumatologic manifestations is well known, especially acute lymphocytic leukemia, lymphomas, plasma cell dyscrasias and myelodysplastic syndrome (MDS). Currently, more has been described about autoimmune manifestations in chronic myelomonocytic leukemia (CMML). Many different clinical scenarios may lead a patient with MDS/CMML initially to seek a rheumatological unit. Autoimmune features such as polymyalgia rheumatic symptoms, myositis, neutrophilic dermatosis, cutaneous vasculitis and positive antinuclear antibodies (ANA) are some examples of clinical presentation of MDS/CMML. Moreover, peripheral cytopenias are a common initial presentation both for systemic lupus erythematous (SLE) and MDS/CMML. The aim of this study was to describe a case of an elderly woman with thrombocytopenia and positivity of antibodies to anti-extractable nuclear antigens (anti-ENA) as initial manifestation of CMML mimicking SLE, and to present some clues that encourage the clinician to perform a bone marrow study in such a clinical scenario.
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Affiliation(s)
- C A Moura
- 1 Programa de Residência de Clínica Médica do Hospital Santo Antonio, Obras Sociais Irmã Dulce, Salvador, Bahia, Brazil.,2 Escola Bahiana de Medicina e Saúde Pública, Salvador, Bahia, Brazil.,3 Universidade Salvador (UNIFACS), Salvador, Bahia, Brazil
| | - M Santiago
- 2 Escola Bahiana de Medicina e Saúde Pública, Salvador, Bahia, Brazil
| | - J Neto
- 3 Universidade Salvador (UNIFACS), Salvador, Bahia, Brazil
| | - V H Gomes de Souza
- 4 Clínica de Assistência Multidisciplinar em Oncologia (AMO), Salvador, Bahia, Brazil
| | - C Geraldo Moura
- 1 Programa de Residência de Clínica Médica do Hospital Santo Antonio, Obras Sociais Irmã Dulce, Salvador, Bahia, Brazil.,2 Escola Bahiana de Medicina e Saúde Pública, Salvador, Bahia, Brazil
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Patnaik MM, Tefferi A. Chronic myelomonocytic leukemia: molecularly contaminated, but not defined. Leuk Lymphoma 2016; 57:1751-2. [DOI: 10.3109/10428194.2016.1169411] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
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Elbæk MV, Sørensen AL, Hasselbalch HC. Chronic inflammation and autoimmunity as risk factors for the development of chronic myelomonocytic leukemia? Leuk Lymphoma 2016; 57:1793-9. [DOI: 10.3109/10428194.2016.1143938] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
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