1
|
Wypyszczak K, Urbanska Z, Miarka-Walczyk K, Kolodrubiec J, Jakubowska J, Spychalska J, Glodkowska-Mrowka E, Ussowicz M, Mlynarski W, Pastorczak A. Transformation of aplastic anemia with paroxysmal nocturnal hemoglobinuria clone to childhood B-cell precursor acute lymphoblastic leukemia. Pediatr Blood Cancer 2024; 71:e30994. [PMID: 38605541 DOI: 10.1002/pbc.30994] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2024] [Revised: 03/19/2024] [Accepted: 03/20/2024] [Indexed: 04/13/2024]
Affiliation(s)
- Kamila Wypyszczak
- Department of Genetic Predisposition to Cancer, Medical University of Lodz, Lodz, Poland
- Department of Pediatrics, Oncology and Hematology, Medical University of Lodz, Lodz, Poland
| | - Zuzanna Urbanska
- Department of Genetic Predisposition to Cancer, Medical University of Lodz, Lodz, Poland
- Department of Pediatrics, Oncology and Hematology, Medical University of Lodz, Lodz, Poland
| | - Karolina Miarka-Walczyk
- Department of Genetic Predisposition to Cancer, Medical University of Lodz, Lodz, Poland
- Department of Pediatrics, Oncology and Hematology, Medical University of Lodz, Lodz, Poland
| | - Julia Kolodrubiec
- Department of Pediatrics, Oncology and Hematology, Medical University of Lodz, Lodz, Poland
| | - Justyna Jakubowska
- Department of Pediatrics, Oncology and Hematology, Medical University of Lodz, Lodz, Poland
| | - Justyna Spychalska
- Department of Hematological and Transfusion Immunology, Institute of Hematology and Transfusion Medicine, Warsaw, Poland
| | - Eliza Glodkowska-Mrowka
- Department of Hematological and Transfusion Immunology, Institute of Hematology and Transfusion Medicine, Warsaw, Poland
- Department of Laboratory Diagnostics and Clinical Immunology of Developmental Age, Medical University of Warsaw, Warsaw, Poland
| | - Marek Ussowicz
- Department of Pediatric Bone Marrow Transplantation, Oncology and Hematology, Wroclaw Medical University, Wroclaw, Poland
| | - Wojciech Mlynarski
- Department of Pediatrics, Oncology and Hematology, Medical University of Lodz, Lodz, Poland
| | - Agata Pastorczak
- Department of Genetic Predisposition to Cancer, Medical University of Lodz, Lodz, Poland
- Department of Pediatrics, Oncology and Hematology, Medical University of Lodz, Lodz, Poland
| |
Collapse
|
2
|
Versino F, Fattizzo B. Complement inhibition in paroxysmal nocturnal hemoglobinuria: From biology to therapy. Int J Lab Hematol 2024; 46 Suppl 1:43-54. [PMID: 38622956 DOI: 10.1111/ijlh.14281] [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: 02/02/2024] [Accepted: 03/23/2024] [Indexed: 04/17/2024]
Abstract
Complement inhibitors are the mainstay of paroxysmal nocturnal hemoglobinuria (PNH) treatment. The anti-C5 monoclonal antibody eculizumab was the first treatment to improve hemolysis, thrombotic risk, and survival in PNH although at the price of a life-long intravenous fortnightly drug. Additionally, suboptimal response may occur in up to 2/3 of patients with persistent anemia due to incomplete control of intravascular hemolysis, development of upstream C3-mediated extravascular hemolysis (EVH), or concomitant bone marrow failure. Ravulizumab, a longer half-life anti-C5 developed from eculizumab, administered every 8 weeks, improved patient convenience, and reduced pharmacokinetic breakthrough hemolysis (BTH) by establishing more stable anti-C5 concentrations. More recently, several other anti-C5 compounds (crovalimab, pozelimab, tesidolumab, cemdisiran, zilucoplan, and coversin) are on study in clinical trials. Upstream inhibition of complement cascade was also explored with the anti-C3 pegcetacoplan, and with the alternative pathway inhibitors iptacopan (anti-factor B) and danicopan (anti-factor D). These drugs efficiently target EVH and are able to improve anemia and transfusion need in suboptimal responders to anti-C5. The route and schedule of administration (twice weekly subcutaneously for pegcetacoplan and twice or thrice oral daily dosing for iptacopan and danicopan, respectively) are very convenient but pose novel issues regarding adherence. Additionally, both anti-C5 and upstream inhibitors do not resolve the unmet need of pharmacodynamic BTH events due to complement amplifying conditions such as infections, traumas, and surgery. In this review, we will recapitulate PNH physiopathology, clinical presentation, and diagnosis and describe available and developing drugs that will lead to a precision medicine approach for this rare though heterogenous disease.
Collapse
Affiliation(s)
- Francesco Versino
- Hematology Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
- Department of Oncology and hemato-oncology, University of Milan, Milan, Italy
| | - Bruno Fattizzo
- Hematology Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
- Department of Oncology and hemato-oncology, University of Milan, Milan, Italy
| |
Collapse
|
3
|
Shingai N, Mizumaki H, Najima Y, Yamada Y, Tran DC, Haraguchi K, Toya T, Okuyama Y, Doki N, Nannya Y, Ogawa S, Nakao S. Case report: Immune pressure on hematopoietic stem cells can drastically expand glycosylphosphatidylinositol-deficient clones in paroxysmal nocturnal hemoglobinuria. Front Immunol 2024; 14:1329403. [PMID: 38288112 PMCID: PMC10822943 DOI: 10.3389/fimmu.2023.1329403] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2023] [Accepted: 12/27/2023] [Indexed: 01/31/2024] Open
Abstract
Introduction Paroxysmal nocturnal hemoglobinuria (PNH) is a rare hematological disease characterized by intravascular hemolysis, thrombosis, and bone marrow (BM) failure. Although PNH is caused by excessive proliferation of hematopoietic stem cell (HSC) clones with loss of function mutations in phosphatidylinositol N-acetylglucosaminyltransferase subunit A (PIGA) genes, what drives PNH clones to expand remains elusive. Case description We present a case of a 26-year-old female who presented with hemolytic anemia, thrombocytopenia, and leukopenia. Flow cytometry analysis of peripheral blood showed that 71.9% and 15.3% of the granulocytes and erythrocytes were glycosylphosphatidylinositol-anchored protein deficient (GPI[-]) cells. The patient was diagnosed with PNH with non-severe aplastic anemia. Deep-targeted sequencing covering 390 different genes of sorted GPI(-) granulocytes revealed three different PIGA mutations (p.I69fs, variant allele frequency (VAF) 24.2%; p.T192P, VAF 5.8%; p.V300fs, VAF 5.1%) and no other mutations. She received six cycles of eculizumab and oral cyclosporine. Although the patient's serum lactate dehydrogenase level decreased, she remained dependent on red blood cell transfusion. Six months after diagnosis, she received a syngeneic bone marrow transplant (BMT) from a genetically identical healthy twin, following an immune ablative conditioning regimen consisting of cyclophosphamide 200 mg/kg and rabbit anti-thymocyte globulin 10 mg/kg. After four years, the patient's blood count remained normal without any signs of hemolysis. However, the peripheral blood still contained 0.2% GPI (-) granulocytes, and the three PIGA mutations that had been detected before BMT persisted at similar proportions to those before transplantation (p.I69fs, VAF 36.1%; p.T192P, VAF 3.7%; p.V300fs, VAF 8.6%) in the small PNH clones that persisted after transplantation. Conclusions The PNH clones that had increased excessively before BMT decreased, but persisted at low percentages for more than four years after the immunoablative conditioning regimen followed by syngeneic BMT. These findings indicate that as opposed to conventional theory, immune pressure on HSCs, which caused BM failure before BMT, was sufficient for PIGA-mutated HSCs to clonally expand to develop PNH.
Collapse
Affiliation(s)
- Naoki Shingai
- Hematology Division, Tokyo Metropolitan Cancer and Infectious Diseases Center, Komagome Hospital, Tokyo, Japan
| | - Hiroki Mizumaki
- Department of Hematology, Kanazawa University, Kanazawa, Japan
| | - Yuho Najima
- Hematology Division, Tokyo Metropolitan Cancer and Infectious Diseases Center, Komagome Hospital, Tokyo, Japan
| | - Yuta Yamada
- Hematology Division, Tokyo Metropolitan Cancer and Infectious Diseases Center, Komagome Hospital, Tokyo, Japan
| | - Dung Cao Tran
- Department of Hematology, Kanazawa University, Kanazawa, Japan
| | - Kyoko Haraguchi
- Division of Transfusion and Cell Therapy, Tokyo Metropolitan Cancer and Infectious Diseases Center, Komagome Hospital, Tokyo, Japan
| | - Takashi Toya
- Hematology Division, Tokyo Metropolitan Cancer and Infectious Diseases Center, Komagome Hospital, Tokyo, Japan
| | - Yoshiki Okuyama
- Division of Transfusion and Cell Therapy, Tokyo Metropolitan Cancer and Infectious Diseases Center, Komagome Hospital, Tokyo, Japan
| | - Noriko Doki
- Hematology Division, Tokyo Metropolitan Cancer and Infectious Diseases Center, Komagome Hospital, Tokyo, Japan
| | - Yasuhito Nannya
- Department of Pathology and Tumor Biology, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Seishi Ogawa
- Department of Pathology and Tumor Biology, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Shinji Nakao
- Department of Hematology, Kanazawa University, Kanazawa, Japan
| |
Collapse
|
4
|
Craven KE, Ewalt MD. Premalignant Clonal Hematopoiesis (Clonal Hematopoiesis of Indeterminate Potential and Clonal Cytopenia of Undetermined Significance). Clin Lab Med 2023; 43:565-576. [PMID: 37865503 DOI: 10.1016/j.cll.2023.06.001] [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] [Indexed: 10/23/2023]
Abstract
Premalignant clonal hematopoiesis is the presence of somatic alterations in the blood of otherwise healthy individuals. Although the condition is not considered as a cancer, it carries an increased risk of developing a hematologic malignancy, particularly in those with large neoplastic clones, multiple pathogenic mutations, and high-risk mutations. In addition to the increased risk of malignancy, clonal hematopoiesis carries a markedly increased risk of cardiovascular events and death. Appropriate identification of this entity is critical to mitigate cardiovascular risk factors and ensure appropriate monitoring for the emergence of blood cancer.
Collapse
Affiliation(s)
- Kelly E Craven
- Department of Pathology and Laboratory Medicine, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, Box 36, New York, NY 10065, USA
| | - Mark D Ewalt
- Department of Pathology and Laboratory Medicine, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, Box 36, New York, NY 10065, USA.
| |
Collapse
|
5
|
Bravo-Perez C, Guarnera L, Williams ND, Visconte V. Paroxysmal Nocturnal Hemoglobinuria: Biology and Treatment. MEDICINA (KAUNAS, LITHUANIA) 2023; 59:1612. [PMID: 37763731 PMCID: PMC10535188 DOI: 10.3390/medicina59091612] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/19/2023] [Revised: 08/22/2023] [Accepted: 08/30/2023] [Indexed: 09/29/2023]
Abstract
Paroxysmal nocturnal hemoglobinuria (PNH) is a nonmalignant clonal hematopoietic disorder characterized by the lack of glycosylphosphatidylinositol-anchored proteins (GPI-APs) as a consequence of somatic mutations in the phosphatidylinositol glycan anchor biosynthesis class A (PIGA) gene. Clinical manifestations of PNH are intravascular hemolysis, thrombophilia, and bone marrow failure. Treatment of PNH mainly relies on the use of complement-targeted therapy (C5 inhibitors), with the newest agents being explored against other factors involved in the complement cascade to alleviate unresolved intravascular hemolysis and extravascular hemolysis. This review summarizes the biology and current treatment strategies for PNH with the aim of reaching a general audience with an interest in hematologic disorders.
Collapse
Affiliation(s)
- Carlos Bravo-Perez
- Department of Translational Hematology & Oncology Research, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH 44114, USA; (C.B.-P.); (L.G.); (N.D.W.)
- Department of Hematology and Medical Oncology, Hospital Universitario Morales Meseguer, IMIB-Pascual Parrilla, CIBERER—Instituto de Salud Carlos III, University of Murcia, 30005 Murcia, Spain
| | - Luca Guarnera
- Department of Translational Hematology & Oncology Research, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH 44114, USA; (C.B.-P.); (L.G.); (N.D.W.)
- Hematology, Department of Biomedicine and Prevention, University of Rome Tor Vergata, 00133 Rome, Italy
| | - Nakisha D. Williams
- Department of Translational Hematology & Oncology Research, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH 44114, USA; (C.B.-P.); (L.G.); (N.D.W.)
| | - Valeria Visconte
- Department of Translational Hematology & Oncology Research, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH 44114, USA; (C.B.-P.); (L.G.); (N.D.W.)
| |
Collapse
|
6
|
Sutra Del Galy A, Willems L, D'Aveni M, Pautas C, Chantepie S, Carpentier B, Barraco F, Banos A, Garidi R, Forcade E, Sicre de Fontbrune F, Peffault de Latour R. Haemolytic paroxysmal nocturnal haemoglobinuria in patients with myeloid neoplasms: A rare association with specific therapeutic implications. Br J Haematol 2023; 201:e16-e20. [PMID: 36807116 DOI: 10.1111/bjh.18693] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2022] [Revised: 01/11/2023] [Accepted: 01/30/2023] [Indexed: 02/20/2023]
Affiliation(s)
| | - Lise Willems
- Service d'Hématologie Clinique, Centre Hospitalier Universitaire Cochin, Paris, France
| | - Maud D'Aveni
- Service d'Hématologie, Centre Hospitalier Régional Universitaire de Nancy, Nancy, France
| | - Cécile Pautas
- Service d'Hématologie Clinique et de Thérapie Cellulaire, Hôpital Henri Mondor, Créteil, France
| | | | | | - Fiorenza Barraco
- Service d'Hématologie, Centre Hospitalier Universitaire Lyon Sud, Lyon, France
| | - Anne Banos
- Service d'Hématologie, Centre Hospitalier de la Côte Basque, Bayonne, France
| | - Reda Garidi
- Service d'Onco-Hématologie, Centre Hospitalier de Saint Quentin, Saint-Quentin, France
| | - Edouard Forcade
- Service d'Hématologie Clinique et Thérapie Cellulaire, Centre Hospitalier Universitaire Bordeaux, Bordeaux, France
| | | | | |
Collapse
|
7
|
Hosokawa K, Nakao S. Somatic mutations and clonal expansions in paroxysmal nocturnal hemoglobinuria. Semin Hematol 2022; 59:143-149. [DOI: 10.1053/j.seminhematol.2022.08.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2022] [Revised: 08/17/2022] [Accepted: 08/17/2022] [Indexed: 01/02/2023]
|
8
|
Mehta Ö, Geduk A. Spontaneous Remission in Paroxysmal Nocturnal Hemoglobinuria: an Extremely Rare Case. Turk J Haematol 2022; 39:148-149. [PMID: 35176840 PMCID: PMC9160701 DOI: 10.4274/tjh.galenos.2022.2021.0672] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
Affiliation(s)
- Özgür Mehta
- Kocaeli University, Department of Hematology, Medical Faculty, Kocaeli, Turkey
| | - Ayfer Geduk
- Kocaeli University, Department of Hematology, Medical Faculty, Kocaeli, Turkey
| |
Collapse
|
9
|
Colden MA, Kumar S, Munkhbileg B, Babushok DV. Insights Into the Emergence of Paroxysmal Nocturnal Hemoglobinuria. Front Immunol 2022; 12:830172. [PMID: 35154088 PMCID: PMC8831232 DOI: 10.3389/fimmu.2021.830172] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2021] [Accepted: 12/30/2021] [Indexed: 11/13/2022] Open
Abstract
Paroxysmal Nocturnal Hemoglobinuria (PNH) is a disease as simple as it is complex. PNH patients develop somatic loss-of-function mutations in phosphatidylinositol N-acetylglucosaminyltransferase subunit A gene (PIGA), required for the biosynthesis of glycosylphosphatidylinositol (GPI) anchors. Ubiquitous in eukaryotes, GPI anchors are a group of conserved glycolipid molecules responsible for attaching nearly 150 distinct proteins to the surface of cell membranes. The loss of two GPI-anchored surface proteins, CD55 and CD59, from red blood cells causes unregulated complement activation and hemolysis in classical PNH disease. In PNH patients, PIGA-mutant, GPI (-) hematopoietic cells clonally expand to make up a large portion of patients’ blood production, yet mechanisms leading to clonal expansion of GPI (-) cells remain enigmatic. Historical models of PNH in mice and the more recent PNH model in rhesus macaques showed that GPI (-) cells reconstitute near-normal hematopoiesis but have no intrinsic growth advantage and do not clonally expand over time. Landmark studies identified several potential mechanisms which can promote PNH clonal expansion. However, to what extent these contribute to PNH cell selection in patients continues to be a matter of active debate. Recent advancements in disease models and immunologic technologies, together with the growing understanding of autoimmune marrow failure, offer new opportunities to evaluate the mechanisms of clonal expansion in PNH. Here, we critically review published data on PNH cell biology and clonal expansion and highlight limitations and opportunities to further our understanding of the emergence of PNH clones.
Collapse
Affiliation(s)
- Melissa A. Colden
- Division of Hematology-Oncology, Department of Medicine, University of Pennsylvania, Philadelphia, PA, United States
- Comprehensive Bone Marrow Failure Center, Department of Pediatrics, Children’s Hospital of Philadelphia, Philadelphia, PA, United States
| | - Sushant Kumar
- Division of Hematology-Oncology, Department of Medicine, University of Pennsylvania, Philadelphia, PA, United States
- Comprehensive Bone Marrow Failure Center, Department of Pediatrics, Children’s Hospital of Philadelphia, Philadelphia, PA, United States
| | - Bolormaa Munkhbileg
- Division of Hematology-Oncology, Department of Medicine, University of Pennsylvania, Philadelphia, PA, United States
- Comprehensive Bone Marrow Failure Center, Department of Pediatrics, Children’s Hospital of Philadelphia, Philadelphia, PA, United States
| | - Daria V. Babushok
- Division of Hematology-Oncology, Department of Medicine, University of Pennsylvania, Philadelphia, PA, United States
- Comprehensive Bone Marrow Failure Center, Department of Pediatrics, Children’s Hospital of Philadelphia, Philadelphia, PA, United States
- *Correspondence: Daria V. Babushok,
| |
Collapse
|
10
|
Chen Y, Liu H, Zeng L, Li L, Lu D, Liu Z, Fu R. A Pig-a conditional knock-out mice model mediated by Vav-iCre: stable GPI-deficient and mild hemolysis. Exp Hematol Oncol 2022; 11:1. [PMID: 35033195 PMCID: PMC8760646 DOI: 10.1186/s40164-022-00254-5] [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] [Subscribe] [Scholar Register] [Received: 11/13/2021] [Accepted: 01/05/2022] [Indexed: 11/10/2022] Open
Abstract
Paroxysmal nocturnal hemoglobinuria is a clonal disease caused by PIG-A mutation of hematopoietic stem cells. At present, there is no suitable PNH animal model for basic research, therefore, it is urgent to establish a stable animal model. We constructed a Pig-a conditional knock-out mice model by ES targeting technique and Vav-iCre. The expressions of GPI and GPI-AP were almost completely absent in CKO homozygote mice, and the proportion of the deficiency remained stable from birth. In CKO heterozygote mice, the proportion of the deficiency of GPI and GPI-AP was partially absent and decreased gradually from birth until it reached a stable level at 3 months after birth and remained there for life. Compared with normal C57BL/6N mice and Flox mice, pancytopenia was found in CKO homozygous mice, and leukopenia and anemia were found in CKO heterozygotes mice. Meanwhile, in CKO mice, the serum LDH, TBIL, IBIL, complement C5b-9 levels were increased, and the concentration of plasma FHb was increased. Hemosiderin granulosa cells can be seen more easily in the spleens of CKO mice. What's more, CKO mice had stable transcription characteristics. In conclusion, our mouse model has stable GPI-deficient and mild hemolysis, which may be an ideal in vivo experimental model for PNH.
Collapse
Affiliation(s)
- Yingying Chen
- Department of Hematology, Tianjin Medical University General Hospital, 154 Anshan Street, Heping District, Tianjin, 300052, People's Republic of China
| | - Hui Liu
- Department of Hematology, Tianjin Medical University General Hospital, 154 Anshan Street, Heping District, Tianjin, 300052, People's Republic of China
| | - Lijie Zeng
- Department of Hematology, Tianjin Medical University General Hospital, 154 Anshan Street, Heping District, Tianjin, 300052, People's Republic of China
| | - Liyan Li
- Department of Hematology, Tianjin Medical University General Hospital, 154 Anshan Street, Heping District, Tianjin, 300052, People's Republic of China
| | - Dan Lu
- Department of Hematology, Tianjin Medical University General Hospital, 154 Anshan Street, Heping District, Tianjin, 300052, People's Republic of China
| | - Zhaoyun Liu
- Department of Hematology, Tianjin Medical University General Hospital, 154 Anshan Street, Heping District, Tianjin, 300052, People's Republic of China
| | - Rong Fu
- Department of Hematology, Tianjin Medical University General Hospital, 154 Anshan Street, Heping District, Tianjin, 300052, People's Republic of China.
| |
Collapse
|
11
|
Chen Y, Liu H, Zeng L, Li L, Lu D, Liu Z, Fu R. SUZ12 participates in the proliferation of PNH clones by regulating histone H3K27me3 levels. J Leukoc Biol 2022; 112:243-255. [PMID: 34990019 DOI: 10.1002/jlb.2a1021-564r] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
Paroxysmal nocturnal hemoglobinuria (PNH) is a disease involving hematopoietic stem cell membrane defects caused by acquired phosphatidylinositol glycan anchor biosynthesis class A (PIGA) mutations. In this study, 97 target genes were selected as a target gene panel and screened in 23 PNH patients via the sequencing of specific DNA target regions. Through functional analysis, we identified that suppressor-of-Zeste 12 (SUZ12) may be involved in the proliferation of PNH clones. mRNA and protein expression levels of SUZ12 and the trimethylation level of histone H3 at lysine 27 (H3K27) in CD59- peripheral blood leukocytes from PNH patients were higher than those in CD59+ cells from PNH patients and peripheral blood leukocytes from healthy controls. In addition, the relative expression of SUZ12 in PNH patients was positively correlated with Ret% and the proportion of PNH clones. When we knocked down SUZ12 expression in a PIGA knockdown THP-1 cell line (THP-1 KD cells), the trimethylation of histone H3K27(H3K27me3) and cell proliferation decreased, apoptosis increased, and cell cycle arrest occurred in G0/G1 phase. In conclusion, SUZ12 participates in the proliferation of PNH clones by regulating histone H3K27me3 levels. Our results may provide new therapeutic targets and possibilities for PNH patients.
Collapse
Affiliation(s)
- Yingying Chen
- Department of Hematology, Tianjin Medical University General Hospital, Tianjin, China
| | - Hui Liu
- Department of Hematology, Tianjin Medical University General Hospital, Tianjin, China
| | - Lijie Zeng
- Department of Hematology, Tianjin Medical University General Hospital, Tianjin, China
| | - Liyan Li
- Department of Hematology, Tianjin Medical University General Hospital, Tianjin, China
| | - Dan Lu
- Department of Hematology, Tianjin Medical University General Hospital, Tianjin, China
| | - Zhaoyun Liu
- Department of Hematology, Tianjin Medical University General Hospital, Tianjin, China
| | - Rong Fu
- Department of Hematology, Tianjin Medical University General Hospital, Tianjin, China
| |
Collapse
|
12
|
Visconte V, Maciejewski JP. Clonal dynamics of hematopoietic stem cell compartment in aplastic anemia. Semin Hematol 2022; 59:47-53. [DOI: 10.1053/j.seminhematol.2021.12.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2021] [Revised: 12/27/2021] [Accepted: 12/30/2021] [Indexed: 11/11/2022]
|
13
|
Votavova H, Belickova M. Hypoplastic myelodysplastic syndrome and acquired aplastic anemia: Immune‑mediated bone marrow failure syndromes (Review). Int J Oncol 2021; 60:7. [PMID: 34958107 PMCID: PMC8727136 DOI: 10.3892/ijo.2021.5297] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2021] [Accepted: 12/01/2021] [Indexed: 11/06/2022] Open
Abstract
Hypoplastic myelodysplastic syndrome (hMDS) and aplastic anemia (AA) are rare hematopoietic disorders characterized by pancytopenia with hypoplastic bone marrow (BM). hMDS and idiopathic AA share overlapping clinicopathological features, making a diagnosis very difficult. The differential diagnosis is mainly based on the presence of dysgranulopoiesis, dysmegakaryocytopoiesis, an increased percentage of blasts, and abnormal karyotype, all favouring the diagnosis of hMDS. An accurate diagnosis has important clinical implications, as the prognosis and treatment can be quite different for these diseases. Patients with hMDS have a greater risk of neoplastic progression, a shorter survival time and a lower response to immunosuppressive therapy compared with patients with AA. There is compelling evidence that these distinct clinical entities share a common pathophysiology based on the damage of hematopoietic stem and progenitor cells (HSPCs) by cytotoxic T cells. Expanded T cells overproduce proinflammatory cytokines (interferon-γ and tumor necrosis factor-α), resulting in decreased proliferation and increased apoptosis of HSPCs. The antigens that trigger this abnormal immune response are not known, but potential candidates have been suggested, including Wilms tumor protein 1 and human leukocyte antigen class I molecules. Our understanding of the molecular pathogenesis of these BM failure syndromes has been improved by next-generation sequencing, which has enabled the identification of a large spectrum of mutations. It has also brought new challenges, such as the interpretation of variants of uncertain significance and clonal hematopoiesis of indeterminate potential. The present review discusses the main clinicopathological differences between hMDS and acquired AA, focuses on the molecular background and highlights the importance of molecular testing.
Collapse
Affiliation(s)
- Hana Votavova
- Department of Genomics, Institute of Hematology and Blood Transfusion, Prague 128 00, Czech Republic
| | - Monika Belickova
- Department of Genomics, Institute of Hematology and Blood Transfusion, Prague 128 00, Czech Republic
| |
Collapse
|
14
|
Giannotta JA, Fattizzo B, Barcellini W. Paroxysmal Nocturnal Hemoglobinuria in the Context of a Myeloproliferative Neoplasm: A Case Report and Review of the Literature. Front Oncol 2021; 11:756589. [PMID: 34858830 PMCID: PMC8632248 DOI: 10.3389/fonc.2021.756589] [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: 08/10/2021] [Accepted: 10/15/2021] [Indexed: 11/13/2022] Open
Abstract
Paroxysmal nocturnal hemoglobinuria (PNH) is characterized by intravascular hemolytic anemia and thrombosis and is notoriously associated with aplastic anemia and myelodysplastic syndromes. Rarer associations include myeloproliferative neoplasms (MPNs), which are also burdened by increased thrombotic tendency. The therapeutic management of this rare combination has not been defined so far. Here, we describe a 62-year-old man who developed a highly hemolytic PNH more than 10 years after the diagnosis of MPN. The patient started eculizumab, obtaining good control of intravascular hemolysis but without amelioration of transfusion-dependent anemia. Moreover, we performed a review of the literature regarding the clinical and pathogenetic significance of the association of PNH and MPN. The prevalence of PNH clones in MPN patients is about 10%, mostly in association with JAK2V617F-positive myelofibrosis. Thrombotic events were a common clinical presentation (35% of subjects), sometimes refractory to combined treatment with cytoreductive agents, anticoagulants, and complement inhibitors. The latter showed only partial effectiveness in controlling hemolytic anemia and, due to the paucity of data, should be taken in consideration after a careful risk/benefit evaluation in this peculiar setting.
Collapse
Affiliation(s)
| | - Bruno Fattizzo
- Hematology Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy.,Department of Oncology and Oncohematology, University of Milan, Milan, Italy
| | - Wilma Barcellini
- Hematology Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| |
Collapse
|
15
|
Gurnari C, Pagliuca S, Kewan T, Bahaj W, Mori M, Patel BJ, Visconte V, Maciejewski JP. Is nature truly healing itself? Spontaneous remissions in Paroxysmal Nocturnal Hemoglobinuria. Blood Cancer J 2021; 11:187. [PMID: 34839350 PMCID: PMC8627504 DOI: 10.1038/s41408-021-00582-5] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2021] [Revised: 10/26/2021] [Accepted: 10/27/2021] [Indexed: 01/03/2023] Open
Affiliation(s)
- Carmelo Gurnari
- Department of Translational Hematology and Oncology Research, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH, USA.,Department of Biomedicine and Prevention, PhD in Immunology, Molecular Medicine and Applied Biotechnology, University of Rome Tor Vergata, Rome, Italy
| | - Simona Pagliuca
- Department of Translational Hematology and Oncology Research, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH, USA.,University of Paris, Paris, France
| | - Tariq Kewan
- Department of Translational Hematology and Oncology Research, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Waled Bahaj
- Department of Translational Hematology and Oncology Research, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Minako Mori
- Department of Translational Hematology and Oncology Research, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Bhumika J Patel
- Department of Translational Hematology and Oncology Research, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Valeria Visconte
- Department of Translational Hematology and Oncology Research, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Jaroslaw P Maciejewski
- Department of Translational Hematology and Oncology Research, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH, USA.
| |
Collapse
|
16
|
Lu J, Samuel S, Saed YA, Li R, Li Y. A case of postpartum AKI: recurrent atypical hemolytic uremic syndrome, HELLP syndrome or paroxysmal nocturnal hemoglobinuria? Lessons for the clinical nephrologist. J Nephrol 2021; 35:679-682. [PMID: 34743310 DOI: 10.1007/s40620-021-01168-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2020] [Accepted: 09/17/2021] [Indexed: 10/19/2022]
Affiliation(s)
- Jian Lu
- Department of Nephrology, The Fifth Hospital (Shanxi Provincial People's Hospital) of Shanxi Medical University, 29 Shuangta Road, Taiyuan, 030012, Shanxi, China
| | | | - Yasin Abdi Saed
- Department of Nephrology, The Fifth Hospital (Shanxi Provincial People's Hospital) of Shanxi Medical University, 29 Shuangta Road, Taiyuan, 030012, Shanxi, China
| | - Rongshan Li
- Department of Nephrology, The Fifth Hospital (Shanxi Provincial People's Hospital) of Shanxi Medical University, 29 Shuangta Road, Taiyuan, 030012, Shanxi, China
| | - Yafeng Li
- Department of Nephrology, The Fifth Hospital (Shanxi Provincial People's Hospital) of Shanxi Medical University, 29 Shuangta Road, Taiyuan, 030012, Shanxi, China.
| |
Collapse
|
17
|
Coexistence of Primary Myelofibrosis and Paroxysmal Nocturnal Hemoglobinuria Clone with JAK2 V617F, U2AF1 and SETBP1 Mutations: A Case Report and Brief Review of Literature. Diagnostics (Basel) 2021; 11:diagnostics11091644. [PMID: 34573985 PMCID: PMC8466901 DOI: 10.3390/diagnostics11091644] [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: 08/17/2021] [Revised: 09/07/2021] [Accepted: 09/07/2021] [Indexed: 11/17/2022] Open
Abstract
Primary myelofibrosis (PMF) and paroxysmal nocturnal hemoglobinuria (PNH) are very rare diseases, respectively, and it is uncommon to have both diseases together. Mutational profiling using next-generation sequencing in PMF and PNH detected additional mutations associated with myeloid neoplasms, suggesting a step-wise clonal evolution. We present here a very rare case with PMF and PNH with JAK2 V617F, U2AF1 and SETBP1 mutations at the time of diagnosis. The combination of these two diseases and three genetic mutations is difficult to interpret at once. (i.e., the sequence of these two clonal diseases or the time points of acquiring these mutations). Our report suggests that when diagnosing or treating patients with PMF, it is necessary to keep in mind that PNH may be present at the same time or sometimes new. The genetic mutations simultaneously found in this patient require further research to elucidate the clinical significance and their genetic associations fully.
Collapse
|
18
|
The predictive value of PNH clones, 6p CN-LOH, and clonal TCR gene rearrangement for aplastic anemia diagnosis. Blood Adv 2021; 5:3216-3226. [PMID: 34427585 DOI: 10.1182/bloodadvances.2021004201] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2021] [Accepted: 05/12/2021] [Indexed: 12/29/2022] Open
Abstract
Acquired aplastic anemia (AA) is a life-threatening bone marrow aplasia caused by the autoimmune destruction of hematopoietic stem and progenitor cells. There are no existing diagnostic tests that definitively establish AA, and diagnosis is currently made via systematic exclusion of various alternative etiologies, including inherited bone marrow failure syndromes (IBMFSs). The exclusion of IBMFSs, which requires syndrome-specific functional and genetic testing, can substantially delay treatment. AA and IBMFSs can have mimicking clinical presentations, and their distinction has significant implications for treatment and family planning, making accurate and prompt diagnosis imperative to optimal patient outcomes. We hypothesized that AA could be distinguished from IBMFSs using 3 laboratory findings specific to the autoimmune pathogenesis of AA: paroxysmal nocturnal hemoglobinuria (PNH) clones, copy-number-neutral loss of heterozygosity in chromosome arm 6p (6p CN-LOH), and clonal T-cell receptor (TCR) γ gene (TRG) rearrangement. To test our hypothesis, we determined the prevalence of PNH, acquired 6p CN-LOH, and clonal TRG rearrangement in 454 consecutive pediatric and adult patients diagnosed with AA, IBMFSs, and other hematologic diseases. Our results indicated that PNH and acquired 6p CN-LOH clones encompassing HLA genes have ∽100% positive predictive value for AA, and they can facilitate diagnosis in approximately one-half of AA patients. In contrast, clonal TRG rearrangement is not specific for AA. Our analysis demonstrates that PNH and 6p CN-LOH clones effectively distinguish AA from IBMFSs, and both measures should be incorporated early in the diagnostic evaluation of suspected AA using the included Bayesian nomogram to inform clinical application.
Collapse
|
19
|
Pasca S, Gondek LP. Clonal hematopoiesis and bone marrow failure syndromes. Best Pract Res Clin Haematol 2021; 34:101273. [PMID: 34404525 DOI: 10.1016/j.beha.2021.101273] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2021] [Accepted: 05/11/2021] [Indexed: 12/11/2022]
Abstract
Bone marrow failure syndromes (BMF) are a group of conditions characterized by inefficient hematopoiesis frequently associated with extra-hematopoietic phenotypes and variable risk of progression to myeloid malignancies. They can be acquired or inherited and mediated by either cell extrinsic factors or cell intrinsic impairment of hematopoietic stem cell (HSC) function. The pathophysiology includes immune-mediated attack (e.g., acquired BMFs) or germline defects in DNA damage repair machinery, telomeres maintenance or ribosomes biogenesis. (e.g., inherited BMF). Clonal hematopoiesis (CH) that frequently accompanies BMF may provide a mechanism of improved HSC fitness through the evasion of extracellular pressure or somatic reversion of germline defects. The mechanism for the CH selective advantage differs depending on the condition in which it occurs. However, this adaptation mechanism, particularly when involving putative oncogenes or tumor suppressors, may lead to increased risk of myeloid malignancies. Surveillance and early detection of leukemogenic clones may lead to timely implementation of curative therapies and improved survival.
Collapse
Affiliation(s)
- Sergiu Pasca
- Department of Oncology, Division of Hematological Malignancies, Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University, Baltimore, MD, USA
| | - Lukasz P Gondek
- Department of Oncology, Division of Hematological Malignancies, Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University, Baltimore, MD, USA.
| |
Collapse
|
20
|
Chen Y, Rong F. Advances in the creation of animal models of paroxysmal nocturnal hemoglobinuria. ACTA ACUST UNITED AC 2021; 26:491-496. [PMID: 34238137 DOI: 10.1080/16078454.2021.1945244] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Paroxysmal nocturnal hemoglobinuria (PNH) is a disease caused by a phosphatidylinositol glycan anchor biosynthesis class A (PIG-A) mutation in hematopoietic stem cells. There are three theories about the possible mechanism of the pathogenesis of PNH: immune escape, anti-apoptotic mechanism, and secondary gene mutation. There has been little gain in the knowledge regarding its pathogenesis during the last decade owing to the lack of representative cell lines and animal models. There have been recent reports about the successful creation of PNH mouse and PNH rhesus macaque models. The detection of glycosylphosphatidylinositol-anchor protein (GPI-AP)-deficient cells and/or fluorescently labeled variant of aerolysin (FLAER) test, estimation of erythrocyte life span, and hemolysis-related experiments demonstrated that these animal models of PNH had GPI-AP-deficient blood cells with shortened lifespans and increased sensitivity to complement-activated hemolysis. However, there were no clinical manifestations such as hemolysis and thrombosis in these animal models. This suggested that the PIG-A mutation is one of the several conditions required for PNH, but it alone is not enough to cause PNH.
Collapse
Affiliation(s)
- Yingying Chen
- Department of Hematology, Tianjin Medical University General Hospital, Tianjin, People's Republic of China
| | - Fu Rong
- Department of Hematology, Tianjin Medical University General Hospital, Tianjin, People's Republic of China
| |
Collapse
|
21
|
Doll H, Coşkun U, Hartford C, Tomazos I. Concept confirmation of the Treatment Administration Satisfaction Questionnaire (TASQ) in rare paroxysmal nocturnal hemoglobinuria. J Patient Rep Outcomes 2021; 5:45. [PMID: 34152498 PMCID: PMC8217362 DOI: 10.1186/s41687-021-00319-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2020] [Accepted: 05/12/2021] [Indexed: 11/16/2022] Open
Abstract
Background This study was conducted to evaluate content validity of the IntraVenous and SubCutaneous Treatment Administration Satisfaction Questionnaires (TASQ-IV and TASQ-SC), for use in a clinical trial population of participants with paroxysmal nocturnal hemoglobinuria (PNH) undergoing eculizumab treatment. Methods Participants underwent semi-structured combined brief introduction to disease history and full cognitive debriefing interviews to establish symptoms and key impacts of PNH and to explore the clarity and relevance of both sets of instructions (TASQ-IV and TASQ-SC). The clarity, relevance, response options, and recall period of the TASQ-IV items were also explored. Results Ten participants with PNH were recruited. Fatigue was the most commonly reported symptom (n = 7); the most commonly reported impact of PNH was on physical activity (n = 4). Nine participants indicated understanding and relevance of the TASQ-IV instructions; three participants suggested changes. Of the 20 TASQ-IV items, ≥ 15 were considered understandable, relevant and to have suitable response options (n ≥ 8). The TASQ-SC instructions were understood by all participants; seven participants indicated relevance. While a few participants suggested minor changes for the items, these reflected the one-off completion of the measure in an interview setting and were thus not considered sufficient to justify modification of the measure for clinical trial completion. Conclusions Most participants understood the TASQ-IV and TASQ-SC instructions (n = 9 and 10, respectively) and the TASQ-IV items were considered clear, relevant and to have suitable response options, demonstrating face and content validity of the instruments for the clinical trial setting. Supplementary Information The online version contains supplementary material available at 10.1186/s41687-021-00319-9.
Collapse
Affiliation(s)
- Helen Doll
- Clinical Outcomes Solutions Ltd, Basepoint, Shearway Road, Shearway Business Park, Folkestone, Kent, CT19 4RH, UK
| | - Ufuk Coşkun
- Clinical Outcomes Solutions Ltd, 1820 E. River Rd, Suite 220, Tucson, AZ, 85718, USA
| | - Chris Hartford
- Clinical Outcomes Solutions Ltd, 1820 E. River Rd, Suite 220, Tucson, AZ, 85718, USA
| | - Ioannis Tomazos
- Alexion Pharmaceuticals Inc., 121 Seaport Blvd, Boston, MA, 02210, USA.
| |
Collapse
|
22
|
Jeong D, Park HS, Kim SM, Im K, Yun J, Lee YE, Ryu S, Ahn YO, Yoon SS, Lee DS. Ultradeep Sequencing Analysis of Paroxysmal Nocturnal Hemoglobinuria Clones Detected by Flow Cytometry: PIG Mutation in Small PNH Clones. Am J Clin Pathol 2021; 156:72-85. [PMID: 33347536 DOI: 10.1093/ajcp/aqaa211] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVES We aimed to determine whether small paroxysmal nocturnal hemoglobinuria (PNH) clones detected by flow cytometry (FCM) harbor PIG gene mutations with quantitative correlation. METHODS We analyzed 89 specimens from 63 patients whose PNH clone size was ≥0.1% by FCM. We performed ultradeep sequencing for the PIGA, PIGM, PIGT, and PIGX genes in these specimens. RESULTS A strong positive correlation between PNH clone size by FCM and variant allele frequency (VAF) of PIG gene mutation was identified (RBCs: r = 0.77, P < .001; granulocytes: r = 0.68, P < .001). Granulocyte clone size of 2.5% or greater and RBCs 0.4% or greater by FCM always harbored PIG gene mutations. Meanwhile, in patients with clone sizes of less than 2.5% in granulocytes or less than 0.4% in RBCs, PIG gene mutations were present in only 15.9% and 12.2% of cases, respectively. In addition, there was not a statistically significant positive correlation between FCM clone size and VAF or the presence or absence of a PIG mutation. CONCLUSIONS Our results showed that in small PNH clones PIG gene mutations were present in only a small portion without significant correlation to VAF or the presence or absence of a PIG mutation.
Collapse
Affiliation(s)
- Dajeong Jeong
- Department of Laboratory Medicine, Seoul National University Hospital, Seoul, Korea
| | - Hee Sue Park
- Department of Laboratory Medicine, Chungbuk National University Hospital, Cheongju, Korea
| | - Sung-Min Kim
- Cancer Research Institute, Seoul National University College of Medicine, Seoul, Korea
| | - Kyongok Im
- Cancer Research Institute, Seoul National University College of Medicine, Seoul, Korea
| | - Jiwon Yun
- Department of Laboratory Medicine, Seoul National University Hospital, Seoul, Korea
| | - Young Eun Lee
- Department of Laboratory Medicine, Seoul National University Hospital, Seoul, Korea
| | - Sohee Ryu
- Department of Laboratory Medicine, Seoul National University Hospital, Seoul, Korea
| | - Yong-Oon Ahn
- Cancer Research Institute, Seoul National University College of Medicine, Seoul, Korea
| | - Sung-Soo Yoon
- Cancer Research Institute, Seoul National University College of Medicine, Seoul, Korea
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea
| | - Dong Soon Lee
- Department of Laboratory Medicine, Seoul National University Hospital, Seoul, Korea
- Cancer Research Institute, Seoul National University College of Medicine, Seoul, Korea
| |
Collapse
|
23
|
Hematopoietic stem progenitor cells lacking HLA differ from those lacking GPI-anchored proteins in the hierarchical stage and sensitivity to immune attack in patients with acquired aplastic anemia. Leukemia 2021; 35:3257-3267. [PMID: 33824463 DOI: 10.1038/s41375-021-01202-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2020] [Revised: 01/27/2021] [Accepted: 02/18/2021] [Indexed: 12/21/2022]
Abstract
To characterize glycosylphosphatidylinositol-anchored protein-deficient (GPI[-]) and HLA-class I allele-lacking (HLA[-]) hematopoietic stem progenitor cells (HSPCs) in acquired aplastic anemia (AA), we studied the peripheral blood (PB) of 56 AA patients in remission who possessed both (n = 13, Group A) or either GPI(-) (n = 34, Group B) and HLA(-) (n = 9, Group C) cell populations. Seventy-seven percent (10/13) of Group A had HLA(-) cells in all lineages of PB cells, including platelets, while only 23% (3/13) had GPI(-) cells in all lineages, and the median percentage of HLA(-) granulocytes in the total granulocytes (21.2%) was significantly higher than that of GPI(-) granulocytes (0.28%, P < 0.05). The greater lineage diversity in HLA(-) cells than in GPI(-) cells was also seen when Group B and Group C were compared. Longitudinal studies of seven patients in Group A showed a gradual decrease in the percentage of HLA(-) granulocytes, with a reciprocal increase in the GPI(-) granulocytes in four patients responding to cyclosporine (CsA) and an increase in the HLA(-) granulocytes with a stable or declining GPI(-) granulocytes in three patients in sustained remission off CsA therapy. These findings suggest that HLA(-) HSPCs differ from GPI(-) HSPCs in the hierarchical stage and sensitivity to immune attack in AA.
Collapse
|
24
|
Chen F, Hu S, Ruan J, Chen M, Han B. Mutational landscape and its clinical significance in paroxysmal nocturnal hemoglobinuria. Blood Cancer J 2021; 11:58. [PMID: 33727526 PMCID: PMC7966366 DOI: 10.1038/s41408-021-00451-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2020] [Revised: 02/14/2021] [Accepted: 02/18/2021] [Indexed: 02/07/2023] Open
Affiliation(s)
- Fangfei Chen
- Department of Hematology, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China.,Division of Gastroenterology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Shimin Hu
- Department of Hematopathology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Jing Ruan
- Department of Hematology, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China
| | - Miao Chen
- Department of Hematology, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China
| | - Bing Han
- Department of Hematology, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China.
| |
Collapse
|
25
|
Brodsky RA. How I treat paroxysmal nocturnal hemoglobinuria. Blood 2021; 137:1304-1309. [PMID: 33512400 PMCID: PMC7955407 DOI: 10.1182/blood.2019003812] [Citation(s) in RCA: 67] [Impact Index Per Article: 22.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2020] [Accepted: 08/28/2020] [Indexed: 01/06/2023] Open
Abstract
Paroxysmal nocturnal hemoglobinuria (PNH) is a rare, clonal, complement-mediated hemolytic anemia with protean manifestations. PNH can present as a hemolytic anemia, a form of bone marrow failure, a thrombophilia, or any combination of the above. Terminal complement inhibition is highly effective for treating intravascular hemolysis from PNH and virtually eliminates the risk of thrombosis, but is not effective for treating bone marrow failure. Here, I present a variety of clinical vignettes that highlight the clinical heterogeneity of PNH and the attributes and limitations of the 2 US Food and Drug Administration-approved C5 inhibitors (eculizumab and ravulizumab) to treat PNH. I review the concept of pharmacokinetic and pharmacodynamic breakthrough hemolysis and briefly discuss new complement inhibitors upstream of C5 that are in clinical development. Last, I discuss the rare indications for bone marrow transplantation in patients with PNH.
Collapse
|
26
|
Chatzidavid S, Giannakopoulou N, Diamantopoulos PT, Gavriilaki E, Katsiampoura P, Lakiotaki E, Sakellariou S, Viniou NA, Dryllis G. JAK2V617F positive polycythemia vera with paroxysmal nocturnal hemoglobinuria and visceral thromboses: a case report and review of the literature. Thromb J 2021; 19:16. [PMID: 33691713 PMCID: PMC7945360 DOI: 10.1186/s12959-021-00269-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2020] [Accepted: 03/02/2021] [Indexed: 12/13/2022] Open
Abstract
Background Polycythemia vera (PV) is characterized by red cell mass expansion in the peripheral blood and can be complicated with thrombosis, bleeding, evolution to acute myeloid leukemia (AML) or a fibrotic phase. Paroxysmal nocturnal hemoglobinuria (PNH) in an acquired clonal haematopoietic stem cell disorder associated with chronic intravascular hemolysis, venous thrombosis, defective hematopoiesis, frequent episodes of infection and, rarely, leukemic transformation. Herein, we report an interesting case of a patient with coexistence of PNH clones and a JAK2V617F positive PV, with unusual thromboses without hemolysis. Case presentation A 51-year-old woman presented with increased levels of hematocrit, multiple liver, spleen, and left kidney infarctions and ascites; further investigation revealed a JAK2V617F-positive polycythemia vera and the presence of a significant PNH population (more than 90% CD55– CD59– cells among both granulocytes and red blood cells). Interestingly, the patient has experienced severe thrombotic events without any signs or symptoms of hemolysis. Conclusions This case raises questions over uncharted aspects of the PNH etiopathogenesis and its potential association with myeloproliferative neoplasms (MPN) and highlights the difficulty of diagnosing and managing patients with more than one potentially thrombophilic conditions, especially with established and severe thromboses.
Collapse
Affiliation(s)
- Sevastianos Chatzidavid
- Hematology Unit, First Department of Internal Medicine, Laikon General Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Nefeli Giannakopoulou
- Hematology Unit, First Department of Internal Medicine, Laikon General Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Panagiotis Theodorou Diamantopoulos
- Hematology Unit, First Department of Internal Medicine, Laikon General Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Eleni Gavriilaki
- Hematology Department - Bone Marrow Transplant Unit, George Papanicolaou Hospital, Thessaloniki, Greece
| | - Panagiota Katsiampoura
- Hematology Unit, First Department of Internal Medicine, Laikon General Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Eleftheria Lakiotaki
- First Department of Pathology, Laikon General Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Stratigoula Sakellariou
- First Department of Pathology, Laikon General Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Nora-Athina Viniou
- Hematology Unit, First Department of Internal Medicine, Laikon General Hospital, National and Kapodistrian University of Athens, Athens, Greece.
| | - Georgios Dryllis
- Hematology Unit, First Department of Internal Medicine, Laikon General Hospital, National and Kapodistrian University of Athens, Athens, Greece
| |
Collapse
|
27
|
Hammond D, Loghavi S. Clonal haematopoiesis of emerging significance. Pathology 2021; 53:300-311. [PMID: 33685721 DOI: 10.1016/j.pathol.2021.02.005] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2020] [Revised: 02/09/2021] [Accepted: 02/09/2021] [Indexed: 12/17/2022]
Abstract
Clonal haematopoiesis (CH) is a ubiquitous feature of aging and provides mechanistic insight into the inextricable relationship between chronic inflammation and age-related diseases. Although CH confers a cumulative risk of subsequent haematological malignancy, particularly myeloid neoplasms, that risk is heavily mutation- and context-specific. Individuals with mutations in DNA damage response pathway genes receiving select cytotoxic therapies for solid tumours are among the highest risk groups for subsequent development of myeloid neoplasms. Multiple lines of evidence suggest that TET2-mutated macrophages causally contribute to cardiometabolic disease through the generation of proinflammatory cytokines. It is speculated that such CH-related inflammation is a shared driver of several other chronic diseases. Whether we can intervene in individuals with CH to diminish the risk of subsequent haematological malignancy or non-haematological disease remains to be seen. However, precision anti-cytokine therapies are a rational starting point to break the feedforward loop between clonal myeloid expansion, inflammation, and end-organ damage.
Collapse
Affiliation(s)
- Danielle Hammond
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Sanam Loghavi
- Department of Hematopathology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA.
| |
Collapse
|
28
|
Secondary myelodysplastic syndrome and leukemia in acquired aplastic anemia and paroxysmal nocturnal hemoglobinuria. Blood 2021; 136:36-49. [PMID: 32430502 DOI: 10.1182/blood.2019000940] [Citation(s) in RCA: 47] [Impact Index Per Article: 15.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2019] [Accepted: 11/09/2019] [Indexed: 02/06/2023] Open
Abstract
Acquired aplastic anemia (AA) and paroxysmal nocturnal hemoglobinuria (PNH) are pathogenically related nonmalignant bone marrow failure disorders linked to T-cell-mediated autoimmunity; they are associated with an increased risk of secondary myelodysplastic syndrome (MDS) and acute myeloid leukemia (AML). Approximately 15% to 20% of AA patients and 2% to 6% of PNH patients go on to develop secondary MDS/AML by 10 years of follow-up. Factors determining an individual patient's risk of malignant transformation remain poorly defined. Recent studies identified nearly ubiquitous clonal hematopoiesis (CH) in AA patients. Similarly, CH with additional, non-PIGA, somatic alterations occurs in the majority of patients with PNH. Factors associated with progression to secondary MDS/AML include longer duration of disease, increased telomere attrition, presence of adverse prognostic mutations, and multiple mutations, particularly when occurring early in the disease course and at a high allelic burden. Here, we will review the prevalence and characteristics of somatic alterations in AA and PNH and will explore their prognostic significance and mechanisms of clonal selection. We will then discuss the available data on post-AA and post-PNH progression to secondary MDS/AML and provide practical guidance for approaching patients with PNH and AA who have CH.
Collapse
|
29
|
Blombery P, Fox L, Ryland GL, Thompson ER, Lickiss J, McBean M, Yerneni S, Hughes D, Greenway A, Mechinaud F, Wood EM, Lieschke GJ, Szer J, Barbaro P, Roy J, Wight J, Lynch E, Martyn M, Gaff C, Ritchie D. Utility of clinical comprehensive genomic characterization for diagnostic categorization in patients presenting with hypocellular bone marrow failure syndromes. Haematologica 2021; 106:64-73. [PMID: 32054657 PMCID: PMC7776333 DOI: 10.3324/haematol.2019.237693] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2019] [Accepted: 02/07/2020] [Indexed: 12/26/2022] Open
Abstract
Bone marrow failure (BMF) related to hypoplasia of hematopoietic elements in the bone marrow is a heterogeneous clinical entity with a broad differential diagnosis including both inherited and acquired causes. Accurate diagnostic categorization is critical to optimal patient care and detection of genomic variants in these patients may provide this important diagnostic and prognostic information. We performed real-time, accredited (ISO15189) comprehensive genomic characterization including targeted sequencing and whole exome sequencing in 115 patients with BMF syndromes (median age 24 years, range: 3 months - 81 years). In patients with clinical diagnoses of inherited BMF syndromes, acquired BMF syndromes or clinically unclassifiable BMF we detected variants in 52% (12 of 23), 53% (25 of 47) and 56% (25 of 45) respectively. Genomic characterization resulted in a change of diagnosis in 30 of 115 (26%) including the identification of germline causes for 3 of 47 and 16 of 45 cases with pre-test diagnoses of acquired and clinically unclassifiable BMF respectively. The observed clinical impact of accurate diagnostic categorization included choice to perform allogeneic stem cell transplantation, disease-specific targeted treatments, identification of at-risk family members and influence of sibling allogeneic stem cell donor choice. Multiple novel pathogenic variants and copy number changes were identified in our cohort including in TERT, FANCA, RPS7 and SAMD9. Whole exome sequence analysis facilitated the identification of variants in two genes not typically associated with a primary clinical manifestation of BMF but also demonstrated reduced sensitivity for detecting low level acquired variants. In conclusion, genomic characterization can improve diagnostic categorization of patients presenting with hypoplastic BMF syndromes and should be routinely performed in this group of patients.
Collapse
Affiliation(s)
- Piers Blombery
- Clinical Haematology, Peter MacCallum Cancer Centre, Melbourne, Australia
| | - Lucy Fox
- Clinical Haematology, Peter MacCallum Cancer Centre, Melbourne, Australia
| | - Georgina L Ryland
- Department of Pathology, Peter MacCallum Cancer Centre, Melbourne, Australia
| | - Ella R Thompson
- University of Melbourne, Peter MacCallum Cancer Centre, Melbourne, Australia
| | - Jennifer Lickiss
- Department of Pathology, Peter MacCallum Cancer Centre, Melbourne, Australia
| | - Michelle McBean
- Department of Pathology, Peter MacCallum Cancer Centre, Melbourne, Australia
| | - Satwica Yerneni
- Department of Pathology, Peter MacCallum Cancer Centre, Melbourne, Australia
| | | | | | | | - Erica M Wood
- Transfusion Research Unit, Monash University, Melbourne
| | - Graham J Lieschke
- Clinical Haematology, Peter MacCallum Cancer Centre/Royal Melbourne Hospital, Melbourne
| | - Jeff Szer
- Clinical Haematology, Peter MacCallum Cancer Centre/Royal Melbourne Hospital, Melbourne
| | - Pasquale Barbaro
- Children Health Queensland and University of Queensland, South Brisbane, QLD
| | - John Roy
- Children Health Queensland and University of Queensland, South Brisbane, QLD
| | - Joel Wight
- Department of Hematology, Austin Health, Melbourne
| | - Elly Lynch
- Melbourne Genomics Health Alliance, Parkville VIC, Australia
| | | | - Clara Gaff
- Melbourne Genomics Health Alliance, Parkville VIC, Australia
| | - David Ritchie
- Clinical Haematology, Peter MacCallum Cancer Centre/Royal Melbourne Hospital, Melbourne, Australia
| |
Collapse
|
30
|
Ishida F, Nakazawa H. T(o) be, or (not) to B, or both? Somatically mutated clonal T cells in common variable immunodeficiency and related immunodeficiencies. Haematologica 2020; 105:2702-2703. [PMID: 33256369 PMCID: PMC7716270 DOI: 10.3324/haematol.2020.261982] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Affiliation(s)
- Fumihiro Ishida
- Academic Assembly School of Medicine and Health Sciences, Institute of Health Science and School of Medicine and Department of Biomedical Laboratory Sciences, Shinshu University.
| | - Hideyuki Nakazawa
- Division of Hematology, Department of Internal Medicine, Shinshu University School of Medicine, Matsumoto, Japan
| |
Collapse
|
31
|
Paroxysmal nocturnal hemoglobinuria caused by CN-LOH of constitutional PIGB mutation and 70-kbp microdeletion on 15q. Blood Adv 2020; 4:5755-5761. [PMID: 33216889 DOI: 10.1182/bloodadvances.2020002210] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2020] [Accepted: 10/20/2020] [Indexed: 12/31/2022] Open
Abstract
Paroxysmal nocturnal hemoglobinuria (PNH) is a rare hematopoietic stem cell (HSC) disorder characterized by defective synthesis of the glycosylphosphatidylinositol (GPI) anchors as a result of somatic mutations in the X-linked PIGA gene. The disease is acquired. No constitutional PNH has been described. Here, we report familial PNH associated with unusual inflammatory symptoms. Genetic analysis revealed a germline heterozygous PIGB mutation on chromosome 15 without mutations in PIGA or any of the other genes involved in GPI biosynthesis. In vitro data confirmed that transfection of the mutant PIGB could not restore the surface expression of GPI-anchored proteins (APs) in PIGB-deficient Chinese hamster ovary cells. Homozygosity was caused by copy number-neutral loss of heterozygosity (CN-LOH) of the germline PIGB mutation, leading to deficient expression of GPI-APs in the affected blood cells of the index patient and her mother. The somatic event leading to homozygosity of the germline mutant PIGB gene involved a 70-kbp microdeletion of chromosome 15q containing the TM2D3 and TARSL2 genes, which was implicated in chromosome 15q mosaicism. Interestingly, we detected the deletion in both the patient and her mother. A sister of the mother, who carried the same germline PIGB mutation but without this microdeletion involving TM2D3 and TARSL2, did not have a PNH clone or CN-LOH. In conclusion, we describe PNH caused by CN-LOH of a germline heterozygous PIGB mutation in a patient and her mother and hypothesize that the 70-kbp microdeletion may have contributed to the PNH clone in both.
Collapse
|
32
|
Vyrides N, Douka V, Gavriilaki E, Papaioannou G, Athanasiadou A, Neofytou S, Vyrides Y, Lalayanni C, Anagnostopoulos A, Kokoris SI. Paroxysmal nocturnal hemoglobinuria and myelodysplastic syndrome: Disappearance of cytogenetic abnormalities. Cancer Genet 2020; 250-251:1-5. [PMID: 33188967 DOI: 10.1016/j.cancergen.2020.11.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2020] [Revised: 09/18/2020] [Accepted: 11/02/2020] [Indexed: 11/16/2022]
Abstract
Paroxysmal nocturnal hemoglobinuria (PNH) is a rare life-threatening disease resulting from clonal hematopoietic stem cell evolution. There is a strong link between PNH and other acquired bone marrow failure syndromes, including myelodysplastic syndrome (MDS). Cytogenetic, morphological abnormalities or both are observed in the range of MDS/PNH diagnosis. Herein, we investigate cytogenetic abnormalities in PNH patients. We found two patients with PNH clones and MDS-associated abnormalities that later disappeared. The first patient, originally diagnosed with MDS and Trisomy 6, developed a large PNH clone. At the time of PNH diagnosis, the abnormal cytogenetic clone was no longer detectable despite persistent trilineage dysplasia. In the second patient, a large PNH clone and MDS-defining abnormality were detected at diagnosis, without evidence of dysplasia. No cytogenetic abnormalities were evident after complement inhibition. Our report adds significant information on the complex link between MDS and PNH, suggesting that distinction between these entities may be difficult in some cases. Especially in transplant eligible patients, the clinical phenotype may be the leading feature for treatment decisions in the era of complement inhibition. Lastly, the transient presence of cytogenetic abnormalities is a unique characteristic of our patients' course that needs to be further elucidated in larger studies.
Collapse
Affiliation(s)
- Niki Vyrides
- Haematology Department, Vyrides Clinic, Nicosia, Cyprus; University of Nicosia Medical School, Nicosia, Cyprus.
| | - Vassiliki Douka
- Hematology Department-BMT Unit, G. Papanicolaou Hospital, Thessaloniki; Greece
| | - Eleni Gavriilaki
- Hematology Department-BMT Unit, G. Papanicolaou Hospital, Thessaloniki; Greece
| | | | | | - Sofia Neofytou
- Cytogenetic Department, Archbishop Makarios III Hospital - Nicosia, Cyprus
| | - Yiannis Vyrides
- Great Western Hospitals NHS Foundation Trust, Swindon, United Kingdom
| | - Chrysavgi Lalayanni
- Hematology Department-BMT Unit, G. Papanicolaou Hospital, Thessaloniki; Greece
| | | | - Styliani I Kokoris
- Laboratory of Hematology and Hospital Blood Transfusion Department, University General Hospital "Attikon", National and Kapodistrian University of Athens, Medical School, Greece
| |
Collapse
|
33
|
Skibenes ST, Clausen I, Raaschou-Jensen K. Next-generation sequencing in hypoplastic bone marrow failure: What difference does it make? Eur J Haematol 2020; 106:3-13. [PMID: 32888355 DOI: 10.1111/ejh.13513] [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: 05/02/2020] [Revised: 08/25/2020] [Accepted: 08/26/2020] [Indexed: 12/16/2022]
Abstract
Hypoplastic bone marrow failure is a diagnostic feature of multiple haematological disorders, which also share a substantial overlap of clinical symptoms. Hence, discrimination of underlying disorders in patients presenting with hypoplastic bone marrow failure remains a major challenge in the clinic. Recent next-generation sequencing (NGS) studies have broadened our understanding of the varying molecular mechanisms and advanced diagnostics of disorders exhibiting hypoplastic bone marrow failure. In this article, we present a literature review of NGS studies of haematological disorders associated with hypoplastic bone marrow failure and highlight the relevance of NGS for improved clinical diagnostics and decision-making.
Collapse
Affiliation(s)
- Sofie T Skibenes
- Department of Hematology, Odense University Hospital, Odense, Denmark
| | - Ida Clausen
- Department of Hematology, Odense University Hospital, Odense, Denmark
| | | |
Collapse
|
34
|
Höchsmann B, Murakami Y, Osato M, Knaus A, Kawamoto M, Inoue N, Hirata T, Murata S, Anliker M, Eggermann T, Jäger M, Floettmann R, Höllein A, Murase S, Ueda Y, Nishimura JI, Kanakura Y, Kohara N, Schrezenmeier H, Krawitz PM, Kinoshita T. Complement and inflammasome overactivation mediates paroxysmal nocturnal hemoglobinuria with autoinflammation. J Clin Invest 2020; 129:5123-5136. [PMID: 31430258 DOI: 10.1172/jci123501] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2018] [Accepted: 08/16/2019] [Indexed: 12/16/2022] Open
Abstract
Patients with paroxysmal nocturnal hemoglobinuria (PNH) have a clonal population of blood cells deficient in glycosylphosphatidylinositol-anchored (GPI-anchored) proteins, resulting from a mutation in the X-linked gene PIGA. Here we report on a set of patients in whom PNH results instead from biallelic mutation of PIGT on chromosome 20. These PIGT-PNH patients have clinically typical PNH, but they have in addition prominent autoinflammatory features, including recurrent attacks of aseptic meningitis. In all these patients we find a germ-line point mutation in one PIGT allele, whereas the other PIGT allele is removed by somatic deletion of a 20q region comprising maternally imprinted genes implicated in myeloproliferative syndromes. Unlike in PIGA-PNH cells, GPI is synthesized in PIGT-PNH cells and, since its attachment to proteins is blocked, free GPI is expressed on the cell surface. From studies of patients' leukocytes and of PIGT-KO THP-1 cells we show that, through increased IL-1β secretion, activation of the lectin pathway of complement and generation of C5b-9 complexes, free GPI is the agent of autoinflammation. Eculizumab treatment abrogates not only intravascular hemolysis, but also autoinflammation. Thus, PIGT-PNH differs from PIGA-PNH both in the mechanism of clonal expansion and in clinical manifestations.
Collapse
Affiliation(s)
- Britta Höchsmann
- Institute of Transfusion Medicine, University of Ulm, Ulm, Germany.,Institute of Clinical Transfusion Medicine and Immunogenetics, German Red Cross Blood Transfusion Service and University Hospital Ulm, Ulm, Germany
| | - Yoshiko Murakami
- Research Institute for Microbial Diseases and.,WPI Immunology Frontier Research Center, Osaka University, Osaka, Japan
| | - Makiko Osato
- Research Institute for Microbial Diseases and.,Department of Hematology and Oncology, Graduate School of Medicine, Osaka University, Osaka, Japan
| | - Alexej Knaus
- Institute for Genomic Statistics and Bioinformatics, Rheinische Friedrich-Wilhelms-Universität Bonn, Bonn, Germany
| | - Michi Kawamoto
- Department of Neurology, Kobe City Medical Center General Hospital, Kobe, Japan
| | - Norimitsu Inoue
- Department of Tumor Immunology, Osaka International Cancer Institute, Osaka, Japan
| | | | - Shogo Murata
- Research Institute for Microbial Diseases and.,Department of Hematology/Oncology, Wakayama Medical University, Wakayama, Japan
| | - Markus Anliker
- Institute of Transfusion Medicine, University of Ulm, Ulm, Germany
| | - Thomas Eggermann
- Institute for Human Genetics,Medical Faculty, RWTH University Aachen, Aachen, Germany
| | - Marten Jäger
- Department of Medical Genetics, Charite Hospital, University of Berlin, Berlin, Germany
| | - Ricarda Floettmann
- Department of Medical Genetics, Charite Hospital, University of Berlin, Berlin, Germany
| | | | - Sho Murase
- Department of Neurology, Kobe City Medical Center General Hospital, Kobe, Japan
| | - Yasutaka Ueda
- Department of Hematology and Oncology, Graduate School of Medicine, Osaka University, Osaka, Japan
| | - Jun-Ichi Nishimura
- Department of Hematology and Oncology, Graduate School of Medicine, Osaka University, Osaka, Japan
| | - Yuzuru Kanakura
- Department of Hematology and Oncology, Graduate School of Medicine, Osaka University, Osaka, Japan
| | - Nobuo Kohara
- Department of Neurology, Kobe City Medical Center General Hospital, Kobe, Japan
| | | | - Peter M Krawitz
- Institute for Genomic Statistics and Bioinformatics, Rheinische Friedrich-Wilhelms-Universität Bonn, Bonn, Germany
| | - Taroh Kinoshita
- Research Institute for Microbial Diseases and.,WPI Immunology Frontier Research Center, Osaka University, Osaka, Japan
| |
Collapse
|
35
|
Abstract
Paroxysmal nocturnal hemoglobinuria (PNH) is an acquired disorder characterized by hemolysis, thrombosis, and bone marrow failure caused by defective expression of glycosylphosphatidylinositol-anchored (GPI-anchored) complement inhibitors. Most commonly, PNH is caused by loss of function of PIGA, which is required for GPI biosynthesis. In this issue of the JCI, Höchsmann et al. report on 4 PNH patients who also had marked autoinflammatory manifestations, including aseptic meningitis. All 4 patients had a germline mutation of the related gene PIGT and a somatically acquired myeloid common deleted region (CDR) on chromosome 20q that deleted the second PIGT allele. The biochemistry and clinical manifestations indicate that these patients have subtle but important differences from those with PNH resulting from PIGA mutations, suggesting PIGT-PNH may be a distinct clinical entity.
Collapse
|
36
|
Li J, Lin Y, Chen L, Qin L, Tan H, Zou J, Zhang D, Nie Y, Wang G, Zhang H, Liu E, Chen X, Ru K. Identification of acquired PIGA mutations and additional variants by next-generation sequencing in paroxysmal nocturnal hemoglobinuria. Int J Lab Hematol 2020; 42:473-481. [PMID: 32359022 DOI: 10.1111/ijlh.13228] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/29/2020] [Revised: 04/10/2020] [Accepted: 04/11/2020] [Indexed: 12/12/2022]
Abstract
INTRODUCTION Paroxysmal Nocturnal Hemoglobinuria (PNH) is an acquired clonal disease of hematopoietic stem cells. It is caused by somatic mutation of the X-linked PIGA gene, resulting in a deficient expression of glycosylphosphatidylinositol-anchored proteins (GPI-APs). In this study, we aimed to explore the diagnostic value of next-generation sequencing (NGS) and potential molecular basis in PNH patients. METHODS Genomic DNA of 85 PNH patients was analyzed by a 114-gene NGS panel. RESULTS Mutational analysis of PIGA identified 124 mutations in 92% PNH patients, including 101 distinct mutations and 23 recurrent mutations. Among them, 102 mutations were newly reported. Most mutations were located in exon 2 of PIGA gene, and truncated mutation was the most common one. Other mutations were detected in 26 out of 85 cases, including five cases of DNMT3A variants, four cases of ASXL1 variants, and four cases of U2AF1 variants. Clonal analysis was performed in one case and outlined a linear evolution pattern in classic PNH. There was a positive correlation between number of PIGA mutations and fraction of GPI-APs deficient granulocytes. CONCLUSION The detection of PIGA mutations and additional variants by targeted NGS not only shed light on the genetic characteristics of PNH, but also provided an important reference value in the diagnosis of PNH at molecular level.
Collapse
Affiliation(s)
- Jing Li
- SINO-US Diagnostics, Tianjin, China
| | - Yani Lin
- SINO-US Diagnostics, Tianjin, China
| | | | - Li Qin
- SINO-US Diagnostics, Tianjin, China
| | - Hao Tan
- SINO-US Diagnostics, Tianjin, China
| | | | | | | | | | | | | | | | - Kun Ru
- SINO-US Diagnostics, Tianjin, China
| |
Collapse
|
37
|
Lv Q, Huiqin Z, Na X, Chunyan L, Zonghong S, Huaquan W. Treatment of Severe Aplastic Anemia with Porcine Anti-Human Lymphocyte Globulin. Curr Pharm Des 2020; 26:2661-2667. [PMID: 32183661 DOI: 10.2174/1381612826666200317131940] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2019] [Accepted: 03/09/2020] [Indexed: 11/22/2022]
Abstract
Aplastic anemia (AA) is a bone marrow failure syndrome characterized by pancytopenia. Decreased numbers of hematopoietic stem cells and impaired bone marrow microenvironment caused by abnormal immune function describe the major pathogenesis of AA. Hematopoietic stem cell transplantation and immunesuppressive therapy are the first-line treatments for AA. Porcine anti-lymphocyte globulin (p-ALG) is a new product developed in China. Several studies have shown that p-ALG exhibited good therapeutic effects in AA.
Collapse
Affiliation(s)
- Qi Lv
- Department of Hematology, General Hospital, Tianjin Medical University, Tianjin 300052, China
| | - Zhang Huiqin
- Department of Hematology, General Hospital, Tianjin Medical University, Tianjin 300052, China
| | - Xiao Na
- Department of Hematology, General Hospital, Tianjin Medical University, Tianjin 300052, China
| | - Liu Chunyan
- Department of Hematology, General Hospital, Tianjin Medical University, Tianjin 300052, China
| | - Shao Zonghong
- Department of Hematology, General Hospital, Tianjin Medical University, Tianjin 300052, China
| | - Wang Huaquan
- Department of Hematology, General Hospital, Tianjin Medical University, Tianjin 300052, China
| |
Collapse
|
38
|
Luzzatto L. PNH phenotypes and their genesis. Br J Haematol 2020; 189:802-805. [PMID: 32166737 DOI: 10.1111/bjh.16473] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2019] [Accepted: 12/16/2019] [Indexed: 12/20/2022]
Affiliation(s)
- Lucio Luzzatto
- Department of Haematology and Blood Tranfusion, Muhimbili University of Health and Allied Sciences, Dar-es-Salaam, Tanzania
| |
Collapse
|
39
|
Lima M. Laboratory studies for paroxysmal nocturnal hemoglobinuria, with emphasis on flow cytometry. Pract Lab Med 2020; 20:e00158. [PMID: 32195308 PMCID: PMC7078534 DOI: 10.1016/j.plabm.2020.e00158] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2019] [Revised: 01/28/2020] [Accepted: 02/28/2020] [Indexed: 12/15/2022] Open
Abstract
Paroxysmal nocturnal hemoglobinuria (PNH) is a rare acquired clonal hematopoietic stem cell disorder caused by somatic mutations in the PIG-A gene, leading to the production of blood cells with absent or decreased expression of glycosylphosphatidylinositol-anchored proteins, including CD55 and CD59. Clinically, PNH is classified into three variants: classic (hemolytic), in the setting of another specified bone marrow disorder (such as aplastic anemia or myelodysplastic syndrome) and subclinical (asymptomatic). PNH testing is recommended for patients with intravascular hemolysis, acquired bone marrow failure syndromes and thrombosis with unusual features. Despite the availability of consensus guidelines for PNH diagnosis and monitoring, there are still discrepancies on how PNH tests are carried out, and these technical variations may lead to an incorrect diagnosis. Herein, we provide a brief historical overview of PNH, focusing on the laboratory tests available and on the current recommendations for PNH diagnosis and monitoring based in flow cytometry.
Collapse
Affiliation(s)
- Margarida Lima
- Laboratório de Citometria, Unidade de Diagnóstico Hematológico, Serviço de Hematologia Clínica, Hospital de Santo António (HSA), Centro Hospitalar Universitário do Porto (CHUP), Porto, Portugal
- Unidade Multidisciplinar de Investigação Biomédica, Instituto de Ciências Biomédicas da Universidade do Porto (UMIB/ICBAS/UP), Porto, Portugal
- Laboratório de Citometria, Hospital de Santo António (HSA), Centro Hospitalar Universitário do Porto (CHUP), Ex-CICAP, Rua D. Manuel II, s/n, 4099-001, Porto, Portugal.
| |
Collapse
|
40
|
Patel BJ, Barot SV, Kuzmanovic T, Kerr C, Przychodzen BP, Thota S, Lee S, Patel S, Radivoyevitch T, Lichtin A, Advani A, Kalaycio M, Sekeres MA, Carraway HE, Maciejewski JP. Distinctive and common features of moderate aplastic anaemia. Br J Haematol 2020; 189:967-975. [PMID: 32004386 PMCID: PMC8340733 DOI: 10.1111/bjh.16460] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2019] [Accepted: 12/02/2019] [Indexed: 11/30/2022]
Abstract
The therapy algorithm for severe aplastic anaemia (sAA) is established but moderate AA (mAA), which likely reflects a more diverse pathogenic mechanism, often represents a treatment/management conundrum. A cohort of AA patients (n = 325) was queried for those with non‐severe disease using stringent criteria including bone marrow hypocellularity and chronic persistence of moderately depressed blood counts. As a result, we have identified and analyzed pathological and clinical features in 85 mAA patients. Progression to sAA and direct clonal evolution (paroxysmal nocturnal haemoglobinuria/acute myeloid leukaemia; PNH/AML) occurred in 16%, 11% and 1% of mAA cases respectively. Of the mAA patients who received immunosuppressive therapy, 67% responded irrespective of time of initiation of therapy while conservatively managed patients showed no spontaneous remissions. Genomic analysis of mAA identified evidence of clonal haematopoiesis with both persisting and remitting patterns at low allelic frequencies; with more pronounced mutational burden in sAA. Most of the mAA patients have autoimmune pathogenesis similar to those with sAA, but mAA contains a mix of patients with diverse aetiologies. Although progression rates differed between mAA and sAA (P = 0·003), cumulative incidences of mortalities were only marginally different (P = 0·095). Our results provide guidance for diagnosis/management of mAA, a condition for which no current standard of care is established.
Collapse
Affiliation(s)
- Bhumika J Patel
- Department of Translational Hematology and Oncology Research, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH, USA.,Leukemia Program, Department of Hematology and Medical Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Shimoli V Barot
- Department of Translational Hematology and Oncology Research, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Teodora Kuzmanovic
- Department of Translational Hematology and Oncology Research, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Cassandra Kerr
- Department of Translational Hematology and Oncology Research, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Bartlomiej P Przychodzen
- Department of Translational Hematology and Oncology Research, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Swapna Thota
- Department of Leukemia, Roswell Park Comprehensive Cancer Center, University of Buffalo, Buffalo, NY, USA
| | - Sarah Lee
- Leukemia Program, Department of Hematology and Medical Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Saurabh Patel
- Department of Translational Hematology and Oncology Research, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH, USA.,Leukemia Program, Department of Hematology and Medical Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Tomas Radivoyevitch
- Department of Translational Hematology and Oncology Research, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH, USA.,Department of Quantitative Health Sciences, Lerner Research Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Alan Lichtin
- Leukemia Program, Department of Hematology and Medical Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Anjali Advani
- Leukemia Program, Department of Hematology and Medical Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Matt Kalaycio
- Leukemia Program, Department of Hematology and Medical Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Mikkael A Sekeres
- Leukemia Program, Department of Hematology and Medical Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Hetty E Carraway
- Leukemia Program, Department of Hematology and Medical Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Jaroslaw P Maciejewski
- Department of Translational Hematology and Oncology Research, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH, USA.,Leukemia Program, Department of Hematology and Medical Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH, USA
| |
Collapse
|
41
|
Patel BJ, Barot SV, Waldron M, Billings S, Vij A, Sekeres MA, Maciejewski JP, Carraway HE. Clonal dynamics of aplastic anemia/paroxysmal nocturnal hemoglobinuria. Leuk Lymphoma 2019; 61:1242-1245. [PMID: 31885297 DOI: 10.1080/10428194.2019.1706734] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Affiliation(s)
- Bhumika J Patel
- Department of Hematology and Medical Oncology, Cleveland Clinic, Cleveland, OH, USA
| | - Shimoli V Barot
- Department of Internal Medicine, Cleveland Clinic, Cleveland, OH, USA
| | | | - Steven Billings
- Department of Pathology, Cleveland Clinic, Cleveland, OH, USA
| | - Alok Vij
- Department of Dermatology, Cleveland Clinic, Cleveland, OH, USA
| | - Mikkael A Sekeres
- Department of Hematology and Medical Oncology, Cleveland Clinic, Cleveland, OH, USA
| | | | - Hetty E Carraway
- Department of Hematology and Medical Oncology, Cleveland Clinic, Cleveland, OH, USA
| |
Collapse
|
42
|
Lobry C, Bains A, Zamechek LB, Ibrahim S, Aifantis I, Araten DJ. Analysis of TET2 mutations in paroxysmal nocturnal hemoglobinuria (PNH). Exp Hematol Oncol 2019; 8:17. [PMID: 31453016 PMCID: PMC6702710 DOI: 10.1186/s40164-019-0142-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2019] [Accepted: 08/01/2019] [Indexed: 12/18/2022] Open
Abstract
Background Large clonal populations of cells bearing PIG-A mutations are the sine qua non of PNH, but the PIG-A mutation itself is insufficient for clonal expansion. The association between PNH and aplastic anemia supports the immune escape model, but not all PNH patients demonstrate a history of aplasia; therefore, second genetic hits driving clonal expansion have been postulated. Based on the previous identification of JAK2 mutations in patients with a myeloproliferative/PNH overlap syndrome, we considered TET2 as a candidate gene in which mutations might be contributing to clonal expansion. Methods Here we sequenced the TET2 and JAK2 genes in 19 patients with large PNH clones. Results We found one patient with a novel somatic nonsense mutation in TET2 in multiple hematopoietic lineages, which was detectable upon repeat testing. This patient has had severe thromboses and has relatively higher peripheral blood counts compared with the other patients—but does not have other features of a myeloproliferative neoplasm. Conclusions We conclude that mutations in TET2 may contribute to clonal expansion in exceptional cases of PNH.
Collapse
Affiliation(s)
- Camille Lobry
- 1Institut National de la Santé et de la Recherche Medicale (INSERM) U1170, Institut Gustave Roussy, 94805 Villejuif, France
| | - Ashish Bains
- 2Pathology and Laboratory Medicine, Temple University, 3401 North Broad Street, Philadelphia, PA 19140 USA
| | - Leah B Zamechek
- 3Columbia University Medical Center, 1130 St. Nicholas Avenue, Room 901, New York City, USA
| | - Sherif Ibrahim
- Cairo Diagnostics, 244 Westchester Avenue, West Harrison, NY 10604 USA
| | - Iannis Aifantis
- 5Department of Pathology, NYU School of Medicine, 550 First Avenue, New York, NY 10016 USA
| | - David J Araten
- 6Division of Hematology, Laura and Isaac Perlmutter Cancer Center, NYU Langone Health and the NYU School of Medicine, 240 East 38th Street, 19th Floor, New York, NY 10016 USA.,7Division of Hematology, New York VA Medical Center, 423 East 23rd Street, New York, NY 10010 USA
| |
Collapse
|
43
|
Leukemia evolving from paroxysmal nocturnal hemoglobinuria. Leukemia 2019; 34:327-330. [PMID: 31431736 DOI: 10.1038/s41375-019-0555-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2019] [Accepted: 07/01/2019] [Indexed: 02/07/2023]
|
44
|
Gutwein O, Englander Y, Herzog-Tzarfati K, Filipovich-Rimon T, Apel A, Marcus R, Rahimi-Levene N, Koren-Michowitz M. Prevalence of Paroxysmal Nocturnal Hemoglobinuria Clones in Myeloproliferative Neoplasm Patients: A Cross-Sectional Study. CLINICAL LYMPHOMA MYELOMA & LEUKEMIA 2019; 19:812-814. [PMID: 31601527 DOI: 10.1016/j.clml.2019.07.441] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/14/2019] [Accepted: 07/29/2019] [Indexed: 10/26/2022]
Abstract
INTRODUCTION The myeloproliferative neoplasms (MPN) are clonal diseases that confer an increased risk of thrombohemorrhagic complications. Paroxysmal nocturnal hemoglobinuria (PNH) is a rare clonal disease associated with an increased thrombotic risk. Small PNH clones are prevalent in aplastic anemia and myelodysplastic syndrome patients, but their prevalence in MPN patients is unknown. PATIENTS AND METHODS Consecutive patients with MPN followed up at a single center were recruited. PNH clones were analyzed in erythrocytes and white blood cells by flow cytometry. RESULTS PNH clones were detected in 2% of patients and were more common in JAK2 V617F positive patients. We could not detect any differences in clinical manifestations or complications in patients either with or without PNH clones because of the small patient numbers. CONCLUSION The prevalence of PNH clones in MPN is similar to that described in myelodysplastic syndromes. Whether PNH clones influence MPN phenotype and complications should be studied prospectively in larger patient cohorts and over long-term follow-up.
Collapse
Affiliation(s)
- Odit Gutwein
- Department of Hematology, Shamir Medical Center (Assaf Harofeh), Zerifin, Israel; Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Yoav Englander
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Katrin Herzog-Tzarfati
- Department of Hematology, Shamir Medical Center (Assaf Harofeh), Zerifin, Israel; Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | | | - Arie Apel
- Department of Hematology, Shamir Medical Center (Assaf Harofeh), Zerifin, Israel
| | - Ronit Marcus
- Department of Hematology, Shamir Medical Center (Assaf Harofeh), Zerifin, Israel
| | - Naomi Rahimi-Levene
- Department of Hematology, Shamir Medical Center (Assaf Harofeh), Zerifin, Israel; Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Maya Koren-Michowitz
- Department of Hematology, Shamir Medical Center (Assaf Harofeh), Zerifin, Israel; Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel.
| |
Collapse
|
45
|
Wong GK, Barmettler S, Heather JM, Millar D, Penny SA, Huissoon A, Richter A, Cobbold M. Aberrant X chromosome skewing and acquired clonal hematopoiesis in adult-onset common variable immunodeficiency. JCI Insight 2019; 4:127614. [PMID: 31341110 PMCID: PMC6675553 DOI: 10.1172/jci.insight.127614] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2019] [Accepted: 06/06/2019] [Indexed: 12/21/2022] Open
Abstract
Advances in genomic medicine have elucidated an increasing number of genetic etiologies for patients with common variable immunodeficiency (CVID). However, there is heterogeneity in clinical and immunophenotypic presentations and a limited understanding of the underlying pathophysiology of many cases. The primary defects in CVID may extend beyond the adaptive immune system, and the combined defect in both the myeloid and lymphoid compartments suggests the mechanism may involve bone marrow output and earlier progenitors. Using the methylation profile of the human androgen receptor (AR) gene as a surrogate epigenetic marker for bone marrow clonality, we examined the hematopoietic compartments of patients with CVID. Our data show that clonal hematopoiesis is common among patients with adult-onset CVID who do not have associated noninfectious complications. Nonblood tissues did not show a skewed AR methylation status, supporting a model of an acquired clonal hematopoietic event. Attenuation of memory B cell differentiation into long-lived plasma cells (CD20–CD27+CD38+CD138+) was associated with marked changes in the postdifferentiation methylation profile, demonstrating the functional consequence of clonal hematopoiesis on humoral immunity in these patients. This study sheds light on a potential etiology of a subset of patients with CVID, and the findings suggest that it is a stage of an acquired lymphocyte maturation disorder. Clonal hematopoiesis is common among a subset of patients with common variable immunodeficiency (CVID), suggesting that CVID may be a stage of lymphoid dysplasia.
Collapse
Affiliation(s)
- Gabriel K Wong
- Institute of Immunology and Immunotherapy, Medical School, University of Birmingham, Edgbaston, United Kingdom
| | - Sara Barmettler
- Allergy and Clinical Immunology Unit, Division of Rheumatology, Allergy and Immunology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - James M Heather
- Massachusetts General Hospital, Cancer Center and Department of Medicine, Harvard Medical School, Boston, Massachusetts, USA
| | - David Millar
- Massachusetts General Hospital, Cancer Center and Department of Medicine, Harvard Medical School, Boston, Massachusetts, USA
| | - Sarah A Penny
- Institute of Immunology and Immunotherapy, Medical School, University of Birmingham, Edgbaston, United Kingdom
| | - Aarnoud Huissoon
- Institute of Immunology and Immunotherapy, Medical School, University of Birmingham, Edgbaston, United Kingdom.,West Midlands Immunodeficiency Centre, Birmingham Heartlands Hospital, Birmingham, United Kingdom
| | - Alex Richter
- Institute of Immunology and Immunotherapy, Medical School, University of Birmingham, Edgbaston, United Kingdom
| | - Mark Cobbold
- Massachusetts General Hospital, Cancer Center and Department of Medicine, Harvard Medical School, Boston, Massachusetts, USA
| |
Collapse
|
46
|
Li L, Liu H, Wang H, Liu Z, Chen Y, Li L, Song J, Wang G, Fu R. Abnormal expression and mutation of the RBPJ gene may be involved in CD59 - clonal proliferation in paroxysmal nocturnal hemoglobinuria. Exp Ther Med 2019; 17:4536-4546. [PMID: 31086586 PMCID: PMC6489004 DOI: 10.3892/etm.2019.7475] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2018] [Accepted: 02/28/2019] [Indexed: 12/20/2022] Open
Abstract
Paroxysmal nocturnal hemoglobinuria (PNH) is an acquired clonal proliferative disease of hematopoietic stem cells. Various gene mutations, including the phosphatidylinositol glycan anchor biosynthesis class A (PIG-A) gene, may contribute to the proliferation of PNH clones. In order to explore the mechanism of PNH clone proliferation, a study was performed on 13 patients with PNH who underwent whole exome sequencing. The frequency of mutations in these patients was explored, and an additional 30 patients with PNH were selected for analysis of cluster of differentiation 59-negative (CD59-) cells. The mRNA expression of 13 genes, which were selected based on their high frequency in patients with PNH and the fact that they met four screening conditions, was determined in these CD59- cells. Cell proliferation, apoptosis and cell cycle were evaluated upon knocking down the recombinant signal binding protein of immunoglobulin κJ region (RBPJ) gene in 5 patients in vitro. The detection rate of PIG-A gene mutation was 61.54% (8/13), and additional mutations in somatic genes were detected, including RBPJ, zinc finger protein 717, polycomb repressive complex 2 subunit and tet methylcytosine dioxygenase. Upon screening according to the mutation frequency and expression level, the present study focused on the RBPJ gene. The expression level of RBPJ in CD59- cells was apparently higher than that in CD59+ cells and normal controls which was significantly correlated with clinical data. Furthermore, the expression of RBPJ in PNH primary cells could be effectively inhibited by small interfering RNA-RBPJ. Once the expression of RBPJ decreased remarkably, the apoptotic rate increased gradually, while cell proliferation activity decreased with transfection time and cells were blocked in G0/G1 phase. In conclusion, mutations and abnormal expression of the RBPJ gene may participate in the abnormal proliferation of PNH clones.
Collapse
Affiliation(s)
- Liyan Li
- Department of Hematology, Tianjin Medical University General Hospital, Tianjin 300052, P.R. China
| | - Hui Liu
- Department of Hematology, Tianjin Medical University General Hospital, Tianjin 300052, P.R. China
| | - Honglei Wang
- Department of Hematology, Tianjin Medical University General Hospital, Tianjin 300052, P.R. China
| | - Zhaoyun Liu
- Department of Hematology, Tianjin Medical University General Hospital, Tianjin 300052, P.R. China
| | - Yingying Chen
- Department of Hematology, Tianjin Medical University General Hospital, Tianjin 300052, P.R. China
| | - Lijuan Li
- Department of Hematology, Tianjin Medical University General Hospital, Tianjin 300052, P.R. China
| | - Jia Song
- Department of Hematology, Tianjin Medical University General Hospital, Tianjin 300052, P.R. China
| | - Guojin Wang
- Department of Hematology, Tianjin Medical University General Hospital, Tianjin 300052, P.R. China
| | - Rong Fu
- Department of Hematology, Tianjin Medical University General Hospital, Tianjin 300052, P.R. China
| |
Collapse
|
47
|
Paroxysmal Nocturnal Hemoglobinuria with a Distinct Molecular Signature Diagnosed Ten Years after Allogenic Bone Marrow Transplantation for Acute Myeloid Leukemia. Case Rep Hematol 2019; 2019:8928623. [PMID: 30867971 PMCID: PMC6379860 DOI: 10.1155/2019/8928623] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2018] [Revised: 12/21/2018] [Accepted: 12/25/2018] [Indexed: 11/17/2022] Open
Abstract
Paroxysmal nocturnal hemoglobinurea (PNH) is a rare disorder of complement regulation due to somatic mutation of PIGA (phosphatidylinositol glycan anchor) gene. We herewith report a case who developed a symptomatic PNH long after an allogenic marrow transplant. Some reasonable arguments concerning the origin of PNH clone have been discussed. The molecular studies revealed presence of JAK2 and TET2 mutations without a BCOR mutation. The literature review has been performed to probe into the complex interplay of autoimmunity and clonal selection and expansion of PNH cells, which occurs early in hematopoietic differentiation. The consequent events such as hypoplastic and/or hemato-oncologic features could further be explained on the basis of next-generation sequencing (NGS) studies. Paroxysmal nocturnal hemoglobinuria (PNH) is a rare clonal disorder of hematopoietic stem cells, characterized by a somatic mutation of the phosphatidylinositol glycan-class A (PIGA). The PIGA gene products are crucial for biosynthesis of glycosylphosphatidylinositol (GPI) anchors, which attaches a number of proteins to the plasma membrane of the cell. Amongst these proteins, the CD55 and CD59 are complement regulatory proteins. The CD55 inhibits C3 convertase whereas the CD59 blocks the membrane attack complex (MAC) by inhibiting the incorporation of C9 to MAC. The loss of complement regulatory protein renders the red cell susceptible to complement-mediated lysis leading to intravascular and extravascular hemolysis. The intravascular hemolysis explains most of the morbid clinical manifestations of the disease. The clinical features of syndrome of PNH are recurrent hemolytic episodes, thrombosis, smooth muscle dystonia, and bone marrow failure; other important complications include renal failure, myelodysplastic syndrome (MDS), and acute myeloid leukemia (AML). The most used therapies were blood transfusions, immunosuppressive, and steroid. Allogeneic stem cell transplantation was also practiced. At present, the therapy of choice is eculizumab (Soliris, Alexion Pharmaceuticals), a humanized monoclonal antibody that blocks activation of the terminal complement at C5. The limiting factor for this therapy is breakthrough hemolysis and the frequent dosing schedule. Ravulizumab (ALXN1210) is the second generation terminal compliment inhibitor which seems to provide a sustained control of hemolysis without breakthrough hemolysis and with a longer dosing interval.
Collapse
|
48
|
Sustained clonal hematopoiesis by HLA-lacking hematopoietic stem cells without driver mutations in aplastic anemia. Blood Adv 2019; 2:1000-1012. [PMID: 29720492 DOI: 10.1182/bloodadvances.2017013953] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2017] [Accepted: 04/07/2018] [Indexed: 11/20/2022] Open
Abstract
Clonal hematopoiesis by hematopoietic stem progenitor cells (HSPCs) that lack an HLA class I allele (HLA- HSPCs) is common in patients with acquired aplastic anemia (AA); however, it remains unknown whether the cytotoxic T lymphocyte (CTL) attack that allows for survival of HLA- HSPCs is directed at nonmutated HSPCs or HSPCs with somatic mutations or how escaped HLA- HSPC clones support sustained hematopoiesis. We investigated the presence of somatic mutations in HLA- granulocytes obtained from 15 AA patients in long-term remission (median, 13 years; range, 2-30 years). Targeted sequencing of HLA- granulocytes revealed somatic mutations (DNMT3A, n = 2; TET2, ZRSR2, and CBL, n = 1) in 3 elderly patients between 79 and 92 years of age, but not in 12 other patients aged 27 to 74 years (median, 51.5 years). The chronological and clonogenic analyses of the 3 cases revealed that ZRSR2 mutation in 1 case, which occurred in an HLA- HSPC with a DNMT3A mutation, was the only mutation associated with expansion of the HSPC clone. Whole-exome sequencing of the sorted HLA- granulocytes confirmed the absence of any driver mutations in 5 patients who had a particularly large loss of heterozygosity in chromosome 6p (6pLOH) clone size. Flow-fluorescence in situ hybridization analyses of sorted HLA+ and HLA- granulocytes showed no telomere attrition in HLA- granulocytes. The findings suggest that HLA- HSPC clones that escape CTL attack are essentially free from somatic mutations related to myeloid malignancies and are able to support long-term clonal hematopoiesis without developing driver mutations in AA patients unless HLA loss occurs in HSPCs with somatic mutations.
Collapse
|
49
|
Boddu PC, Kadia TM. Molecular pathogenesis of acquired aplastic anemia. Eur J Haematol 2018; 102:103-110. [DOI: 10.1111/ejh.13182] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2018] [Revised: 10/03/2018] [Accepted: 10/04/2018] [Indexed: 12/27/2022]
Affiliation(s)
- Prajwal C. Boddu
- Department of Leukemia University of Texas MD Anderson Cancer Center Houston Texas
| | - Tapan M. Kadia
- Department of Leukemia University of Texas MD Anderson Cancer Center Houston Texas
| |
Collapse
|
50
|
Babushok DV. A brief, but comprehensive, guide to clonal evolution in aplastic anemia. HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2018; 2018:457-466. [PMID: 30504346 PMCID: PMC6245980 DOI: 10.1182/asheducation-2018.1.457] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/07/2023]
Abstract
Acquired aplastic anemia (AA) is an immune-mediated bone marrow aplasia that is strongly associated with clonal hematopoiesis upon marrow recovery. More than 70% of AA patients develop somatic mutations in their hematopoietic cells. In contrast to other conditions linked to clonal hematopoiesis, such as myelodysplastic syndrome (MDS) or clonal hematopoiesis of indeterminate potential in the elderly, the top alterations in AA are closely related to its immune pathogenesis. Nearly 40% of AA patients carry somatic mutations in the PIGA gene manifested as clonal populations of cells with the paroxysmal nocturnal hemoglobinuria phenotype, and 17% of AA patients have loss of HLA class I alleles. It is estimated that between 20% and 35% of AA patients have somatic mutations associated with hematologic malignancies, most characteristically in the ASXL1, BCOR, and BCORL1 genes. Risk factors for evolution to MDS in AA include the duration of disease, acquisition of high-risk somatic mutations, and age at AA onset. Emerging data suggest that several HLA class I alleles not only predispose to the development of AA but may also predispose to clonal evolution in AA patients. Long-term prospective studies are needed to determine the true prognostic implications of clonal hematopoiesis in AA. This article provides a brief, but comprehensive, review of our current understanding of clonal evolution in AA and concludes with 3 cases that illustrate a practical approach for integrating results of next-generation molecular studies into the clinical care of AA patients in 2018.
Collapse
Affiliation(s)
- Daria V. Babushok
- Division of Hematology-Oncology, Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, PA; and
- Comprehensive Bone Marrow Failure Center, Department of Pediatrics, Children’s Hospital of Philadelphia, Philadelphia, PA
| |
Collapse
|