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Nikitin E, Kislova M, Morozov D, Belyakova V, Suvorova A, Sveshnikova J, Vyscub G, Matveeva I, Shirokova M, Shipaeva A, Klitochenko T, Makarovskaya P, Dmitrieva E, Biderman B, Sudarikov A, Obukhova T, Samoilova O, Kaplanov K, Konstantinova T, Mayorova O, Poddubnaya I, Ptushkin V. Ibrutinib in combination with rituximab is highly effective in treatment of chronic lymphocytic leukemia patients with steroid refractory and relapsed autoimmune cytopenias. Leukemia 2023; 37:1464-1473. [PMID: 37202442 PMCID: PMC10195665 DOI: 10.1038/s41375-023-01891-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2022] [Revised: 03/08/2023] [Accepted: 03/30/2023] [Indexed: 05/20/2023]
Abstract
Autoimmune hemolytic anemia (AIHA) and pure red cell aplasia (PRCA) are common complications of CLL. The optimal treatment of steroid refractory AIHA/PRCA is not well established. We conducted a multicenter study of ibrutinib and rituximab in patients with relapsed/refractory to steroids AIHA/PRCA and underlying CLL. Protocol included induction (ibrutinib 420 mg/day and rituximab, 8 weekly and 4 monthly infusions) and maintenance phase with ibrutinib alone until progression or unacceptable toxicity. Fifty patients were recruited (44-warm AIHA, 2-cold AIHA, 4-PRCA). After the induction 34 patients (74%) have achieved complete response, 10 (21.7%) partial response. Median time to hemoglobin normalization was 85 days. With regards to CLL response 9 (19%) patients have achieved CR, 2 (4%) patients-stabilization and 39 (78%)-PR. The median follow-up was 37.56 months. In AIHA group 2 patients had a relapse. Among 4 patients with PRCA 1 patient did not respond, and 1 patient had a relapse after CR, 2 remained in CR. The most common adverse events were neutropenia (62%), infections (72%), gastrointestinal complications (54%). In conclusion ibrutinib in combination with rituximab is an active second-line treatment option for patients with relapsed or refractory AIHA/PRCA and underlying CLL.
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MESH Headings
- Humans
- Rituximab
- Leukemia, Lymphocytic, Chronic, B-Cell/drug therapy
- Leukemia, Lymphocytic, Chronic, B-Cell/complications
- Anemia, Hemolytic, Autoimmune/drug therapy
- Anemia, Hemolytic, Autoimmune/complications
- Thrombocytopenia
- Red-Cell Aplasia, Pure
- Steroids
- Recurrence
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Affiliation(s)
- Eugene Nikitin
- State Budgetary Healthcare Institution of the city of Moscow City Clinical Hospital named after S.P. Botkin of Moscow City Healthcare Department, Moscow, Russian Federation.
- Federal State Budgetary Educational Institution of Further Professional Education "Russian Medical Academy of Continuous Professional Education" of the Ministry of Healthcare of the Russian Federation, Moscow, Russian Federation.
| | - Maria Kislova
- State Budgetary Healthcare Institution of the city of Moscow City Clinical Hospital named after S.P. Botkin of Moscow City Healthcare Department, Moscow, Russian Federation
| | - Dmitry Morozov
- State Budgetary Health Institution of the Nizhny Novgorod Region "Nizhny Novgorod Regional Clinical Hospital named after N.A. Semashko", Nizhny, Novgorod, Russian Federation
| | - Vera Belyakova
- State Budgetary Healthcare Institution of the city of Moscow Blood Center named after O.K. Gavrilov of the Moscow City Healthcare Department, Moscow, Russian Federation
| | - Anna Suvorova
- State Budgetary Health Institution of the Nizhny Novgorod Region "Nizhny Novgorod Regional Clinical Hospital named after N.A. Semashko", Nizhny, Novgorod, Russian Federation
| | - Julia Sveshnikova
- State Autonomous Healthcare Institution of the Sverdlovsk Region "Sverdlovsk Regional Clinical Hospital N 1", Ekaterinburg, Russian Federation
| | - Galina Vyscub
- State Budgetary Health Institution "Volgograd Regional Clinical Oncology Center", Volgograd, Russian Federation
| | - Irina Matveeva
- State Budgetary Health Institution "Volgograd Regional Clinical Oncology Center", Volgograd, Russian Federation
| | - Maria Shirokova
- State Budgetary Healthcare Institution of the city of Moscow City Clinical Hospital named after S.P. Botkin of Moscow City Healthcare Department, Moscow, Russian Federation
| | - Anna Shipaeva
- State Budgetary Health Institution "Volgograd Regional Clinical Oncology Center", Volgograd, Russian Federation
| | - Tatyana Klitochenko
- State Budgetary Health Institution "Volgograd Regional Clinical Oncology Center", Volgograd, Russian Federation
| | - Polina Makarovskaya
- State Budgetary Health Institution of the Nizhny Novgorod Region "Nizhny Novgorod Regional Clinical Hospital named after N.A. Semashko", Nizhny, Novgorod, Russian Federation
| | - Elena Dmitrieva
- State Budgetary Healthcare Institution of the city of Moscow City Clinical Hospital named after S.P. Botkin of Moscow City Healthcare Department, Moscow, Russian Federation
| | - Bella Biderman
- National Medical Research Center for Hematology, Moscow, Russian Federation
| | - Andrei Sudarikov
- National Medical Research Center for Hematology, Moscow, Russian Federation
| | - Tatyana Obukhova
- National Medical Research Center for Hematology, Moscow, Russian Federation
| | - Olga Samoilova
- State Budgetary Health Institution of the Nizhny Novgorod Region "Nizhny Novgorod Regional Clinical Hospital named after N.A. Semashko", Nizhny, Novgorod, Russian Federation
| | - Kamil Kaplanov
- State Budgetary Healthcare Institution of the city of Moscow City Clinical Hospital named after S.P. Botkin of Moscow City Healthcare Department, Moscow, Russian Federation
| | - Tatyana Konstantinova
- State Autonomous Healthcare Institution of the Sverdlovsk Region "Sverdlovsk Regional Clinical Hospital N 1", Ekaterinburg, Russian Federation
| | - Olga Mayorova
- State Budgetary Healthcare Institution of the city of Moscow Blood Center named after O.K. Gavrilov of the Moscow City Healthcare Department, Moscow, Russian Federation
| | - Irina Poddubnaya
- Federal State Budgetary Educational Institution of Further Professional Education "Russian Medical Academy of Continuous Professional Education" of the Ministry of Healthcare of the Russian Federation, Moscow, Russian Federation
| | - Vadim Ptushkin
- State Budgetary Healthcare Institution of the city of Moscow City Clinical Hospital named after S.P. Botkin of Moscow City Healthcare Department, Moscow, Russian Federation
- Federal State Budgetary Educational Institution of Further Professional Education "Russian Medical Academy of Continuous Professional Education" of the Ministry of Healthcare of the Russian Federation, Moscow, Russian Federation
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Xu Q, Yu J, Lin X, Li Y, Zhang K. CB-LPD, MGUS, T-LGLL, and PRCA: A rare case report of 4 concomitant hematological disorders. Medicine (Baltimore) 2021; 100:e27874. [PMID: 34964755 PMCID: PMC8615434 DOI: 10.1097/md.0000000000027874] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2021] [Accepted: 11/03/2021] [Indexed: 01/05/2023] Open
Abstract
RATIONALE Monoclonal gammopathy of undetermined significance (MGUS) is a clinically asymptomatic clonal plasma cell or lymphoplasmacytic proliferative disorder. Recently, some case reports have described the association of pure red cell aplasia (PRCA) with MGUS, even with a relatively low monoclonal immunoglobulin burden. T large granular lymphocyte leukemia (T-LGLL) is a chronic lymphoproliferative disorder characterized by clonal expansion of T large granular lymphocytes, which is rare in China. There are some reports about T-LGL leukemia in patients with B-cell lymphoma; however, it is very rare that T-LGLL coexists with MGUS and clonal B-cell lymphoproliferative disorders (CB-LPD). PATIENT CONCERNS A 77-year-old man was hospitalized because of anemia. He was diagnosed with MGUS, CB-LPD, and PRCA. During the development of the disease, a group of abnormal T lymphocytes was detected by flow cytometry of peripheral blood. DIAGNOSIS Combining clinical manifestations with the result of T cell receptor gene rearrangement and immunophenotype, it was consistent with the diagnosis of T large granular lymphocyte leukemia. INTERVENTIONS The patient was treat with bortezomib and dexamethasone regimen, Rituximab and sirolimus. OUTCOMES The patient was transfusion independent after therapies. LESSONS We report a patient with 4 concomitant hematological disorders: T-LGLL, MGUS, CB-LPD, and PRCA, aiming to represent the clinical and flow cytometry characteristics of these concomitant diseases, analyze the mechanism between diseases, and provide a clinical reference.
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Affiliation(s)
- Qinhong Xu
- Department of Hematology, Zhongshan Hospital, Xiamen University, Fujian Medical University Clinic Teaching Hospital, Xiamen, Fujian, China
| | - Jieni Yu
- Department of Hematology, Zhongshan Hospital, Xiamen University, Fujian Medical University Clinic Teaching Hospital, Xiamen, Fujian, China
| | - Xiaoyan Lin
- The Center of Clinical Laboratory, Zhongshan Hospital, Xiamen University, Fujian Medical University Clinic Teaching Hospital, Xiamen, Fujian, China
| | - Youli Li
- Department of Hematology, Zhongshan Hospital, Xiamen University, Fujian Medical University Clinic Teaching Hospital, Xiamen, Fujian, China
| | - Kejie Zhang
- Department of Hematology, Zhongshan Hospital, Xiamen University, Fujian Medical University Clinic Teaching Hospital, Xiamen, Fujian, China
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Wu X, Yang Y, Lu X, Yin H, Wang S, Wang S, Hong M, Zhu Y, Lu R, Qiao C, Wu Y, He G, Li J. Induced complete remission faster in adult patients with acquired pure red cell aplasia by combining cyclosporine A with corticosteroids. Medicine (Baltimore) 2019; 98:e17425. [PMID: 31593095 PMCID: PMC6799648 DOI: 10.1097/md.0000000000017425] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
To evaluate whether the adult patients with acquired pure red cell aplasia (PRCA) could benefit more from cyclosporine A (CsA) combined with corticosteroids (CS) than CsA or CS alone.Seventy-three patients were evaluated in 2 institutions (6 patients lost to follow-up).The induction therapy included CsA (n = 21), CS (n = 21), or CsA combined with CS (n = 31), and remission was achieved in 16/21 (76.2%), 10/21 (47.6%), and 21/31 (71.0%) patients, respectively. Higher complete remission (CR) rate was achieved in CsA combined with CS group than in CS group (61.3% vs 19.0%, P = .003). Patients achieved CR faster in CsA combined with CS group than in CS group or CsA group (median time, 1 month vs 2 month vs 3 month, P = .010). By multivariate analysis, CsA combined with CS therapy and primary PRCA were the influence factors for CR rate. Twenty-seven patients relapsed due to discontinuation or tapering therapy, and 19 patients regained response by increasing the dose of original regimens or changing to other immunosuppressive therapy. Complete remission to induction therapy was a correlative factor for death (P = .035).CsA combined with CS produced faster and higher CR rate in treating adult patients with PRCA than did CsA or CS alone.
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Affiliation(s)
- Xuemei Wu
- Department of Hematology, Jiangsu Province Hospital, The First Affiliated Hospital of Nanjing Medical University, Key Laboratory of Hematology of Nanjing Medical University, Collaborative Innovation Center for Cancer Personalized Medicine Nanjing, Jiangsu Province
| | - Yan Yang
- First Affiliated Hospital of Jilin University, Changchun, Jilin Province, China
| | - Xingyu Lu
- Department of Hematology, Jiangsu Province Hospital, The First Affiliated Hospital of Nanjing Medical University, Key Laboratory of Hematology of Nanjing Medical University, Collaborative Innovation Center for Cancer Personalized Medicine Nanjing, Jiangsu Province
| | - Hua Yin
- Department of Hematology, Jiangsu Province Hospital, The First Affiliated Hospital of Nanjing Medical University, Key Laboratory of Hematology of Nanjing Medical University, Collaborative Innovation Center for Cancer Personalized Medicine Nanjing, Jiangsu Province
| | - Suli Wang
- Department of Hematology, Jiangsu Province Hospital, The First Affiliated Hospital of Nanjing Medical University, Key Laboratory of Hematology of Nanjing Medical University, Collaborative Innovation Center for Cancer Personalized Medicine Nanjing, Jiangsu Province
| | - Shuai Wang
- Department of Hematology, Jiangsu Province Hospital, The First Affiliated Hospital of Nanjing Medical University, Key Laboratory of Hematology of Nanjing Medical University, Collaborative Innovation Center for Cancer Personalized Medicine Nanjing, Jiangsu Province
| | - Ming Hong
- Department of Hematology, Jiangsu Province Hospital, The First Affiliated Hospital of Nanjing Medical University, Key Laboratory of Hematology of Nanjing Medical University, Collaborative Innovation Center for Cancer Personalized Medicine Nanjing, Jiangsu Province
| | - Yu Zhu
- Department of Hematology, Jiangsu Province Hospital, The First Affiliated Hospital of Nanjing Medical University, Key Laboratory of Hematology of Nanjing Medical University, Collaborative Innovation Center for Cancer Personalized Medicine Nanjing, Jiangsu Province
| | - Ruinan Lu
- Department of Hematology, Jiangsu Province Hospital, The First Affiliated Hospital of Nanjing Medical University, Key Laboratory of Hematology of Nanjing Medical University, Collaborative Innovation Center for Cancer Personalized Medicine Nanjing, Jiangsu Province
| | - Chun Qiao
- Department of Hematology, Jiangsu Province Hospital, The First Affiliated Hospital of Nanjing Medical University, Key Laboratory of Hematology of Nanjing Medical University, Collaborative Innovation Center for Cancer Personalized Medicine Nanjing, Jiangsu Province
| | - Yujie Wu
- Department of Hematology, Jiangsu Province Hospital, The First Affiliated Hospital of Nanjing Medical University, Key Laboratory of Hematology of Nanjing Medical University, Collaborative Innovation Center for Cancer Personalized Medicine Nanjing, Jiangsu Province
| | - Guangsheng He
- Department of Hematology, Jiangsu Province Hospital, The First Affiliated Hospital of Nanjing Medical University, Key Laboratory of Hematology of Nanjing Medical University, Collaborative Innovation Center for Cancer Personalized Medicine Nanjing, Jiangsu Province
| | - Jianyong Li
- Department of Hematology, Jiangsu Province Hospital, The First Affiliated Hospital of Nanjing Medical University, Key Laboratory of Hematology of Nanjing Medical University, Collaborative Innovation Center for Cancer Personalized Medicine Nanjing, Jiangsu Province
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De Back TR, Kater AP, Tonino SH. Autoimmune cytopenias in chronic lymphocytic leukemia: a concise review and treatment recommendations. Expert Rev Hematol 2018; 11:613-624. [DOI: 10.1080/17474086.2018.1489720] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Affiliation(s)
- Tim R. De Back
- Department of Hematology and Lymphoma and Myeloma Center (LYMMCARE), Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - Arnon P. Kater
- Department of Hematology and Lymphoma and Myeloma Center (LYMMCARE), Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - Sanne H. Tonino
- Department of Hematology and Lymphoma and Myeloma Center (LYMMCARE), Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
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Response to cyclosporine A and corticosteroids in adult patients with acquired pure red cell aplasia: serial experience at a single center. Int J Hematol 2018; 108:123-129. [DOI: 10.1007/s12185-018-2446-y] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2018] [Revised: 03/22/2018] [Accepted: 03/22/2018] [Indexed: 10/17/2022]
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Poudyal BS, Tuladhar S, Gyawali B. TKI-induced pure red cell aplasia: first case report of pure red cell aplasia with both imatinib and nilotinib. ESMO Open 2016; 1:e000058. [PMID: 27843612 PMCID: PMC5070250 DOI: 10.1136/esmoopen-2016-000058] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2016] [Accepted: 04/28/2016] [Indexed: 11/05/2022] Open
Abstract
Tyrosine-kinase inhibitors (TKIs) represent the only hopes for long-term survival for patients with chronic myeloid leukaemia (CML) and gastrointestinal stromal tumours. Thus, uninterrupted use of TKIs is of importance in such patients. Pure red cell aplasia (PRCA) is a rare disorder, not previously known to be associated with TKIs. We present, to the best of our knowledge, the first case of a patient with CML who developed PRCA secondary to both imatinib and nilotinib. Although PRCA was controlled on withdrawal of TKI, TKI continuation in the patient with CML is important. So we treated him with prednisone, but his haemoglobin started to drop on resumption of imatinib. He was changed to nilotinib but again developed PRCA, which did not improve with steroids. We treated him with cyclosporine and were able to reintroduce nilotinib at a reduced dose without further complications. This case report makes physicians aware of this rare complication of TKIs and also provides encouragement that PRCA could be controlled and TKI continued.
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Affiliation(s)
- Bishesh Sharma Poudyal
- Clinical Haematology and Bone Marrow Transplant Unit, Civil Service Hospital, Kathmandu, Nepal; Department of Haemato-Oncology, Nobel Hospital, Kathmandu, Nepal
| | - Sampurna Tuladhar
- Department of Pathology , Civil Service Hospital , Kathmandu , Nepal
| | - Bishal Gyawali
- Department of Haemato-Oncology , Nobel Hospital , Kathmandu , Nepal
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Abstract
Hypoproliferative anemia results from the inability of bone marrow to produce adequate numbers of red blood cells. The list of conditions that cause hypoproliferative anemia is long, starting from common etiologies as iron deficiency to rarer diagnoses of constitutional bone marrow failure syndromes. There is no perfect diagnostic algorithm, and clinical data may not always clearly distinguish "normal" from "abnormal", yet it is important for practicing clinicians to recognize each condition so that treatment can be initiated promptly. This review describes diagnostic approaches to hypoproliferative anemia, with particular emphasis on bone marrow failure syndromes.
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Affiliation(s)
- Kazusa Ishii
- Hematology Branch, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD.
| | - Neal S Young
- Hematology Branch, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD
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8
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Visco C, Barcellini W, Maura F, Neri A, Cortelezzi A, Rodeghiero F. Autoimmune cytopenias in chronic lymphocytic leukemia. Am J Hematol 2014; 89:1055-62. [PMID: 24912821 DOI: 10.1002/ajh.23785] [Citation(s) in RCA: 76] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2014] [Revised: 05/28/2014] [Accepted: 06/06/2014] [Indexed: 12/20/2022]
Abstract
Chronic lymphocytic leukemia (CLL) is frequently complicated by secondary autoimmune cytopenias (AIC) represented by autoimmune hemolytic anemia (AIHA), immune thrombocytopenia (ITP), pure red cell aplasia, and autoimmune granulocytopenia. The distinction of immune cytopenias from cytopenias due to bone marrow infiltration, usually associated with a worse outcome and often requiring a different treatment, is mandatory. AIHA and ITP are more frequently found in patients with unfavorable biological risk factors for CLL. AIC secondary to CLL respond less favorably to standard treatments than their primary forms, and treating the underlying CLL with chemotherapy or monoclonal antibodies may ultimately be necessary.
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Affiliation(s)
- Carlo Visco
- Department of Cell Therapy and Hematology; Ospedale San Bortolo Vicenza
| | - Wilma Barcellini
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico; Milan
| | - Francesco Maura
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico; Milan
- Department of Clinical Sciences and Community Health; University of Milan; Milan
| | - Antonino Neri
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico; Milan
- Department of Clinical Sciences and Community Health; University of Milan; Milan
| | - Agostino Cortelezzi
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico; Milan
- Department of Clinical Sciences and Community Health; University of Milan; Milan
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Pure red cell aplasia complicating the course of long-standing mantle cell lymphoma. Int J Hematol 2014; 99:777-81. [PMID: 24668076 DOI: 10.1007/s12185-014-1563-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2013] [Revised: 02/22/2014] [Accepted: 02/23/2014] [Indexed: 10/25/2022]
Abstract
Pure red cell aplasia (PRCA) is a rare cause of severe hypoplastic anemia characterized by profound depletion of erythroid precursors. Although PRCA may be associated with lymphoproliferative diseases, it has never been described in mantle cell lymphoma (MCL). We report what to our knowledge is the first case of a patient with indolent, non-nodal MCL complicated by PRCA. The patient presented with severe hypoproliferative anemia in the setting of a long-standing diagnosis of B-cell chronic lymphocytic leukemia. Bone marrow studies revealed the complete absence of erythroid progenitors. Cyclin D1 positivity on immunohistochemistry, confirmed by a positive FISH for t(11;14) (q13;q32), established the final diagnosis of MCL in conjunction with PRCA. Rituximab monotherapy led to rapid remission of splenomegaly and the leukemic picture, but the patient achieved transfusion independency only with subsequent administration of cyclosporine-A, and remained so during the subsequent 15 months despite the gradual disease recurrence.
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Dharmshaktu P, Gupta N, Dhanwal DK. Successful treatment of acquired pure red cell aplasia with oral corticosteroids in a patient with B-cell CLL. BMJ Case Rep 2013; 2013:bcr2013201027. [PMID: 24234432 PMCID: PMC3830188 DOI: 10.1136/bcr-2013-201027] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
We present the case of a 57-year-old male patient diagnosed with chronic lymphoid leukaemia (CLL) B-cell type along with moderate anaemia. On follow-up investigations the aetiology of anaemia turned out to be pure red cell aplasia (PRCA) on trephine bone biopsy with an elevated serum erythropoietin level. The patient received blood transfusion support. He showed remarkable improvement on oral corticosteroids (prednisolone 60 mg/daily dose) with no further requirement of blood transfusion over next 3 months. However, when the dose of steroid was tapered down to 10 mg/day, the anaemia reappeared. An increase in the dose of steroid brought the haemoglobin level back to normal. Anaemia in CLL can be due to many reasons, of which PRCA is an uncommon association occurring in only around 1% of patients with CLL and usually refractory to the conventional treatment with steroids. This PRCA secondary to CLL is considered to be immune in origin and a response to combination of immunosuppressive therapy such as steroids, cyclosporine, rituximab is anticipated. Our case responded completely to oral steroids alone.
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MESH Headings
- Administration, Oral
- Adrenal Cortex Hormones/administration & dosage
- Adrenal Cortex Hormones/therapeutic use
- Bone Marrow/pathology
- Diagnosis, Differential
- Humans
- Leukemia, Lymphocytic, Chronic, B-Cell/complications
- Leukemia, Lymphocytic, Chronic, B-Cell/diagnosis
- Male
- Middle Aged
- Prednisolone/administration & dosage
- Prednisolone/therapeutic use
- Red-Cell Aplasia, Pure/diagnosis
- Red-Cell Aplasia, Pure/drug therapy
- Red-Cell Aplasia, Pure/etiology
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Sharma P, Singh T, Mishra D, Gaiha M. Parvovirus B-19 induced acute pure red cell aplasia in patients with chronic lymphocytic leukemia and neurofibromatosis type-1. Hematology 2013; 11:257-9. [PMID: 17178664 DOI: 10.1080/10245330600954171] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022] Open
Abstract
Parvovirus B19 induced pure red cell aplasia (PRCA) has been previously reported in a variety of settings. We present two cases, an adult patient with chronic lymphocytic leukemia (CLL) and a child with neurofibromatosis type-1 (NF-1), where the abrupt appearance of severe anemia raised ominous clinical suspicions. Evidence of recent parvovirus B19 infection in association with the selective erythroid precursor deficiency in marrow helped exclude other etiologies. We emphasize the importance of bearing this infectious agent in mind, even when there are associated disorders (such as CLL) that may independently cause PRCA. An association of NF-1 with acute PRCA has not been described in indexed English literature in the past.
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Affiliation(s)
- Prashant Sharma
- Department of Pathology, Maulana Azad Medical College, Bahadur Shah Zafar Marg, New Delhi, 110002, India.
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Abstract
We report results of Rituximab therapy in four patients with chronic immune thrombocytopenic purpura (ITP) refractory to 3-8 prior therapeutic regimens. Rituximab was administered at a dose of 375 mg/m2 once weekly for 4-6 weeks. Three out of four patients achieved a complete remission (rise to platelet count above 100,000/microl). Response duration was 4, 16+, and 11+ months. Rituximab was well tolerated but one patient (a 77 year-old male) developed two serious infections, pneumonia and a hepatic abscess, at 2 and 4 months. We conclude that Rituximab is effective in patients with refractory ITP; nevertheless, careful patient selection is mandatory.
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Affiliation(s)
- Chrisavgi Lalayanni
- Department of Hematology and Bone Marrow Transplantation Unit, George Papanicolaou Hospital, Thessaloniki, Greece
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Laurenti L, Vannata B, Innocenti I, Autore F, Santini F, Sica S, Efremov DG. The use of monoclonal antibodies in the treatment of autoimmune complications of chronic lymphocytic leukemia. Mediterr J Hematol Infect Dis 2013; 5:e2013027. [PMID: 23667725 PMCID: PMC3647707 DOI: 10.4084/mjhid.2013.027] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2013] [Accepted: 04/04/2013] [Indexed: 12/27/2022] Open
Abstract
Autoimmune cytopenias are a frequent complication in CLL, occurring in approximately 5-10% of the patients. The most common manifestation is autoimmune haemolytic anaemia, followed by immune thrombocytopenia and only rarely pure red blood cell aplasia or autoimmune granulocytopenia. Initial treatment is as for the idiopathic autoimmune cytopenias, with most patients responding to conventional corticosteroid therapy. Patients, who do not respond to conventional therapy after 4-6 weeks, should be considered for alternative immunosuppression, monoclonal antibody therapy or splenectomy. While randomized trials demonstrating the benefit of rituximab in CLL-related autoimmune diseases are still lacking, there are considerable data in the literature that provide evidence for its effectiveness. The monoclonal antibody alemtuzumab also displays considerable activity against both the malignant disease and the autoimmune complication in patients with CLL, although at the expense of greater toxicity. A number of new monoclonal antibodies, such as ofatumumab, GA-101, lumiliximab, TRU-016, epratuzumab, and galiximab, are currently investigated in CLL and their activity in CLL-related autoimmune cytopenias should be evaluated in future studies.
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Affiliation(s)
- Luca Laurenti
- Department of Hematology, Catholic University of Rome, “A. Gemelli” Hospital, Largo A. Gemelli 8, Rome, Italy
| | - Barbara Vannata
- Department of Hematology, Catholic University of Rome, “A. Gemelli” Hospital, Largo A. Gemelli 8, Rome, Italy
| | - Idanna Innocenti
- Department of Hematology, Catholic University of Rome, “A. Gemelli” Hospital, Largo A. Gemelli 8, Rome, Italy
| | - Francesco Autore
- Department of Hematology, Catholic University of Rome, “A. Gemelli” Hospital, Largo A. Gemelli 8, Rome, Italy
| | - Francesco Santini
- Department of Hematology, Catholic University of Rome, “A. Gemelli” Hospital, Largo A. Gemelli 8, Rome, Italy
| | - Simona Sica
- Department of Hematology, Catholic University of Rome, “A. Gemelli” Hospital, Largo A. Gemelli 8, Rome, Italy
| | - Dimitar G. Efremov
- Department of Molecular Hematology, International Centre for Genetic Engineering & Biotechnology, Campus A. Buzzati-Traverso, Rome, Italy
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Stephens DM, Byrd JC. Improving the Treatment Outcome of Patients with Chronic Lymphocytic Leukemia Through Targeted Antibody Therapy. Hematol Oncol Clin North Am 2013; 27:303-27. [DOI: 10.1016/j.hoc.2012.12.003] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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Coleman N, Murphy PT, Thornton P, Quinn J. Pure red cell aplasia complicating chronic lymphocytic leukemia: rapid response to high-dose methylprednisolone and rituximab. Leuk Lymphoma 2013; 54:2333-5. [PMID: 23480495 DOI: 10.3109/10428194.2013.780652] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Affiliation(s)
- Niamh Coleman
- Department of Haematology, Beaumont Hospital , Dublin , Ireland
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16
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Pure red cell aplasia associated with CD20+ myeloma: complete remission with rituximab. Ann Hematol 2013; 92:1425-6. [PMID: 23494205 DOI: 10.1007/s00277-013-1721-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2013] [Accepted: 02/27/2013] [Indexed: 10/27/2022]
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17
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Oscier D, Dearden C, Eren E, Erem E, Fegan C, Follows G, Hillmen P, Illidge T, Matutes E, Milligan DW, Pettitt A, Schuh A, Wimperis J. Guidelines on the diagnosis, investigation and management of chronic lymphocytic leukaemia. Br J Haematol 2012; 159:541-64. [PMID: 23057493 DOI: 10.1111/bjh.12067] [Citation(s) in RCA: 53] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
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18
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Gupta RK, Ezeonyeji AN, Thomas AS, Scully MA, Ehrenstein MR, Isenberg DA. A case of pure red cell aplasia and immune thrombocytopenia complicating systemic lupus erythematosus: response to rituximab and cyclophosphamide. Lupus 2011; 20:1547-50. [PMID: 21993386 DOI: 10.1177/0961203311411349] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Pure red cell aplasia (PRCA) is a recognized but rare complication of systemic lupus erythematosus (SLE) and is characterized by the near absence of red blood cell precursors in the bone marrow but with normal megakaryocyte and granulocytes. We report a novel case of acquired PRCA occurring simultaneously with immune thrombocytopenia in the context of active SLE. Both syndromes were refractory to conventional treatment but responded to rituximab and cyclophosphamide.
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Affiliation(s)
- R K Gupta
- Department of Rheumatology, University College Hospital, London, UK
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19
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Hodgson K, Ferrer G, Pereira A, Moreno C, Montserrat E. Autoimmune cytopenia in chronic lymphocytic leukaemia: diagnosis and treatment. Br J Haematol 2011; 154:14-22. [DOI: 10.1111/j.1365-2141.2011.08707.x] [Citation(s) in RCA: 66] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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20
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Rituximab–cyclophosphamide–dexamethasone combination in the management of autoimmune cytopenias associated with chronic lymphocytic leukemia. Leukemia 2010; 25:473-8. [DOI: 10.1038/leu.2010.278] [Citation(s) in RCA: 52] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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21
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Zaja F, Vianelli N, Sperotto A, Patriarca F, Tani M, Marin L, Tiribelli M, Candoni A, Baccarani M, Fanin R. Anti-CD20 Therapy for Chronic Lymphocytic Leukemia-associated Autoimmune Diseases. Leuk Lymphoma 2010; 44:1951-5. [PMID: 14738149 DOI: 10.1080/1042819031000119235] [Citation(s) in RCA: 58] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Rituximab is active in chronic lymphocytic leukemia (CLL) and may interfere with autoantibodies production in some immune diseases. We report the results of rituximab treatment in 7 patients with CLL-associated symptomatic autoimmune diseases refractory to standard immunosuppressive therapies: warm antibody hemolytic anemia (AHA) 4 patients, cold agglutinin disease (CAD) 1, immune thrombocytopenia (IT) 1, axonal degenerating neuropathy (ADN) 1. Rituximab was given at the dose of 375 mg/m2 per week for 4 weeks. One patient with AHA and one with CAD achieved complete normalization of hemoglobin levels and laboratory signs of haemolysis, with response duration (RD) of 8+ and 38+ months, respectively. In the patient with IT, complete remission was reached after the first week of treatment and RD was 6 months. The patient with ADN achieved a marked neurological improvement after rituximab therapy, with RD of 12 months. Retreatment of both patients with IT and ADN was effective. Rituximab may be an alternative agent for the treatment CLL-associated autoimmune diseases.
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MESH Headings
- Adult
- Aged
- Aged, 80 and over
- Anemia, Hemolytic, Autoimmune/drug therapy
- Anemia, Hemolytic, Autoimmune/etiology
- Antibodies, Monoclonal/therapeutic use
- Antibodies, Monoclonal, Murine-Derived
- Antigens, CD20/immunology
- Antigens, CD20/metabolism
- Antineoplastic Agents/therapeutic use
- Humans
- Immunosuppressive Agents/therapeutic use
- Leukemia, Lymphocytic, Chronic, B-Cell/complications
- Leukemia, Lymphocytic, Chronic, B-Cell/drug therapy
- Lymphoma, B-Cell/drug therapy
- Male
- Middle Aged
- Nerve Degeneration/drug therapy
- Nerve Degeneration/etiology
- Peripheral Nervous System Diseases/drug therapy
- Peripheral Nervous System Diseases/etiology
- Purpura, Thrombocytopenic, Idiopathic/drug therapy
- Purpura, Thrombocytopenic, Idiopathic/etiology
- Rituximab
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Affiliation(s)
- Francesco Zaja
- Clinica Ematologica, Policlinico Universitario, P. zza S. M. Misericordia, 33100 Udine, Italy.
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22
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Jaglowski SM, Alinari L, Lapalombella R, Muthusamy N, Byrd JC. The clinical application of monoclonal antibodies in chronic lymphocytic leukemia. Blood 2010; 116:3705-14. [PMID: 20610811 PMCID: PMC2981531 DOI: 10.1182/blood-2010-04-001230] [Citation(s) in RCA: 88] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2010] [Accepted: 06/23/2010] [Indexed: 01/02/2023] Open
Abstract
Chronic lymphocytic leukemia (CLL) represents the most prevalent adult leukemia. Treatment with chemotherapy over the past 3 decades has been palliative. The introduction of therapeutic antibodies has increased the number of treatment options for this disease. Despite this increase, our true understanding of the mechanism of action of antibody therapy in CLL remains limited. Rituximab, a CD20 antibody, is currently widely used in combination-based strategies for both previously untreated symptomatic CLL and as salvage therapy. Recent data suggest that the addition of rituximab to fludarabine with or without cyclophosphamide prolongs survival in younger patients with CLL. Other improved CD20 antibodies with promising clinical activity, including ofatumumab and GA-101, are coming forward. Alemtuzumab, a CD52 antibody, likewise has demonstrated benefit in both symptomatic, previously untreated CLL and in patients with relapsed disease but has less selectivity. Development of other therapeutic antibodies targeting alternative B-cell-specific antigens in CLL has been less successful, although many promising candidate antibodies and/or small modular immune pharmaceuticals (SMIPs) are coming forward. In addition, recent efforts to combine currently applied therapeutic antibodies with other biologic and targeted therapies with efficacy in CLL offers the potential to move toward alternative non-chemotherapy-based treatment approaches.
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MESH Headings
- Adult
- Alemtuzumab
- Antibodies, Monoclonal/immunology
- Antibodies, Monoclonal/therapeutic use
- Antibodies, Monoclonal, Humanized
- Antibodies, Monoclonal, Murine-Derived/therapeutic use
- Antibodies, Neoplasm/therapeutic use
- Antineoplastic Agents/therapeutic use
- Autoimmune Diseases/etiology
- Autoimmune Diseases/therapy
- Clinical Trials as Topic
- Combined Modality Therapy
- Humans
- Leukemia, B-Cell/immunology
- Leukemia, B-Cell/therapy
- Leukemia, Lymphocytic, Chronic, B-Cell/complications
- Leukemia, Lymphocytic, Chronic, B-Cell/immunology
- Leukemia, Lymphocytic, Chronic, B-Cell/therapy
- Models, Immunological
- Rituximab
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Affiliation(s)
- Samantha M Jaglowski
- Division of Hematology-Oncology, Department of Internal Medicine, College of Medicine, The Ohio State University, Columbus, OH, USA
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23
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Kaneko H, Shimura K, Nishida K, Fujiwara Y, Matsumoto Y, Kuroda J, Horiike S, Yokota S, Ohkawara Y, Taniwaki M. Pure red cell aplasia caused by parvovirus B19 in two patients without chronic hemolysis. J Infect Chemother 2010; 17:268-71. [PMID: 20820839 DOI: 10.1007/s10156-010-0106-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2010] [Accepted: 07/24/2010] [Indexed: 11/26/2022]
Abstract
Infection with human parvovirus B19 (PVB19) induces acquired pure red cell aplasia (PRCA). Chronic hemolytic anemia is well known as an underlying condition. However, additional factors have been recognized to accompany parvoviral PRCA; however, there are only limited reports on iron-deficiency anemia (IDA) and rituximab-induced B-cell dysfunction. We report two patients with PVB19-associated PRCA confirmed by positivity of viral DNA. Although they had no chronic hemolysis, patient 1 had IDA, and patient 2 had remitted small-lymphocytic lymphoma treated with rituximab-containing chemotherapy. Absence of reticulocytes in peripheral blood and marked depletion of erythroid precursors in bone marrow were observed both. Whereas patient 1 received only symptomatic therapy because anemia was not severe, patient 2 was treated with steroids, as PRCA etiology was at first uncertain, and immunological PRCA was not excluded. Both showed rapid increase of reticulocyte counts and recovery from anemia. Although immunoglobulin is considered effective for parvoviral PRCA, notable adverse reactions have been reported. When anemic symptom is not severe, reticulocyte observation only is recommended. The effects of steroids should also be re-evaluated. Optimal treatment according to disease severity remains to be established.
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MESH Headings
- Adult
- Anemia, Iron-Deficiency/complications
- Antibodies, Monoclonal/therapeutic use
- Antibodies, Monoclonal, Murine-Derived/therapeutic use
- DNA, Viral/analysis
- DNA, Viral/genetics
- Female
- Hemolysis
- Humans
- Leukemia, Lymphocytic, Chronic, B-Cell/complications
- Leukemia, Lymphocytic, Chronic, B-Cell/therapy
- Middle Aged
- Parvoviridae Infections/virology
- Parvovirus B19, Human/genetics
- Parvovirus B19, Human/isolation & purification
- Red-Cell Aplasia, Pure/virology
- Rituximab
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Affiliation(s)
- Hiroto Kaneko
- Department of Hematology, Aiseikai-Yamashina Hospital, 19-4 Shichouno-cho, Yamashina-ku, Kyoto, 607-8086, Japan.
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24
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Abstract
Rituximab is a class I chimeric anti-CD20 antibody that has shown efficacy in chronic lymphocytic leukemia (CLL), both as a single agent and in combination with traditional chemotherapies. The modest activity demonstrated in early studies evaluating rituximab in relapsed CLL was improved with higher doses or more dose-intensive regimens that overcame the unfavorable pharmacokinetic features commonly found in CLL. These studies led to a variety of combination trials of rituximab with chemotherapy, where both phase II and later phase III studies have shown great promise for the advancement of CLL therapy. Despite the therapeutic success of rituximab in CLL, studies demonstrating the definitive relative mechanism of tumor clearance are still lacking and this requires further investigation. In addition to being used as a therapy for CLL, rituximab is an effective treatment for autoimmune CLL complications such as hemolytic anemia and immune thrombocytopenia (ITP). Patients with CLL may experience early infusion-related side effects that can be diminished with corticosteroid pretreatment and stepped-up dosing. Risk factors for infusion-related toxicity may relate to atypical CLL expressing bright CD20 antigen expression, although several different studies have not clearly implicated elevated white blood cell count as a risk factor. Other adverse events, including delayed cytopenias, reactivation of hepatitis B, and development of progressive multifocal leukoencephalopathy, are rare. Future efforts focusing on novel combination-based strategies will be required to fully appreciate the benefit of this therapy in CLL.
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Affiliation(s)
- Samantha M Jaglowski
- Division of Hematology-Oncology, Department of Medicine, The Ohio State University, Columbus, OH
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25
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Abstract
Patients with B-chronic lymphocytic leukaemia /small lymphocytic lymphoma (CLL) have a 5-10% risk of developing autoimmune complications, which primarily cause cytopaenia. These autoimmune cytopaenias can occur at any stage of CLL and do not have independent prognostic significance. The most common autoimmune complication is autoimmune haemolytic anaemia with a lower frequency of immune thrombocytopaenia and pure red blood cell aplasia and only rarely, autoimmune granulocytopaenia (AIG). Autoimmune cytopaenia should always be considered in the differential diagnosis of cytopaenia in patients with CLL. Patients with CLL can also have more than one form of autoimmune cytopaenia, which can occur together with bone-marrow failure. Treatment is usually effective but rarely curative for autoimmune cytopaenia complicating CLL. Optimal therapy will depend on a timely and accurate diagnosis of autoimmune cytopaenia and should be individualised according to the severity of the cytopaenia and the presence or absence of concomitant progressive CLL requiring therapy.
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Affiliation(s)
- Clive S Zent
- Division of Hematology, Mayo Clinic, 200 1st Street SW, Rochester, MN 55905, USA.
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26
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Abstract
Although chronic lymphocytic leukemia (CLL) remains incurable, over the past decade there have been major advances in understanding the pathophysiology of CLL and in the treatment of this disease. This has led to greatly increased response rates and durations of response but not yet improved survival. Advances in the use of prognostic factors that identify patients at high risk for progression have led us to the question whether there is still a role for a "watch and wait" approach in asymptomatic high-risk patients or whether they should be treated earlier in their disease course. Questions remain, including, what is the optimal first-line treatment and its timing and is there any role of maintenance therapy or stem cell transplantation in this disease? CLL is a disease of the elderly and not all patients are eligible for aggressive up-front chemoimmunotherapy regimens, so what is the optimal treatment approach for more frail elderly patients? It is highly likely that our treatment approaches will continue to evolve as the results of ongoing clinical trials are released and that further improvements in the outcome of this disease will result from identification of therapies that target the underlying pathophysiology of CLL.
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MESH Headings
- Age Factors
- Clinical Trials as Topic
- Combined Modality Therapy/methods
- Health Services for the Aged
- Humans
- Leukemia, Lymphocytic, Chronic, B-Cell/diagnosis
- Leukemia, Lymphocytic, Chronic, B-Cell/mortality
- Leukemia, Lymphocytic, Chronic, B-Cell/physiopathology
- Leukemia, Lymphocytic, Chronic, B-Cell/therapy
- Prognosis
- Risk Factors
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Affiliation(s)
- John G Gribben
- Institute of Cancer, Queen Mary University of London, Barts and The London School of Medicine and Dentistry, London, United Kingdom.
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27
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Smolej L, Belada D, Cermanová M, Maisnar V, Lunáková E. Severe anemia caused by combination of autoimmune hemolysis, pure red cell aplasia and massive bone marrow infiltration in an elderly patient with chronic lymphocytic leukemia: successful treatment with rituximab. Leuk Res 2010; 34:e140-1. [PMID: 20053448 DOI: 10.1016/j.leukres.2009.11.013] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2009] [Revised: 11/14/2009] [Accepted: 11/15/2009] [Indexed: 11/16/2022]
MESH Headings
- Aged
- Anemia, Hemolytic/complications
- Anemia, Hemolytic/drug therapy
- Antibodies, Monoclonal/therapeutic use
- Antibodies, Monoclonal, Murine-Derived
- Antineoplastic Agents/therapeutic use
- Antineoplastic Combined Chemotherapy Protocols/therapeutic use
- Autoimmune Diseases/complications
- Autoimmune Diseases/drug therapy
- Chlorambucil/therapeutic use
- Cyclophosphamide/therapeutic use
- Humans
- Leukemia, Lymphocytic, Chronic, B-Cell/complications
- Leukemia, Lymphocytic, Chronic, B-Cell/drug therapy
- Leukemia, Lymphocytic, Chronic, B-Cell/physiopathology
- Male
- Prednisone/therapeutic use
- Red-Cell Aplasia, Pure/complications
- Red-Cell Aplasia, Pure/drug therapy
- Rituximab
- Salvage Therapy/methods
- Vincristine/therapeutic use
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28
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Ratanatharathorn V, Pavletic S, Uberti JP. Clinical applications of rituximab in allogeneic stem cell transplantation: Anti-tumor and immunomodulatory effects. Cancer Treat Rev 2009; 35:653-61. [DOI: 10.1016/j.ctrv.2009.07.004] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2009] [Revised: 07/15/2009] [Accepted: 07/18/2009] [Indexed: 11/24/2022]
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29
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Sawada K, Hirokawa M, Fujishima N. Diagnosis and management of acquired pure red cell aplasia. Hematol Oncol Clin North Am 2009; 23:249-59. [PMID: 19327582 DOI: 10.1016/j.hoc.2009.01.009] [Citation(s) in RCA: 48] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Pure red cell aplasia is a syndrome characterized by a severe normocytic anemia, reticulocytopenia, and absence of erythroblasts from an otherwise normal bone marrow. Although the causes and natural course of this syndrome are variable and although the anemia in some patients can be managed by treatment of an underlying inflammatory or neoplastic disease, the pathogenesis of a large number of cases is autoimmune, including those associated with thymoma, and are best managed with immunosuppressive therapy.
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Affiliation(s)
- Kenichi Sawada
- Division of Hematology, Department of Medicine, Akita University School of Medicine, Hondo 1-1-1, Akita 018-8543, Japan.
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30
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MacCallum S, Groves M, Brass D, Cunningham J, Sales M, Gelly K, Tauro S. Autoimmune pancytopenia following combination chemotherapy for chronic lymphocytic leukaemia: Figure 1. J Clin Pathol 2009; 62:468-70. [DOI: 10.1136/jcp.2008.061143] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
Autoimmune haemolysis or thrombocytopenia can complicate purine nucleoside monotherapy for chronic lymphocytic leukaemia (CLL), but Evans syndrome is rare. This is a report of the occurrence of pancytopenia secondary to a unique combination of red cell aplasia with autoimmune thrombocytopenia and neutropenia in a patient with CLL following treatment with fludarabine and cyclophosphamide. This case is unusual for the simultaneous targeting of three haemopoietic lineages by immune dysfunction following fludarabine and cyclophosphamide, which is a treatment regimen believed to reduce autoimmune haematological toxicity in CLL.
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31
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D'Arena G, Cascavilla N. Chronic Lymphocytic Leukemia-Associated Pure Red Cell Aplasia. Int J Immunopathol Pharmacol 2009; 22:279-86. [DOI: 10.1177/039463200902200204] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Pure red cell aplasia (PRCA) is a well-known marrow failure which may be acquired or constitutional/congenital, as the Diamond-Blackfan syndrome. Acquired PRCA may show as a primary hematological disorder or secondary to an associated disease, infection or drug. PRCA rarely complicates chronic lymphocytic leukemia (CLL), may occur anytime in the course of the disease and, in this context, it is a minority of total PRCA. Anemia due to PRCA in CLL patients must be carefully evaluated and differentiated from other causes (autoimmune hemolytic anemia, neoplastic lymphocyte infiltration of bone marrow, chemotherapy) that require a different therapeutic approach. PRCA is thought to be an immunologically mediated disorder, but there is no uniformity in the setting of the management. Immunosuppressive therapy is frequently given, such as steroids and cyclosporin-A. Recently, anecdotal cases have been published on the effectiveness of monoclonal antibodies rituximab and alemtuzumab.
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Affiliation(s)
- G. D'Arena
- Hematology and Stem Cell Transplantation Unit, IRCCS “Casa Sollievo della Sofferenza” Hospital, San Giovanni Rotondo, Italy
| | - N. Cascavilla
- Hematology and Stem Cell Transplantation Unit, IRCCS “Casa Sollievo della Sofferenza” Hospital, San Giovanni Rotondo, Italy
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32
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D’Arena G, Vigliotti ML, Dell’Olio M, Villa MR, Mantuano S, Scalzulli PR, La Sala A, Abbadessa A, Mastrullo L, Cascavilla N. Rituximab to treat chronic lymphoproliferative disorder-associated pure red cell aplasia. Eur J Haematol 2009; 82:235-9. [DOI: 10.1111/j.1600-0609.2008.01187.x] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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33
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Sawada K, Fujishima N, Hirokawa M. Acquired pure red cell aplasia: updated review of treatment. Br J Haematol 2008; 142:505-14. [PMID: 18510682 PMCID: PMC2592349 DOI: 10.1111/j.1365-2141.2008.07216.x] [Citation(s) in RCA: 146] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [Abstract] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Pure red cell aplasia (PRCA) is a syndrome characterized by a severe normocytic anaemia, reticulocytopenia, and absence of erythroblasts from an otherwise normal bone marrow. Primary PRCA, or secondary PRCA which has not responded to treatment of the underlying disease, is treated as an immunologically-mediated disease. Although vigorous immunosuppressive treatments induce and maintain remissions in a majority of patients, they carry an increased risk of serious complications. Corticosteroids were used in the treatment of PRCA and this has been considered the treatment of first choice although relapse is not uncommon. Cyclosporine A (CsA) has become established as one of the leading drugs for treatment of PRCA. However, common concerns have been the number of patients treated with CsA who achieve sustained remissions and the number that relapse. This article reviews the current status of CsA therapy and compares it to other treatments for diverse PRCAs.
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Affiliation(s)
- Kenichi Sawada
- Department of Internal Medicine III, Division of Haematology, Akita University Graduate School of Medicine, Akita, Japan.
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34
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Abstract
Abstract
The majority of disease-specific complications in chronic lymphocytic leukemia (CLL), notably infection and autoimmunity, relate to the underlying alterations in immune function. Both cellular and humoral immunity are impaired with qualitative and quantitative defects in B cells, T cells, NK cells, neutrophils and the monocyte/macrophage lineage. Virtually all patients have reduced immunoglobulin levels, even in early stages, and this is associated with an increased frequency and severity of infection. Although prophylactic intravenous immunoglobulin may be of clinical benefit in selected patients, it does not reduce mortality and is certainly not cost-effective. Autoimmune complications occur in up to a quarter of CLL patients and predominantly target blood cells. Autoimmune hemolytic anemia (AHA) is the most common manifestation; immune thrombocytopenia, pure red cell aplasia and autoimmune neutropenia are less common, while non-hematological autoimmunity is rare. The UK CLL4 trial is the largest prospective trial in CLL to examine the significance of both a positive direct antiglobulin test (DAT) and AHA. The study confirmed the usefulness of the DAT in predicting the development of AHA or not, demonstrated that AHA occurred more frequently in patients receiving treatment with chlorambucil or fludarabine alone compared with the combination of fludarabine and cyclophosphamide, and showed that a positive DAT and the development of AHA were poor prognostic markers. Management of CLL-associated autoimmunity rests on good supportive care and the use of immunosuppressive therapies such as steroids and cyclosporine. Splenectomy remains useful, and monoclonal antibodies (rituximab and alemtuzumab) have given promising results.
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35
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Lussana F, Caberlon S, Altomare S, Lanfredini M, Cattaneo M. A rare case of autoimmune haemolytic anaemia due to warm IgA autoantibodies with reticulocytopenia. Intern Emerg Med 2007; 2:153-6. [PMID: 17634826 DOI: 10.1007/s11739-007-0048-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2006] [Accepted: 10/25/2006] [Indexed: 11/27/2022]
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36
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Borthakur G, O'Brien S, Wierda WG, Thomas DA, Cortes JE, Giles FJ, Kantarjian HM, Lerner S, Keating MJ. Immune anaemias in patients with chronic lymphocytic leukaemia treated with fludarabine, cyclophosphamide and rituximab ? incidence and predictors. Br J Haematol 2007; 136:800-5. [PMID: 17341265 DOI: 10.1111/j.1365-2141.2007.06513.x] [Citation(s) in RCA: 75] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Immune anaemias (IA) [auto-immune haemolytic anaemia (AIHA) and pure red cell aplasia (PRCA)] are complications of chronic lymphocytic leukaemia (CLL). Fludarabine has been associated with AIHA, whereas both rituximab and cyclophosphamide have been used to treat this condition. Combining these agents with fludarabine may reduce the likelihood of AIHA. We report on the incidence, outcome and pretreatment predictors of IA in 300 patients treated with fludarabine, cyclophosphamide and rituximab (FCR). Nineteen patients (6.5%) developed IA [AIHA (5.8%), PRCA (0.7%)] on or after treatment with FCR. Most patients (82.4%) with AIHA had a negative direct antiglobulin test (DAT). Additional markers of haemolysis (indirect hyperbilirubinaemia, reticulocytosis, low haptoglobin and elevated lactate dehydrogenase levels) confirmed the presence of AIHA in these patients. The majority of patients responded to therapies including steroids, ciclosporin, i.v. immunoglobulin, etc. High pretreatment levels of beta-2 microglobulin predicted for development of IA. No haemolytic crisis was observed during FCR therapy in eight patients with AIHA prior to FCR. Thus, the incidence of IA among CLL patients treated with FCR was comparable with historical rates. The diagnosis of AIHA can be considered even if the DAT is negative. Pre-existing AIHA need not preclude front-line FCR therapy.
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MESH Headings
- Adolescent
- Adult
- Aged
- Anemia, Hemolytic, Autoimmune/diagnosis
- Anemia, Hemolytic, Autoimmune/drug therapy
- Anemia, Hemolytic, Autoimmune/etiology
- Antibodies, Monoclonal/administration & dosage
- Antibodies, Monoclonal, Murine-Derived
- Antineoplastic Combined Chemotherapy Protocols/therapeutic use
- Cyclophosphamide/administration & dosage
- Female
- Glucocorticoids/administration & dosage
- Humans
- Leukemia, Lymphocytic, Chronic, B-Cell/blood
- Leukemia, Lymphocytic, Chronic, B-Cell/drug therapy
- Male
- Middle Aged
- Prospective Studies
- Red-Cell Aplasia, Pure/diagnosis
- Red-Cell Aplasia, Pure/drug therapy
- Red-Cell Aplasia, Pure/etiology
- Retrospective Studies
- Rituximab
- Treatment Outcome
- Vidarabine/administration & dosage
- Vidarabine/analogs & derivatives
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Affiliation(s)
- Gautam Borthakur
- Department of Leukemia, M.D. Anderson Cancer Center, Houston, TX 77030, USA.
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37
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Cho JH, Choi WS, Huh KR, Won JE, Lee YK, Zang DY, Kim HJ. A Case of Immunoglobulin Therapy for Pure Red Cell Aplasia Induced by Parvovirus B19. THE KOREAN JOURNAL OF HEMATOLOGY 2007. [DOI: 10.5045/kjh.2007.42.3.283] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Affiliation(s)
- Jae Hyun Cho
- Department of Internal Medicine, College of Medicine, Hallym University, Chuncheon, Korea
| | - Won Sub Choi
- Department of Internal Medicine, College of Medicine, Hallym University, Chuncheon, Korea
| | - Kyung Rim Huh
- Department of Internal Medicine, College of Medicine, Hallym University, Chuncheon, Korea
| | - Ji Eon Won
- Department of Internal Medicine, College of Medicine, Hallym University, Chuncheon, Korea
| | - Young Kyung Lee
- Department of Laboratory Medicine, College of Medicine, Hallym University, Chuncheon, Korea
| | - Dae Young Zang
- Department of Internal Medicine, College of Medicine, Hallym University, Chuncheon, Korea
| | - Hyo Jung Kim
- Department of Internal Medicine, College of Medicine, Hallym University, Chuncheon, Korea
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38
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Dungarwalla M, Marsh JCW, Tooze JA, Lucas G, Ouwehand W, Pettengell R, Dearden CE, Gordon Smith EC, Elebute MO. Lack of clinical efficacy of rituximab in the treatment of autoimmune neutropenia and pure red cell aplasia: implications for their pathophysiology. Ann Hematol 2006; 86:191-7. [PMID: 17123083 DOI: 10.1007/s00277-006-0202-5] [Citation(s) in RCA: 43] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2006] [Accepted: 09/11/2006] [Indexed: 11/25/2022]
Abstract
We describe 11 patients with severe refractory autoimmune cytopenias treated with the anti-CD20 monoclonal antibody rituximab. Six patients had autoimmune neutropenia (AIN), two had pure red cell aplasia (PRCA), one had AIN and autoimmune haemolytic anaemia, one had AIN and immune thrombocytopaenia purpura (ITP) and one had PRCA and ITP. Rituximab was administered at a dose of 375 mg/m(2) as an intravenous infusion weekly for 4 weeks. Six of eight patients with AIN and all three patients with PRCA did not respond. Two patients died: one with resistant AIN and autoimmune haemolytic anaemia died of pneumocytis pneumonia infection, and one with PRCA and ITP died of an acute exacerbation of bronchiectasis. Rituximab in AIN and PRCA appears to be less effective than Campath-1H when compared to historical data from our group. This supports the hypothesis that T cells may be important in the pathophysiology of AIN and PRCA.
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MESH Headings
- Adult
- Aged
- Anemia, Hemolytic, Autoimmune/drug therapy
- Anemia, Hemolytic, Autoimmune/pathology
- Antibodies, Monoclonal/administration & dosage
- Antibodies, Monoclonal/adverse effects
- Antibodies, Monoclonal/therapeutic use
- Antibodies, Monoclonal, Murine-Derived
- Bronchiectasis/chemically induced
- Drug Administration Routes
- Drug Administration Schedule
- Female
- Humans
- Immunologic Factors/administration & dosage
- Immunologic Factors/adverse effects
- Immunologic Factors/therapeutic use
- Male
- Middle Aged
- Neutropenia/drug therapy
- Neutropenia/pathology
- Pilot Projects
- Pneumonia, Pneumocystis/chemically induced
- Purpura, Thrombocytopenic/drug therapy
- Purpura, Thrombocytopenic/pathology
- Red-Cell Aplasia, Pure/drug therapy
- Red-Cell Aplasia, Pure/pathology
- Rituximab
- Time Factors
- Treatment Outcome
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Affiliation(s)
- M Dungarwalla
- Department of Haematology, St George's Hospital, Tooting, London, UK
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39
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Pamuk GE, Turgut B, Demir M, Tezcan F, Vural O. The successful treatment of refractory autoimmune hemolytic anemia with rituximab in a patient with chronic lymphocytic leukemia. Am J Hematol 2006; 81:631-3. [PMID: 16906592 DOI: 10.1002/ajh.20671] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
The most frequent autoimmune complication in chronic lymphocytic leukemia (CLL) is autoimmune hemolytic anemia (AIHA). There are various treatment modalities; however, there is not much experience with the use of the chimeric anti-CD20 monoclonal antibody rituximab in the autoimmune complications of CLL. Here, we present our patient with CLL and AIHA whose AIHA was unresponsive to various treatment modalities. The administration of 375 mg/m(2)/day rituximab weekly for four cycles halted hemolysis and resulted in resolution of the patient's anemia. One year after therapy, the patient is well with a normal blood count. Rituximab might be preferred over other treatment modalities in the autoimmune complications of CLL because it is effective and has fewer side effects than other therapies.
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MESH Headings
- Aged
- Anemia, Hemolytic, Autoimmune/complications
- Anemia, Hemolytic, Autoimmune/diagnosis
- Anemia, Hemolytic, Autoimmune/drug therapy
- Antibodies, Monoclonal/administration & dosage
- Antibodies, Monoclonal, Murine-Derived
- Follow-Up Studies
- Humans
- Leukemia, Lymphocytic, Chronic, B-Cell/complications
- Male
- Rituximab
- Treatment Outcome
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Affiliation(s)
- Gülsüm Emel Pamuk
- Division of Hematology, Trakya University Medical Faculty, Edirne, Turkey.
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40
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Abstract
Traditionally, the goal of therapy in chronic lymphocytic leukemia (CLL) has been palliative, with first-line therapy using alkylating agents and/or involved field radiotherapy (depending on the stage of disease and sites of involvement) because of the older age of affected patients and the low rate of complete remissions (CRs) with no improvement in overall survival despite treatment. With increasing knowledge about the biology, molecular genetics, and prognostic factors of the disease, the philosophy of care for patients with CLL has evolved from palliation to aiming for a potential cure, especially in younger patients. Furthermore, multiple treatment options have emerged, including purine analogues, monoclonal antibodies, and potentially stem cell transplantation. These have been associated with higher frequencies of CRs and longer durations of responses compared to conventional chemotherapy. In addition, a subset of patients treated with chemoimmunotherapy can achieve durable CRs and molecular remissions. This may translate into improved disease-free survival and potentially a "cure." Because of the heterogeneous nature of CLL, new prognostic markers are currently being incorporated into clinical trials to determine their role in routine clinical practice. This review summarizes current therapeutic regimens that are being evaluated in patients with CLL and management of disease-related complications.
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Affiliation(s)
- Karen W L Yee
- Department of Leukemia, University of Texas M. D. Anderson Cancer Center, Houston, TX 77030, USA
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41
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Abstract
For decades, chemotherapy was the only available approach for patients with advanced lymphoid malignancies. Treatment paradigms were dramatically altered by the availability of novel and active targeted agents, particularly the monoclonal antibodies, alemtuzumab and rituximab. These agents are now playing an increasingly important role in the treatment of lymphoid malignancies. Alemtuzumab is being used earlier in the course of chronic lymphocytic leukemia in patients with a more intact immune system, when it is likely to have its greatest activity. The immunosuppressive properties of monoclonal antibodies are also being explored in the stem cell transplant setting, including in vivo purging and, with alemtuzumab, for the management of graft-versus-host disease. Rituximab has become ubiquitous in the treatment of most B-cell malignancies. Further research with this antibody is focused on optimizing its use and determining its role in each of the relevant disease states. In addition, newer antibodies are in development for treating chronic lymphocytic leukemia and other B-cell malignancies. New treatment regimens, including combinations of monoclonal antibodies, could enhance complete response rates and prolong progression-free survival, perhaps eventually improving our ability to cure patients with lymphoid malignancies.
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Affiliation(s)
- Bruce D Cheson
- Department of Hematology, Georgetown University Hospital, Lombardi Comprehensive Cancer Center, Washington, DC 20007, USA.
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42
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Narra K, Borghaei H, Al-Saleem T, Höglund M, Smith MR. Pure red cell aplasia in B-cell lymphoproliferative disorder treated with rituximab: Report of two cases and review of the literature. Leuk Res 2006; 30:109-14. [PMID: 16043218 DOI: 10.1016/j.leukres.2005.05.017] [Citation(s) in RCA: 35] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2005] [Accepted: 05/23/2005] [Indexed: 11/17/2022]
Abstract
Pure red cell aplasia (PRCA) is an unusual cause of anemia in patients with chronic lymphoproliferative disorders. Here, we present two cases of PRCA, one associated with chronic lymphocytic leukemia (CLL) and the other with splenic marginal zone lymphoma, in which the PRCA responded dramatically to treatment with rituximab. We then review the literature on PRCA in lymphoma and response to rituximab. PRCA associated with CLL or lymphoma may be another indication for rituximab therapy.
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MESH Headings
- Antibodies, Monoclonal/administration & dosage
- Antibodies, Monoclonal, Murine-Derived
- Antineoplastic Agents/administration & dosage
- Female
- Humans
- Leukemia, Lymphocytic, Chronic, B-Cell/complications
- Leukemia, Lymphocytic, Chronic, B-Cell/drug therapy
- Leukemia, Lymphocytic, Chronic, B-Cell/pathology
- Lymphoma/complications
- Lymphoma/drug therapy
- Lymphoma/pathology
- Middle Aged
- Red-Cell Aplasia, Pure/complications
- Red-Cell Aplasia, Pure/drug therapy
- Red-Cell Aplasia, Pure/pathology
- Rituximab
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Affiliation(s)
- Kalyani Narra
- Department of Medical Oncology, Fox Chase Cancer Center, 333 Cottman Avenue, Philadelphia, PA 19111, USA.
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43
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Jiménez-Gonzalo FJ, Ríos-Herranz E, García-Donas Gabaldón G. [Pure red cell aplasia associated with chronic lymphocytic leukaemic successfully treated with rituximab]. Med Clin (Barc) 2005; 125:717-8. [PMID: 16324487 DOI: 10.1016/s0025-7753(05)72165-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
MESH Headings
- Aged
- Antibodies, Monoclonal/therapeutic use
- Antibodies, Monoclonal, Murine-Derived
- Antineoplastic Agents/therapeutic use
- Humans
- Leukemia, Lymphocytic, Chronic, B-Cell/complications
- Leukemia, Lymphocytic, Chronic, B-Cell/drug therapy
- Male
- Red-Cell Aplasia, Pure/complications
- Rituximab
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44
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Abstract
Rituximab, a human/mouse chimeric anti-CD20 antibody, has become part of standard therapy for patients with CD20-expressing B-cell lymphoma, and is currently under investigation for other indications including autoimmune diseases, in particular rheumatoid arthritis (RA). Its characteristic tolerability profile was established soon after clinical testing began and compares favourably with chemotherapy. The majority of patients experience mild to moderate infusion-related reactions (IRRs) during the first administration of rituximab, but the incidence decreases markedly with subsequent infusions. Current data suggest that the type of adverse events in patients with RA are similar to those in lymphoma, but that adverse events related to the rituximab infusions are less severe and less frequent. Rituximab induces a rapid depletion of normal CD20-expressing B-cells in the peripheral blood, and levels remain low or undetectable for 2-6 months before returning to pretreatment levels, generally within 12 months. Serum immunoglobulin levels remain largely stable, although a reduction in IgM has been described. T-cells are unaffected by rituximab and consequently opportunistic infections rarely occur in association with rituximab therapy. When used in combination with a variety of chemotherapeutic regimens, rituximab does not add to the toxicity of chemotherapy, with the exception of a higher rate of neutropenia. However, this does not translate into a higher infection rate. Over 540,000 patients worldwide have now received rituximab and serious adverse reactions have occurred in a small minority of patients, but for the great majority of patients, rituximab is safe and well tolerated.
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Affiliation(s)
- Eva Kimby
- Center of Hematology, Karolinska University Hospital, Stockholm, Sweden.
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45
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Morimoto A, Kuriyama K, Tsuji K, Isoda K, Hibi S, Todo S, Sugimoto T, Imashuku S. Use of rituximab to treat refractory Diamond-Blackfan anemia. Eur J Haematol 2005; 74:442-4. [PMID: 15813920 DOI: 10.1111/j.1600-0609.2004.00394.x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
We report here the first case with Diamond-Blackfan anemia (DBA) who responded to rituximab. The patient is an 8-yr-old Japanese girl with refractory DBA accompanied by complex congenital heart disease. She received two doses of rituximab, 375 mg/m(2)/wk. She became transfusion independent 6 months after the treatment without any serious side effect. However, after 8 months of transfusion-free period, her condition returned to the pretreatment level with recovery of peripheral B cells. Rituximab may be a successful therapy for refractory DBA where B cells play a crucial role in the pathogenesis of the severe anemia.
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Affiliation(s)
- Akira Morimoto
- Department of Pediatrics, Kyoto Prefectural University of Medicine, Graduate School of Medical Science, Kyoto, Japan.
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46
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Oyaizu N, Kozai Y, Kodo H, Sunaga S, Iwabuchi K, Higashihara M, Mori S. A case of pure red cell aplasia complicated with diffuse large B cell lymphoma, T-cell-rich/histiocyte-rich variant: effectiveness of rituximab and implications for a common immunopathogenic role of B lymphocytes. Acta Haematol 2005; 113:194-7. [PMID: 15870490 DOI: 10.1159/000084450] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2004] [Accepted: 08/18/2004] [Indexed: 11/19/2022]
Abstract
Diffuse large B cell lymphoma, T-cell-rich/histiocyte-rich variant (DLBL-TH), is characterized by the presence of neoplastic B cells set in a background containing numerous non-neoplastic T lymphocytes and histiocytes. We report here the case of a patient with DLBL-TH who developed overt pure red cell aplasia (PRCA) following chemotherapy and autologous peripheral blood stem cell transplantation. Posttransplantation bone marrow biopsies revealed the absence of erythroid precursors associated with lymphoid aggregates composed of B cells mixed with numerous T cells and histiocytes. Administration of rituximab has led to complete recovery of erythropoiesis, which was associated not only with B cell depletion but also with a marked reduction in bone marrow T cells and histiocytes. These observations strongly suggest the particular pathogenetic role of the patient's B cells in inducing PRCA and recruiting T cells and histiocytes in situ.
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MESH Headings
- Antibodies, Monoclonal/administration & dosage
- Antibodies, Monoclonal, Murine-Derived
- Antineoplastic Agents/administration & dosage
- B-Lymphocytes/pathology
- Erythropoiesis/drug effects
- Histiocytes/pathology
- Humans
- Lymphoma, B-Cell/complications
- Lymphoma, B-Cell/pathology
- Lymphoma, B-Cell/therapy
- Lymphoma, Large B-Cell, Diffuse/complications
- Lymphoma, Large B-Cell, Diffuse/pathology
- Lymphoma, Large B-Cell, Diffuse/therapy
- Male
- Middle Aged
- Peripheral Blood Stem Cell Transplantation
- Red-Cell Aplasia, Pure/drug therapy
- Red-Cell Aplasia, Pure/etiology
- Red-Cell Aplasia, Pure/pathology
- Rituximab
- T-Lymphocytes/pathology
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Affiliation(s)
- Naoki Oyaizu
- Department of Laboratory Medicine, Institute of Medical Science, University of Tokyo, Tokyo, Japan.
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47
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Liu NS, O'Brien S. Monoclonal antibodies in the treatment of chronic lymphocytic leukemia. Med Oncol 2005; 21:297-304. [PMID: 15579912 DOI: 10.1385/mo:21:4:297] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2004] [Accepted: 04/27/2004] [Indexed: 11/11/2022]
Abstract
Traditional therapy for chronic lymphocytic leukemia (CLL) has consisted of alkylating agents, purine analogs, or a combination of these drugs. These agents are effective at producing remissions but are not curative.Thus, new drugs are still needed to improve the outcome of patients with CLL. The introduction of monoclonal antibodies, such as rituximab and alemtuzumab, provides a novel therapeutic modality.Rituximab is an active agent in CLL. Standard doses of rituximab result in higher response rates in previously untreated than in relapsed patients but low complete response (CR) rates. Rituximab is most effective in combination with chemotherapy, especially fludarabine-based regimens in the first-line and salvage setting. Rituximab is also useful in the treatment of complications of CLL, such as pure red cell aplasia, autoimmune thrombocytopenia, and autoimmune hemolytic anemia. Alemtuzumab has impressive activity in patients with refractory CLL and may play an important role in the consolidation treatment of CLL. Alemtuzumab is most efficacious at clearing disease in the peripheral blood and bone marrow. Bulky lymphadenopathy is less sensitive to therapy. Because of the significant lymphopenia associated with alemtuzumab, antibacterial and antiviral prophylaxis should always be used.
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MESH Headings
- Alemtuzumab
- Antibodies, Monoclonal/therapeutic use
- Antibodies, Monoclonal, Humanized
- Antibodies, Monoclonal, Murine-Derived
- Antibodies, Neoplasm/therapeutic use
- Antineoplastic Agents/therapeutic use
- Clinical Trials as Topic
- Drug Resistance, Neoplasm
- Humans
- Leukemia, Lymphocytic, Chronic, B-Cell/immunology
- Leukemia, Lymphocytic, Chronic, B-Cell/therapy
- Recurrence
- Rituximab
- Treatment Outcome
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Affiliation(s)
- Nina Shih Liu
- Department of Leukemia, The University of Texas, M.D. Anderson Cancer Center, Houston, TX 77030, USA
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48
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Gorman C, Leandro M, Isenberg D. Does B cell depletion have a role to play in the treatment of systemic lupus erythematosus? Lupus 2005; 13:312-6. [PMID: 15230284 DOI: 10.1191/0961203304lu1018oa] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
B cell dysfunction and pathogenic autoantibody formation are thought to be critical in the pathogenesis of systemic lupus erythematosus (SLE). In this review we will summarize the results of attempts to utilize B cell depletion, based on the use of a chimeric monoclonal antibody (MAb) specific for human CD20, rituximab, for the treatment of patients with SLE.
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Affiliation(s)
- C Gorman
- Centre for Rheumatology, The Middlesex Hospital, University College London, UK
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49
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Isobe Y, Sugimoto K, Shiraki Y, Nishitani M, Koike K, Oshimi K. Successful high-titer immunoglobulin therapy for persistent parvovirus B19 infection in a lymphoma patient treated with rituximab-combined chemotherapy. Am J Hematol 2004; 77:370-3. [PMID: 15558805 DOI: 10.1002/ajh.20200] [Citation(s) in RCA: 34] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
A 40-year-old female diagnosed with follicular lymphoma was treated with rituximab-combined chemotherapy. Although she achieved complete remission, she developed progressive anemia and reticulocytopenia. Bone marrow examination revealed features of pure red cell aplasia and hemophagocytosis. In addition, the appearance of large pronormoblasts suggested that she was infected with parvovirus B19. Excess viral DNA in her bone marrow confirmed that her illness was caused by persistent parvovirus B19 infection. Serum immunoglobulin levels decreased beyond the lower normal limit, which indicated that her humoral immunity was impaired after rituximab-combined chemotherapy. Although she had been infected with parvovirus B19, she was re-infected and failed to control the viral expansion. High-titer immunoglobulin against parvovirus B19 was intravenously administrated and resulted in remarkable reticulocytosis and improvement of anemia. High-titer immunoglobulin, which contained a sufficient amount of neutralizing antibodies against parvovirus B19, likely inactivated most viruses in vivo. We successfully eradicated the virus after 2 courses of high-dose therapy at 0.5 g/kg/day every week followed by 8 courses of maintenance therapy at 0.1 g/kg/day every other week. It is important to consider that parvovirus B19 infection is a possible cause of progressive anemia in B-cell lymphoma patients treated with rituximab-combined chemotherapy. We propose that the use of high-titer immunoglobulin against parvovirus B19 may enable such immunocompromised patients to eradicate the virus before sufficient immune system reconstruction.
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MESH Headings
- Adult
- Antibodies, Monoclonal/administration & dosage
- Antibodies, Monoclonal/therapeutic use
- Antibodies, Monoclonal, Murine-Derived
- Antineoplastic Combined Chemotherapy Protocols/administration & dosage
- Antineoplastic Combined Chemotherapy Protocols/therapeutic use
- Bone Marrow/pathology
- Female
- Humans
- Immunocompromised Host
- Immunoglobulins, Intravenous/administration & dosage
- Immunoglobulins, Intravenous/therapeutic use
- Lymphoma, Follicular/complications
- Lymphoma, Follicular/drug therapy
- Lymphoma, Follicular/immunology
- Opportunistic Infections/complications
- Opportunistic Infections/drug therapy
- Opportunistic Infections/immunology
- Parvoviridae Infections/complications
- Parvoviridae Infections/drug therapy
- Parvoviridae Infections/immunology
- Parvovirus B19, Human/drug effects
- Rituximab
- Treatment Outcome
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Affiliation(s)
- Yasushi Isobe
- Division of Hematology, Department of Medicine, Juntendo University School of Medicine, Tokyo, Japan.
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50
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Mantadakis E, Danilatou V, Stiakaki E, Kalmanti M. Rituximab for refractory Evans syndrome and other immune-mediated hematologic diseases. Am J Hematol 2004; 77:303-10. [PMID: 15495242 DOI: 10.1002/ajh.20180] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
The authors describe a 21-year-old man with long-lasting Evans syndrome refractory to corticosteroids and immunosuppressive agents; the patient responded to four weekly infusions of rituximab. The patient relapsed with thrombocytopenia 7 months post-therapy and was successfully re-treated with two weekly doses of the same monoclonal antibody. He remains in remission for 7-plus months after the second treatment. Therapy was well tolerated, and no infectious complications occurred, despite avoiding administration of prophylactic gammaglobulin. Rituximab appears safe and modestly effective in a variety of immune-mediated hematologic diseases, including autoimmune hemolytic anemia, chronic immune thrombocytopenia, Evans syndrome, pure red cell aplasia, mixed type II cryoglobulinemia, cold agglutinin disease, and Waldenstrom's macroglobulinemia. However, as most of the published literature consists of case reports and small case series, international collaboration is essential in order to better define the efficacy and safety of this agent in children and adults with hematologic diseases.
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MESH Headings
- Adult
- Anemia, Hemolytic, Autoimmune/blood
- Anemia, Hemolytic, Autoimmune/drug therapy
- Anemia, Hemolytic, Autoimmune/immunology
- Antibodies, Monoclonal/adverse effects
- Antibodies, Monoclonal/therapeutic use
- Antibodies, Monoclonal, Murine-Derived
- Follow-Up Studies
- Humans
- Male
- Platelet Count
- Purpura, Thrombocytopenic, Idiopathic/blood
- Purpura, Thrombocytopenic, Idiopathic/drug therapy
- Purpura, Thrombocytopenic, Idiopathic/immunology
- Rituximab
- Time Factors
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Affiliation(s)
- Elpis Mantadakis
- Department of Pediatric Hematology/Oncology, University Hospital of Heraklion, Heraklion, Crete, Greece
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