Acquired immune-mediated thrombophilia in lymphoproliferative disorders

Treating Acquired Factor VIII Inhibitor and Tumor-Induced Hypoglycemia in a Case of Relapsed Diffuse Large B-Cell Lymphoma

Diffuse large B-cell lymphoma (DLCBL) is a heterogenous disease, with many phenotypic subtypes and occasional paraneoplastic syndromes being present. Herein, we describe a case of a 63-year-old woman, with relapsed/refractory DLBCL (RR-DLBCL) with artifactual hypoglycemia on laboratory testing, likely related to the mechanical effects of a new factor VIII inhibitor. We demonstrate our workup, consideration, treatment, and her clinical course. This patient did not present with a bleeding phenotype despite her aberrant laboratory results, and therefore determining her risk of bleeding to weigh against further diagnostic procedures presented a difficult decision. We utilized rotational thromboelastometry (ROTEM) to assist with clinical decision making regarding her paraneoplastic factor VIII inhibitor and the patient's bleeding risk. This led to a short course of dexamethasone. Her ROTEM improved, and an excisional biopsy was performed without any bleeding. To our knowledge, this is the only reported instance where this technology was utilized in this setting. We believe utilizing ROTEM to determine bleeding risk may be a beneficial tool for clinical practice in such additional rare cases.

Cancer risk and gammopathies in 2123 adults with Gaucher disease type 1 in the International Gaucher Group Gaucher Registry

There are numerous reports of cancers in Gaucher disease (GD) from mostly small single-center studies; however, precise risk estimates and cancer types involved have not been delineated. We conducted a study involving 2123 patients with GD type 1 (GD1) to assess the incidence of hematological malignancies, gammopathies, and solid tumors in an international observational study, the International Cooperative Gaucher Group Gaucher Registry (Clinicaltrials.gov: NCT00358943). Risk for cancer overall and for each type of malignancy was compared to the United States (US) population using the Surveillance, Epidemiology, and End Results database. Natural history of gammopathy was determined through assessing the progression from a diagnosis of monoclonal gammopathy of unknown significance (MGUS) to multiple myeloma (MM). Risk for hematological malignancies was more than four times higher than expected compared to the general population: non-Hodgkin lymphoma was approximately three times higher; MM was approximately nine times higher. Age-specific incidence rates of MGUS were unexpectedly high among younger patients. The 10-year cumulative incidence of MM after diagnosis of MGUS was 7.9%, comparable to the general population. Compared to the general US population, GD1 patients were at higher risk for solid malignancies of liver (2.9 times), kidney (2.8 times), melanoma (2.5 times), and breast (1.4 times). Colorectal, prostate, and lung cancer risks were lower than expected. These findings help advance care of patients with GD1 by supporting recommendations for individualized monitoring for malignancies and antecedents such as MGUS for MM and provoke important questions of the role of glucosylceramide and related sphingolipids in cancer biology.

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

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

Venous thromboembolic complications in lymphoma patients

Lymphomas represent a heterogeneous group of malignant hematological diseases with high risk for development of venous thromboembolic complications (VTE). Consequently, VTE significantly impacts morbidity and mortality in these patients. Another concern is the financial burden of the healthcare system caused by diagnostic and therapeutic procedures of cancer-associated thrombosis (CAT). The complex biology of lymphoma, in conjunction with patient and treatment related risk factors for the development of VTE, results in a procoagulant hemostatic dysregulation. Considering the incidence of VTE in patients with lymphoma, there is an emerging demand for both reliable risks assessment model (RAM) for prediction of VTE, as well as for effective VTE prophylaxis and treatment. The clinical course of patients with malignant diseases is accompanied by a wide range of potential treatment complications, making the task of prevention and treatment of VTE even more challenging. In recent years, great progress has been achieved in understanding the pathophysiological mechanisms of thrombotic complications, while the significant number of randomized controlled trials (RCT) have provided standards of prophylaxis and treatment of VTE complications in patients with malignancy. In comparison to previous recommendations and guidelines for CAT, the use of direct oral anticoagulants (DOAC) has been gradually approaching low molecular weight heparins (LMWH) in terms of efficacy and safety profile in these indications. This systematic review is focused on the latest pathophysiological advances, risk factors assessment, prophylactic and therapeutic recommendations and guidelines concerning VTE in patients with lymphoma.

Hematological Malignancies and Arterial Thromboembolism

Established guidelines exist for prevention and treatment of venous thromboembolism in hematological malignancies, but none for arterial thromboembolism. However, arterial and venous thromboembolism share the same provoking features—including altered procoagulant factors and defective fibrinolytic system. The morbidity for arterial thromboembolism is increasing in hematological malignancies, with the advent of immunomodulatory and targeted therapy. However, survival rate for hematological malignancy is improving. Consequently, as patients with hematological malignancies live longer, comorbidities including diabetes, hypertension and dyslipidemia, may accentuate arterial thrombosis. Thus far, the scientific literature on prophylaxis and treatment for arterial thromboembolism in hematological malignancies is limited. This review highlights the pathogenesis, incidence and clinical features of arterial thromboembolism in hematological malignancies.

An unusual presentation of primary pulmonary extranodal marginal zone lymphoma of mucosal associated lymphoid tissue: An autopsy case report

A 40 year old female with no documented medical history presented to the Emergency Department with several days of lethargy and altered mental status. She was found to be anemic, thrombocytopenic, and hypotensive. The patient was found to be in severe metabolic acidosis, became bradycardic, and quickly deteriorated. Clinicians suspected thrombotic thrombocytopenic purpura, and the diagnosis was supported by ADAMTS13 testing. The clinicians attempted to place a Quinton catheter for emergent plasmapheresis, but the patient expired before definitive treatment could be initiated. Autopsy was obtained and revealed a right middle lobe consolidation grossly consistent with lymphoid tissue or tumor.

Venous thromboembolic events in lymphoma patients: Actual relationships between epidemiology, mechanisms, clinical profile and treatment

Venous thromboembolic events (VTE) are an underestimated health problem in patients with lymphoma. Many factors contribute to the pathogenesis of thromboembolism and the interplay between various mechanisms that provoke VTE is still poorly understood. The identification of parameters that are associated with an increased risk of VTE in lymphoma patients led to the creation of several risk-assessment models. The models that evaluate potential VTE risk in lymphoma patients in particular are quite limited, and have to be validated in larger study populations. Furthermore, the VTE prophylaxis in lymphoma patients is largely underused, despite the incidence of VTE. The lack of adequate guidelines for the prophylaxis and treatment of VTE in lymphoma patients, together with a cautious approach due to an increased risk of bleeding, demands great efforts to ensure the implementation of current knowledge in order to reduce the incidence and complications of VTE in lymphoma patients.

An Overview of Thrombophilia and Associated Laboratory Testing

Venous thromboembolism, usually entailing deep vein thrombosis, pulmonary embolism, or both, is a complex and multifactorial disorder, in which a number of putative conditions interplay and finally contribute to propel the individual risk over a certain degree, so ultimately culminating in the development of venous occlusive disorders. Thrombophilia is commonly defined as a propensity to develop venous thromboembolism on the basis of an underlying hypercoagulable state attributable to inherited or acquired disorders of blood coagulation or fibrinolysis. The thrombophilic conditions are conventionally classified as inherited (or genetically determined) and acquired. The former include deficiencies of natural anticoagulants such as antithrombin, protein C, protein S, increased values of clotting factors (especially factor VIII), as well as prothrombotic polymorphisms in genes encoding for factor V (i.e., factor V Leiden) and prothrombin. The latter conditions mainly entail antiphospholipid antibody syndrome, malignancy, acquired elevations of coagulation factors or acquired reduction of natural inhibitors, or hyperhomocysteinemia. Deepened knowledge of all potential risk factors, as well as the clear understanding of their role in the pathophysiology of venous thrombosis, are both essential to help achieve a faster and more efficient diagnosis of this condition as well as a more effective prophylaxis of patients at higher risk and treatment of those with manifest disease.

The challenges of lupus anticoagulants

The term "lupus anticoagulant" (LA) refers to a heterogeneous group of immunoglobulins behaving as acquired in vitro inhibitors of coagulation. These antibodies, namely anti-β2GPI and anti-prothrombin antibodies, induce the in vitro elongation of clotting time interfering with phospholipid-dependent coagulation cofactors. Positive LA is associated with thrombosis and pregnancy complications, providing one of the three laboratory criteria for the classification of the anti-phospholipid syndrome. LA is the strongest predictor of clinical events, especially when associated with other anti-phospholipid antibodies. Much more controversial is the risk conveyed by isolated and weak LA. LA detection is technically laborious, envisaging screening, mixing and confirming tests. Hopefully critical issues in LA detection, such as the interference of anticoagulants, will be overcome, in the next future.

ADAMTS13 Endopeptidase Protects against Vascular Endothelial Growth Factor Inhibitor-Induced Thrombotic Microangiopathy

Thrombotic microangiopathy (TMA) is a life-threatening condition that affects some, but not all, recipients of vascular endothelial growth factor (VEGF) inhibitors given as part of chemotherapy. TMA is also a complication of preeclampsia, a disease characterized by excess production of the VEGF-scavenging soluble VEGF receptor 1 (soluble fms-like tyrosine kinase 1; sFlt-1). Risk factors for VEGF inhibitor-related TMA remain unknown. We hypothesized that deficiency of the VWF-cleaving ADAMTS13 endopeptidase contributes to the development of VEGF inhibitor-related TMA. ADAMTS13(-/-) mice overexpressing sFlt-1 presented all hallmarks of TMA, including thrombocytopenia, schistocytosis, anemia, and VWF-positive microthrombi in multiple organs. Similar to VEGF inhibitor-related TMA in humans, these mice exhibited severely impaired kidney function and hypertension. In contrast, wild-type mice overexpressing sFlt-1 developed modest hypertension but no other features of TMA. Recombinant ADAMTS13 therapy ameliorated all symptoms of TMA in ADAMTS13(-/-) mice overexpressing sFlt-1 and normalized BP in wild-type mice. ADAMTS13 activity may thus be a critical determinant for the development of TMA secondary to VEGF inhibition. Administration of recombinant ADAMTS13 may serve as a therapeutic approach to treat or prevent thrombotic complications of VEGF inhibition.

Interference from lupus anticoagulant on von Willebrand factor measurement in splenic marginal zone lymphoma: a case report

We present a case concerning a patient with splenic marginal zone lymphoma (SMZL) and isolated prolonged activated partial thromboplastin time (aPTT) caused by lupus anticoagulant. Von Willebrand factor (VWF) activity and antigen were immeasurable by latex particle immunoturbidimetric assays, and several coagulation factor levels were decreased. However, VWF activity and antigen were normal when analyzed by other methods. Also, coagulation factor levels were normal if an aPTT reagent with low lupus anticoagulant sensitivity or a chromogenic method was applied. Altogether, the initial findings were because of lupus anticoagulant interference and in fact, the patient had normal VWF activity and coagulation status. Interference of lupus anticoagulant in clot-based assays is well known but has not previously been described in VWF assays. This is furthermore the first report in which lupus anticoagulant activity in SMZL cannot be ascribed to a monoclonal immunoglobulin. In our study, aPTT normalized after treatment, suggesting resolution of lupus anticoagulant. APTT could thus be a marker of treatment response in SMZL. Whether treatment decreases the thrombosis risk due to lupus anticoagulant remains unknown.

Post-surgical hemorrhagic infarction of the adrenal gland as the first clinical manifestation of antiphospholipid syndrome after 43 years of antibody-positivity

We report on a male patient who tested positive for antiphospholipid antibodies for 43 years without thromboembolic manifestation of antiphospholipid syndrome (APS). He has been followed up in a prospective cohort study since 2001. Following his second hip replacement surgery, the patient developed acute adrenal failure due to bilateral hemorrhagic infarction. Prophylactic anticoagulation, surgery, or an immunological reaction to blood transfusion may have triggered this late and unusually located primary manifestation of APS in our patient.