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Cunningham I, Sánchez Sosa S, Hamele-Bena D. Single organ microenvironment and the common features of tumors of leukemia, lymphoma, and myeloma cells growing there: A literature review. Eur J Haematol 2021; 108:169-177. [PMID: 34779527 DOI: 10.1111/ejh.13727] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2021] [Revised: 11/10/2021] [Accepted: 11/12/2021] [Indexed: 11/27/2022]
Abstract
OBJECTIVE To explore whether the growth and treatment resistance of lymphoma and myeloma tumors is similar to that previously observed in leukemic and solid tumors growing in the same organ microenvironment. METHODS All published cases of 3 primary hematologic malignancies in breast, without systemic involvement, were identified, with follow-ups solicited from authors. Treatment approaches were analyzed to highlight the most effective. RESULTS Similar histologic features and biology among primary tumors of leukemia, lymphoma, plasmacytoma, and solid breast cancer was revealed. Review of treatments: tumor-directed, chemotherapy, or combination showed the benefit of tumor removal, and use of systemic agents in adjunct, not primary, treatment. Optimal assessment is limited by few cases of PET/CT verifying limited tumor extent. The common biology observed and cases of long survival after tumor/stroma eradication point to the complicity of organ microenvironment in the chemoresistance and treatment failure commonly observed in patients. CONCLUSIONS The interaction of an organ microenvironment, particularly its adipocytes, with malignant cells, results in similar histologic changes, metastatic potential, and chemoresistance in 3 hematologic malignancies and solid cancers. Improved survival in hematologic malignancies could result from adopting PET/CT to find tumor and its extent, eradicating tumor, and elucidating common therapeutic targets.
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Affiliation(s)
- Isabel Cunningham
- Division of Hematology Oncology, Columbia University Vagelos College of Physicians and Surgeons, New York, New York, USA
| | | | - Diane Hamele-Bena
- Department of Pathology & Cell Biology, Columbia University Vagelos College of Physicians and Surgeons, New York, New York, USA
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Akahane K, Shirai K, Wakatsuki M, Suzuki M, Hatanaka S, Takahashi Y, Kawahara M, Ogawa K, Takahashi S, Oyama-Manabe N, Ashizawa M, Kimura SI, Kako S, Kanda Y. Dosimetric evaluation of ovaries and pelvic bones associated with clinical outcomes in patients receiving total body irradiation with ovarian shielding. JOURNAL OF RADIATION RESEARCH 2021; 62:918-925. [PMID: 34350969 PMCID: PMC8438484 DOI: 10.1093/jrr/rrab066] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/10/2021] [Revised: 05/11/2021] [Indexed: 05/11/2023]
Abstract
Total body irradiation (TBI) with ovarian shielding is expected to preserve fertility among hematopoietic stem cell transplant (HSCT) patients with myeloablative TBI-based regimens. However, the radiation dose to the ovaries that preserves ovarian function in TBI remains poorly understood. Furthermore, it is uncertain whether the dose to the shielded organs is associated with relapse risk. Here, we retrospectively evaluated the relationship between fertility and the dose to the ovaries, and between relapse risk and the dose to the pelvic bones. A total of 20 patients (median age, 23 years) with standard-risk hematologic diseases were included. Median follow-up duration was 31.9 months. The TBI prescribed dose was 12 Gy in six fractions for three days. Patients' ovaries were shielded with cylinder-type lead blocks. The dose-volume parameters (D98% and Dmean) in the ovaries and the pelvic bones were extracted from the dose-volume histogram (DVH). The mean ovary Dmean for all patients was 2.4 Gy, and 18 patients recovered menstruation (90%). The mean ovary Dmean for patients with menstrual recovery and without recovery were 2.4 Gy and 2.4 Gy, respectively, with no significant difference (P = 0.998). Hematological relapse was observed in five patients. The mean pelvis Dmean and pelvis D98% for relapse and non-relapse patients were 11.6 Gy and 11.7 Gy and 5.6 Gy and 5.3 Gy, respectively. Both parameters showed no significant difference (P = 0.827, 0.807). In conclusion, TBI with ovarian shielding reduced the radiation dose to the ovaries to 2.4 Gy, and preserved fertility without increasing the risk of relapse.
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Affiliation(s)
- Keiko Akahane
- Department of Radiology, Jichi Medical University Saitama Medical Center, Saitama 330-8503, Japan
| | - Katsuyuki Shirai
- Department of Radiology, Jichi Medical University Saitama Medical Center, Saitama 330-8503, Japan
- Department of Radiology, Jichi Medical University, Tochigi 329-0498, Japan
- Correspondence. Department of Radiology, Jichi Medical University Saitama Medical Center, 1-847, Amanuma-cho, Omiya-ku, Saitama, 330-8503, Japan, E-mail:
| | - Masaru Wakatsuki
- QST Hospital, National Institutes for Quantum and Radiological Science and Technology, Chiba 263-8555, Japan
| | - Masato Suzuki
- Department of Radiology, Jichi Medical University Saitama Medical Center, Saitama 330-8503, Japan
| | - Shogo Hatanaka
- Department of Radiation Oncology, Saitama Medical Center, Saitama Medical University, Saitama 350-8550, Japan
| | - Yuta Takahashi
- Department of Radiology, Jichi Medical University Saitama Medical Center, Saitama 330-8503, Japan
| | - Masahiro Kawahara
- Department of Radiology, Jichi Medical University Saitama Medical Center, Saitama 330-8503, Japan
| | - Kazunari Ogawa
- Department of Radiology, Jichi Medical University, Tochigi 329-0498, Japan
| | - Satoru Takahashi
- Department of Radiology, Jichi Medical University, Tochigi 329-0498, Japan
| | - Noriko Oyama-Manabe
- Department of Radiology, Jichi Medical University Saitama Medical Center, Saitama 330-8503, Japan
| | - Masahiro Ashizawa
- Division of Hematology, Department of Medicine, Jichi Medical University, Tochigi 350-8550, Japan
| | - Shun-ichi Kimura
- Division of Hematology, Jichi Medical University Saitama Medical Center, Saitama 330-8503, Japan
| | - Shinichi Kako
- Division of Hematology, Jichi Medical University Saitama Medical Center, Saitama 330-8503, Japan
| | - Yoshinobu Kanda
- Division of Hematology, Department of Medicine, Jichi Medical University, Tochigi 350-8550, Japan
- Division of Hematology, Jichi Medical University Saitama Medical Center, Saitama 330-8503, Japan
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Post-transplant leukemia relapse in organs: biology. and behavior in 585 reports. Crit Rev Oncol Hematol 2020; 157:103170. [PMID: 33316638 DOI: 10.1016/j.critrevonc.2020.103170] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2020] [Revised: 09/21/2020] [Accepted: 11/05/2020] [Indexed: 02/07/2023] Open
Abstract
Resistance of extramedullary leukemia growth post-transplant prevents cure. Review of its behavior detailed in 585 published cases should lead to better treatment. Leukemic tumors were found up to 13 years after transplant, most in sites inaccessible to physical exam. In 83%, marrow was not in morphologic relapse; next relapse was most often extramedullary. Induction protocols alone produced few durable responses in acute leukemias and fatal marrow aplasia in 17 %. Overall, 120 patients survived over 2 years, 43 relapse-free up to 18 years, the majority after combined tumor-directed and systemic therapy. Overall median survival was 9 months. This review highlights how results can improve: by defining extent of leukemia involvement with scans before transplant, and emergently when leukemic tumor is found after, ablating tumor directly to abort metastasis, and determining dosing of systemic chemotherapy that protects, without ablating, donor marrow. Monitoring total body remission with body scans should increase transplant cures.
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Cunningham I, Hamele‐Bena D, Guo Y, Shiomi T, Papp AC, Chakravarti B, Yang J, Shyr Y, Fisher RA. Extramedullary leukemia behaving as solid cancer: clinical, histologic, and genetic clues to chemoresistance in organ sites. Am J Hematol 2019; 94:1200-1207. [PMID: 31353508 DOI: 10.1002/ajh.25594] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2019] [Revised: 07/03/2019] [Accepted: 07/22/2019] [Indexed: 01/14/2023]
Abstract
Recent studies of leukemic tumors in individual extramedullary sites showed they adopt the clinical and metastatic behavior of solid cancers originating in those sites. To elucidate features of leukemic tumors that render them resistant to agents effective against marrow leukemia, we analyzed a series of AML breast tumors by histology, immunohistochemistry, and RNA sequencing. Striking histologic similarities to solid cancers were found: a single-filing architectural pattern virtually identical to that of invasive lobular breast carcinoma and dense desmoplastic keloid-like fibrosis similar to colon, gallbladder, and pancreas carcinomas. Sequencing found 2157 genes significantly downregulated in AML breast tumors compared to normal breast. Comparison to triple-negative breast cancer found 859 genes similarly downregulated. At least 30 of these genes have been associated with poor prognosis in breast cancers. Five were reported in AML marrow studies to correlate with poor prognosis. The findings of this pilot study suggest the seed-and-soil interaction recognized in solid cancer growth may help explain how leukemic cells, in some patients, adopt solid tumor behavior in non-marrow sites. Transformed cells that metastasize from tumor to marrow can impart chemoresistance and be an unrecognized cause of treatment failure and death. Further studies comparing leukemic tumor to simultaneous marrow could potentially identify biomarkers that predict extramedullary resistance and lead to new therapeutic targets. Recognizing the potential for leukemia to adopt solid tumor phenotype, and implementation of body scanning and ablative tumor treatment, could decrease the persistently high rates of marrow resistance and treatment failure.
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Affiliation(s)
- Isabel Cunningham
- Division of Hematology OncologyColumbia University Vagelos College of Physicians and Surgeons New York New York
| | - Diane Hamele‐Bena
- Department of Pathology and Cell BiologyColumbia University Vagelos College of Physicians and Surgeons New York New York
| | - Yan Guo
- BioinformaticsUniversity of New Mexico Albuquerque New Mexico
| | - Takayuki Shiomi
- Department of PathologyInternational University of Health and Welfare Chiba Japan
| | - Audrey C. Papp
- Center for PharmacogenomicsOhio State University Columbus Ohio
| | | | - Jianqi Yang
- Department of PharmacologyUniversity of Iowa Iowa City Iowa
| | - Yu Shyr
- Department of BiostatisticsVanderbilt University Nashville Tennessee
| | - Rory A. Fisher
- Department of PharmacologyUniversity of Iowa Iowa City Iowa
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Gaudichon J, Jakobczyk H, Debaize L, Cousin E, Galibert MD, Troadec MB, Gandemer V. Mechanisms of extramedullary relapse in acute lymphoblastic leukemia: Reconciling biological concepts and clinical issues. Blood Rev 2019; 36:40-56. [PMID: 31010660 DOI: 10.1016/j.blre.2019.04.003] [Citation(s) in RCA: 48] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2018] [Revised: 04/03/2019] [Accepted: 04/15/2019] [Indexed: 12/17/2022]
Abstract
Long-term survival rates in childhood acute lymphoblastic leukemia (ALL) are currently above 85% due to huge improvements in treatment. However, 15-20% of children still experience relapses. Relapses can either occur in the bone marrow or at extramedullary sites, such as gonads or the central nervous system (CNS), formerly referred to as ALL-blast sanctuaries. The reason why ALL cells migrate to and stay in these sites is still unclear. In this review, we have attempted to assemble the evidence concerning the microenvironmental factors that could explain why ALL cells reside in such sites. We present criteria that make extramedullary leukemia niches and solid tumor metastatic niches comparable. Indeed, considering extramedullary leukemias as metastases could be a useful approach for proposing more effective treatments. In this context, we conclude with several examples of potential niche-based therapies which could be successfully added to current treatments of ALL.
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Affiliation(s)
- Jérémie Gaudichon
- CNRS, IGDR (Institut de Génétique et Développement de Rennes), Univ Rennes, UMR 6290, Rennes F-35000, France; Pediatric Hematology and Oncology Department, University Hospital, Caen, France.
| | - Hélène Jakobczyk
- CNRS, IGDR (Institut de Génétique et Développement de Rennes), Univ Rennes, UMR 6290, Rennes F-35000, France
| | - Lydie Debaize
- CNRS, IGDR (Institut de Génétique et Développement de Rennes), Univ Rennes, UMR 6290, Rennes F-35000, France
| | - Elie Cousin
- CNRS, IGDR (Institut de Génétique et Développement de Rennes), Univ Rennes, UMR 6290, Rennes F-35000, France; Pediatric Hematology Department, University Hospital, Rennes, France
| | - Marie-Dominique Galibert
- CNRS, IGDR (Institut de Génétique et Développement de Rennes), Univ Rennes, UMR 6290, Rennes F-35000, France.
| | - Marie-Bérengère Troadec
- CNRS, IGDR (Institut de Génétique et Développement de Rennes), Univ Rennes, UMR 6290, Rennes F-35000, France
| | - Virginie Gandemer
- CNRS, IGDR (Institut de Génétique et Développement de Rennes), Univ Rennes, UMR 6290, Rennes F-35000, France; Pediatric Hematology Department, University Hospital, Rennes, France.
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Cunningham I, Worthley D. Leukemia in gastrointestinal organs as cause of treatment failure: 378 cases analyzed. Am J Hematol 2018; 93:1327-1336. [PMID: 30105897 DOI: 10.1002/ajh.25250] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2018] [Revised: 07/31/2018] [Accepted: 08/06/2018] [Indexed: 12/19/2022]
Abstract
Leukemia growing as tumors in gastrointestinal organs is an under-investigated cause of treatment failure and death. These present with symptoms often mistaken for common toxicities but may grow large before symptoms. To synthesize experience available only in case reports, 378 were analyzed. Invasive and metastatic behavior typical of solid GI tumors was revealed even when marrow was uninvolved. Within 3 months of diagnosis, 33% had died, 47% within 1 year. Survivals of 4 to 18 years after involvement suggest cure is possible. Evidence is presented that combined local and systemic therapy has successfully treated GI leukemic tumors when identified early.
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Affiliation(s)
- Isabel Cunningham
- Columbia University College of Physicians and Surgeons, New York, New York
| | - Daniel Worthley
- Cancer Theme, South Australian Health and Medical Research Institute, Adelaide, Australia
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Cunningham I, Kohno B. 18 FDG-PET/CT: 21st century approach to leukemic tumors in 124 cases. Am J Hematol 2016; 91:379-84. [PMID: 26718745 DOI: 10.1002/ajh.24287] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2015] [Accepted: 12/22/2015] [Indexed: 12/11/2022]
Abstract
Extramedullary tumors remain an obstacle to curing more acute leukemia patients. Their incidence is unknown because the presence of occult tumors that contribute to relapse is not routinely sought as in other cancers. No standard approach exists for treating tumors at most sites, apparent clinical response is typically followed by further tumors, and achievement of lengthy remission is uncommon. Body scanning with (18) FDG PET/CT now provides a means to identify the extent of occult tumors that enables directed tumor eradication and a way to evaluate tumor response. To evaluate its potential benefits, analysis was undertaken of 124 published cases scanned after apparent tumors were diagnosed. Clinical and radiologic exams underestimated extent of disease in over half of 100 cases. Among 70 cases that reported scans after various treatments, 70% achieved negative scans. Half relapsed subsequently but disease-free survivals up to 6 years were documented. These reported cases add to our knowledge of extramedullary leukemia in showing that further tumors are more likely than marrow relapse, clinical and radiologic evaluation of response is inadequate, intensive chemotherapy alone generally does not prevent progression and is associated with significant mortality, and tumor-directed plus systemic therapies appears the most effective approach, particularly to AML tumors. This analysis suggests this technology could increase our ability to eradicate all foci of leukemia, and identify tumors responsible for refractory, residual, and relapsed disease.
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Affiliation(s)
- Isabel Cunningham
- Hematology Oncology; Columbia University College of Physicians and Surgeons; New York
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Nunes V, Della Starza I, Canichella M, Cavalli M, De Propris MS, Messina M, Capria S, Torelli GF, Vitale A, Guarini A, Chiaretti S, Foà R. A case of late isolated ovarian relapse of acute lymphoblastic leukemia after an allogeneic stem cell transplant. Leuk Lymphoma 2014; 56:1517-20. [DOI: 10.3109/10428194.2014.956317] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Kidney and pancreatic extramedullary relapse in adult acute lymphoblastic leukemia: a case report and review of the literature. Case Rep Hematol 2013; 2013:637264. [PMID: 23984125 PMCID: PMC3747418 DOI: 10.1155/2013/637264] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2013] [Accepted: 06/30/2013] [Indexed: 11/18/2022] Open
Abstract
Extramedullary relapse of acute lymphoblastic leukemia (ALL) is rare and has been primarily reported in pediatric patients or hematopoietic stem cell transplant recipients. We report a case of a 62-year-old woman who presented with relapsed ALL involving her kidneys, pancreas, and bone marrow 2 years after completing chemotherapy with a standard ALL protocol. Unfortunately, her extramedullary disease progressed despite treatment. To the best of our knowledge, this is the first reported case of extramedullary relapse of B-cell ALL to the kidneys and pancreas occurring in an adult patient who had not previously undergone a hematopoietic stem cell transplant. A literature review of kidney and pancreatic extramedullary relapse in ALL is also included.
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