Hypercalcemia and osteolytic bone lesions as the major symptoms in a chronic lymphocytic leukemia/small lymphocytic lymphoma patient: a rare case

Successful Treatment of Methotrexate-associated Lymphoproliferative Disorder with the Pola-R-CHP Regimen

Methotrexate-associated lymphoproliferative disorder (MTX-LPD) constitutes a subset of lymphoid proliferations and lymphomas that are associated with immune deficiency and dysregulation. The clinical management of MTX-LPDs is contingent on their histopathological subtypes. Polatuzumab vedotin is a novel therapeutic approach that is particularly beneficial for selecting patients with previously untreated diffuse large B-cell lymphoma (DLBCL); however, DLBCL-type MTX-LPD is still treated with rituximab, cyclophosphamide, doxorubicin, vincristine, and prednisone (R-CHOP) because of the exclusion of MTX-LPD from clinical trials. We recently encountered a case of DLBCL-type MTX-LPD with parathyroid hormone-related protein-C (PTHrP)-mediated hypercalcemia that was managed with polatuzumab vedotin, rituximab, cyclophosphamide, doxorubicin, and prednisone (Pola-R-CHP). We herein report our experience to encourage hematologists to explore the safe and effective use of Pola-R-CHP under such conditions.

Extramedullary and extranodal manifestations in chronic lymphocytic leukemia - an update

Chronic lymphocytic leukemia/small lymphocytic lymphoma (CLL/SLL) is a common leukemia characterized by clonal expansion of mature CD5+/CD23 + B cells in the blood, bone marrow (BM) and lymphoid tissues. CLL can undergo extramedullary and extranodal infiltration, with one study noting an incidence of only 0.3 per 100,000 people, and in 17.6% of CLL patients in another report. The most common extranodal sites of leukemic involvement are the skin and central nervous system; however, other organs, including liver, lungs, kidney, gastrointestinal tract, bone, prostate and heart, are occasionally involved. The prognostic significance of extra-medullary CLL is still under debate, but the prognosis in such patients seems to be better in the era of novel targeted drugs. Following a diagnosis of extranodal CLL, survival appears to depend on the site of infiltration. This review presents an overview of CLL in patients with extramedullary and extranodal leukemic lesions, focusing on its epidemiology, pathogenesis, prognosis, clinical characteristics and treatment results.

A case of bone lesion in a patient with relapsed chronic lymphocytic leukemia and review of the literature

Skeletal involvement in CLL is very rare. We present a case of ileum bone lesion during in a patient receiving 5th line of therapy. Despite radiotherapy and salvage therapies, subsequent bone lesions led to a fatal outcome. Further studies on the mechanism by which bone disease develops are currently needed.

Hypercalcaemia, renal failure, anaemia and osteolytic lesions (CRAB) in chronic lymphocytic leukaemia mimicking multiple myeloma

Classical CRAB features (hypercalcaemia, renal failure, anaemia, osteolytic lesions) have been traditionally defined in patients with plasma cell dyscrasia. But these can be rare and uncommon presentations of other chronic lymphoproliferative disorders (CLPD). The pathophysiological basis of CRAB features in other CLPD need to be explored further for better outcomes and therapeutic interventions. These can present a diagnostic dilemma and requires extensive workup to rule out coexisting malignancy and myeloma. Here, we report an unusual case of B CLPD in a middle-aged male who presented with classical CRAB features along with a brief literature review. After detailed investigations, he was diagnosed as chronic lymphocytic leukaemia, without any second malignancy and responded well to ibrutinib-based therapy.

Chronic lymphocytic leukemia cells impair osteoblastogenesis and promote osteoclastogenesis: role of TNFα, IL-6 and IL-11 cytokines

Bone skeletal alterations are no longer considered a rare event in Chronic Lymphocytic Leukemia (CLL), especially at more advanced stages of the disease. This study is aimed at elucidating the mechanisms underlying this phenomenon. Bone marrow stromal cells, induced to differentiate toward osteoblasts in osteogenic medium, appeared unable to complete their maturation upon co-culture with CLL cells, CLL cells-derived conditioned media (CLL-cm) or CLL-sera (CLL-sr). Inhibition of osteoblast differentiation was documented by decreased levels of RUNX2 and osteocalcin mRNA expression, by increased osteopontin and DKK-1 mRNA levels, and by a marked reduction of mineralized matrix deposition. The addition of neutralizing TNFα, IL-11 or anti-IL-6R monoclonal antibodies to these co-cultures resulted into restoration of bone mineralization, indicating the involvement of these cytokines: these findings were further supported by silencing TNFα, IL-11 and IL-6 in leukemic cells. We also demonstrated that the addition of CLL-cm to monocytes, previously stimulated with MCSF and RANKL, significantly amplified the formation of large mature osteoclasts as well as their bone resorption activity. Moreover enhanced osteoclastogenesis, induced by CLL-cm, was significantly reduced by treating cultures with the anti-TNFα moAb Infliximab; an analogous effect was observed by the use of the BTK inhibitor Ibrutinib. CLL cells, co-cultured with mature osteoclasts, were interestingly protected from apoptosis and upregulated Ki-67. These experimental results parallel the direct correlation between TNFα amounts in CLL sera and the degree of compact bone erosion we previously described, further strengthening the indication of a reciprocal influence between leukemic cells expansion and bone structure derangement.