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Chandrakasan S, Jordan MB, Baker A, Behrens EM, Bhatla D, Chien M, Eckstein OS, Henry MM, Hermiston ML, Hinson AP, Leiding JW, Oladapo A, Patel SA, Pednekar P, Ray AK, Dávila Saldaña B, Sarangi SN, Walkovich KJ, Yee JD, Zoref-Lorenz A, Allen CE. Real-world treatment patterns and outcomes in patients with primary hemophagocytic lymphohistiocytosis treated with emapalumab. Blood Adv 2024; 8:2248-2258. [PMID: 38429096 DOI: 10.1182/bloodadvances.2023012217] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2023] [Revised: 01/19/2024] [Accepted: 02/09/2024] [Indexed: 03/03/2024] Open
Abstract
ABSTRACT Hemophagocytic lymphohistiocytosis (HLH) is a rare, life-threatening, hyperinflammatory syndrome. Emapalumab, a fully human monoclonal antibody that neutralizes the proinflammatory cytokine interferon gamma, is approved in the United States to treat primary HLH (pHLH) in patients with refractory, recurrent, or progressive disease, or intolerance with conventional HLH treatments. REAL-HLH, a retrospective study, conducted across 33 US hospitals, evaluated real-world treatment patterns and outcomes in patients treated with ≥1 dose of emapalumab between 20 November 2018 and 31 October 2021. In total, 46 patients met the pHLH classification criteria. Median age at diagnosis was 1.0 year (range, 0.3-21.0). Emapalumab was initiated for treating refractory (19/46), recurrent (14/46), or progressive (7/46) pHLH. At initiation, 15 of 46 patients were in the intensive care unit, and 35 of 46 had received prior HLH-related therapies. Emapalumab treatment resulted in normalization of key laboratory parameters, including chemokine ligand 9 (24/33, 72.7%), ferritin (20/45, 44.4%), fibrinogen (37/38, 97.4%), platelets (39/46, 84.8%), and absolute neutrophil count (40/45, 88.9%). Forty-two (91.3%) patients were considered eligible for transplant. Pretransplant survival was 38 of 42 (90.5%). Thirty-one (73.8%) transplant-eligible patients proceeded to transplant, and 23 of 31 (74.2%) of those who received transplant were alive at the end of the follow-up period. Twelve-month survival probability from emapalumab initiation for the entire cohort (N = 46) was 73.1%. There were no discontinuations because of adverse events. In conclusion, results from the REAL-HLH study, which describes treatment patterns, effectiveness, and outcomes in patients with pHLH treated with emapalumab in real-world settings, are consistent with the emapalumab pivotal phase 2/3 pHLH trial.
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Affiliation(s)
- Shanmuganathan Chandrakasan
- Division of Bone Marrow Transplant, Aflac Cancer and Blood Disorders Center, Children's Healthcare of Atlanta, Emory University, Atlanta, GA
| | - Michael B Jordan
- Division of Bone Marrow Transplantation and Immune Deficiency, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH
| | - Ashley Baker
- Department of Pediatrics, Division of Hematology Oncology, University of Oklahoma Health Sciences Center, Oklahoma City, OK
| | - Edward M Behrens
- Division of Rheumatology, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Deepika Bhatla
- Department of Pediatric Hematology Oncology, Saint Louis University, St. Louis, MO
| | - May Chien
- Department of Hematology-Oncology, Lucile Packard Children's Hospital at Stanford University, Palo Alto, CA
| | - Olive S Eckstein
- Division of Pediatric Hematology and Oncology, Baylor College of Medicine, Houston, TX
| | - Michael M Henry
- Department of Pediatric Hematology-Oncology, Phoenix Children's, Phoenix, AZ
| | - Michelle L Hermiston
- Department of Pediatric Hematology-Oncology, University of California San Francisco, San Francisco, CA
| | - Ashley P Hinson
- Department of Pediatric Hematology-Oncology, Atrium Health, Levine Children's Hospital, Charlotte, NC
| | - Jennifer W Leiding
- Division of Allergy and Immunology, Department of Pediatrics, Johns Hopkins University, Baltimore, MD
| | | | - Sachit A Patel
- Department of Pediatrics, University of Nebraska Medical Center, Omaha, NE
| | | | - Anish K Ray
- Department of Pediatric Hematology-Oncology, Cook Children's Medical Center, Fort Worth, TX
| | - Blachy Dávila Saldaña
- Division of Blood and Marrow Transplantation, Children's National Medical Center, Washington, DC
| | - Susmita N Sarangi
- Department of Pediatric Hematology-Oncology, MedStar Georgetown University Hospital, Washington, DC
| | - Kelly J Walkovich
- Division of Pediatric Hematology/Oncology, Department of Pediatrics, University of Michigan Medical School, Ann Arbor, MI
| | | | - Adi Zoref-Lorenz
- Division of Bone Marrow Transplantation and Immune Deficiency, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
- Division of Hematology, Hematology Institute, Meir Medical Center, Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Carl E Allen
- Division of Pediatric Hematology and Oncology, Baylor College of Medicine, Houston, TX
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Shapira S, Hirschberger N, Ofran Y, Mizrahi B, Mandel E, Benjamini O, Rabinowicz N, Zoref-Lorenz A. The effect of mind-body intervention on lymphocyte doubling time and treatment free survival in treatment-naïve chronic lymphocytic leukemia patients. Acta Haematol 2024:000538055. [PMID: 38461815 DOI: 10.1159/000538055] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2023] [Accepted: 02/16/2024] [Indexed: 03/12/2024]
Abstract
INTRODUCTION Mind-Body Intervention (MBI) serves as supportive aid in oncology. We hypothesized that MBI could impact the progression of Chronic Lymphocytic Leukemia (CLL) in the 'watch and wait' (w&w) phase. METHODS MBI was utilized in a non-randomized prospective controlled study between 02/2020-02/2022 in 76 treatment-naïve CLL patients in the w&w phase (37 intervention and 39 control patients). The primary and secondary endpoints were prolongation of Lymphocyte Doubling Time (LDT) and treatment-free survival (TFS). The prolongation of LDT was compared at 0, 180, 360, and 540 days using paired t-tests. TFS was compared between intervention and control groups using the log-rank test. Cox proportional hazards models were used to calculate the hazard ratio (HR) and 95% confidence interval (CI) for TFS in the intervention group compared to the control, stratified by the study covariates. RESULTS MBI prolonged LDT at all time points, including at day 360 (Median of 2.47 years; CI 1.05-3.9; p= 0.001). TFS at 18 months was longer in the intervention group compared to the control group (HR 0.23; CI 0.06-0.79, p=0.01). CONCLUSIONS MBI was associated with prolonged LDT and TFS in patients with CLL in the w&w phase. These results provide a basis for a larger randomized-control trial.
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Verkamp B, Zoref-Lorenz A, Francisco B, Kieser P, Mack J, Blackledge T, Brik Simon D, Yacobovich J, Jordan MB. Early response markers predict survival after etoposide-based therapy of hemophagocytic lymphohistiocytosis. Blood Adv 2023; 7:7258-7269. [PMID: 37903321 PMCID: PMC10698531 DOI: 10.1182/bloodadvances.2023010546] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2023] [Revised: 09/29/2023] [Accepted: 10/01/2023] [Indexed: 11/01/2023] Open
Abstract
Hemophagocytic lymphohistiocytosis (HLH) is a life-threatening hyperinflammatory syndrome that is most commonly treated with etoposide and dexamethasone. This standard of care therapy has improved survival, but ∼15% of patients still die in the first months after diagnosis, and poor responses prompting salvage therapy are frequent. Thus, identifying patients at risk promptly is likely to improve outcomes. We conducted a multi-institutional, retrospective study of pediatric and young adults treated per HLH-94 or HLH-2004 from 2010 to 2019 to identify patients at risk for early mortality. Biweekly data during the first 100 days of treatment were analyzed using receiver operating curves to define optimal prognostic indicators and their thresholds. The primary end point was survival to bone marrow transplant (BMT) or ∼1 year if no BMT was pursued. Eighty-nine patients met the study inclusion criteria. Pre-BMT mortality was 13% (n = 12), and overall mortality was 27% (n = 24). Laboratory markers measured on day 7 of therapy more efficiently predicted outcomes than did either pretreatment or later assessments. The most potent day 7 unfavorable marker was improvement in soluble CD25 (sCD25) of less than 25% from pretherapy levels. Absolute sCD25 level, platelet count, absolute lymphocyte count, and blood urea nitrogen were also discriminatory markers (area under the curve ≥ 0.7). The presence of ≥3 of these unfavorable markers was strongly associated with pre-BMT mortality (accuracy, 0.93). Thus, serial monitoring of sCD25 and assessment of other early (day 7) response markers optimally predicts prognosis with etoposide-based therapy and may indicate the need for earlier use of alternative, response-adapted therapeutic strategies for HLH.
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Affiliation(s)
- Bethany Verkamp
- Cancer and Blood Diseases Institute, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH
| | - Adi Zoref-Lorenz
- Hematology Institute, Meir Medical Center, Kfar Saba, Israel
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
- Division of Immunobiology, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH
| | - Brenton Francisco
- Department of Pediatrics, Mount Sinai Kravis Children’s Hospital, New York, NY
| | - Pearce Kieser
- Division of Immunobiology, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH
| | - Joana Mack
- Division of Hematology and Oncology, Arkansas Children’s Hospital, Little Rock, AR
| | - Tucker Blackledge
- Division of Hematology and Oncology, Arkansas Children’s Hospital, Little Rock, AR
| | - Dafna Brik Simon
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
- Department of Pediatric Hematology Oncology, Schneider Children’s Medical Center of Israel, Petah Tikva, Israel
| | - Joanne Yacobovich
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
- Department of Pediatric Hematology Oncology, Schneider Children’s Medical Center of Israel, Petah Tikva, Israel
| | - Michael B. Jordan
- Division of Immunobiology, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH
- Division of Bone Marrow Transplantation and Immune Deficiency, Department of Pediatrics, Cincinnati Children’s Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, OH
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Zoref-Lorenz A. Inpatient recognition and management of HLH. Hematology Am Soc Hematol Educ Program 2023; 2023:259-266. [PMID: 38066887 PMCID: PMC10727013 DOI: 10.1182/hematology.2023000509] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/18/2023]
Abstract
Hemophagocytic lymphohistiocytosis (HLH) is one of the life-threatening emergencies that a hematologist may be called upon to diagnose and manage. It is a hyperinflammatory process that develops in patients with genetic abnormalities, hematologic malignancies, chronic inflammatory states, or infections. The main clinical challenges are recognizing HLH, determining whether the immune response is aberrant or appropriate, and deciding upon therapy. Patients may present with fever, central nervous system symptoms, cytopenias, or elevated liver enzymes. Recognizing HLH is challenging because its features overlap with numerous systemic disorders, thus requiring a high level of suspicion and timely investigations to confirm the diagnosis and detect the underlying trigger. Once HLH is diagnosed, careful consideration of immunosuppressive therapy's potential benefit versus harm is necessary. Such therapy can sometimes be tailored to the underlying trigger. In the acute setting, the competing pressures of completing a thorough diagnostic process (including evaluation for the presence of lymphoma and infection) and the need for expedited treatment must be balanced. During the management of an HLH patient, continuous vigilance for the presence of as-yet unrecognized disease triggers, monitoring response, and identifying emerging complications is critical. This review will discuss the recognition and management of HLH in the inpatient setting.
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Affiliation(s)
- Adi Zoref-Lorenz
- Hematology Institute, Meir Medical Center, Kfar Saba, Israel
- Division of Immunobiology, Cincinnati Children's Medical Center, Cincinnati, OH
- School of Medicine, Tel Aviv University, Tel Aviv, Israel
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5
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Geerlinks AV, Scull B, Krupski C, Fleischmann R, Pulsipher MA, Eapen M, Connelly JA, Bollard CM, Pai SY, Duncan C, Kean LS, Baker KS, Burroughs L, Andolina JR, Shenoy S, Roehrs P, Hanna R, Talano JA, Schultz KR, Stenger EO, Lin H, Zoref-Lorenz A, McClain KL, Jordan MB, Man TK, Allen CE, Marsh RA. Alemtuzumab and CXCL9 levels predict likelihood of sustained engraftment after reduced intensity conditioning HCT. Blood Adv 2023:495332. [PMID: 37042921 PMCID: PMC10368780 DOI: 10.1182/bloodadvances.2022009478] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2022] [Revised: 02/24/2023] [Accepted: 03/14/2023] [Indexed: 04/13/2023] Open
Abstract
Overall survival following reduced intensity conditioning (RIC) allogeneic hematopoietic cell transplantation (HCT) using alemtuzumab, fludarabine, and melphalan is favorable in patients transplanted for inborn errors of immunity (IEI), but RIC is associated with high rates of mixed chimerism (MC) and secondary graft failure (GF). We hypothesized that peri-transplant alemtuzumab levels or specific patterns of inflammation would predict these risks. We assessed samples from BMT CTN 1204 (NCT01998633) to study the impact of alemtuzumab levels and cytokine patterns on MC and impending or established secondary GF (defined as donor chimerism <5% after initial engraftment and/or requirement of cellular intervention). Thirty-three patients with HLH (n=25) and other IEI (n=8) who underwent HCT with T-cell replete grafts were included. Patients with day 0 alemtuzumab levels ≤0.32μg/mL had a markedly lower incidence of MC, 14.3%, versus 90.9% in patients >0.32μg/mL (p=0.008). Impending or established secondary GF was only observed in patients with day 0 alemtuzumab levels >0.32µg/mL (p=0.08). Unexpectedly, patients with impending or established secondary GF had lower CXCL9 levels. The cumulative incidence of impending or established secondary GF in patients with a day +14 CXCL9 level ≤2394pg/mL (day +14 median) was 73.6% versus 0% in patients >2394pg/mL (p=0.002). CXCL9 levels inversely correlated with alemtuzumab levels. These findings support a relationship between alemtuzumab levels, CXCL9 levels, and sustained engraftment. These data suggest a model in which higher levels of alemtuzumab at day 0 deplete donor T-cells, inhibit the graft-versus-marrow reaction (thereby suppressing CXCL9 levels), and adversely impact sustained engraftment in the non-myeloablative HCT setting. Clinical Trial # NCT01998633.
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Affiliation(s)
- Ashley V Geerlinks
- Children's Hospital, London Health Sciences Centre, Western University, London, Canada
| | - Brooks Scull
- Baylor College of Medicine, Houston, Texas, United States
| | - Christa Krupski
- Cincinnati Children's Hospital Medical Center/University of Cincinnati, Cincinnati, Ohio, United States
| | | | - Michael A Pulsipher
- Huntsman Cancer Institute/Intermountain Primary Chlldren's Hospital, Spencer Fox Eccles School of Medicine, University of Utah., Salt Lake City, Utah, United States
| | - Mary Eapen
- Medical College of Wisconsin, Milwaukee, Wisconsin, United States
| | - James A Connelly
- Vanderbilt University Medical Center, Nashville, Tennessee, United States
| | - Catherine M Bollard
- Children's National Hospital and The George Washington University, United States
| | - Sung-Yun Pai
- National Institutes of Health, Bethesda, Maryland, United States
| | - Christine Duncan
- Dana Farber Cancer Institute, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, United States
| | - Leslie S Kean
- Dana-Farber/Boston Children's Cancer and Blood Disorders Center, Boston, Massachusetts, United States
| | - K Scott Baker
- Fred Hutchinson Cancer Center, Seattle, Washington, United States
| | - Lauri Burroughs
- Fred Hutchinson Cancer Research Center and the University of Washington, Seattle, Washington, United States
| | - Jeffrey R Andolina
- University of Rochester Medical Center, Rochester, New York, United States
| | - Shalini Shenoy
- Washington University School of Medicine, St. Louis, Missouri, United States
| | - Philip Roehrs
- University of Virginia, Charlottesville, Virginia, United States
| | - Rabi Hanna
- Cleveland Clinic, Cleveland, Ohio, United States
| | - Julie-An Talano
- Medical College of Wisconsin, Milwaukee, Wisconsin, United States
| | | | - Elizabeth O Stenger
- Aflac Cancer and Blood Disorders Center of Children's Healthcare of Atlanta and Emory University Department of Pediatrics, Atlanta, Georgia, United States
| | - Howard Lin
- Texas Children's Hospital, United States
| | | | | | - Michael B Jordan
- CINCINNATI CHILDREN'S HOSP MED CTR, Cincinnati, Ohio, United States
| | - Tsz-Kwong Man
- Baylor College of Medicine, Houston, Texas, United States
| | - Carl E Allen
- Baylor College of Medicine, Houston, Texas, United States
| | - Rebecca A Marsh
- Cincinnati Children's Hospital Medical Center, United States
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Zoref-Lorenz A, Keiser P, Israeli S, Yacobovich J, Jordan MB. Deep Multi-Omic Analysis of Familial Hemophagocytic Lymphohistiocytosis Reveals Distinctive Immune Features of the Disease. Transplant Cell Ther 2023. [DOI: 10.1016/s2666-6367(23)00457-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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7
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Zoref-Lorenz A, Yuklea M, Topaz G, Jordan MB, Ellis M. A Case of Chronic Lymphocytic Leukemia Complicated by Hemophagocytic Lymphohistiocytosis: Identifying the Aberrant Immune Response. J Gen Intern Med 2022; 37:1542-1546. [PMID: 35178648 PMCID: PMC9086000 DOI: 10.1007/s11606-022-07395-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2021] [Accepted: 01/03/2022] [Indexed: 10/19/2022]
Abstract
Hemophagocytic lymphohistiocytosis (HLH) is a life-threatening hyperinflammatory syndrome that may complicate hematologic malignancies. HLH and malignancies have common clinical features, and HLH diagnostic criteria (HLH-2004/Hscore) were not validated in this specific population. We describe a case of a 72-year-old patient with a history of chronic lymphocytic leukemia stable for over 10 years who presented with fever and cytopenia. After excluding infectious etiologies and the progression of her disease, HLH was diagnosed. The patient was treated with etoposide, dexamethasone, intravenous immunoglobulin, and rituximab. Despite initial clinical improvement, the patient deteriorated and developed pulmonary aspergillosis and CNS involvement that reflected uncontrolled HLH. The patient died 45 days after her presentation. An unusual feature of this case was that HLH was not triggered by infection, disease transformation, or treatment. This case emphasizes the challenges of differentiating the development of overwhelming HLH from other complications associated with hematologic malignancy.
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MESH Headings
- Aged
- Etoposide/therapeutic use
- Female
- Fever
- Humans
- Immunity
- Leukemia, Lymphocytic, Chronic, B-Cell/complications
- Leukemia, Lymphocytic, Chronic, B-Cell/diagnosis
- Leukemia, Lymphocytic, Chronic, B-Cell/drug therapy
- Lymphohistiocytosis, Hemophagocytic/complications
- Lymphohistiocytosis, Hemophagocytic/diagnosis
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Affiliation(s)
- Adi Zoref-Lorenz
- Hematology Institute, Meir Medical Center, Kfar Saba, Israel.
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel.
- Division of Immunobiology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA.
- Division of Bone Marrow Transplantation and Immune Deficiency, Cancer and Blood Diseases Institute, Cincinnati Children's Hospital Medical Center, 3333 Burnet Ave, Cincinnati, OH, USA.
| | - Mona Yuklea
- Hematology Institute, Meir Medical Center, Kfar Saba, Israel
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Guy Topaz
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
- Department of Internal Medicine C, Meir Medical Center, Kfar Saba, Israel
| | - Michael B Jordan
- Division of Immunobiology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
- Division of Bone Marrow Transplantation and Immune Deficiency, Cancer and Blood Diseases Institute, Cincinnati Children's Hospital Medical Center, 3333 Burnet Ave, Cincinnati, OH, USA
| | - Martin Ellis
- Hematology Institute, Meir Medical Center, Kfar Saba, Israel
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
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Setiadi A, Zoref-Lorenz A, Lee CY, Jordan MB, Chen LYC. Malignancy-associated haemophagocytic lymphohistiocytosis. Lancet Haematol 2022; 9:e217-e227. [PMID: 35101205 DOI: 10.1016/s2352-3026(21)00366-5] [Citation(s) in RCA: 28] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2021] [Revised: 11/08/2021] [Accepted: 11/15/2021] [Indexed: 01/13/2023]
Abstract
Haemophagocytic lymphohistiocytosis (HLH) is an inflammatory syndrome that can occur with cancer (malignancy-associated HLH) or with immune-activating therapies for cancer. Patients with lymphoma appear to be at particularly high risk for malignancy-associated HLH. The familial form of HLH is characterised by uncontrolled activation of macrophages and cytotoxic T cells, which can be identified by genetics or specific immune markers. However, the pathophysiology of malignancy-associated HLH is not well understood, and distinguishing pathological immune activation from the laboratory and clinical abnormalities seen in cancer and cancer treatment is challenging. Emerging diagnostic tools, such as serum cytokine or chemokine concentrations, flow cytometry, and other functional measures, are discussed. Mortality remains high with current approaches. Targeted therapy, including blockade of specific cytokines such as IL-1, IL-6, and IFNγ, and inhibition of the JAK-STAT pathways might improve outcomes for some patients. Finally, we discuss a framework for thinking of malignancy-associated HLH within a larger umbrella concept of cytokine storm syndrome.
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Affiliation(s)
- Audi Setiadi
- Department of Pathology and Laboratory Medicine, British Columbia Children's Hospital, Vancouver, BC, Canada
| | - Adi Zoref-Lorenz
- Hematology Institute, Meir Medical Center, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel; Division of Immunobiology, Cincinnati Children's Medical Center, Cincinnati, OH, USA
| | - Christina Y Lee
- Division of Hematologic Malignancies, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Michael B Jordan
- Division of Immunobiology, Cincinnati Children's Medical Center, Cincinnati, OH, USA; Division of Bone Marrow Transplantation and Immune Deficiency, Cincinnati Children's Medical Center, Cincinnati, OH, USA
| | - Luke Y C Chen
- Division of Hematology, Department of Medicine, Vancouver General Hospital, Vancouver, BC, Canada; Centre for Health Education Scholarship, University of British Columbia, Vancouver, BC, Canada.
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Zoref-Lorenz A, Murakami J, Hofstetter L, Iyer S, Alotaibi AS, Mohamed SF, Miller PG, Guber E, Weinstein S, Yacobovich J, Nikiforow S, Ebert BL, Lane A, Pasvolsky O, Raanani P, Nagler A, Berliner N, Daver N, Ellis M, Jordan MB. An improved index for diagnosis and mortality prediction in malignancy-associated hemophagocytic lymphohistiocytosis. Blood 2022; 139:1098-1110. [PMID: 34780598 PMCID: PMC8854682 DOI: 10.1182/blood.2021012764] [Citation(s) in RCA: 40] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2021] [Accepted: 10/28/2021] [Indexed: 11/20/2022] Open
Abstract
Hemophagocytic lymphohistiocytosis (HLH) is a life-threatening inflammatory syndrome that may complicate hematologic malignancies (HMs). The appropriateness of current criteria for diagnosing HLH in the context of HMs is unknown because they were developed for children with familial HLH (HLH-2004) or derived from adult patient cohorts in which HMs were underrepresented (HScore). Moreover, many features of these criteria may directly reflect the underlying HM rather than an abnormal inflammatory state. To improve and potentially simplify HLH diagnosis in patients with HMs, we studied an international cohort of 225 adult patients with various HMs both with and without HLH and for whom HLH-2004 criteria were available. Classification and regression tree and receiver-operating curve analyses were used to identify the most useful diagnostic and prognostic parameters and to optimize laboratory cutoff values. Combined elevation of soluble CD25 (>3900 U/mL) and ferritin (>1000 ng/mL) best identified HLH-2004-defining features (sensitivity, 84%; specificity, 81%). Moreover, this combination, which we term the optimized HLH inflammatory (OHI) index, was highly predictive of mortality (hazard ratio, 4.3; 95% confidence interval, 3.0-6.2) across diverse HMs. Furthermore, the OHI index identified a large group of patients with high mortality risk who were not defined as having HLH according to HLH-2004/HScore. Finally, the OHI index shows diagnostic and prognostic value when used for routine surveillance of patients with newly diagnosed HMs as well as those with clinically suspected HLH. Thus, we conclude that the OHI index identifies patients with HM and an inflammatory state associated with a high mortality risk and warrants further prospective validation.
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Affiliation(s)
- Adi Zoref-Lorenz
- Hematology Institute, Meir Medical Center, Kfar Saba, Israel
- Division of Immunobiology, Cincinnati Children's Medical Center, Cincinnati, OH
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Jun Murakami
- Clinical Laboratory, Transfusion Medicine and Cell Therapy, University of Toyama, Toyama, Japan
| | - Liron Hofstetter
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
- Institute of Hematology, Davidoff Cancer Center, Rabin Medical Center, Petah-Tikva, Israel
| | | | - Ahmad S Alotaibi
- Department of Leukemia, University of Texas MD Anderson Cancer Center, Houston, TX
- Oncology Center, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
| | | | - Peter G Miller
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA
- Division of Hematology, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
- Broad Institute of MIT and Harvard, Cambridge, MA
| | - Elad Guber
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
- Pulmonary Institute, Meir Medical Center, Kfar Saba, Israel
| | - Shiri Weinstein
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
- Internal Medicine "D," Sheba Medical Center, Ramat Gan, Israel
| | - Joanne Yacobovich
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
- Schneider Children's Medical Center of Israel, Petah Tikva, Israel
| | - Sarah Nikiforow
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA
| | - Benjamin L Ebert
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA
- Broad Institute of MIT and Harvard, Cambridge, MA
- Howard Hughes Medical Institute, Bethesda, MD
| | - Adam Lane
- Department of Pediatrics, University of Cincinnati, and Cancer and Blood Diseases Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - Oren Pasvolsky
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
- Institute of Hematology, Davidoff Cancer Center, Rabin Medical Center, Petah-Tikva, Israel
| | - Pia Raanani
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
- Institute of Hematology, Davidoff Cancer Center, Rabin Medical Center, Petah-Tikva, Israel
| | - Arnon Nagler
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
- Hematology Institute, Sheba Medical Center, Ramat Gan, Israel; and
| | - Nancy Berliner
- Division of Hematology, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Naval Daver
- Department of Leukemia, University of Texas MD Anderson Cancer Center, Houston, TX
| | - Martin Ellis
- Hematology Institute, Meir Medical Center, Kfar Saba, Israel
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Michael B Jordan
- Division of Immunobiology, Cincinnati Children's Medical Center, Cincinnati, OH
- Division of Bone Marrow Transplantation and Immune Deficiency, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, OH
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Chaturvedi V, Marsh RA, Zoref-Lorenz A, Owsley E, Chaturvedi V, Nguyen TC, Goldman JR, Henry MM, Greenberg JN, Ladisch S, Hermiston ML, Jeng M, Naqvi A, Allen CE, Wong HR, Jordan MB. T-cell activation profiles distinguish hemophagocytic lymphohistiocytosis and early sepsis. Blood 2021; 137:2337-2346. [PMID: 33512385 PMCID: PMC8085480 DOI: 10.1182/blood.2020009499] [Citation(s) in RCA: 58] [Impact Index Per Article: 19.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2020] [Accepted: 11/25/2020] [Indexed: 12/18/2022] Open
Abstract
Hemophagocytic lymphohistiocytosis (HLH) is a fatal disorder of immune hyperactivation that has been described as a cytokine storm. Sepsis due to known or suspected infection has also been viewed as a cytokine storm. Although clinical similarities between these syndromes suggest similar immunopathology and may create diagnostic uncertainty, distinguishing them is critical as treatments are widely divergent. We examined T-cell profiles from children with either HLH or sepsis and found that HLH is characterized by acute T-cell activation, in clear contrast to sepsis. Activated T cells in patients with HLH were characterized as CD38high/HLA-DR+ effector cells, with activation of CD8+ T cells being most pronounced. Activated T cells were type 1 polarized, proliferative, and displayed evidence of recent and persistent activation. Circulating activated T cells appeared to be broadly characteristic of HLH, as they were seen in children with and without genetic lesions or identifiable infections and resolved with conventional treatment of HLH. Furthermore, we observed even greater activation and type 1 polarization in tissue-infiltrating T cells, described here for the first time in a series of patients with HLH. Finally, we observed that a threshold of >7% CD38high/HLA-DR+ cells among CD8+ T cells had strong positive and negative predictive value for distinguishing HLH from early sepsis or healthy controls. We conclude that the cytokine storm of HLH is marked by distinctive T-cell activation whereas early sepsis is not, and that these 2 syndromes can be readily distinguished by T-cell phenotypes.
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Affiliation(s)
- Vandana Chaturvedi
- Division of Immunobiology, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, University of Cincinnati, Cincinnati, OH
| | - Rebecca A Marsh
- Division of Bone Marrow Transplantation and Immune Deficiency, Cancer and Blood Diseases Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - Adi Zoref-Lorenz
- Division of Immunobiology, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, University of Cincinnati, Cincinnati, OH
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Erika Owsley
- Division of Bone Marrow Transplantation and Immune Deficiency, Cancer and Blood Diseases Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - Vijaya Chaturvedi
- Division of Bone Marrow Transplantation and Immune Deficiency, Cancer and Blood Diseases Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - Trung C Nguyen
- Section of Critical Care, Department of Pediatrics, Baylor College of Medicine, Houston, TX
| | - Jordana R Goldman
- Center for Translational Research on Inflammatory Diseases, Michael E. DeBakey VA Medical Center, Houston, TX
| | - Michael M Henry
- Center for Cancer and Blood Disorders, Phoenix Children's Hospital, Phoenix, AZ
| | - Jay N Greenberg
- Division of Hematology, Department of Pediatrics, Children's National Hospital, Washington, DC
| | - Stephan Ladisch
- Division of Hematology, Department of Pediatrics, Children's National Hospital, Washington, DC
| | - Michelle L Hermiston
- Division of Hematology Oncology, Department of Pediatrics, UCSF School of Medicine, San Francisco, CA
| | - Michael Jeng
- Hematology and Oncology, Department of Pediatrics, Stanford Medical School, Stanford, CA
| | - Ahmed Naqvi
- Department of Pediatrics, The Hospital for Sick Children, Toronto, ON, Canada
| | - Carl E Allen
- Section of Hematology/Oncology, Department of Pediatrics, Baylor College of Medicine, Houston, TX; and
| | - Hector R Wong
- Division of Critical Care, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - Michael B Jordan
- Division of Immunobiology, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, University of Cincinnati, Cincinnati, OH
- Division of Bone Marrow Transplantation and Immune Deficiency, Cancer and Blood Diseases Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
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Zoref-Lorenz A, Jordan MB. Challenges in improving global outcomes for hemophagocytic lymphohistiocytosis. Pediatr Hematol Oncol 2021; 38:191-193. [PMID: 33843440 DOI: 10.1080/08880018.2021.1912228] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Affiliation(s)
- Adi Zoref-Lorenz
- Hematology Institute, Meir Medical Center, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.,Division of Immunobiolgy, Cincinnati Children's Medical Center, Cincinnati, OH, USA
| | - Michael B Jordan
- Division of Immunobiolgy, Cincinnati Children's Medical Center, Cincinnati, OH, USA.,Division of Bone Marrow Transplantation and Immune Deficiency, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, OH, USA
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Pasvolsky O, Zoref-Lorenz A, Abadi U, Geiger KR, Hayman L, Vaxman I, Raanani P, Leader A. Hemophagocytic lymphohistiocytosis as a harbinger of aggressive lymphoma: a case series. Int J Hematol 2019; 109:553-562. [PMID: 30850926 DOI: 10.1007/s12185-019-02623-z] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2018] [Revised: 03/04/2019] [Accepted: 03/05/2019] [Indexed: 12/23/2022]
Abstract
Hemophagocytic lymphohistiocytosis (HLH) is a rare hyperinflammatory syndrome, which can manifest either secondary to a variety of underlying causes, or due to a primary genetic defect. Malignancy is the most common underlying disease in adults with HLH, with lymphomas being the most common malignancy. Lymphoma-associated hemophagocytic syndrome (LAHS) typically follows a rapidly progressive clinical course and is associated with poor prognosis. We herein present four patients with HLH associated with aggressive lymphoma. At initial presentation, the underlying etiology of the HLH was unclear. Two patients were eventually diagnosed with anaplastic large cell lymphoma, while the other two had diffuse large B cell lymphoma. Two of the patients experienced rapid clinical deterioration, one at diagnosis and the other at relapse, and both died prior to diagnosis of lymphoma despite HLH-directed therapy. These cases highlight the need for intensive management in adults with HLH without a clear etiology, especially in cases when lymphoma-associated HLH is suspected. We describe the current pitfalls in diagnosis and treatment of LAHS and discuss possible ways to improve patient management.
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Affiliation(s)
- Oren Pasvolsky
- Davidoff Cancer Center, Rabin Medical Center, Institute of Hematology, Beilinson Hospital, 49100, Petah Tikva, Israel. .,Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel.
| | - Adi Zoref-Lorenz
- Department of Internal Medicine B, Meir Medical Center, Kfar Saba, Israel.,Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Uri Abadi
- Hematology Institute and Blood Bank, Meir Medical Center, Kfar Saba, Israel.,Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Karyn Revital Geiger
- Davidoff Cancer Center, Rabin Medical Center, Institute of Hematology, Beilinson Hospital, 49100, Petah Tikva, Israel.,Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Lucille Hayman
- Department of Pathology, Rabin Medical Center, Petah Tikva, Israel.,Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Iuliana Vaxman
- Davidoff Cancer Center, Rabin Medical Center, Institute of Hematology, Beilinson Hospital, 49100, Petah Tikva, Israel.,Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Pia Raanani
- Davidoff Cancer Center, Rabin Medical Center, Institute of Hematology, Beilinson Hospital, 49100, Petah Tikva, Israel.,Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Avi Leader
- Davidoff Cancer Center, Rabin Medical Center, Institute of Hematology, Beilinson Hospital, 49100, Petah Tikva, Israel.,Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
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13
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Topaz G, Karas A, Kassem N, Kitay-Cohen Y, Pereg D, Shilo L, Zoref-Lorenz A, Hershko AY. Iodinated Contrast Media Allergy in Patients Hospitalized for Investigation of Chest Pain. The Journal of Allergy and Clinical Immunology: In Practice 2018; 6:2059-2064. [DOI: 10.1016/j.jaip.2018.03.012] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/09/2017] [Revised: 03/13/2018] [Accepted: 03/25/2018] [Indexed: 10/17/2022]
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