1
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Bender ST, Zeremski V, Wiech T, Mertens PR, Gross C. Case report: Acute kidney injury as the initial manifestation of chronic lymphocytic leukemia/small lymphocytic lymphoma. Front Med (Lausanne) 2023; 10:1279005. [PMID: 37928472 PMCID: PMC10622965 DOI: 10.3389/fmed.2023.1279005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2023] [Accepted: 09/20/2023] [Indexed: 11/07/2023] Open
Abstract
Chronic lymphocytic leukemia (CLL) is a lymphoproliferative disorder often diagnosed after incidental finding of leukocytosis. Renal involvement is usually clinically silent. Symptomatic renal impairment due to CLL/small lymphocytic lymphoma (SLL) cell infiltration in the kidney tissue is uncommon, and acute kidney injury (AKI) as a presenting feature is rare. In this case report, we describe the case of a patient with AKI caused by CLL/SLL infiltration as a presenting feature. Our report highlights the possibility of kidney injury as the first evident symptom of CLL/SLL. Kidney biopsy is the mainstay in these cases in order to establish a diagnosis. Treatment with zanubrutinib resulted in improved kidney function.
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Affiliation(s)
- Sascha T. Bender
- University Clinic for Nephrology and Hypertension, Diabetes and Endocrinology, Otto-von-Guericke University, Magdeburg, Germany
| | - Vanja Zeremski
- University Hospital for Hematology and Oncology, Otto-von-Guericke University, Magdeburg, Germany
| | - Thorsten Wiech
- Institute for Pathology, University Hospital Hamburg-Eppendorf, Hamburg, Germany
| | - Peter R. Mertens
- University Clinic for Nephrology and Hypertension, Diabetes and Endocrinology, Otto-von-Guericke University, Magdeburg, Germany
| | - Christian Gross
- University Clinic for Nephrology and Hypertension, Diabetes and Endocrinology, Otto-von-Guericke University, Magdeburg, Germany
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2
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Cox MC, Esposito F, Postorino M, Venditti A, Di Napoli A. Serum Paraprotein Is Associated with Adverse Prognostic Factors and Outcome, across Different Subtypes of Mature B-Cell Malignancies-A Systematic Review. Cancers (Basel) 2023; 15:4440. [PMID: 37760410 PMCID: PMC10527377 DOI: 10.3390/cancers15184440] [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: 07/20/2023] [Revised: 08/20/2023] [Accepted: 08/30/2023] [Indexed: 09/29/2023] Open
Abstract
The presence of a serum paraprotein (PP) is usually associated with plasma-cell dyscrasias, Waldenstrom Macroglobulinemia/lymphoplasmacytic lymphoma, and cryoglobulinemia. However, PP is also often reported in other high- and low-grade B-cell malignancies. As these reports are sparse and heterogeneous, an overall view on this topic is lacking, Therefore, we carried out a complete literature review to detail the characteristics, and highlight differences and similarities among lymphoma entities associated with PP. In these settings, IgM and IgG are the prevalent PP subtypes, and their serum concentration is often low or even undetectable without immunofixation. The relevance of paraproteinemia and its prevalence, as well as the impact of IgG vs. IgM PP, seems to differ within B-NHL subtypes and CLL. Nonetheless, paraproteinemia is almost always associated with advanced disease, as well as with immunophenotypic, genetic, and clinical features, impacting prognosis. In fact, PP is reported as an independent prognostic marker of poor outcome. All the above call for implementing clinical practice, with the assessment of paraproteinemia, in patients' work-up. Indeed, more studies are needed to shed light on the biological mechanism causing more aggressive disease. Furthermore, the significance of paraproteinemia, in the era of targeted therapies, should be assessed in prospective trials.
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Affiliation(s)
- Maria Christina Cox
- UOC Malattie Linfoproliferative, Fondazione Policlinico Tor Vergata, 00133 Roma, Italy
| | - Fabiana Esposito
- Ematologia, Dipartimento di Biomedicina e Prevenzione, Università Tor Vergata, 00133 Roma, Italy; (F.E.)
| | - Massimiliano Postorino
- Ematologia, Dipartimento di Biomedicina e Prevenzione, Università Tor Vergata, 00133 Roma, Italy; (F.E.)
| | - Adriano Venditti
- Ematologia, Dipartimento di Biomedicina e Prevenzione, Università Tor Vergata, 00133 Roma, Italy; (F.E.)
| | - Arianna Di Napoli
- Department of Clinical and Molecular Medicine, School of Medicine and Psychology, Sapienza University, 00189 Roma, Italy;
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3
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Khan S, Allsup D, Molica S. An updated perspective on immunoglobulin replacement in chronic lymphocytic leukaemia in the era of targeted therapies. Front Oncol 2023; 13:1135812. [PMID: 37091176 PMCID: PMC10117948 DOI: 10.3389/fonc.2023.1135812] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2023] [Accepted: 03/27/2023] [Indexed: 04/25/2023] Open
Abstract
Chronic lymphocytic leukaemia (CLL) is a malignancy of clonally expanded antigen-switched, neoplastic, mature B cells. CLL is characterised by a variable degree of immunosuppression and secondary hypogammaglobulinemia. B-cell depleting therapies have historically been deployed with a proportion of patients becoming resistant to multiple lines of treatment with an associated worsening of immunosuppression and heightened infection risk. Advances in molecular diagnostics and the development of new therapies targeting Bruton's tyrosine kinase and B-cell lymphoma-2 have resulted in novel insights into the cellular mechanisms associated with an increased infection risk and T-cell escape from the complex tumour environment found in CLL. Generally, immunoglobulin replacement therapy with polyvalent human immunoglobulin G (IgG) is indicated in patients with recurrent severe bacterial infections and low IgG levels, but there is no consensus on the threshold IgG level for initiation of such therapy. A proportion of CLL patients have residual IgG production, with preserved quality of the immunoglobulin molecules, and therefore a definition of 'IgG quality' may allow for lower dosing or less frequent treatment with immunoglobulin therapy in such patients. Immunoglobulin therapy can restore innate immunity and in conjunction with CLL targeted therapies may allow T-cell antigen priming, restore T-cell function thereby providing an escape from tumour-associated autoimmunity and the development of an immune-mediated anti-tumour effect. This review aims to discuss the mechanisms by which CLL-targeted therapy may exert a synergistic therapeutic effect with immunoglobulin replacement therapy both in terms of reducing tumour bulk and restoration of immune function.
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Affiliation(s)
- Sujoy Khan
- Department of Immunology and Allergy, Castle Hill Hospital, Hull University Teaching Hospital National Health Service (NHS) Trust, Cottingham, United Kingdom
| | - David Allsup
- Department of Haematology, Castle Hill Hospital, Hull University Teaching Hospital NHS Trust, Cottingham, United Kingdom
- Centre for Biomedicine, Hull York Medical School, University of Hull, Hull, United Kingdom
| | - Stefano Molica
- Department of Haematology, Castle Hill Hospital, Hull University Teaching Hospital NHS Trust, Cottingham, United Kingdom
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4
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Harris RA, Gary EB, Rout ED, Avery AC, Moore AR. Detection and Characterization of Paraproteinemia in Canine Chronic B-cell Lymphocytic Leukemia Using Routine and Free Light Chain Immunofixation. Vet Clin Pathol 2022; 51:551-559. [PMID: 35883213 PMCID: PMC10087490 DOI: 10.1111/vcp.13156] [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: 12/20/2021] [Revised: 04/14/2022] [Accepted: 05/02/2022] [Indexed: 11/30/2022]
Abstract
BACKGROUND Hyperglobulinemia is reported in 26% of canine chronic B-cell lymphocytic leukemia (B-CLL) cases. However, few cases have been characterized by protein electrophoresis and immunofixation (IF), and the incidence of a monoclonal protein (M-protein) is unknown using these techniques. OBJECTIVE To characterize and determine the proportion of canine B-CLL cases with an M-protein using plasma protein electrophoresis (PPE), routine and free light chain (fLC) IF, and to assess if productive B-CLL cases express MUM1/IRF4 by cell tube block (CTB). METHODS PPE, routine (targeting IgG, IgA, IgM, IgG4, and light chain) and fLC IF were performed using 48 dog B-CLL plasma samples from patients diagnosed via peripheral blood flow cytometry. CTB was performed on a separate cohort of 15 patients. RESULTS Hyperproteinemia (>7.5 g/dL) was present in 17/48 cases (35%). An M-protein was detected in 32/48 cases (67%). Of these, 19/32 cases (59%) had only complete (monoclonal heavy and light chain) M-proteins detected, 10/32 cases (31%) had both complete and fLC M-proteins detected, and 3/32 cases (9%) had only an fLC M-protein detected. IgM was the most common clonal immunoglobulin isotype detected (23 cases). CD21+ cell counts were higher in cases with detectable M-protein. Plasma fLC IF suggested β-γ region interference, likely caused by clotting proteins. All B-CLL cases consistently expressed PAX5 and did not express MUM1/IRF4. CONCLUSIONS Most B-CLL cases had an M-protein and were not hyperproteinemic. Most cases with paraproteins had a complete IgM monoclonal gammopathy; a subset had documented fLCs. The prognostic significance of heavy and fLC presence should be evaluated.
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Affiliation(s)
- R Adam Harris
- Department of Microbiology, Immunology and Pathology, Colorado State University, Fort Collins, Colorado, USA
| | - Erik B Gary
- Department of Microbiology, Immunology and Pathology, Colorado State University, Fort Collins, Colorado, USA
| | - Emily D Rout
- Department of Microbiology, Immunology and Pathology, Colorado State University, Fort Collins, Colorado, USA
| | - Anne C Avery
- Department of Microbiology, Immunology and Pathology, Colorado State University, Fort Collins, Colorado, USA
| | - A Russell Moore
- Department of Microbiology, Immunology and Pathology, Colorado State University, Fort Collins, Colorado, USA
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5
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Ma T, Wang H, Su T, Wang S. Case Report: Chronic Lymphocytic Leukemia With Recurrent Complement-Mediated Thrombotic Microangiopathy and C3 Glomerulonephritis. Front Med (Lausanne) 2022; 9:813439. [PMID: 35223908 PMCID: PMC8866726 DOI: 10.3389/fmed.2022.813439] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2021] [Accepted: 01/13/2022] [Indexed: 11/13/2022] Open
Abstract
Chronic lymphocytic leukemia/small lymphocytic lymphoma (CLL/SLL) is a monoclonal B cell lymphocytosis that produces nephrotoxic monoclonal immunoglobulin (MIg). However, the role of MIg in CLL and how it affects CLL patient survival are still unknown. Here, we report a case of MIg with renal significance (MGRS) associated with CLL. A 59-year-old Chinese woman complaining of abdominal pain, skin purpura, and typical soy-colored urine was admitted to the hospital for investigation. Laboratory tests revealed that she had microangiopathic hemolytic anemia, thrombocytopenia, acute kidney injury (AKI), and hypocomplementemia. She also reported cryoglobulinemia, thrombotic microangiopathy (TMA), and AKI 2 years previously. Peripheral blood smears at that time showed 4% schistocytes, a negative Coombs' test, and elevated lactate dehydrogenase (LDH). Based on a diagnosis of complement-mediated TMA, the patient was treated by plasmapheresis and achieved clinical disease remission. However, the serum hypocomplement 4 and cryoglobulinemia persisted. Further investigation showed elevated B lymphocytes and monoclonal serum IgMκ; however, the cryoprecipitate contained monoclonal IgMκ and polyclonal IgG, as well as immunoglobulins κ and λ. After plasmapheresis, her LDH, platelets, and complement 3 (C3) levels returned to normal. Biopsies of the bone marrow and an enlarged subclavicular lymph node revealed CLL/SLL. Renal pathological findings indicated significant arteriolar endothelial cells myxoid edema and glomerular endothelial cells swelling, however no thromboli, cryoglobulin formation and vasculitis were observed. We also found mild mesangial proliferative C3 glomerulonephritis and renal interstitial CLL cells infiltration. Collectively, these clinical and pathological manifestations were attributed to monoclonal IgMκ, which triggered C3 activation. MGRS associated with CLL was finally confirmed. Six cycles of rituximab, cyclophosphamide, verodoxin, and dexamethasone therapy were administered, after which she received ibrutinib. The patient experienced disease remission, and her serum C4 level returned to normal. Cryoglobulin and IgMκ were not detected. This is a special presentation of CLL/SLL with monoclonal IgMκ, which is a type of MGRS. Activation of the complement system by MIg led to TMA with C3 glomerulonephritis. Treatment for TMA and CLL/SLL should be initiated in a timely manner to improve patient prognosis.
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Affiliation(s)
- Tiantian Ma
- Renal Division, Department of Medicine, Peking University First Hospital, Beijing, China.,Institute of Nephrology, Peking University, Beijing, China.,Key Laboratory of Renal Disease, Ministry of Health of China, Beijing, China.,Key Laboratory of Renal Disease, Ministry of Education, Beijing, China
| | - Hui Wang
- Laboratory of Electron Microscopy, Ultrastructural Pathology Center, Peking University First Hospital, Beijing, China
| | - Tao Su
- Renal Division, Department of Medicine, Peking University First Hospital, Beijing, China.,Institute of Nephrology, Peking University, Beijing, China.,Key Laboratory of Renal Disease, Ministry of Health of China, Beijing, China.,Key Laboratory of Renal Disease, Ministry of Education, Beijing, China
| | - Suxia Wang
- Laboratory of Electron Microscopy, Ultrastructural Pathology Center, Peking University First Hospital, Beijing, China
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6
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Wang H, Yu X, Zhang X, Wang S, Zhao M. The pathological features of leukemic cells infiltrating the renal interstitium in chronic lymphocytic leukemia/small lymphocytic lymphoma from a large single Chinese center. Diagn Pathol 2021; 16:59. [PMID: 34218814 PMCID: PMC8254985 DOI: 10.1186/s13000-021-01120-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2021] [Accepted: 06/21/2021] [Indexed: 11/10/2022] Open
Abstract
Background Chronic lymphocytic leukemia/small lymphocytic lymphoma (CLL/SLL) is rare in Asians, and patients with CLL/SLL seldomly undergo kidney biopsy. The histopathological features and clinical relevance of tubulointerstitial injury in CLL/SLL have not been extensively characterized. Hence, we attempted to describe the clinical characteristics, renal pathology and clinical outcome of a well-characterized population of CLL/SLL patients with CLL cell infiltration in the renal interstitium from a large single center in China. Methods Between January 1st, 2010 and September 31st, 2020, 31946renal biopsies were performed at Peking University First Hospital, and 10 CLL/SLL patients with CLL cell infiltration in the renal interstitium were included. Complete clinical data were collected from these 10 patients, and renal specimens were examined by routine light microscopy, immunofluorescence and electron microscopy. Results The extent of the infiltrating CLL cells in patients with CLL/SLL varied among different patients and ranged from 10 to 90% of kidney parenchyma. Six (60%) of 10 patients presented with an extent of infiltrating CLL cells ≥50%. Interestingly, we found that three patients (3/10, 30%) expressed monoclonal immunoglobulins in the infiltrating CLL cells, and special cytoplasmic crystalline structures were found in two of the three patients by electron microscopy for the first time. Severe renal insufficiency (Scr ≥200 μmol/L) was associated with ≥50% interstitial infiltration of CLL cells in the renal interstitium. Conclusions The current study confirmed that CLL cells infiltrating the renal interstitium can directly secrete monoclonal immunoglobulins, indicating that the interstitial infiltrating CLL cells possibly cause renal injury directly by secreting monoclonal immunoglobulins in situ. This finding may prove a new clue to elucidate the pathogenetic mechanism of renal injury involved with CLL/SLL. Supplementary Information The online version contains supplementary material available at 10.1186/s13000-021-01120-4.
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Affiliation(s)
- Hui Wang
- Laboratory of Electron Microscopy, Peking University First Hospital, Beijing, 100034, People's Republic of China.,Renal Pathology Center, Institute of Nephrology, Peking University, Beijing, 100034, People's Republic of China
| | - Xiaojuan Yu
- Renal Pathology Center, Institute of Nephrology, Peking University, Beijing, 100034, People's Republic of China.,Department of Nephrology, Peking University First Hospital, Beijing, 100034, People's Republic of China
| | - Xu Zhang
- Laboratory of Electron Microscopy, Peking University First Hospital, Beijing, 100034, People's Republic of China.,Renal Pathology Center, Institute of Nephrology, Peking University, Beijing, 100034, People's Republic of China
| | - Suxia Wang
- Laboratory of Electron Microscopy, Peking University First Hospital, Beijing, 100034, People's Republic of China. .,Renal Pathology Center, Institute of Nephrology, Peking University, Beijing, 100034, People's Republic of China.
| | - Minghui Zhao
- Renal Pathology Center, Institute of Nephrology, Peking University, Beijing, 100034, People's Republic of China.,Department of Nephrology, Peking University First Hospital, Beijing, 100034, People's Republic of China
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7
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Mozas P, Pineyroa JA, Nadeu F, Magnano L, Rivero A, Rivas-Delgado A, Bataller A, Fabregat A, Gine E, Baumann T, Villamor N, Arostegui JI, Aymerich M, Lopez-Guillermo A, Campo E, Delgado J. Serum monoclonal component in chronic lymphocytic leukemia: baseline correlations and prognostic impact. Haematologica 2021; 106:1754-1757. [PMID: 33147939 PMCID: PMC8168485 DOI: 10.3324/haematol.2020.263228] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2020] [Indexed: 11/18/2022] Open
Affiliation(s)
- Pablo Mozas
- Department of Hematology, Hospital Clínic, Barcelona
| | | | - Ferran Nadeu
- Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain; Centro de Investigación Biomédica en Red de Cáncer (CIBERONC), Madrid
| | - Laura Magnano
- Department of Hematology, Hospital Clínic, Barcelona, Spain; Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona
| | - Andrea Rivero
- Department of Hematology, Hospital Clínic, Barcelona
| | | | - Alex Bataller
- Department of Hematology, Hospital Clínic, Barcelona
| | - Aleix Fabregat
- Department of Biochemistry and Molecular Biology, Hospital Clínic, Barcelona
| | - Eva Gine
- Department of Hematology, Hospital Clínic, Barcelona, Spain; Centro de Investigación Biomédica en Red de Cáncer (CIBERONC), Madrid
| | - Tycho Baumann
- Department of Hematology, Hospital Clínic, Barcelona
| | - Neus Villamor
- Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain; Centro de Investigación Biomédica en Red de Cáncer (CIBERONC), Madrid, Spain; Hematopathology Unit, Department of Pathology, Hospital Clínic, Barcelona
| | | | - Marta Aymerich
- Hematopathology Unit, Department of Pathology, Hospital Clínic, Barcelona
| | - Armando Lopez-Guillermo
- Department of Hematology, Hospital Clínic, Barcelona, Spain; Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain; Centro de Investigación Biomédica en Red de Cáncer (CIBERONC), Madrid, Spain; Universitat de Barcelona
| | - Elias Campo
- Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain; Centro de Investigación Biomédica en Red de Cáncer (CIBERONC), Madrid, Spain; Hematopathology Unit, Department of Pathology, Hospital Clínic, Barcelona, Spain; Universitat de Barcelona
| | - Julio Delgado
- Department of Hematology, Hospital Clínic, Barcelona, Spain; Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain; Centro de Investigación Biomédica en Red de Cáncer (CIBERONC), Madrid
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8
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Rout ED, Labadie JD, Yoshimoto JA, Avery PR, Curran KM, Avery AC. Clinical outcome and prognostic factors in dogs with B-cell chronic lymphocytic leukemia: A retrospective study. J Vet Intern Med 2021; 35:1918-1928. [PMID: 33998726 PMCID: PMC8295712 DOI: 10.1111/jvim.16160] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2020] [Revised: 04/28/2021] [Accepted: 04/30/2021] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND B-cell chronic lymphocytic leukemia (BCLL) in dogs generally is considered an indolent disease, but previous studies indicate a wide range in survival times. OBJECTIVES We hypothesized that BCLL has a heterogeneous clinical course, similar to chronic lymphocytic leukemia in humans. We aimed to assess presentation and outcome in dogs with BCLL and evaluate the prognostic relevance of clinical and flow cytometric factors. ANIMALS One hundred and twenty-one dogs with BCLL diagnosed by flow cytometry. Three breed groups were represented: small breed dogs (n = 55) because of increased risk of BCLL; Boxers (n = 33) because of preferential use of unmutated immunoglobulin genes; and other breeds (n = 33). METHODS Retrospective study reviewing signalment, clinicopathologic data, physical examination findings, treatment, and survival of dogs with BCLL. Cellular proliferation, determined by the percentage of Ki67-expressing CD21+ B-cells by flow cytometry, was measured in 39 of 121 cases. Clinical and laboratory variables were evaluated for association with survival. RESULTS The median survival time (MST) for all cases was 300 days (range, 1-1644 days). Boxers had significantly shorter survival (MST, 178 days) than non-Boxers (MST, 423 days; P < .0001), and no significant survival difference was found between small breeds and other non-Boxer breeds. Cases with high Ki67 (>40% Ki67-expressing B-cells) had significantly shorter survival (MST, 173 days) than did cases with <40% Ki67 (MST undetermined; P = .03), regardless of breed. Cases with a high lymphocyte count (>60 000 lymphocytes/μL) or clinical signs at presentation had significantly shorter survival. CONCLUSIONS AND CLINICAL IMPORTANCE B-cell chronic lymphocytic leukemia had a variable clinical course and Boxer dogs and cases with high Ki67 had more aggressive disease.
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Affiliation(s)
- Emily D Rout
- Department of Microbiology, Immunology and Pathology, College of Veterinary Medicine and Biomedical Sciences, Colorado State University, Fort Collins, Colorado, USA
| | - Julia D Labadie
- Department of Microbiology, Immunology and Pathology, College of Veterinary Medicine and Biomedical Sciences, Colorado State University, Fort Collins, Colorado, USA
| | - Janna A Yoshimoto
- Department of Microbiology, Immunology and Pathology, College of Veterinary Medicine and Biomedical Sciences, Colorado State University, Fort Collins, Colorado, USA
| | - Paul R Avery
- Department of Microbiology, Immunology and Pathology, College of Veterinary Medicine and Biomedical Sciences, Colorado State University, Fort Collins, Colorado, USA
| | - Kaitlin M Curran
- Department of Clinical Sciences, Carlson College of Veterinary Medicine, Oregon State University, Corvallis, Oregon, USA
| | - Anne C Avery
- Department of Microbiology, Immunology and Pathology, College of Veterinary Medicine and Biomedical Sciences, Colorado State University, Fort Collins, Colorado, USA
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9
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Tuchman SA, Zonder JA. The Spectrum of Monoclonal Immunoglobulin-Associated Diseases. Hematol Oncol Clin North Am 2020; 34:997-1008. [PMID: 33099435 DOI: 10.1016/j.hoc.2020.07.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The spectrum of immunoglobulin paraprotein-associated diseases requiring therapy extends beyond multiple myeloma and AL amyloidosis. Awareness of these is essential in ensuring timely accurate diagnosis and appropriate treatment. As most paraprotein-associated diseases are fairly uncommon, therapeutic decisions must often be made in the absence of data from randomized controlled trials. Treatment is generally directed at the underlying clonal cell population. This review focuses on the spectrum of the less common paraprotein-associated disorders. In most instances, the monoclonal immunoglobulin plays a direct role in the pathophysiology of the disease course; in a select few, the paraprotein may be a disease marker.
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Affiliation(s)
- Sascha A Tuchman
- Division of Hematology, University of North Carolina - Chapel Hill, Comprehensive Cancer Center, 170 Manning Dr., CB#7305, Chapel Hill, NC 27599, USA
| | - Jeffrey A Zonder
- Barbara Ann Karmanos Cancer Institute/Wayne State University School of Medicine, Myeloma and Amyloidosis Team, Barbara Ann Karmanos Cancer Institute, Detroit, MI, USA.
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10
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Corbingi A, Innocenti I, Tomasso A, Pasquale R, Visentin A, Varettoni M, Flospergher E, Autore F, Morelli F, Trentin L, Reda G, Efremov DG, Laurenti L. Monoclonal gammopathy and serum immunoglobulin levels as prognostic factors in chronic lymphocytic leukaemia. Br J Haematol 2020; 190:901-908. [PMID: 32712965 DOI: 10.1111/bjh.16975] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2020] [Accepted: 05/31/2020] [Indexed: 12/17/2022]
Abstract
The relationship between chronic lymphocytic leukaemia (CLL) and qualitative/quantitative gammaglobulin abnormalities is well established. Nevertheless, in order to better understand this kind of connection, we examined 1505 patients with CLL and divided them into four subgroups on the basis of immunoglobulin (Ig) aberrations at diagnosis. A total of 73 (4·8%), 149 (10%), 200 (13·2%) and 1083 (72%) patients were identified with IgM monoclonal gammopathy (IgM/CLL), IgG monoclonal gammopathy (IgG/CLL), hypogammaglobulinaemia (hypo-γ) and normal Ig levels (γ-normal) respectively. IgM paraprotein was significantly associated with a more advanced Binet/Rai stage and del(17p)/TP53 mutation, while IgG abnormalities correlated with a higher occurrence of trisomy 12. Patients with any type of Ig abnormality had shorter treatment-free survival (TFS) but no significant impact affecting overall survival (OS) compared to those with normal Ig levels.
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Affiliation(s)
- Andrea Corbingi
- Department of Hematology, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Idanna Innocenti
- Department of Hematology, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Annamaria Tomasso
- Department of Hematology, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Raffaella Pasquale
- Department of Hematology, Fondazione IRCCS Ca'Granda, Ospedale Maggiore Policlinico, Milan, Italy
| | - Andrea Visentin
- Hematology and Clinical Immunology Unit, Department of Medicine, Università degli Studi di Padova, Padova, Italy
| | - Marzia Varettoni
- Department of Hematology, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Elena Flospergher
- Department of Hematology, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Francesco Autore
- Department of Hematology, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Francesca Morelli
- Department of Hematology, Università degli Studi di Firenze, Florence, Italy
| | - Livio Trentin
- Hematology and Clinical Immunology Unit, Department of Medicine, Università degli Studi di Padova, Padova, Italy
| | - Gianluigi Reda
- Department of Hematology, Fondazione IRCCS Ca'Granda, Ospedale Maggiore Policlinico, Milan, Italy
| | - Dimitar G Efremov
- Molecular Haematology, International Centre for Genetic Engineering and Biotechnology, Trieste, Italy
| | - Luca Laurenti
- Department of Hematology, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy.,Department of Hematology, Università Cattolica del Sacro Cuore, Rome, Italy
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11
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Smolej L. Incidence and prognostic significance of serum immunoglobulins and paraproteins in patients with chronic lymphocytic leukaemia: another valuable piece of the puzzle. Br J Haematol 2020; 190:815-816. [PMID: 32686123 DOI: 10.1111/bjh.16972] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2020] [Accepted: 06/23/2020] [Indexed: 11/30/2022]
Affiliation(s)
- Lukáš Smolej
- 4th Department of Internal Medicine - Hematology, University Hospital and Faculty of Medicine, Hradec Králové, Czech Republic
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12
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Wright N, Voshtina E, George G, Singavi A, Field J. Cryoglobulinemic vasculitis with interruption of ibrutinib therapy for chronic lymphocytic leukemia (CLL). Int J Hematol 2019; 110:751-755. [PMID: 31494832 DOI: 10.1007/s12185-019-02729-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2019] [Revised: 08/18/2019] [Accepted: 08/22/2019] [Indexed: 11/29/2022]
Abstract
Chronic lymphocytic leukemia (CLL) can trigger autoimmune phenomena, with immune thrombocytopenia (ITP) the most common presentation. Upon cessation of CLL therapy, including ibrutinib, autoimmune flares can occur. In a 68-year-old man with CLL, ibrutinib was held for 2 weeks prior to elective shoulder surgery. Eleven days after stopping therapy, he presented with a purpuric rash on his right hip, buttock, and lower extremities. He experienced two episodes of seizure activity while hospitalized. MRI brain demonstrated patchy areas of altered signal involving deep white matter and sub-cortical white matter structures concerning for cerebral vasculitis. Although there was no evidence of hemolysis, serum cold agglutinin titer was elevated at > 1:512 and cryoglobulin levels were positive at 36%. He was diagnosed with type I cryoglobulinemia and treated with rituximab, plasmapheresis, methylprednisolone, and ibrutinib was restarted. This regimen resolved his symptoms. A rare complication of CLL is the production of cryoglobulins, which can present at initial diagnosis or in relapsed disease. Our case demonstrates that the cessation of ibrutinib therapy, even for a short time, can precipitate complications. To our knowledge, we report the first case of a patient with well-controlled CLL who rapidly developed cryoglobulinemic vasculitis after stopping ibrutinib therapy.
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Affiliation(s)
- Nicholas Wright
- Hematology/Oncology Department, Medical College of Wisconsin Affiliated Hospitals, 9200 West Wisconsin Ave, Milwaukee, WI, 53226, USA. .,, 2139A N 72nd St, Wauwatosa, WI, 53213, USA.
| | - Ensi Voshtina
- Hematology/Oncology Department, Medical College of Wisconsin Affiliated Hospitals, 9200 West Wisconsin Ave, Milwaukee, WI, 53226, USA
| | - Gemlyn George
- Hematology/Oncology Department, Medical College of Wisconsin Affiliated Hospitals, 9200 West Wisconsin Ave, Milwaukee, WI, 53226, USA
| | - Arun Singavi
- Hematology/Oncology Department, Medical College of Wisconsin Affiliated Hospitals, 9200 West Wisconsin Ave, Milwaukee, WI, 53226, USA
| | - Joshua Field
- Hematology/Oncology Department, Medical College of Wisconsin Affiliated Hospitals, 9200 West Wisconsin Ave, Milwaukee, WI, 53226, USA
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13
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Tadmor T, Braester A, Najib D, Aviv A, Herishanu Y, Yuklea M, Shvidel L, Rahimi-Levene N, Ruchlemer R, Arad A, Fogl C, Henig C, Barak M, Magal L, Polliack A, Townsend K. A new risk model to predict time to first treatment in chronic lymphocytic leukemia based on heavy chain immunoparesis and summated free light chain. Eur J Haematol 2019; 103:335-341. [PMID: 31278876 DOI: 10.1111/ejh.13288] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2019] [Revised: 05/16/2019] [Accepted: 05/20/2019] [Indexed: 12/29/2022]
Abstract
BACKGROUND Chronic lymphocytic leukemia (CLL) is frequently accompanied by immune dysregulation. AIMS In this multicenter prospective study, we investigated whether heavy + light chains (HLC: IgGκ, IgGλ, IgAκ, IgAκ, IgMκ, IgMλ) and IgG subclasses (IgG1, IgG2, IgG3, and IgG4) could be used as novel prognostic markers of immunoparesis in 105 treatment-naïve patients with CLL. RESULTS Heavy + light chains immunoparesis of ≥1, ≥2, and ≥3 isotypes was evident in 74 (70%), 58 (55%), and 36 (34%) patients, respectively. Severe HLC immunoparesis was identified in 40 (38%) patients. Of the IgG subclasses, IgG1 and IgG2 were most frequently suppressed, affecting 46 (44%) and 36 (34%) patients, respectively; 63 (60%) patients had low levels of at least one IgG subclass. In multivariate analysis, severe HLC immunoparesis (hazard ratio [HR]: 36.5; P = .010) and ΣFLC ≥ 70 mg/L (HR: 13.2; P = .004) were the only factors independently associated with time to first treatment (TTFT). A risk model including these variables identified patients with 0, 1, and 2 risk factors and significantly different TTFT (P < .001). Patients with two factors represented an ultra-high-risk group with a median TTFT of only 1.3 months. CONCLUSION The above findings demonstrate the potential for the use of HLC immunoparesis, together with sFLC measurements, as future prognostic biomarkers in CLL.
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Affiliation(s)
- Tamar Tadmor
- Bnai Zion Medical Center, Haifa, Israel.,The Ruth and Bruce Rappaport Faculty of Medicine, Technion, Haifa, Israel
| | - Andrei Braester
- Western Galilee Hospital, Nahariya, Israel.,Bar Ilan University, Ramat Gan, Israel
| | | | | | - Yair Herishanu
- Tel-Aviv Sourasky Medical Center, Tel Aviv, Israel.,Tel-Aviv University, Tel Aviv, Israel
| | | | | | | | | | - Ariela Arad
- Department of Hematology, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
| | | | - Clara Henig
- Haifa and Western Galilee Laboratory, Nesher, Israel
| | - Mira Barak
- Haifa and Western Galilee Laboratory, Nesher, Israel
| | - Lee Magal
- Almog Diagnostic, Park Shoham, Israel
| | - Aaron Polliack
- Department of Hematology, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
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14
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Tedeschi A, Conticello C, Rizzi R, Benevolo G, Laurenti L, Petrucci MT, Zaja F, Varettoni M. Diagnostic framing of IgM monoclonal gammopathy: Focus on Waldenström macroglobulinemia. Hematol Oncol 2018; 37:117-128. [DOI: 10.1002/hon.2539] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2018] [Revised: 07/12/2018] [Accepted: 07/12/2018] [Indexed: 11/10/2022]
Affiliation(s)
- Alessandra Tedeschi
- Department of HematologyNiguarda Cancer Center, ASST Grande Ospedale Metropolitano Niguarda Milan Italy
| | - Concetta Conticello
- Department of Clinical and Molecular Biomedicine, Haematology SectionUniversity of Catania Catania Italy
| | - Rita Rizzi
- Department of Emergency and Organ Transplantation, Hematology SectionUniversity of Bari Medical School Bari Italy
| | - Giulia Benevolo
- Division of HematologyAOU Città della Salute e della Scienza Torino Italy
| | - Luca Laurenti
- Department of HematologyCatholic University Hospital “A. Gemelli” Rome Italy
| | - Maria Teresa Petrucci
- Hematology, Department of Cellular Biotechnologies and Hematology“Sapienza” University Rome Italy
| | - Francesco Zaja
- Clinica Ematologica, Centro Trapianti e Terapie Cellulari “Carlo Melzi”University of Udine Udine Italy
| | - Marzia Varettoni
- Division of HematologyFondazione IRCCS Policlinico S. Matteo Pavia Italy
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15
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Chauzeix J, Laforêt M, Deveza M, Crowther L, Marcellaud E, Derouault P, Lia A, Boyer F, Bargues N, Olombel G, Jaccard A, Feuillard J, Gachard N, Rizzo D. Normal serum protein electrophoresis and mutated IGHV genes detect very slowly evolving chronic lymphocytic leukemia patients. Cancer Med 2018; 7:2621-2628. [PMID: 29745034 PMCID: PMC6010869 DOI: 10.1002/cam4.1510] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2017] [Revised: 03/29/2018] [Accepted: 03/29/2018] [Indexed: 12/01/2022] Open
Abstract
More than 35 years after the Binet classification, there is still a need for simple prognostic markers in chronic lymphocytic leukemia (CLL). Here, we studied the treatment-free survival (TFS) impact of normal serum protein electrophoresis (SPE) at diagnosis. One hundred twelve patients with CLL were analyzed. The main prognostic factors (Binet stage; lymphocytosis; IGHV mutation status; TP53, SF3B1, NOTCH1, and BIRC3 mutations; and cytogenetic abnormalities) were studied. The frequencies of IGHV mutation status, cytogenetic abnormalities, and TP53, SF3B1, NOTCH1, and BIRC3 mutations were not significantly different between normal and abnormal SPE. Normal SPE was associated with Binet stage A, nonprogressive disease for 6 months, lymphocytosis below 30 G/L, and the absence of the IGHV3-21 gene rearrangement which is associated with poor prognosis. The TFS of patients with normal SPE was significantly longer than that of patients with abnormal SPE (log-rank test: P = 0.0015, with 51% untreated patients at 5.6 years and a perfect plateau afterward vs. a median TFS at 2.64 years for abnormal SPE with no plateau). Multivariate analysis using two different Cox models and bootstrapping showed that normal SPE was an independent good prognostic marker for either Binet stage, lymphocytosis, or IGHV mutation status. TFS was further increased when both normal SPE and mutated IGHV were present (log-rank test: P = 0.008, median not reached, plateau at 5.6 years and 66% untreated patients). A comparison with other prognostic markers suggested that normal SPE could reflect slowly advancing CLL disease. Altogether, our results show that a combination of normal SPE and mutated IGHV genes defines a subgroup of patients with CLL who evolve very slowly and who might never need treatment.
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MESH Headings
- Aged
- Biomarkers, Tumor
- Blood Proteins
- Cytogenetic Analysis
- Electrophoresis
- Female
- High-Throughput Nucleotide Sequencing
- Humans
- Immunoglobulin Heavy Chains/blood
- Immunoglobulin Heavy Chains/genetics
- Leukemia, Lymphocytic, Chronic, B-Cell/blood
- Leukemia, Lymphocytic, Chronic, B-Cell/diagnosis
- Leukemia, Lymphocytic, Chronic, B-Cell/genetics
- Male
- Middle Aged
- Mutation
- Neoplasm Metastasis
- Neoplasm Staging
- Prognosis
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Affiliation(s)
- Jasmine Chauzeix
- Hématologie BiologiqueCentre Hospitalier Universitaire de LimogesLimogesFrance
- Faculté de Médecine de LimogesUMR CNRS 7276 CRIBLLimogesFrance
| | | | - Mélanie Deveza
- Hématologie BiologiqueCentre Hospitalier Universitaire de LimogesLimogesFrance
| | - Liam Crowther
- Faculté de Médecine de LimogesUMR CNRS 7276 CRIBLLimogesFrance
| | | | | | | | - François Boyer
- Faculté de Médecine de LimogesUMR CNRS 7276 CRIBLLimogesFrance
| | - Nicolas Bargues
- Hématologie BiologiqueCentre Hospitalier Universitaire de LimogesLimogesFrance
| | - Guillaume Olombel
- Faculté de Médecine de LimogesUMR CNRS 7276 CRIBLLimogesFrance
- ImmunologieCentre Hospitalier Universitaire de LimogesLimogesFrance
| | - Arnaud Jaccard
- Faculté de Médecine de LimogesUMR CNRS 7276 CRIBLLimogesFrance
- Hématologie Clinique et Thérapie CellulaireCentre Hospitalier Universitaire de LimogesLimogesFrance
| | - Jean Feuillard
- Hématologie BiologiqueCentre Hospitalier Universitaire de LimogesLimogesFrance
- Faculté de Médecine de LimogesUMR CNRS 7276 CRIBLLimogesFrance
| | - Nathalie Gachard
- Hématologie BiologiqueCentre Hospitalier Universitaire de LimogesLimogesFrance
- Faculté de Médecine de LimogesUMR CNRS 7276 CRIBLLimogesFrance
| | - David Rizzo
- Hématologie BiologiqueCentre Hospitalier Universitaire de LimogesLimogesFrance
- Faculté de Médecine de LimogesUMR CNRS 7276 CRIBLLimogesFrance
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16
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Vander Meeren S, Heyrman B, Renmans W, Bakkus M, Maes B, De Raeve H, Schots R, Jochmans K. Lymphoma-like monoclonal B cell lymphocytosis in a patient population: biology, natural evolution, and differences from CLL-like clones. Ann Hematol 2018; 97:1219-1227. [PMID: 29492600 DOI: 10.1007/s00277-018-3282-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2017] [Accepted: 02/16/2018] [Indexed: 01/23/2023]
Abstract
High-count monoclonal B cell lymphocytosis (MBL) with a chronic lymphocytic leukemia (CLL) phenotype is a well-known entity, featuring 1-4% annual risk of progression towards CLL requiring treatment. Lymphoma-like MBL (L-MBL), on the other hand, remains poorly defined and data regarding outcome are lacking. We retrospectively evaluated 33 L-MBL cases within our hospital population and compared them to 95 subjects with CLL-like MBL (C-MBL). Diagnoses of L-MBL were based on asymptomatic B cell clones with Matutes score < 3, B cells < 5.0 × 103/μl, and negative computerized tomography scans. We found that median B cell counts were considerably lower compared to C-MBL (0.6 vs 2.3 × 103/μl) and remained stable over time. Based on immunophenotyping and immunogenetic profiling, most L-MBL clones did not correspond to known lymphoma entities. A strikingly high occurrence of paraproteinemia (48%), hypogammaglobulinemia (45%), and biclonality (21%) was seen; these incidences being significantly higher than in C-MBL (17, 21, and 5%, respectively). Unrelated monoclonal gammopathy of undetermined significance was a frequent feature, as the light chain type of 5/12 paraproteins detected was different from the clonal surface immunoglobulin. After 46-month median follow-up, 2/24 patients (8%) had progressed towards indolent lymphoma requiring no treatment. In contrast, 41% of C-MBL cases evolved to CLL and 17% required treatment. We conclude that clinical L-MBL is characterized by pronounced immune dysregulation and very slow or absent progression, clearly separating it from its CLL-like counterpart.
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Affiliation(s)
- Sam Vander Meeren
- Department of Clinical Biology, Hematology Division, Vrije Universiteit Brussel (VUB), Universitair Ziekenhuis Brussel (UZ Brussel), Brussels, Belgium.
| | - Bert Heyrman
- Department of Internal Medicine, Hematology Division, ZNA Middelheim, Antwerpen, Belgium
| | - Wim Renmans
- Department of Clinical Biology, Hematology Division, Vrije Universiteit Brussel (VUB), Universitair Ziekenhuis Brussel (UZ Brussel), Brussels, Belgium
| | - Marleen Bakkus
- Department of Clinical Biology, Hematology Division, Vrije Universiteit Brussel (VUB), Universitair Ziekenhuis Brussel (UZ Brussel), Brussels, Belgium
| | - Brigitte Maes
- Department of Clinical Biology, Hematology Division, Jessa Ziekenhuis, Hasselt, Belgium
| | - Hendrik De Raeve
- Department of Pathology, Vrije Universiteit Brussel (VUB), Universitair Ziekenhuis Brussel (UZ Brussel), Brussels, Belgium
| | - Rik Schots
- Department of Internal Medicine, Hematology Division, Vrije Universiteit Brussel (VUB), Universitair Ziekenhuis Brussel (UZ Brussel), Brussels, Belgium
| | - Kristin Jochmans
- Department of Clinical Biology, Hematology Division, Vrije Universiteit Brussel (VUB), Universitair Ziekenhuis Brussel (UZ Brussel), Brussels, Belgium
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17
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Tachiki L, Dong ZM, Burwick N. Atypical chronic lymphocytic leukemia presenting with massive IgM paraprotein. Ann Hematol 2018; 97:921-922. [PMID: 29411125 DOI: 10.1007/s00277-018-3261-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2018] [Accepted: 01/28/2018] [Indexed: 11/29/2022]
Affiliation(s)
- Lisa Tachiki
- University of Washington School of Medicine, 1959 NE Pacific Street, Box 356421, Seattle, WA, 98195, USA.
| | - Zhao Ming Dong
- University of Washington School of Medicine, 1959 NE Pacific Street, Box 356421, Seattle, WA, 98195, USA.,VA Puget Sound Healthcare System, 1660 S. Columbian Way, Seattle, WA, 98108, USA
| | - Nicholas Burwick
- University of Washington School of Medicine, 1959 NE Pacific Street, Box 356421, Seattle, WA, 98195, USA.,VA Puget Sound Healthcare System, 1660 S. Columbian Way, Seattle, WA, 98108, USA
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18
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Arora S, Levitan D, Regmi N, Sidhu G, Gupta R, Nicastri AD, Saggi SJ, Braverman A. Cryoglobulinemia in a patient with chronic lymphocytic leukemia - A case report and review of literature of renal involvement in CLL. Blood Cells Mol Dis 2016; 60:7-11. [PMID: 27519936 DOI: 10.1016/j.bcmd.2016.05.009] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2016] [Revised: 05/21/2016] [Accepted: 05/21/2016] [Indexed: 10/21/2022]
Abstract
The incidence of glomerulonephritis, as a manifestation of chronic lymphocytic leukemia/small lymphocytic lymphoma (CLL/SLL), has always been considered low. Though renal infiltration is usually detected at post-mortem, it does not often interfere with kidney function [1]. Though immunoglobulin (Ig) levels in most CLL patients are subnormal, small monoclonal Ig peaks are occasionally detected in serum. They were present in a number of reported CLL nephropathy patients, and not all were cryoglobulins; serum and glomerular staining were concordant for Ig type [2,3,4]. Myeloma, which secretes monoclonal light chains, causes nephropathy in 25% of patients. But the little presumably secreted by small plasma cell clones, without myeloma, may also be nephrotoxic. The same is true of the low secretory CLL cells, which may occasionally be associated with cryoglobulins and other nephrotoxic Igs [5]. We report a patient with early stage CLL (Rai stage 0) with cryoglobulins, which led to membranoproliferative glomerulonephritis (MPGN), and death. We located reports of 51 patients with CLL-associated nephrotic syndrome or nephropathy, mostly from MPGN related to local Ig deposits. In those patients screened for cryoglobulins, about half tested positive. Many were early stage cases, where MPGN developed long after CLL presentation, and responded to its treatment. As early diagnosis and treatment CLL-related nephropathy may be curative, we propose a prospective study to determine the incidence of hyperalbuminuria development after presentation.
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Affiliation(s)
- Swaty Arora
- Department of Hematology & Oncology, Department of Medicine, State University New York, Downstate, USA.
| | - Daniel Levitan
- Department of Pathology, State University New York, Downstate, USA
| | - Narottam Regmi
- Department of Nephrology, Department of Medicine, State University New York, Downstate, USA
| | - Gurinder Sidhu
- Department of Hematology & Oncology, Department of Medicine, State University New York, Downstate, USA
| | - Raavi Gupta
- Department of Pathology, State University New York, Downstate, USA
| | | | - Subodh J Saggi
- Department of Nephrology, Department of Medicine, State University New York, Downstate, USA
| | - Albert Braverman
- Department of Hematology & Oncology, Department of Medicine, State University New York, Downstate, USA
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19
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Baliakas P, Puiggros A, Xochelli A, Sutton LA, Nguyen-Khac F, Gardiner A, Plevova K, Minga E, Hadzidimitriou A, Walewska R, McCarthy H, Ortega M, Collado R, González T, Granada I, Luño E, Kotašková J, Moysiadis T, Davis Z, Stavroyianni N, Anagnostopoulos A, Strefford JC, Pospisilova S, Davi F, Athanasiadou A, Rosenquist R, Oscier D, Espinet B, Stamatopoulos K. Additional trisomies amongst patients with chronic lymphocytic leukemia carrying trisomy 12: the accompanying chromosome makes a difference. Haematologica 2016; 101:e299-302. [PMID: 27102498 DOI: 10.3324/haematol.2015.140202] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Affiliation(s)
- Panagiotis Baliakas
- Department of Immunology, Genetics and Pathology, Science for Life Laboratory, Uppsala University, Sweden
| | - Anna Puiggros
- Laboratori de Citogenètica Molecular Servei de Patologia Hospital del Mar, Barcelona, Spain Grup de Recerca Translacional en Neoplàsies Hematològiques, Cancer Research Program, IMIM-Hospital del Mar, Barcelona, Spain
| | - Aliki Xochelli
- Department of Immunology, Genetics and Pathology, Science for Life Laboratory, Uppsala University, Sweden Institute of Applied Biosciences, CERTH, Thessaloniki, Greece
| | - Lesley-Ann Sutton
- Department of Immunology, Genetics and Pathology, Science for Life Laboratory, Uppsala University, Sweden
| | - Florence Nguyen-Khac
- AP-HP, Pitie-Salpetriere Hospital, Department of Hematology, and UPMC Univ Paris 06, UMRS 1138, France
| | - Anne Gardiner
- Department of Haematology, Royal Bournemouth Hospital, UK
| | - Karla Plevova
- Central European Institute of Technology, Masaryk University and University Hospital Brno, Czech Republic
| | - Eva Minga
- Institute of Applied Biosciences, CERTH, Thessaloniki, Greece
| | | | | | - Helen McCarthy
- Department of Haematology, Royal Bournemouth Hospital, UK
| | | | - Rosa Collado
- Consorcio Hospital General Universitario de Valencia, Spain
| | - Teresa González
- Fundación Pública Galega de Medicina Xenómica, Santiago de Compostela, Spain
| | - Isabel Granada
- Institut de Recerca Contra la Leucèmia Josep Carreras (IJC), ICO-Hospital GeransTrias i Pujol, Universitat Autònoma de Barcelona, Badalona, Spain
| | - Elisa Luño
- Hospital Universitario Central de Asturias, Oviedo, Spain
| | - Jana Kotašková
- Central European Institute of Technology, Masaryk University and University Hospital Brno, Czech Republic
| | | | - Zadie Davis
- Department of Haematology, Royal Bournemouth Hospital, UK
| | - Niki Stavroyianni
- Hematology Department and HCT Unit, G. Papanicolaou Hospital, Thessaloniki, Greece
| | | | | | - Sarka Pospisilova
- Central European Institute of Technology, Masaryk University and University Hospital Brno, Czech Republic
| | - Frederic Davi
- AP-HP, Pitie-Salpetriere Hospital, Department of Hematology, and UPMC Univ Paris 06, UMRS 1138, France
| | | | - Richard Rosenquist
- Department of Immunology, Genetics and Pathology, Science for Life Laboratory, Uppsala University, Sweden
| | - David Oscier
- Department of Haematology, Royal Bournemouth Hospital, UK
| | - Blanca Espinet
- Laboratori de Citogenètica Molecular Servei de Patologia Hospital del Mar, Barcelona, Spain Grup de Recerca Translacional en Neoplàsies Hematològiques, Cancer Research Program, IMIM-Hospital del Mar, Barcelona, Spain
| | - Kostas Stamatopoulos
- Department of Immunology, Genetics and Pathology, Science for Life Laboratory, Uppsala University, Sweden Institute of Applied Biosciences, CERTH, Thessaloniki, Greece
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20
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The mystery of chronic lymphocytic leukemia (CLL): Why is it absent in Asians and what does this tell us about etiology, pathogenesis and biology? Blood Rev 2014; 29:205-13. [PMID: 25541495 DOI: 10.1016/j.blre.2014.12.001] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2014] [Revised: 12/01/2014] [Accepted: 12/09/2014] [Indexed: 11/23/2022]
Abstract
Chronic lymphocytic leukemia/small lymphocytic lymphoma is common in persons of predominately European descent but rare in Asians. Why is unknown but is likely genetically-determined. Environmental factors may also operate but are likely to be less important. When CLL occurs in Asians it has different features than CLL in persons of predominately European descent. The reason(s) for this is also not understood. We reviewed data on CLL in Asians (mostly Han Chinese but also other ethnic groups) and compared these data with those from persons of predominately European descent with CLL. CLL incidence was about 5-10-fold less in Asians. Asians with CLL are younger, have atypical morphologic and immunologic features, an increased proportion of IGHV mutations and rearrangements and briefer freedom-from-progression than persons of predominately European descent with CLL. These observations provide clues to the etiology and biology of CLL. But the mystery continues; more research is needed.
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21
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Rizzo D, Chauzeix J, Trimoreau F, Woillard JB, Genevieve F, Bouvier A, Labrousse J, Poli C, Guerin E, Dmytruk N, Remenieras L, Feuillard J, Gachard N. IgM peak independently predicts treatment-free survival in chronic lymphocytic leukemia and correlates with accumulation of adverse oncogenetic events. Leukemia 2014; 29:337-45. [PMID: 24943833 DOI: 10.1038/leu.2014.198] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2013] [Revised: 03/25/2014] [Accepted: 03/28/2014] [Indexed: 01/24/2023]
Abstract
We examined the significance of IgM peaks in chronic lymphocytic leukemia (CLL), including its association with newly reported MYD88, BIRC3, NOTCH1 and SF3B1 mutations. A total of 27, 25, 41 and 57 patients with monoclonal IgM or IgG peaks (IgM and IgG groups), hypogammaglobulinemia (Hypo-γ group) and normal immunoglobulin serum levels (normal-γ group) were, respectively, included. IgM peaks were mainly associated with Binet stage C and the del(17p). Biased usage of IGHV3-48 was shared by both IgM and IgG groups. IGHV3-74 and IGHV4-39 gene rearrangements were specific for IgM and IgG peaks, respectively. SF3B1, NOTCH1, MYD88 and BIRC3 mutation frequencies were 12%, 4%, 2% and 2%, respectively, being over-represented in IgM, IgG and Hypo-γ groups for SF3B1, and being equal between normal-γ and IgM groups for MYD88. Overall, 76%, 87%, 49% and 42% of cases from IgM, IgG, Hypo-γ and normal-γ groups had at least one intermediate or poor prognosis genetic marker, respectively. By multivariate analysis, IgM peaks were associated with shorter treatment-free survival independently from any other univariate poor prognosis biological parameters, including IgG peaks, Hypo-γ, IGHV status, SF3B1 mutations, cytogenetics and lymphocytosis. Therefore, as with IgG peaks, IgM peaks aggravated the natural course of CLL, with increased accumulation of adverse genetic events.
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Affiliation(s)
- D Rizzo
- 1] Laboratory of Hematology, University Hospital Dupuytren, Limoges, France [2] UMR CNRS 7276, Faculty of Medicine, Limoges, France
| | - J Chauzeix
- 1] Laboratory of Hematology, University Hospital Dupuytren, Limoges, France [2] UMR CNRS 7276, Faculty of Medicine, Limoges, France
| | - F Trimoreau
- Laboratory of Hematology, University Hospital Dupuytren, Limoges, France
| | - J B Woillard
- UMR INSERM S-850, Faculty of Medicine, Limoges, France
| | - F Genevieve
- Laboratory of Hematology, University Hospital, Angers, France
| | - A Bouvier
- Laboratory of Hematology, University Hospital, Angers, France
| | - J Labrousse
- Laboratory of Hematology, University Hospital, Angers, France
| | - C Poli
- 1] Laboratory of Immunology and Allergology, University Hospital, Angers, France [2] UMR Inserm 892, CNRS 6299, Faculty of Medicine, Angers, France
| | - E Guerin
- Laboratory of Hematology, University Hospital Dupuytren, Limoges, France
| | - N Dmytruk
- Clinical Hematology and Cellular Therapy, University Hospital Dupuytren, Limoges, France
| | - L Remenieras
- Clinical Hematology and Cellular Therapy, University Hospital Dupuytren, Limoges, France
| | - J Feuillard
- 1] Laboratory of Hematology, University Hospital Dupuytren, Limoges, France [2] UMR CNRS 7276, Faculty of Medicine, Limoges, France
| | - N Gachard
- 1] Laboratory of Hematology, University Hospital Dupuytren, Limoges, France [2] UMR CNRS 7276, Faculty of Medicine, Limoges, France
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Shvidel L, Tadmor T, Braester A, Bairey O, Rahimi-Levene N, Herishanu Y, Klepfish A, Ruchlemer R, Berrebi A, Polliack A. Serum immunoglobulin levels at diagnosis have no prognostic significance in stage A chronic lymphocytic leukemia: a study of 1113 cases from the Israeli CLL Study Group. Eur J Haematol 2014; 93:29-33. [PMID: 24547751 DOI: 10.1111/ejh.12290] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/06/2014] [Indexed: 01/21/2023]
Abstract
OBJECTIVES Hypogammaglobulinemia, commonly encountered in chronic lymphocytic leukemia (CLL), is one of the main causes of morbidity and mortality; however, its prognostic significance in patients diagnosed in early stages of disease remains uncertain. The aim of this study was to evaluate the predictive power of hypogammaglobulinemia at Bonet stage A. METHODS Using the database of the Israeli CLL Study Group, we analyzed the relationship between low serum levels of IgG, IgA, and IgM; the presence of paraproteinemia, as well as other well-recognized prognostic markers in CLL; and time to first treatment (TTT) and overall survival. A total of 1113 patients consecutively diagnosed during the last 25 yrs with Binet stage A CLL were evaluated, and baseline information on serum immunoglobulin levels was found in 857 of the cases. RESULTS Overall survival times correlated with age >65 yr, male gender, the presence of lymphadenopathy, high serum beta 2-microglobulin (b2m), CD38 and ZAP-70 expression, but not with low levels of immunoglobulin or the presence of paraproteinemia. By univariate analysis, patients with low IgA levels had a shorter TTT; however, on multivariate analysis, the presence of lymphadenopathy (P 0.02), b2m (P 0.04), CD38 (P < 0.001), and ZAP-70 (P < 0.001) was the only laboratory parameters with prognostic significance. CONCLUSIONS In our cohort of patients with early-stage CLL, baseline hypogammaglobulinemia and the presence of paraproteinemia were not found to correlate with prognosis.
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Affiliation(s)
- Lev Shvidel
- Kaplan Medical Center, Rehovot, Hadassah and Hebrew University Medical School, Jerusalem, Israel
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Zand L, Kattah A, Fervenza FC, Smith RJH, Nasr SH, Zhang Y, Vrana JA, Leung N, Cornell LD, Sethi S. C3 glomerulonephritis associated with monoclonal gammopathy: a case series. Am J Kidney Dis 2013; 62:506-14. [PMID: 23623956 DOI: 10.1053/j.ajkd.2013.02.370] [Citation(s) in RCA: 132] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2012] [Accepted: 02/26/2013] [Indexed: 02/06/2023]
Abstract
BACKGROUND C3 glomerulonephritis (GN) is a proliferative GN resulting from glomerular deposition of complement factors due to dysregulation of the alternative pathway of complement. Dysregulation of the alternative pathway of complement may occur as a result of mutations or functional inhibition of complement-regulating proteins. Functional inhibition of the complement-regulating proteins may result from a monoclonal gammopathy. STUDY DESIGN Case series. SETTING & PARTICIPANTS 32 Mayo Clinic patients with C3 GN, 10 (31%) of whom had evidence of a monoclonal immunoglobulin in serum. OUTCOMES Clinical features, hematologic and bone marrow biopsy findings, kidney biopsy findings, kidney measures, complement pathway abnormalities, treatment, and follow-up of patients with C3 GN that was associated with a monoclonal gammopathy. RESULTS Mean age of patients with C3 GN associated with monoclonal gammopathy was 54.5 years. Bone marrow biopsy done in 9 patients revealed monoclonal gammopathy of undetermined significance in 5 patients, small lymphocytic lymphoma/chronic lymphocytic leukemia in one patient, and no abnormal clones in the other 3 patients. Kidney biopsy showed membranoproliferative GN with bright capillary wall C3 staining in all 10 patients. Evaluation of the alternative pathway of complement showed abnormalities in 7 of 9 patients tested. No mutation in complement-regulating proteins was detected in any patient. As an index case, one patient with C3 GN and chronic lymphocytic leukemia was treated with rituximab, cyclophosphamide, vincristine, and prednisone, and one patient with C3 GN and monoclonal gammopathy of undetermined significance was treated with dexamethasone and bortezomib. Both patients showed significant decreases in hematuria and proteinuria and stabilization of kidney function. LIMITATIONS Studies to show evidence of direct activation of the alternative pathway by monoclonal immunoglobulin were not done. CONCLUSIONS The study highlights the association of C3 GN and monoclonal gammopathy, in particular in the older population, and the importance of targeting the underlying hematologic malignancy as an approach to treating C3 GN.
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Affiliation(s)
- Ladan Zand
- Department of Internal Medicine, Division of Nephrology and Hypertension, Mayo Clinic, Rochester, MN 55905, USA
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