Paraneoplastic pemphigus: an association with fludarabine?

Paraneoplastic pemphigus/paraneoplastic autoimmune multiorgan syndrome: Part I. Clinical overview and pathophysiology

Paraneoplastic pemphigus/paraneoplastic autoimmune multiorgan syndrome (PNP/PAMS) is a highly fatal autoimmune blistering disease. The condition occurs in patients with underlying benign or malignant neoplasms, most commonly lymphoproliferative disorders. Both humoral and cell-mediated immunities contribute to the pathogenesis, and autoantibodies against plakin family proteins are characteristic. Patients typically present with severe stomatitis and polymorphous skin lesions, which are often resistant to treatment. Bronchiolitis obliterans (BO) is a frequent complication which contributes to the high mortality rate of PNP/PAMS. Given the rarity of this disorder and heterogeneity of clinical presentation, clinicians should maintain a high index of suspicion for PNP/PAMS to avoid delayed diagnosis. In this first part of a two-part continuing medical education (CME) series, risk factors, pathogenesis, and clinical features of PNP/PAMS are discussed.

Chronic lymphocytic leukemia and small lymphocytic lymphoma: two faces of the same disease

INTRODUCTION

Chronic lymphocytic leukemia (CLL) and small lymphocytic lymphoma (SLL) are considered indolent lymphocytic malignancies, more often requiring active surveillance rather than intervention. Despite the indolent nature of CLL/SLL, treatment is likely indicated in a patients' lifetime. Recent changes in the therapeutic landscape have created more options to the clinician. Areas covered: The authors provide a broad assessment of the current state of disease, including the work-up, prognostic features, and mutational aspects of the disease that should be acknowledged when developing a rational treatment plan. Key studies, guideline recommendations, and expert analysis are used to create this update on CLL/SLL. Expert commentary: The recent pace of treatment additions in CLL/SLL is a welcome addition. Moving forward, it is anticipated that treatment modalities will continue to evolve, leading to additional management options that truly would define CLL/SLL as a chronic disease.

Cutaneous reactions to chemotherapeutic drugs and targeted therapies for cancer: part I. Conventional chemotherapeutic drugs

Conventional chemotherapy continues to be an important part of cancer management, but may cause various cutaneous reactions because it disturbs specific cell cycle phases. The alkylating agents cyclophosphamide, ifosfamide, and thiotepa can produce hyperpigmentation, while hypersensitivity reactions can be seen with platinum alkylating agents. Antimetabolites vary in reactions from exanthematous to bullous skin lesions. 5-fluorouracil and its derivatives and liposomal doxorubicin and daunorubicin are characteristically known to cause hand-foot syndrome, while bleomycin can cause fibrosis and flagellate dermatitis. Several hypersensitivity reactions may also occur from mitotic inhibitors and topoisomerase inhibitors. These different characteristic presentations are important to dermatologists in identifying the correct diagnosis and management for the cancer patient.

The etiology of paraneoplastic autoimmunity

Although they may sometimes appear similar, paraneoplastic autoimmunity has a unique pathogenesis, different from the classical autoimmune diseases not associated with cancer. When distinguished clinically, paraneoplastic autoimmunity is more severe and often presents with a broader range of clinical signs and symptoms. Management of these patients is difficult and is usually centered in part on treatment of the underlying malignancy. Self-antigens recognized in the setting of paraneoplastic autoimmunity can be diverse, and the number of determinants recognized within a single antigen can be numerous. This review uses prototypic examples of paraneoplastic immune-mediated diseases and their associated malignancies to describe the mechanisms by which immune dysregulation can occur in the setting of cancer. Specific diseases covered include paraneoplastic pemphigus, Sweet's syndrome, pyoderma gangrenosum, thymoma-associated multiorgan autoimmunity, myasthenia gravis, autoimmune hemolytic anemia, immune thrombocytopenia, and the paraneoplastic neurological syndromes. The malignancies discussed include thymoma, non-Hodgkin's lymphoma, and chronic lymphocytic leukemia, among others. The mechanisms by which cancers induce autoimmunity are broken down into the following categories: disruption of central tolerance, peripheral immune dysregulation, and alteration of self-antigens. For each category, examples of paraneoplastic autoimmune diseases and their associated malignancies are discussed. Finally, mechanisms by which cancer treatment can lead to autoimmunity and examples of polymorphisms that are linked to both cancer and autoimmunity are discussed.

Autoimmune bullous diseases associations

The presence of one autoimmune disorder helps lead to the discovery of other autoimmune conditions. It is thought that diseases in which autoimmunity is a feature tend to be associated together more often than one can ascribe to chance. A variety of diseases have been implicated in the onset of intraepidermal and subepidermal autoimmune diseases. The presence of one autoimmune disease should alert the physician to watch for a second immunologic disorder. A list of autoimmune bullous diseases associations includes autoimmune bullous diseases, pemphigus, pemphigoid, epidermolysis bullosa acquisita, dermatitis herpetiformis (Duhring), linear immunoglobulin A disease, and multiple autoimmune syndrome.

Chronic lymphocytic leukemia and autoimmunity: a systematic review

Chronic lymphocytic leukemia is frequently associated with immune disturbances. The relationship between chronic lymphocytic leukemia and autoimmune cytopenias, particularly autoimmune hemolytic anemia and immune thrombocytopenia, is well established. The responsible mechanisms, particularly the role of leukemic cells in orchestrating the production of polyclonal autoantibodies, are increasingly well understood. Recent studies show that autoimmune cytopenia is not necessarily associated with poor prognosis. On the contrary, patients with anemia or thrombocytopenia due to immune mechanisms have a better outcome than those in whom these features are due to bone marrow infiltration by the disease. Moreover, fears about the risk of autoimmune hemolysis following single agent fludarabine may no longer be appropriate in the age of chemo-immunotherapy regimens. However, treatment of patients with active hemolysis may pose important problems needing an individualized and clinically sound approach. The concept that autoimmune cytopenia may precede the leukemia should be revisited in the light of recent data showing that autoimmune cytopenia may be observed in monoclonal B-cell lymphocytosis, a condition that can only be detected by using sensitive flow cytometry techniques. On the other hand, there is no evidence of an increased risk of non-hemic autoimmune disorders in chronic lymphocytic leukemia. Likewise, there is no epidemiological proof of an increased risk of chronic lymphocytic leukemia in patients with non-hemic autoimmunity. Finally, since immune disorders are an important part of chronic lymphocytic leukemia, studies aimed at revealing the mechanisms linking the neoplastic and the immune components of the disease should help our understanding of this form of leukemia.

Paraneoplastic conjunctival cicatrization: two different pathogenic types

PURPOSE

To describe the clinical and immunopathologic features of patients with 2 different types of paraneoplastic conjunctival cicatrization.

DESIGN

Retrospective observational case analyses with a review of the literature.

PARTICIPANTS

One patient with paraneoplastic ocular cicatricial pemphigoid (POCP) and 1 patient with paraneoplastic pemphigus (PNP) with ocular involvement.

METHODS

Critical review of clinical history, diagnostic studies, and immunopathologic results of biopsies in the 2 cases, together with a review of the literature.

MAIN OUTCOME MEASURES

Ability to recognize paraneoplastic conjunctival cicatrization and to diagnose the conditions accurately.

RESULTS

The first patient, 46 years of age, presented with conjunctival scarring and symblephara, cough, oral lesions, and chest rash. Concurrently, a diagnosis of pulmonary squamous cell carcinoma was made. Conjunctival biopsy revealed a subepithelial bulla, an inflammatory infiltrate of T and B lymphocytes, and basement membrane zone deposition of immunoglobulin (Ig)-G and C3 consistent with POCP. The second patient, 54 years of age, had a recently diagnosed B-cell chronic lymphocytic leukemia, followed 1 month later with ocular irritation and bilateral extensive symblephara. Extensive oral lesions and skin involvement of the lower half of the body were seen. Skin biopsy disclosed subepidermal bullae and mostly T cells with virtually no B cells in the dermal infiltrate (the patient was being treated with rituximab). Linear subepithelial deposition of IgG and C3 and deposition within the epidermis were consistent with PNP. Further indirect immunofluorescence and immunoprecipitation studies with the patient's serum-derived antibodies established PNP as the definitive diagnosis.

CONCLUSIONS

Underlying malignancy is an important consideration in younger patients with puzzling bilateral cicatrizing conjunctivitis, and a paraneoplastic condition can be established from either a conjunctival or a skin biopsy.

FINANCIAL DISCLOSURE(S)

The author(s) have no proprietary or commercial interest in any materials discussed in this article.

Paraneoplastic autoimmune multiorgan syndrome: Review of the literature and support for a cytotoxic role in pathogenesis

Paraneoplastic autoimmune multiorgan syndrome (PAMS), first described as paraneoplastic pemphigus in 1990, is an autoimmune blistering disease associated with neoplasia. Patients with this rare disorder have severe blistering and painful erosions of the oral cavity and various other cutaneous findings ranging from classic pemphigus vulgaris-like erosions to targetoid lesions resembling erythema multiforme and papular to more confluent lichenoid eruptions. This syndrome involves multiple organ systems, and its high rate of mortality often stems from constrictive bronchiolitis obliterans. The histologic findings are as diverse as the clinical presentation, often making diagnosis difficult initially. Immunodermatologic and serologic laboratory findings typically establish the diagnosis. These results can be confirmed with immunoprecipitation profiling of specific molecular weight protein markers. The proposed pathogenesis of PAMS continues to evolve, and recent reports implicate the involvement of cell-mediated, cytotoxic immunity, in addition to humoral autoantibodies. This review characterizes and summarizes the clinical, pathologic, and immunohistologic features of PAMS and outlines the possible role of cytotoxic T lymphocytes in the pathogenesis of this syndrome.

Chemotherapeutic agents and the skin: An update

Chemotherapeutic agents give rise to numerous well described adverse effects that may affect the skin, hair, mucous membranes, or nails. The mucocutaneous effects of longstanding agents have been extensively studied and reviewed. Over the last 2 decades, a number of new molecular entities for the treatment of cancer have been approved by the United States Food and Drug Administration (FDA). This article reviews the cutaneous toxicity patterns of these agents. It also reviews one drug that has not received FDA approval but is in use outside the United States and is important dermatologically. Particular emphasis is placed on the novel signal transduction inhibitors as well as on newer literature pertaining to previously described reactions.

LEARNING OBJECTIVES

At the completion of this learning activity, participants should able to list the newer chemotherapeutic agents that possess significant mucocutaneous side effects and describe the range of reactions that are seen with each drug. In addition, they should be able to formulate appropriate management strategies for these reactions.

Autoimmunity and malignancy in hematology—More than an association

Several associations between hematological malignancies and autoimmunity directed against hematopoietic cells exist. Antibody mediated elimination of mature blood cells such as autoimmune hemolytic anemia (AIHA) and immune thrombocytopenia (ITP) are frequent complications of non-Hodgkin lymphomas, most prominently chronic lymphocytic leukemia. Autoimmunity directed against hematopoietic precursor cells is the hallmark of aplastic anemia, but many features of this disease are shared by two related disorders, paroxysmal nocturnal hemoglobinuria (PNH) and myelodysplastic syndrome (MDS). While the clinical associations between hematological malignancy and autoimmunity have been described many decades ago, only in the last several years have the common pathogenetic mechanisms been elucidated. We summarize the recent progress made in understanding how hematological malignancy gives rise to autoimmunity directed against blood cells and vice versa, and illustrate parallels in the etiology of malignant and autoimmune hematological disorders. Specifically, recent progress in the recognition of the association of lymphoproliferative disorders and autoimmunity against mature blood cells, and common pathogenetic background of aplastic anemia, paroxysmal nocturnal hemoglobinuria, and myelodysplastic syndrome are discussed.

Paraneoplastic pemphigus associated with fludarabine use

Paraneoplastic pemphigus is a severe mucocutaneous disease associated with B-cell lymphoproliferative disorders. A 51-yr-old man presented to the oncology clinic with mucocutaneous skin lesions after six cycles of fludarabine for non-Hodgkin's lymphoma. A punch biopsy from the skin showed suprabasal acantholysis and blister formation in the epidermis and upper dermis. Direct immunofluorescence demonstrated intercellular IgG deposition in all epidermal layers and complement (C3) at the basement membrane. The indirect immunofluorescence on rat bladder showed intercellular binding of IgG. These findings were consistent with paraneoplastic pemphigus associated with fludarabine use. The temporal association between fludarabine use and paraneoplastic pemphigus suggests there is an etiopathological link between these two entities.

Paraneoplastic pemphigus

A paraneoplasticus pemphigus malignus vagy benignus tumorokhoz társuló autoimmun hólyagos megbetegedés diagnosztikus és immunológiai kritériumait 1990-ben fektette le Anhalt . Klinikailag súlyos, fájdalmas, mélyre terjedő bőr- és nyálkahártyatünetek jellemzik. A bőrtünetek polimorf jellegűek, általában dominál a hólyagképződés. Egyes esetekben, az ún. „graft-versus-host-disease” formákban előfordul, hogy kizárólag papulosus, lichenoid bőrtünetek észlelhetők, hólyagképződés nincs, vagy csak később jelenik meg. Elsősorban ezen alcsoport betegeiben a bőr- és nyálkahártyatünetek mellett súlyos dyspnoét okozó pulmonalis érintettség is kialakul, melynek hátterében bronchiolitis obliterans áll. A paraneoplasticus pemphigus diagnosztikájában alapvető fontosságú a bőr/nyálkahártyák direkt immunfluoreszcens, továbbá a szérum indirekt immunhisztológiai és immunoblot vizsgálata. Az eddig azonosított autoantigének döntő többsége a plakincsalád tagja: envoplakin (210 kDa), periplakin (190 kDa), plectin (~500 kDa), desmoplakin I (250 kDa), desmoplakin II (210 kDa), bullosus pemphigoid antigén 1 (230 kDa). A plakinok mellett a desmosomalis cadherinek közé sorolt desmoglein 1 és 3 a bullosus pemphigoid antigén 2 (180 kDa), a desmocollin 2 és 3, továbbá egy még nem azonosított, 170 kDa molekulatömegű transzmembrán fehérje szintén autoantigénje a kórképnek. A paraneoplasticus pemphigus nagy mortalitású kórkép, az esetek több mint 90%-ában halálos kimenetelű. A háttérben álló tumor eltávolítása mellett a bázisterápia továbbra is a nagy dózisú szisztémás szteroidkezelés, melyet citosztatikumok, immunmodulánsok adásával egészítenek ki. Szóba jön ezenkívül plasmapheresis, plazmacsere, photopheresis, nagy dózisú intravénás immunglobulin és anti-CD20 monoklonális antitest (rituximab) adása is.

Paraneoplastic pemphigus without an underlying neoplasm

We describe a 52-year-old man with paraneoplastic pemphigus (PNP) without any evidence of an underlying neoplasm over an 8-year follow-up period. He had a chronic relapsing vesiculobullous eruption for approximately 7 years (from April 1998 to May 2005). Initially, scattered flaccid vesicles with crusts developed on the face and trunk, which waxed and waned several times. Our patient was diagnosed as having PNP based on immunopathological criteria for PNP, i.e. histopathological, immunoblotting and immunoprecipitation analyses. However, physical and laboratory examinations including serial blood tests with peripheral blood smear, whole-body positron emission tomography/computed tomography and abdominal ultrasound were unable to detect any underlying neoplasm over an 8-year follow-up period.

Cutaneous reactions to chemotherapy and their management

International data from 2002 report 10.9 million new cases of cancer and 6.7 million cancer deaths. Chemotherapy is an essential component in the multidisciplinary management of most cancers. Cutaneous reactions to chemotherapeutics are common and may contribute significantly to the morbidity, and rarely to the mortality, of patients undergoing such treatments. Recognition and management of these reactions is important to provide optimal care. This article aims to present the most common cutaneous reactions to frequently used chemotherapies and provides management guidelines. A MEDLINE search from 1966 through June 2005 was conducted to identify reports of common cutaneous toxicities with systemic chemotherapy and their appropriate management. An analysis of our literature search is presented in review form outlining common chemotherapy-related cutaneous reactions and their management, as well as the chemotherapeutics responsible for the cutaneous toxicity. Chemotherapy-related cutaneous toxicity includes generalized rashes such as the spectrum between erythema multiforme and toxic epidermal necrolysis, and site-specific toxicity such as mucositis, alopecia, nail changes, extravasation reactions, or hand-foot syndrome. Most of the toxicity is reversible with chemotherapy dose reductions or delays. Certain toxicities can be effectively treated or prevented, allowing optimal delivery of chemotherapy (e.g. premedications to prevent hypersensitivity, prophylactic mouthwashes to prevent mucositis). Newer non-chemotherapeutic targeted therapies such as epidermal growth factor receptor inhibitors (e.g. gefitinib, cetuximab) may also be associated with cutaneous toxicity and can be distressing for patients. Recent data suggest that skin toxicity associated with these agents may correlate with efficacy. Cutaneous toxicity occurs frequently with chemotherapy and non-chemotherapeutic biologic therapies. Early recognition and treatment of the toxicity facilitates good symptom control, prevents treatment-related morbidity, and allows continuation of anti-cancer therapy.

Cutaneous paraneoplastic syndromes: uncommon presentations

Paraneoplastic syndromes are a group of clinical manifestations associated with a malignancy, but not directly related to the primary tumor itself or to its metastases. Characteristically, they follow a course parallel to the tumor, resolve with successful treatment of the primary tumor, and tend to recur with its relapse or the onset of metastases. The mechanism by which they occur is not well understood, but may be related to the production of bioactive substances by or in response to the tumor, such as polypeptide hormones, hormone-like peptides, antibodies or immune complexes, cytokines, or growth factors.

Paraneoplastic pemphigus: A brief update

First described in 1990, paraneoplastic pemphigus is an autoimmune condition that causes considerable morbidity, is resistant to therapy and is frequently fatal. Clinical heterogeneity is being recognized as more cases are reported and the documented auto-antigen profile is also increasing. Target antigens are now known to be not restricted to the skin, suggesting that this condition is part of a paraneoplastic autoimmune multiorgan syndrome.

PNP with Waldenstrom's macroglobulinaemia

We describe a 65-year-old Caucasian man with Waldenstrom's macroglobulinaemia who developed paraneoplastic pemphigus (PNP) 3 years after his haematological diagnosis. This is a very rare malignancy that is associated with PNP. The evolution of PNP in this patient appears to exhibit the postulated immunological phenomenon of epitope spreading.

Cutaneous findings in chronic lymphocytic leukaemia

BACKGROUND

Chronic lymphocytic leukaemia (CLL) is a malignancy characterized by clonal expansion of B lymphocytes with distinct morphology and immunophenotype. The dermatological literature relating to CLL is sparse. A global descriptive survey of a large number of CLL patients has not previously been published.

OBJECTIVES

To report the spectrum of dermatological conditions seen in a large series of CLL patients.

METHODS

Skin complications in patients with established CLL were identified retrospectively from clinical and photographic records, principally a database of over 750 consecutive cases. These events were classified, enumerated and compared.

RESULTS

Forty patients with 125 skin manifestations were identified and studied. Forty-one manifestations had documented clinical or histological atypia. In 21 of these 41 complications there had been no prior immunosuppressive therapy. We observed that cutaneous malignancies frequently presented atypically both clinically and histologically. There were 18 patients with 56 instances of basal cell carcinoma (BCC) or squamous cell carcinoma (SCC), and clinical atypia was more common with SCC than with BCC. Other cutaneous findings included varicella zoster (n = 6), leukaemia cutis (n = 3), acute graft-versus-host disease (n = 5), cutaneous drug eruptions (n = 9), multiple warts (n = 3), herpes simplex (n = 3), cutaneous T-cell lymphoma (n = 2), eosinophilic folliculitis (n = 2), malignant melanoma (n = 2) and Merkel cell tumour (n = 2).

CONCLUSIONS

We have identified a range of dermatological conditions in CLL patients, with a tendency to atypical presentations. The atypia was independent of prior chemotherapy.

Alemtuzumab-induced remission of both severe paraneoplastic pemphigus and leukaemic bone marrow infiltration in a case of treatment-resistant B-cell chronic lymphocytic leukaemia

BACKGROUND

Alemtuzumab (MabCampath; ILEX Pharmaceuticals, Geneva, Switzerland) is a humanised monoclonal antibody directed against CD52. It belongs to a new group of monoclonal antibodies with anti-neoplastic effects used in chronic lymphocytic leukaemia (CLL) either as first-line treatment or in those cases resistant to alkylating drugs. Paraneoplastic pemphigus (PNP) is a severe mucocutaneus disease mostly associated with B-cell lymphoproliferative disorders. Independent of the course of the underlying malignancy, this disease is often resistant to conventional immunosuppressive treatment and may lead to death as a result of infectious complications.

CASE PRESENTATION

We report a case where an ongoing long-term remission of PNP has been induced by alemtuzumab in a patient with an underlying B-CLL. A 68-yr-old male with a 4-yr history of B-CLL presented with a widespread blistering eruption on the extremities and trunk and a severe stomatitis. The diagnosis of PNP relied on the clinical, histological and direct immunofluorescence findings. Despite intensive treatment strategies with various immunosuppressive drugs and antibiotics, blisters continued to develop and the patient was deteriorating. When treated with alemtuzumab the mucocutaneous lesions healed almost completely within a few weeks and the patients' general condition improved significantly. After 12 wk of treatment with alemtuzumab, the CLL infiltration of the bone marrow previously quantified at 75-80% remitted completely. Twelve months later, the patient was still in remission with only a small residual ulceration on the lip and one on the penis.

CONCLUSIONS

Based on this case report we recommend treatment with alemtuzumab to severe cases of PNP in CLL. However, further follow-up of this case is needed in order to assess the long-term effect of alemtuzumab treatment in PNP.

Paraneoplastic pemphigus secondary to fludarabine evolving into unusual oral pemphigus vegetans

We report a patient with chronic lymphocytic leukaemia who developed paraneoplastic pemphigus (PNP) soon after the initiation of fludarabine therapy. He presented with severe oral and cutaneous erosions. Initially, he had high titres of circulating autoantibodies as detected by indirect immunofluorescence (IF) on multiple epithelial substrates (normal human skin, monkey oesophagus, and rat bladder) and by desmoglein 1 and 3 enzyme-linked immunosorbent assays (ELISAs). His oral erosions have subsequently progressed into unusual hyperplastic papillomatous lesions affecting the inner aspect of lips and buccal mucosae, histologically consistent with pemphigus vegetans. Desmoglein 1 antibodies and IF on rat bladder substrate have become negative after 18 months of therapy. Several agents had been initiated to bring the disease under control originally, but a partial remission was achieved and maintained with mycophenolate mofetil and low-dose prednisolone.

Exacerbation of paraneoplastic pemphigus by cyclophosphamide treatment: detection of novel autoantigens and bronchial autoantibodies

A 48-year-old woman with a follicular, grade III, B-cell non-Hodgkin lymphoma developed clinical, immunopathological and histological features of paraneoplastic pemphigus. The skin symptoms flared after repeated cyclophosphamide infusions, and were preceded and accompanied by a progressive dyspnoea. Although the skin and oral mucosal disease went into remission with high-dose steroid and intravenous immunoglobulin therapy, the severe alveolitis led to death. Immunoblotting of human epidermal extracts showed that the patient's serum IgG reacted with the 210-kDa envoplakin, 190-kDa periplakin, as well as the recombinant protein of BP180 NC16a domain. IgG and IgA enzyme-linked immunosorbent assays for desmoglein 3 were positive, too. Indirect immunofluorescence studies on COS-7 cells transiently transfected with desmocollin 1-3 cDNAs showed that the patient's serum contained IgG and IgA antibodies to desmocollin 3 as well as IgG antibodies to desmocollin 2. Serum IgG and IgA strongly stained rat bronchial epithelium, corresponding to autoantibodies possibly involved in the pathomechanism of the severe lung disease. In this case, which was characterized by a mixed IgA/IgG antibody panel displaying known and unique antigenicity, the serious episodes of paraneoplastic pemphigus flared after cyclophosphamide treatment.

Paraneoplastic pemphigus with bronchiolitis obliterans in a child

Paraneoplastic pemphigus (PNP) is a rare blistering autoimmune disease associated with an underlying neoplasm, mucous membrane erosions, and occasionally bronchiolitis obliterans. Most cases have been reported in adults and the number of childhood cases in the current literature is limited. We describe a young patient with PNP who was initially misdiagnosed as having recurrent Stevens-Johnson syndrome. This patient had an underlying inflammatory myofibroblastic tumor and subsequently developed fatal progressive bronchiolitis obliterans.