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Kashiwagi H, Kuwana M, Murata M, Shimada N, Takafuta T, Yamanouchi J, Kato H, Hato T, Tomiyama Y. Reference guide for the diagnosis of adult primary immune thrombocytopenia, 2023 edition. Int J Hematol 2024; 119:1-13. [PMID: 37957517 PMCID: PMC10770234 DOI: 10.1007/s12185-023-03672-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2023] [Revised: 09/29/2023] [Accepted: 10/02/2023] [Indexed: 11/15/2023]
Abstract
Primary immune thrombocytopenia (ITP) is an autoimmune disorder characterized by isolated thrombocytopenia due to accelerated platelet destruction and impaired platelet production. Diagnosis of ITP is still challenging because ITP has been diagnosed by exclusion. Exclusion of thrombocytopenia due to bone marrow failure is especially important in Japan because of high prevalence of aplastic anemia compared to Western countries. Hence, we propose a new diagnostic criteria involving the measurement of plasma thrombopoietin (TPO) levels and percentage of immature platelet fraction (RP% or IPF%); 1) isolated thrombocytopenia with no morphological evidence of dysplasia in any blood cell type in a blood smear, 2) normal or slightly increased plasma TPO level (< cutoff), 3) elevated RP% or IPF% (> upper limit of normal), and 4) absence of other conditions that potentially cause thrombocytopenia including secondary ITP. A diagnosis of ITP is made if conditions 1-4 are all met. Cases in which criterion 2 or 3 is not met or unavailable are defined as "possible ITP," and diagnosis of ITP can be made mainly by typical clinical course. These new criteria enable us to clearly differentiate ITP from aplastic anemia and other forms of hypoplastic thrombocytopenia and can be highly useful in clinical practice for avoiding unnecessary bone marrow examination as well as for appropriate selection of treatments.
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Affiliation(s)
- Hirokazu Kashiwagi
- Department of Blood Transfusion, Osaka University Hospital, Suita, Osaka, 565-0871, 2-15, Yamadaoka, Japan.
| | - Masataka Kuwana
- Department of Allergy and Rheumatology, Nippon Medical School Graduate School of Medicine, Tokyo, Japan
| | - Mitsuru Murata
- Center for Clinical Medical Research, International University of Health and Welfare, Ohtawara, Tochigi, Japan
| | - Naoki Shimada
- Center for Basic Medical Research, International University of Health and Welfare, Ohtawara, Tochigi, Japan
| | - Toshiro Takafuta
- Department of Internal Medicine, Hiroshima City Funairi Citizens Hospital, Hiroshima, Hiroshima, Japan
| | - Jun Yamanouchi
- Division of Blood Transfusion and Cell Therapy, Ehime University Hospital, Toon, Ehime, Japan
| | - Hisashi Kato
- Department of Hematology and Oncology, Graduate School of Medicine, Osaka University, Suita, Osaka, Japan
| | - Takaaki Hato
- Japanese Red Cross Ehime Blood Center, Matsuyama, Ehime, Japan
| | - Yoshiaki Tomiyama
- Department of Hematology and Oncology, Graduate School of Medicine, Osaka University, Suita, Osaka, Japan
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2
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Groarke EM, Patel BA, Shalhoub R, Gutierrez-Rodrigues F, Desai P, Leuva H, Zaimoku Y, Paton C, Spitofsky N, Lotter J, Rios O, Childs RW, Young DJ, Dulau-Florea A, Dunbar CE, Calvo KR, Wu CO, Young NS. Predictors of clonal evolution and myeloid neoplasia following immunosuppressive therapy in severe aplastic anemia. Leukemia 2022; 36:2328-2337. [PMID: 35896822 PMCID: PMC9701554 DOI: 10.1038/s41375-022-01636-8] [Citation(s) in RCA: 18] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2021] [Revised: 06/21/2022] [Accepted: 06/23/2022] [Indexed: 12/18/2022]
Abstract
Predictors, genetic characteristics, and long-term outcomes of patients with SAA who clonally evolved after immunosuppressive therapy (IST) were assessed. SAA patients were treated with IST from 1989-2020. Clonal evolution was categorized as "high-risk" (overt myeloid neoplasm [meeting WHO criteria for dysplasia, MPN or acute leukemia] or isolated chromosome-7 abnormality/complex karyotype without dysplasia or overt myeloid neoplasia) or "low-risk" (non-7 or non-complex chromosome abnormalities without morphological evidence of dysplasia or myeloid neoplasia). Univariate and multivariate analysis using Fine-Gray competing risk regression model determined predictors. Long-term outcomes included relapse, overall survival (OS) and hematopoietic stem cell transplant (HSCT). Somatic mutations in myeloid cancer genes were assessed in evolvers and in 407 patients 6 months after IST. Of 663 SAA patients, 95 developed clonal evolution. Pre-treatment age >48 years and ANC > 0.87 × 109/L were strong predictors of high-risk evolution. OS was 37% in high-risk clonal evolution by 5 years compared to 94% in low-risk. High-risk patients who underwent HSCT had improved OS. Eltrombopag did not increase high-risk evolution. Splicing factors and RUNX1 somatic variants were detected exclusively at high-risk evolution; DNMT3A, BCOR/L1 and ASXL1 were present in both. RUNX1, splicing factors and ASXL1 somatic mutations detected at 6 months after IST predicted high-risk evolution.
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Affiliation(s)
- Emma M. Groarke
- Hematology Branch, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD
| | - Bhavisha A. Patel
- Hematology Branch, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD
| | - Ruba Shalhoub
- Office of Biostatistics, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD
| | | | - Parth Desai
- Hematology Branch, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD
| | - Harshraj Leuva
- Hematology Branch, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD
| | - Yoshitaka Zaimoku
- Hematology Branch, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD
| | - Casey Paton
- Hematology Branch, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD
| | - Nina Spitofsky
- Hematology Branch, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD
| | - Jennifer Lotter
- Hematology Branch, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD
| | - Olga Rios
- Hematology Branch, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD
| | - Richard W. Childs
- Transplant Immunotherapy, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD
| | - David J. Young
- Translational Stem Cell Biology Branch, National Heart, Lung and Blood Institute, National Institutes of Health, Bethesda, MD
| | - Alina Dulau-Florea
- Hematology Section, Department of Laboratory Medicine, Clinical Center, National Institutes of Health, Bethesda, MD
| | - Cynthia E. Dunbar
- Translational Stem Cell Biology Branch, National Heart, Lung and Blood Institute, National Institutes of Health, Bethesda, MD
| | - Katherine R. Calvo
- Hematology Section, Department of Laboratory Medicine, Clinical Center, National Institutes of Health, Bethesda, MD
| | - Colin O. Wu
- Office of Biostatistics, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD
| | - Neal S. Young
- Hematology Branch, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD
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3
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Secondary myelodysplastic syndrome and leukemia in acquired aplastic anemia and paroxysmal nocturnal hemoglobinuria. Blood 2021; 136:36-49. [PMID: 32430502 DOI: 10.1182/blood.2019000940] [Citation(s) in RCA: 47] [Impact Index Per Article: 15.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2019] [Accepted: 11/09/2019] [Indexed: 02/06/2023] Open
Abstract
Acquired aplastic anemia (AA) and paroxysmal nocturnal hemoglobinuria (PNH) are pathogenically related nonmalignant bone marrow failure disorders linked to T-cell-mediated autoimmunity; they are associated with an increased risk of secondary myelodysplastic syndrome (MDS) and acute myeloid leukemia (AML). Approximately 15% to 20% of AA patients and 2% to 6% of PNH patients go on to develop secondary MDS/AML by 10 years of follow-up. Factors determining an individual patient's risk of malignant transformation remain poorly defined. Recent studies identified nearly ubiquitous clonal hematopoiesis (CH) in AA patients. Similarly, CH with additional, non-PIGA, somatic alterations occurs in the majority of patients with PNH. Factors associated with progression to secondary MDS/AML include longer duration of disease, increased telomere attrition, presence of adverse prognostic mutations, and multiple mutations, particularly when occurring early in the disease course and at a high allelic burden. Here, we will review the prevalence and characteristics of somatic alterations in AA and PNH and will explore their prognostic significance and mechanisms of clonal selection. We will then discuss the available data on post-AA and post-PNH progression to secondary MDS/AML and provide practical guidance for approaching patients with PNH and AA who have CH.
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Vyrides N, Douka V, Gavriilaki E, Papaioannou G, Athanasiadou A, Neofytou S, Vyrides Y, Lalayanni C, Anagnostopoulos A, Kokoris SI. Paroxysmal nocturnal hemoglobinuria and myelodysplastic syndrome: Disappearance of cytogenetic abnormalities. Cancer Genet 2020; 250-251:1-5. [PMID: 33188967 DOI: 10.1016/j.cancergen.2020.11.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2020] [Revised: 09/18/2020] [Accepted: 11/02/2020] [Indexed: 11/16/2022]
Abstract
Paroxysmal nocturnal hemoglobinuria (PNH) is a rare life-threatening disease resulting from clonal hematopoietic stem cell evolution. There is a strong link between PNH and other acquired bone marrow failure syndromes, including myelodysplastic syndrome (MDS). Cytogenetic, morphological abnormalities or both are observed in the range of MDS/PNH diagnosis. Herein, we investigate cytogenetic abnormalities in PNH patients. We found two patients with PNH clones and MDS-associated abnormalities that later disappeared. The first patient, originally diagnosed with MDS and Trisomy 6, developed a large PNH clone. At the time of PNH diagnosis, the abnormal cytogenetic clone was no longer detectable despite persistent trilineage dysplasia. In the second patient, a large PNH clone and MDS-defining abnormality were detected at diagnosis, without evidence of dysplasia. No cytogenetic abnormalities were evident after complement inhibition. Our report adds significant information on the complex link between MDS and PNH, suggesting that distinction between these entities may be difficult in some cases. Especially in transplant eligible patients, the clinical phenotype may be the leading feature for treatment decisions in the era of complement inhibition. Lastly, the transient presence of cytogenetic abnormalities is a unique characteristic of our patients' course that needs to be further elucidated in larger studies.
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Affiliation(s)
- Niki Vyrides
- Haematology Department, Vyrides Clinic, Nicosia, Cyprus; University of Nicosia Medical School, Nicosia, Cyprus.
| | - Vassiliki Douka
- Hematology Department-BMT Unit, G. Papanicolaou Hospital, Thessaloniki; Greece
| | - Eleni Gavriilaki
- Hematology Department-BMT Unit, G. Papanicolaou Hospital, Thessaloniki; Greece
| | | | | | - Sofia Neofytou
- Cytogenetic Department, Archbishop Makarios III Hospital - Nicosia, Cyprus
| | - Yiannis Vyrides
- Great Western Hospitals NHS Foundation Trust, Swindon, United Kingdom
| | - Chrysavgi Lalayanni
- Hematology Department-BMT Unit, G. Papanicolaou Hospital, Thessaloniki; Greece
| | | | - Styliani I Kokoris
- Laboratory of Hematology and Hospital Blood Transfusion Department, University General Hospital "Attikon", National and Kapodistrian University of Athens, Medical School, Greece
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5
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Wang J, Shen P, Wu X, Jin W. Risk factors associated with poor response to immunosuppressive therapy in acquired aplastic anemia: A meta-analysis of retrospective studies. Exp Ther Med 2020; 19:3104-3112. [PMID: 32256799 PMCID: PMC7086236 DOI: 10.3892/etm.2020.8536] [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: 07/09/2019] [Accepted: 01/22/2020] [Indexed: 11/16/2022] Open
Abstract
Acquired aplastic anemia (AA) is a rare hematological disease characterized by bone marrow hypocellularity and varying degrees of pancytopenia. Immunosuppressive therapy (IST) is currently one of the first-line treatments for AA; however, unresponsiveness remains a major concern. Although previous studies have suggested several common risk factors for unresponsiveness, there are currently no widely accepted predictors. Therefore, a meta-analysis of clinical trials including information on factors associated with unresponsiveness of AA to IST was performed in the present study. The PubMed, Embase and Cochrane Library databases were searched for clinical studies on AA evaluating the association between risk factors and unresponsiveness to IST. After the factors were defined from the selected studies, the association between these factors and unresponsiveness to IST was analyzed using Review Manager software. A total of 10 studies comprising 1,820 cases were included in the present meta-analysis. The following factors were identified as predictors of unresponsiveness: Age (≥60 years), sex, absolute neutrophil count, severity of the disease, paroxysmal nocturnal hemoglobinuria clone, human leukocyte antigen (HLA)-DR2 and cytogenetic abnormalities (CAs). Among these factors, only age (≥60 years) [odds ratio (OR)=1.65], HLA-DR2 negativity (OR=2.72) and CAs (OR=1.93) exhibited a statistically significant association with unresponsiveness to IST (P=0.006, P=0.04 and P=0.01, respectively). In conclusion, the present meta-analysis revealed that age ≥60 years, HLA-DR2 negativity and CAs are risk factors for unresponsiveness to IST. This result may enable clinicians to select an effective therapeutic scheme for patients with AA and even provide novel clues to the pathogenesis of AA.
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Affiliation(s)
- Jia Wang
- Department of Pathology, Xinhua Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200092, P.R. China
| | - Ping Shen
- Department of Pathology, Shanghai Children's Medical Center Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai 200092, P.R. China
| | - Xiangru Wu
- Department of Pathology, Xinhua Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200092, P.R. China
| | - Wenjie Jin
- Department of Orthopaedics, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 201999, P.R. China
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HLA-DR(negative), CD34(negative) hypergranular acute myeloid leukemia with trisomy 6 and del(5)(q22q33): case report and review of the literature. J Pediatr Hematol Oncol 2011; 33:e289-95. [PMID: 21768886 DOI: 10.1097/mph.0b013e31821503c8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
We report a unique pediatric case of hypergranular acute myeloid leukemia with myelodysplasia-related changes. The patient presented with moderate leukocytosis with neutrophilia with left-shift maturation and dysplasia, anemia, and multiple sclerotic bone lesions. The bone marrow was hypercellular with a predominance of myeloblast cells and/or abnormal promyelocytes with hypergranular cytoplasm. Flow cytometric immunophenotyping showed that the leukemic cells were positive for CD13, CD33, and myeloperoxidase, and negative for HLA-DR and CD34. Morphology and immunophenotyping were highly suggestive of acute promyelocytic leukemia. The classic t(15;17) or other RARα rearrangements were not detected by cytogenetic or molecular assays, ruling out acute promyelocytic leukemia. Standard cytogenetic analysis showed that the karyotype of the predominant clone was 47,XY,+6 with evidence of clonal evolution to 47,XY,+6,del(5)(q22q33). A literature and database review showed that trisomy 6 is a rare occurrence in hematological malignancies and, to our knowledge, has never been reported in association with del(5)(q22q33) in a child presenting with hypergranular acute myeloid leukemia with myelodysplasia-related changes. We present a current review of the literature and summarize the clinical features of 57 cases of trisomy 6 as the primary chromosomal abnormality in hematological disease.
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Cho SY, Oh SH, Suh JT, Lee HJ, Lee WI, Baek SK, Cho KS, Park TS. Hypoplastic myelodysplastic syndrome associated with der(1;7)(q10;p10) presenting as bone marrow failure. Acta Haematol 2011; 126:110-3. [PMID: 21646778 DOI: 10.1159/000328036] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2011] [Accepted: 03/21/2011] [Indexed: 01/02/2023]
Affiliation(s)
- Sun Young Cho
- Department of Laboratory Medicine, School of Medicine, Kyung Hee University, Seoul, Korea
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Lee JH, Kwon KA, Lee S, Oh SY, Kim SH, Kwon HC, Han JY, Song MK, Chung JS, Lee HS, Kim YS, Lee SM, Joo YD, Kim HJ. Incidence and clinical characteristics of clonal cytogenetic abnormalities of acquired aplastic anemia in adults. THE KOREAN JOURNAL OF HEMATOLOGY 2010; 45:242-6. [PMID: 21253425 PMCID: PMC3023049 DOI: 10.5045/kjh.2010.45.4.242] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/19/2010] [Revised: 10/30/2010] [Accepted: 11/18/2010] [Indexed: 12/02/2022]
Abstract
Background Cytogenetic abnormalities (CAs) have been reported frequently in patients with otherwise typical aplastic anemia (AA), but their implications in the prognosis and in the evolution to hematologic malignancies are controversial. Methods We retrospectively analyzed 127 adult AA patients who had successful cytogenetic analysis at initial diagnosis. Results The patients were classified into 3 groups according to the initial and follow-up results of cytogenetic profiles. Group 1 included patients who had persistent AA with normal cytogenetic profiles (N=117); Group 2, those who had a normal cytogenetic profile at initial diagnosis but later acquired CA (N=4, 3.1%); and Group 3, those who had CA at the initial diagnosis, regardless of follow-up cytogenetic status (N=6,4.7%). In Group 2, 2 patients later developed CA without progression to acute myeloid leukemia (AML) or myelodysplastic syndrome (MDS); the other 2 patients later progressed to AML. None of the patients in Group 3 progressed to AML or MDS. There was no significant difference in overall survival between Groups 1 and 3. Conclusion AA patients with CA at initial diagnosis or follow-up may not be at greater risk for evolution to AML or MDS, or show shorter survival periods. Prospective studies and a larger patient samples are needed to establish the clinical relevance of CA.
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Affiliation(s)
- Ji Hyun Lee
- Department of Internal Medicine, Dong-A University College of Medicine, Busan, Korea
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9
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Sloand EM, Olnes MJ, Shenoy A, Weinstein B, Boss C, Loeliger K, Wu CO, More K, Barrett AJ, Scheinberg P, Young NS. Alemtuzumab treatment of intermediate-1 myelodysplasia patients is associated with sustained improvement in blood counts and cytogenetic remissions. J Clin Oncol 2010; 28:5166-73. [PMID: 21041705 DOI: 10.1200/jco.2010.29.7010] [Citation(s) in RCA: 108] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE Myelodysplastic syndromes (MDS) are characterized by ineffective hematopoiesis and progression to leukemia. Clinical and experimental evidence suggests an immune-mediated pathophysiology in some patients, in whom immunosuppressive therapy (IST) with horse antithymocyte globulin (h-ATG) and cyclosporine (CsA) can be effective. Because of the toxicities associated with h-ATG/CsA, we investigated an alternative regimen with alemtuzumab in MDS. PATIENTS AND METHODS We conducted a nonrandomized, off-label, pilot, phase I/II study of alemtuzumab monotherapy in patients with MDS who were judged likely to respond to IST based on the following criteria: HLA-DR15-negative patients whose age plus the number of months of RBC transfusion dependence (RCTD) was less than 58; and HLA-DR15-positive patients whose age plus RCTD was less than 72. In total, 121 patients with MDS were screened, of whom 32 met eligibility criteria to receive alemtuzumab 10 mg/d intravenously for 10 days. Primary end points were hematologic responses at 3, 6, and 12 months after alemtuzumab. RESULTS Seventeen (77%) of 22 evaluable intermediate-1 patients and four (57%) of seven evaluable intermediate-2 patients responded to treatment with a median time to response of 3 months. Four of seven evaluable responders with cytogenetic abnormalities before treatment had normal cytogenetics by 1 year after treatment. Five (56%) of nine responding patients evaluable at 12 months had normal blood counts, and seven (78%) of nine patients were transfusion independent. CONCLUSION Alemtuzumab is safe and active in MDS and may be an attractive alternative to ATG in selected patients likely to respond to IST.
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Affiliation(s)
- Elaine M Sloand
- Hematology Branch, National Heart, Lung, and Blood Institute, Bldg 10 CRC 4-5230, Bethesda, MD 20892, USA.
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Tripathi AK, Tripathi P, Kumar A, Ahmad R, Singh RK, Balapure AK, Vishwakermad AL. S-phase fraction as a useful marker for prognosis and therapeutic response in patients with aplastic anemia. Hematol Oncol Stem Cell Ther 2010; 1:216-20. [PMID: 20058476 DOI: 10.1016/s1658-3876(08)50007-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND The functional definition of aplastic anemia (AA) is the failure of hematopoietic stem cells to proliferate. The aim of the present study was to analyze the S-phase fraction (SPF) (proliferative activity) in patients with AA at diagnosis to explore its relationship with disease characteristics and its value in discriminating among patients with different prognoses. We also investigated whether the SPF value influenced the response to immunosuppressive therapy in AA patients. PATIENTS AND METHODS The analysis of SPF at the time of diagnosis was carried out by flow cytometry on peripheral blood samples from 53 consecutive patients with AA and 30 age- and sex-matched controls. All patients were given cyclosporine and followed up periodically to determine response to therapy. RESULTS Based on the median SPF, AA patients were divided into two groups: patients with SPF < 0.59% (n = 27) and patients with SPF > 0.59% (n = 26). An SPF > 0.59% was associated with advanced age (P = .02) and elevated serum LDH level (P = .01). Patients with an SPF > 0.59% also had a higher incidence of paroxysmal nocturnal hemoglobinuria and cytogenetic abnormalities. During a median follow-up of 18 months, 3.7% of patients with SPF < or = 0.59 and 11.5% of patients with SPF > 0.59% developed dysplasia and one patient with SPF > 0.59% converted into AML. A significantly higher (P = .018) overall response rate of 53.9% was found in patients with SPF > 0.59% versus 22.2% of patients with SPF < or = 0.59% at 6 months. CONCLUSIONS Independently of the peripheral blood count, the SPF at diagnosis may provide information on the expected response to immunosuppressive therapy and the propensity for disease to evolve into MDS/AML. Hence, SPF may serve as an early indicator for the evolution of MDS/AML in patients with AA and thus contribute to therapeutic decisions.
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Affiliation(s)
- Anil Kumar Tripathi
- Department of Medicine, CSM Medical University, Lucknow, Uttar Pradesh, India.
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11
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Sloand EM, Barrett AJ. Immunosuppression for myelodysplastic syndrome: how bench to bedside to bench research led to success. Hematol Oncol Clin North Am 2010; 24:331-41. [PMID: 20359629 PMCID: PMC3793398 DOI: 10.1016/j.hoc.2010.02.009] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Laboratory evidence and clinical evidence suggest that some patients with myelodysplastic syndrome (MDS) have immunologically mediated disease. This article describes the laboratory evidence supporting a role for the immune system in the marrow failure of MDS and clinical trials using IST in these patients.
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Affiliation(s)
- Elaine M Sloand
- Hematology Branch, Division of Intramural Research, National Heart, Lung and Blood Institute, 10 Center Drive, Bethesda, MD 20892, USA.
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Marsh JCW, Ball SE, Cavenagh J, Darbyshire P, Dokal I, Gordon-Smith EC, Keidan J, Laurie A, Martin A, Mercieca J, Killick SB, Stewart R, Yin JAL. Guidelines for the diagnosis and management of aplastic anaemia. Br J Haematol 2009; 147:43-70. [PMID: 19673883 DOI: 10.1111/j.1365-2141.2009.07842.x] [Citation(s) in RCA: 384] [Impact Index Per Article: 25.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Affiliation(s)
- Judith C W Marsh
- Department of Haematological Medicine, King's College Hospital, London, UK.
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13
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Abstract
Myelodysplasia must be considered in the differential diagnosis of patients who have bone marrow failure, but bone marrow cellularity per se may not substantially affect either response to therapy or prognosis. It is unclear whether the primary pathophysiologic defect differs between hyper- and hypoplastic patients who have myelodysplasia. Cellularity does not seem to affect response to immunosuppressive therapy significantly and does not seem to be the major factor affecting improvements in response to lenalidomide, stem cell transplantation, or hematopoietic growth factors.
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Affiliation(s)
- Elaine M Sloand
- Hematology Branch, National Heart Lung and Blood Institute, 10 Center Drive, Bldg10, CRC Rm 4E5230, Bethesda, MD 20892, USA.
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Gurion R, Gafter-Gvili A, Paul M, Vidal L, Ben-Bassat I, Yeshurun M, Shpilberg O, Raanani P. Hematopoietic growth factors in aplastic anemia patients treated with immunosuppressive therapy-systematic review and meta-analysis. Haematologica 2009; 94:712-9. [PMID: 19336743 DOI: 10.3324/haematol.2008.002170] [Citation(s) in RCA: 54] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
Immunosuppressive therapy is the treatment for aplastic anemia patients ineligible for transplantation. The role of hematopoietic growth factors as adjunct to treatment in these patients is unclear. We conducted a systematic review and meta-analysis of randomized controlled trials comparing treatment with immunosuppressive therapy and hematopoietic growth factors to immunosuppressive therapy alone in patients with aplastic anemia. Two reviewers appraised the quality of trials and extracted data. For each trial, results were expressed as relative risks with 95% confidence intervals (CI) for dichotomous data. The addition of hematopoietic growth factors yielded no difference in overall mortality at 100 days, one year and five years [relative risks 1.33 (95% CI 0.56-3.18), relative risks 0.90 (95% CI 0.50-1.63) and relative risks 0.89 (95% CI 0.55-1.46), respectively]. There was no difference in overall hematologic response and in the occurrence of infections. HGF significantly decreased the risk for relapse, relative risks 0.45 (95% CI 0.30-0.68, 3 trials). Hematopoietic growth factors were not associated with higher occurrence of myelodysplastic syndrome and acute myeloid leukemia or paroxysmal nocturnal hemoglobinuria. The addition of hematopoietic growth factors does not affect mortality, response rate or infections occurrence. Therefore, it should not be recommended routinely as an adjunct to the immunosuppressive therapy for patients with aplastic anemia.
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Affiliation(s)
- Ronit Gurion
- Institute of Hematology, Davidoff Center, Beilinson Hospital, Rabin Medical Center, Petah-Tikva, Israel.
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15
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Sloand EM, Rezvani K. The Role of the Immune System in Myelodysplasia: Implications for Therapy. Semin Hematol 2008; 45:39-48. [DOI: 10.1053/j.seminhematol.2007.11.006] [Citation(s) in RCA: 50] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
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17
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Teramura M, Kimura A, Iwase S, Yonemura Y, Nakao S, Urabe A, Omine M, Mizoguchi H. Treatment of severe aplastic anemia with antithymocyte globulin and cyclosporin A with or without G-CSF in adults: a multicenter randomized study in Japan. Blood 2007; 110:1756-61. [PMID: 17526862 DOI: 10.1182/blood-2006-11-050526] [Citation(s) in RCA: 83] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
We report the results of a randomized study to elucidate whether addition of granulocyte colony-stimulating factor (G-CSF) to immunosuppressive therapy is valuable for the treatment of severe aplastic anemia (SAA) in adults. A total of 101 previously untreated patients (median age, 54 years; range, 19 to 75 years) were randomized to receive antithymocyte globulin (ATG) and cyclosporin A (CyA) (G-CSF- group) or ATG, CyA, and G-CSF (G-CSF+ group). In the G-CSF+ group, the hematologic response rate at 6 months was higher (77% vs 57%; P = .03) than in the G-CSF- group. No differences were observed between the groups in terms of the incidence of infections and febrile episodes. There were no differences between the G-CSF- group and the G-CSF+ group in terms of survival (88% vs 94% at 4 years), and the development of myelodysplastic syndrome (MDS)/acute leukemia (AL) (1 patient vs 2 patients). However, the relapse rate was lower in the G-CSF+ group compared with the G-CSF- group (42% vs 15% at 4 years; P = .01). Further follow-up is required to elucidate the role of G-CSF in immunosuppressive therapy for adult SAA.
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Affiliation(s)
- Masanao Teramura
- Department of Hematology, Tokyo Women's Medical University, Tokyo.
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18
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Abstract
The current outlook for a child with severe idiopathic aplastic anaemia (AA) is very much better than in previous decades. In part, this may reflect better differentiation of idiopathic and inherited marrow failure. For children with idiopathic AA and a human leucocyte antigen (HLA)-matched sibling donor (MSD), allogeneic haematopoietic stem-cell transplantation (AHSCT) is the primary therapy of choice, offering long-term disease-free survival of 90%, although graft-versus-host disease remains a cause of long-term morbidity. A greater treatment challenge remains for those children without a MSD. Combination immunosuppressive therapy (IST) is associated with response rates of 70% or more. However, relapse and clonal evolution with transformation to myelodysplasia or acute myeloid leukaemia remain significant problems after IST and long-term event-free survival rates are less impressive. For children who do not have a sustained response to IST, alternate donor AHSCT should be considered. New HLA typing technologies, novel stem cell sources, reduced-intensity conditioning and graft engineering have reduced toxicity and improved the outcome after alternate donor AHSCT. Emerging therapies that capitalise on recent advances in our understanding of the pathophysiology of idiopathic AA and the immunobiology of AHSCT and IST may further improve the long-term outcome of this disease.
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Affiliation(s)
- Jeffrey K Davies
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA 02115, USA
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19
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Affiliation(s)
- Hack Ki Kim
- Department of Pediatrics, College of Medicine, The Catholic University of Korea, Seoul, Korea
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20
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Gupta V, Brooker C, Tooze JA, Yi QL, Sage D, Turner D, Kangasabapathy P, Marsh JCW. Clinical relevance of cytogenetic abnormalities at diagnosis of acquired aplastic anaemia in adults. Br J Haematol 2006; 134:95-9. [PMID: 16803574 DOI: 10.1111/j.1365-2141.2006.06105.x] [Citation(s) in RCA: 54] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
The outcome of 81 adult aplastic anaemia patients who had successful cytogenetics at diagnosis and received immunosuppressive therapy was evaluated. Ten patients had an abnormal karyotype, six of which had a trisomy. Four of five evaluable patients with a trisomy responded. One patient with monosomy 7 achieved a complete response and later developed haemolytic paroxysmal nocturnal haemoglobinuria but no recurrence of monosomy 7. None of the patients with a non-numerical karyotypic abnormality responded. No significant differences in survival or later clonal disorders were observed between patients with a normal karyotype and those with an abnormal karyotype.
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Affiliation(s)
- Vikas Gupta
- Department of Haematology, St George's Hospital, London, UK
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21
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Gupta V, Gordon-Smith EC, Cook G, Parker A, Duguid JKM, Wilson KMO, Yi QL, Marsh JCW. A third course of anti-thymocyte globulin in aplastic anaemia is only beneficial in previous responders. Br J Haematol 2005; 129:110-7. [PMID: 15801963 DOI: 10.1111/j.1365-2141.2005.05406.x] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
This retrospective study evaluated the outcome of 18 patients with aplastic anaemia treated with a third course of anti-thymocyte globulin (ATG)-containing immunosuppressive therapy (IST). Of the 18 patients, seven had responded to one of the previous courses of ATG and 11 were refractory to both the previous courses. Self-limiting grade >/=3 liver toxicity was observed in three patients. Two patients had to discontinue ATG because of severe systemic side effects. The incidence and manifestations of serum sickness did not appear to be different during the three courses. All of the seven patients that previously responded to one of the courses responded to a third course. In contrast, of 11 patients refractory to the previous courses, only two had a transient partial response. The 3-yr event-free survival for the patients who had responded to one of the previous courses of ATG was significantly superior to that of patients refractory to both the previous courses of ATG (83% vs. 0%, P = 0.0001). For aplastic anaemia patients, a third course of ATG-containing IST is a reasonable option in previous responders. Patients refractory to previous two courses of ATG have a much lower response rate and may be suitable candidates for novel therapeutic options.
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Affiliation(s)
- Vikas Gupta
- Division of Haematology, Department of Cellular and Molecular Sciences, St George's Hospital and Medical School, London, UK
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22
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Marsh JCW, Ball SE, Darbyshire P, Gordon-Smith EC, Keidan AJ, Martin A, McCann SR, Mercieca J, Oscier D, Roques AWW, Yin JAL. Guidelines for the diagnosis and management of acquired aplastic anaemia. Br J Haematol 2003; 123:782-801. [PMID: 14632769 DOI: 10.1046/j.1365-2141.2003.04721.x] [Citation(s) in RCA: 111] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Affiliation(s)
- J C W Marsh
- St. George's Hospital Medical School, London, UK.
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23
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Valent P, Wimazal F, Schwarzinger I, Sperr WR, Geissler K. Pathogenesis, classification, and treatment of myelodysplastic syndromes (MDS). Wien Klin Wochenschr 2003; 115:515-36. [PMID: 13677270 DOI: 10.1007/bf03041035] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
Myelodysplastic syndromes (MDS) comprise a heterogeneous group of clonal myeloid disorders characterized by morphologic dysplasia in one or more cell lineages. Dysplasia in MDS is associated with insufficient production of blood cells and consecutive cytopenia(s). The natural course and prognosis of MDS vary among patients and depend on genetic defects that occur during clonal evolution. In a significant group of patients (roughly 30%) progression to secondary leukemia is observed. These patients appear to have a grave prognosis. The treatment of patients with MDS has to be adjusted to the individual situation and age in each case. In many patients, control of blast cell production by palliative cytoreduction, continuous support with red blood cells, as well as other supportive measures, seem appropriate. In other patients, however, curative therapy (chemotherapy, stem cell transplantation) should be considered. The final decision to offer curative therapy must be based on many different factors including age and the overall situation of the patient. Recently established scoring systems aimed at predicting survival and evolution of leukemia in MDS may be helpful in this regard.
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Affiliation(s)
- Peter Valent
- Division of Hematology and Hemostaseology, Department of Internal Medicine I, University of Vienna, Vienna, Austria.
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Yamada T, Tsurumi H, Kasahara S, Hara T, Sawada M, Moriwaki H. Immunosuppressive therapy for myelodysplastic syndrome: efficacy of methylprednisolone pulse therapy with or without cyclosporin A. J Cancer Res Clin Oncol 2003; 129:485-91. [PMID: 12856174 DOI: 10.1007/s00432-003-0477-z] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2003] [Accepted: 06/07/2003] [Indexed: 10/26/2022]
Abstract
We investigated whether immunosuppressive therapy using methylprednisolone (mPSL) with or without cyclosporin A (CsA) could benefit patients with myelodysplastic syndrome (MDS). Eligibility criteria for this study were a clinical diagnosis of MDS with less than 5% blast in peripheral blood, less than 10% blast in bone marrow and advanced cytopenia. Among 73 patients with MDS, 18 eligible and consecutive patients (8 men and 10 women), aged 48 to 87 years (median: 66.5 years) were assigned to receive mPSL pulse therapy (1,000 mg daily for 3 consecutive days, followed by tapering oral prednisolone; n= 12) or mPSL pulse with CsA therapy (4 to 5 mg/kg administered twice daily; n= 6). Six of 18 patients (33.3%; 3 of 10 patients with RA, 2 of 6 patients with RAEB, 1 of 2 patients with CMMoL) responded to immunosuppressive therapy. Four patients responded to mPSL pulse alone, and two patients responded to mPSL pulse with CsA. One of 6 patients with hypocellular bone marrow and 5 of 12 patients with normocellular or hypercellular marrow responded to immunosuppressive therapy. No patient with myelofibrosis responded to the therapy. The duration of response ranged from 4 to 59 months (median: 14 months). Although a significant difference was observed between responders and nonresponders in the survival rate ( P<0.05), no significant difference was found in clinical characteristics at entry between responders and nonresponders. In responders, mean hemoglobin levels were significantly increased ( P<0.01), and the required red cell transfusion dose was significantly reduced ( P<0.01). It is possible that immunosuppressive therapy might be effective for a certain subset of patients with MDS.
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Affiliation(s)
- Toshiki Yamada
- First Department of Internal Medicine, Gifu University School of Medicine, 40 Tsukasa-machi, 500-8705, Gifu, Japan
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25
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Taguchi A, Tominaga T, Nakamori Y, Miyazaki M, Shinohara K. Two cases of acute myeloblastic leukemia evolving from aplastic anemia. Int J Hematol 2003; 77:471-5. [PMID: 12841385 DOI: 10.1007/bf02986615] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Two cases of acute myeloblastic leukemia (AML) evolving from aplastic anemia are presented. The first case was diagnosed 18 years ago, and treatment with bolus methylprednisolone, prednisolone, and androgens resulted in partial hematological response. Severe pancytopenia recurred, and AML M0 by French-American-British classification developed. The second case was diagnosed 7 years ago. The patient had HLA DRB1*1501, and treatment with granulocyte colony-stimulating factor (G-CSF), cyclosporine, and methenolone resulted in complete hematological response. Thrombocytopenia recurred and did not respond to cyclosporine and methenolone or to later treatment with antithymocyte globulin, and AML M1 developed. Cytogenetic studies demonstrated 7q- in the first patient and +8 in the second patient. No mutations of N-ras or p53 were observed in either patient. These patients were treated with cytosine arabinoside, aclacinomycin, and G-CSF (CAG) chemotherapy, and the number of leukemic cells decreased substantially. However, pancytopenia after CAG chemotherapy persisted, and the first patient died of pneumonia and the second patient of cerebral hemorrhage.
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Affiliation(s)
- Akihiko Taguchi
- Division of Hematology, Department of Medicine, Yamaguchi Prefecture Central Hospital, Hofu, Japan
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26
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Selleri C, Maciejewski JP, Catalano L, Ricci P, Andretta C, Luciano L, Rotoli B. Effects of cyclosporine on hematopoietic and immune functions in patients with hypoplastic myelodysplasia: in vitro and in vivo studies. Cancer 2002; 95:1911-22. [PMID: 12404285 DOI: 10.1002/cncr.10915] [Citation(s) in RCA: 40] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Immunosuppression may benefit some patients with hypoplastic myelodysplasia (HMDS) and refractory anemia (RA), but its mechanism of action is still obscure. METHODS Using flow cytometry, we studied Fas-receptor (Fas-R), Fas-ligand (Fas-L), and interferon-gamma (IFN-gamma) expression in CD34(+) cells and lymphocytes obtained from 11 HMDS and 20 RA patients. In colony assays and long-term cultures, the effects of Fas triggering, IFN-gamma blockade, or cyclosporine(CsA) on the growth of hematopoietic progenitors (colony-forming cells [CFC]) were determined. The effects of CsA at daily doses of 1-3 mg/kg for at least 3 months in HMDS patients were also studied. RESULTS In basal conditions, committed and immature progenitor cells were found decreased in myelodysplastic (MDS) patients. No significant differences between HMDS and RA patients were detected. IFN-gamma-expressing CD4(+) cells were significantly increased in HMDS patients, whereas intracytoplasmic Fas-L expression was only borderline elevated in CD3(+) MDS cells. Increased numbers of CD34(+) cells expressing Fas-R were found in HMDS and RA patients. CFC and secondary CFC showed higher susceptibility to Fas-L-mediated inhibition and the blockade of IFN-gamma improved marrow primary, but not secondary, CFC growth. CsA added in vitro to patient's lymphocytes significantly decreased the number of IFN-gamma-expressing CD4(+) cells, but not Fas-L production. These effects were associated with increased colony formation. Similar to IFN-gammablockade, production of secondary CFC was not enhanced by CsA. Administration of CsA to patients resulted in prolonged partial hematologic improvement in 8 of 11 HMDS patients. CONCLUSIONS Increased frequency of IFN-gamma producing CD4(+) cells supports the involvement of lymphocyte-mediated suppression of hematopoiesis in the development of cytopenia in MDS patients. The ability of CsA to decrease in vitro IFN-gamma production may improve hematopoietic function, explaining the beneficial effect of this agent in HMDS patients.
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Affiliation(s)
- Carmine Selleri
- Division of Hematology, Federico II University of Naples, Italy.
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27
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Wong KF, So CC. Hypoplastic myelodysplastic syndrome-a clinical, morphologic, or genetic diagnosis? CANCER GENETICS AND CYTOGENETICS 2002; 138:85-8. [PMID: 12419592 DOI: 10.1016/s0165-4608(02)00581-2] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
We report a middle-aged female with an 11-year history of nonprogressive pancytopenia and severely hypoplastic marrow with minimal morphologic dysplasia. A diagnosis of hypoplastic myelodysplastic syndrome (MDS) was made because of the finding of a persistent clonal abnormality, del(13)(q12q14), and the subsequent demonstration of a single Auer rod-containing blast in the peripheral blood smear. The case illustrates the problems in the differentiation between aplastic anemia and hypoplastic MDS.
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Affiliation(s)
- K F Wong
- Department of Pathology, Queen Elizabeth Hospital, 30 Gascoigne Road, Kowloon, SAR, Hong Kong, China.
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28
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Kawata E, Kuroda J, Kimura S, Kamitsuji Y, Kobayashi Y, Yoshikawa T. Aplastic anemia evolving into overt myelodysplastic syndrome/acute myeloid leukemia with t(3;5)(p25;q31). CANCER GENETICS AND CYTOGENETICS 2002; 137:91-4. [PMID: 12393278 DOI: 10.1016/s0165-4608(02)00556-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Advances in the treatment of aplastic anemia (AA) have led to the long-term survival of nontransplanted AA patients; however, the issue of subsequent hematological clonal disorders has been raised as some AA patients treated with immunosuppressive therapy or granulocyte-colony stimulating factor (G-CSF) went on to develop myelodysplastic syndromes (MDS) and/or acute myeloid leukemia (AML) with the frequent presentation of monosomy 7. We report a case of AA progressing to overt MDS/AML following 11 years of treatment that included immunosuppressive therapy and G-CSF. The patient's MDS/AML proved refractory to therapy including myeloablative treatment with allogenic peripheral blood stem cell transplantation. Earlier reports and the present case strongly suggest that there is no recurrent chromosomal aberration other than monosomy 7 in cases of AA that progress to MDS/AML. To our knowledge, ours is the first reported case of a t(3;5)(p25;q31) among AA patients that have progressed to MDS/AML.
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MESH Headings
- Adult
- Anemia, Aplastic/complications
- Anemia, Aplastic/genetics
- Chromosomes, Human, Pair 3/genetics
- Chromosomes, Human, Pair 5/genetics
- Female
- Humans
- Karyotyping
- Leukemia, Myeloid, Acute/complications
- Leukemia, Myeloid, Acute/genetics
- Myelodysplastic Syndromes/complications
- Myelodysplastic Syndromes/genetics
- Translocation, Genetic/genetics
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Affiliation(s)
- Eri Kawata
- First Department of Internal Medicine, Kyoto Prefectural University of Medicine, 465 Kajii Kamigyo-ku, Kyoto 602, Japan
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29
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Kojima S, Ohara A, Tsuchida M, Kudoh T, Hanada R, Okimoto Y, Kaneko T, Takano T, Ikuta K, Tsukimoto I. Risk factors for evolution of acquired aplastic anemia into myelodysplastic syndrome and acute myeloid leukemia after immunosuppressive therapy in children. Blood 2002; 100:786-90. [PMID: 12130487 DOI: 10.1182/blood.v100.3.786] [Citation(s) in RCA: 117] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Long-term survivors of acquired aplastic anemia (AA) have an increased risk of developing myelodysplastic syndrome (MDS) and acute myeloid leukemia (AML) after immunosuppressive therapy (IST). It is uncertain whether the increased survival time simply discloses the natural history of AA as a premalignant disease or whether secondary disease is related to the therapy itself. Between November 1992 and September 1997, 113 AA children with normal cytogenetics at diagnosis were treated with IST using antithymocyte globulin, cyclosporin, and danazol with or without granulocyte colony-stimulating factor (G-CSF). We assessed risk factors for developing MDS/AML by Cox proportional hazards models. Twelve of 113 patients developed MDS between 9 and 81 months following the time of diagnosis, giving a cumulative incidence of 13.7 +/- 3.9%. The following cytogenetic abnormalities were observed at the time of diagnosis of MDS: monosomy 7 (6 patients), monosomy7/trisomy21 (1 patient), trisomy 11 (1 patient), del (11) (9?:14) (1 patient), add (9q) (1 patient), add 7 (q 32) (1 patient), and trisomy 9 (1 patient). The number of days of G-CSF therapy and nonresponse to therapy at 6 months were statistically significant risk factors by multivariate analysis. The present study suggests a close relationship between long-term use of G-CSF and secondary MDS in nonresponders to IST.
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Affiliation(s)
- Seiji Kojima
- Department of Developmental Pediatrics, Nagoya University School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya 466-8550, Japan.
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30
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Gordon-Smith EC, Marsh JC, Gibson FM. Views on the pathophysiology of aplastic anaemia. Int J Hematol 2002; 76 Suppl 2:163-6. [PMID: 12430919 DOI: 10.1007/bf03165109] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Aplastic anaemia seems to be predominantly a defect of the stem cell rather than the stroma, though abnormalities of the microenvironment may co-exist. There is highly suggestive evidence that the stem cell is the target of an immune attack, though the main evidence remains the response to immunosuppression with antilymphocyte globulin and cyclosporin. The stem cell defect remains even after recovery of the peripheral blood counts and the AA marrow is a fertile environment for the emergence of abnormal clones, particularly PNH. However, it has recently become apparent that there is an overlap with the myelodysplastic syndromes and clones of monosomy 7 and trisomy 8 amongst others are not uncommon in aplastic anaemia. Recent work has suggested that the emergence of a clone of monosomy 7 cells carries a poor prognosis, whereas trisomy 8 has a good prognosis particularly in response to cyclosporin. However, the setting in which monosomy 7 arises may affect the phenotypic expression. The immune targeting of stem cells may be associated with increased apoptosis in aplastic anaemia, in part mediated by fas expression, but not exclusively. Understanding the pathophysiology of AA should help to improve and perhaps target therapy.
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31
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Ohga S, Ohara A, Hibi S, Kojima S, Bessho F, Tsuchiya S, Ohshima Y, Yoshida N, Kashii Y, Nishimura S, Kawakami K, Nishikawa K, Tsukimoto I. Treatment responses of childhood aplastic anaemia with chromosomal aberrations at diagnosis. Br J Haematol 2002; 118:313-9. [PMID: 12100167 DOI: 10.1046/j.1365-2141.2002.03582.x] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
The clinical outcome of childhood aplastic anaemia (AA) with aberrant cytogenetic clones at diagnosis was surveyed. Among 198 children with newly diagnosed AA registered with the AA Committee of the Japanese Society of Paediatric Hematology between 1994 and 1998, cytogenetic studies of bone marrow (BM) cells were completed in 159 patients. Apart from one Robertsonian translocation, seven patients (4.4%) showed clonal chromosomal abnormalities in hypoplastic BM without myelodysplastic features. The patients included six girls and one boy with a median age of 11 years (range 5-14 years). Six patients had del(6), del(5), del(13), del(20), or -7, and one showed add(9). Four patients responded to the first immunosuppressive therapy (IST: cyclosporin A plus anti-thymocyte globulin) and one obtained a spontaneous remission. Cytogenetic abnormalities remained in two patients with an IST response. On the other hand, two patients showed no IST response. One did not respond to repeat IST and died of acute graft-versus-host disease after an unrelated-BM transplant. Another obtained a complete response after a successful BM transplant. No haematological findings at diagnosis predicted the treatment response. No significant morphological changes developed during the course of the illness. A literature review revealed that half of 24 AA patients with chromosomal abnormalities responded to the first IST, and that +6 was the sole predictable marker for IST unresponsiveness. These results suggest that IST can be applied as the initial therapy for AA with cytogenetic abnormalities in the absence of completely matched donors.
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Affiliation(s)
- Shouichi Ohga
- Aplastic Anaemia Committee of the Japanese Society of Paediatric Haematology, Tokyo, Japan.
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32
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Ishiyama K, Karasawa M, Miyawaki S, Ueda Y, Noda M, Wakita A, Sawanobori M, Nagai H, Nakao S. Aplastic anaemia with 13q-: a benign subset of bone marrow failure responsive to immunosuppressive therapy. Br J Haematol 2002; 117:747-50. [PMID: 12028052 DOI: 10.1046/j.1365-2141.2002.03518.x] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
In an attempt to determine the pathological significance of a long arm deletion of chromosome 13 (13q-) in bone marrow failure syndrome, we reviewed the clinical records of nine patients who were initially diagnosed with aplastic anaemia due to bone marrow hypoplasia without dysplasia. Six patients responded to immunosuppressive therapy and the other three improved with steroids. None of the patients developed acute leukaemia (follow up: 54-129 months) and the estimated 5-year survival was 78%. These findings indicate that pancytopenia with 13q- represents bone marrow failure of a benign nature, similar to aplastic anaemia without karyotypic abnormalities, rather than preleukaemia.
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Affiliation(s)
- Ken Ishiyama
- Cellular Transplantation Biology, Division of Cancer Medicine, Kanazawa University Graduate School of Medical Science, 13-1 Takaramachi, Kanazawa, Ishikawa 920-8641, Japan
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33
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Maciejewski JP, Risitano A, Sloand EM, Nunez O, Young NS. Distinct clinical outcomes for cytogenetic abnormalities evolving from aplastic anemia. Blood 2002; 99:3129-35. [PMID: 11964274 DOI: 10.1182/blood.v99.9.3129] [Citation(s) in RCA: 196] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
A serious complication of aplastic anemia (AA) is its evolution to clonal hematologic diseases such as myelodysplasia (MDS) and leukemia, which is usually associated with the appearance of a cytogenetic abnormality in bone marrow cells. We present here an analysis of a cohort of 30 patients with otherwise typical AA in whom clonal karyotypic evolution was observed during frequent periodic marrow examinations. The actuarial risk for this complication has been estimated in other studies at around 15% at 5 years. Conversion from normal to abnormal karyotype occurred at a constant rate after initial diagnosis, with about 50% of cases developing within the first 30 months. Transient chromosomal abnormalities were infrequent. Clinically, AA patients with clonal cytogenetic patterns were heterogenous; a variety of karyotypic defects with numerical and structural abnormalities of chromosome 7 accounted for 40% of all cases followed by trisomy 8, structural and numerical abnormalities of chromosome 13, deletion of Y chromosome, and complex cytogenetic abnormalities. Unlike in primary MDS, aberrancies of chromosome 5 and 20 were infrequent. The clinical course depended on the specific abnormal cytogenetic pattern. Most deaths related to leukemic transformation occurred in patients with abnormalities of chromosome 7 or complex cytogenetic alterations or both. Evolution of chromosome 7 abnormalities was seen most often in refractory patients who had failed to respond to therapy. In contrast, trisomy 8 developed in patients with good hematologic responses who often required chronic immunosuppression with cyclosporine A (CsA), and survival was excellent. Although AA patients with monosomy 7 showed a similar prognosis to those with primary MDS, trisomy 8 in AA appears to have a more favorable prognosis than in MDS.
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MESH Headings
- Adolescent
- Adult
- Aged
- Anemia, Aplastic/drug therapy
- Anemia, Aplastic/genetics
- Anemia, Aplastic/pathology
- Anemia, Refractory, with Excess of Blasts
- Cell Transformation, Neoplastic/genetics
- Cell Transformation, Neoplastic/pathology
- Child
- Chromosome Aberrations
- Chromosomes, Human, Pair 7
- Chromosomes, Human, Pair 8
- Clone Cells/pathology
- Female
- Hemoglobinuria, Paroxysmal/etiology
- Hemoglobinuria, Paroxysmal/genetics
- Hemoglobinuria, Paroxysmal/pathology
- Humans
- Immunosuppressive Agents/therapeutic use
- Karyotyping
- Leukemia, Myeloid/etiology
- Leukemia, Myeloid/genetics
- Leukemia, Myeloid/pathology
- Male
- Middle Aged
- Myelodysplastic Syndromes/etiology
- Myelodysplastic Syndromes/genetics
- Myelodysplastic Syndromes/pathology
- Prognosis
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Affiliation(s)
- Jaroslaw P Maciejewski
- Hematology Branch, National Heart, Lung and Blood Institute, National Institutes of Health, Bethesda, MD, USA.
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34
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Kuriyama K, Todo S, Ikushima S, Fujii N, Yoshihara T, Tsunamoto K, Naya M, Hojo M, Hibi S, Morimoto A, Imashuku S. Risk factors for cytomegalovirus retinitis following bone marrow transplantation from unrelated donors in patients with severe aplastic anemia or myelodysplasia. Int J Hematol 2001; 74:455-60. [PMID: 11794704 DOI: 10.1007/bf02982092] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
Two cases of cytomegalovirus (CMV) retinitis following bone marrow transplantation (BMT) from unrelated donors are reported. 1 patient had been treated for severe aplastic anemia (SAA) and the other for hypoplastic myelodysplastic syndrome (MDS). Because first line therapy with antithymocyte globulin (ATG) and cyclosporin A (CsA) had failed, BMT was performed following a conditioning regimen of ATG, cyclophosphamide, and total lymphoid irradiation. Treatment for CMV retinitis was successfully carried out with gancyclovir (systemic and intraocular injection), foscarnet, and photocoagulation (Case 1) and gancyclovir and foscarnet (Case 2). Both patients also developed Epstein-Barr virus-associated lymphoproliferative disease (EBV-LPD). We compared these 2 cases with 14 SAA patients who did not develop CMV retinitis after BMT using marrow from either HLA-identical siblings (n = 9) or from unrelated donors (n = 5). Unlike the retinitis patients, the latter 5 patients received ATG only once. The retinitis patients had significantly lower CD4+ T-cell levels in their peripheral blood than the 14 patients who did not develop CMV retinitis. We believe that repeated treatment with ATG and transplantation from unrelated donors may lead to immune dysfunction that could increase the likelihood of CMV retinitis, as well as LPD. For such BMT patients, regular ophthalmic examinations and careful testing for CMV antigenemia are recommended.
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Affiliation(s)
- K Kuriyama
- Department of Pediatrics, Kyoto Prefectural University of Medicine, Japan.
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35
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Araten DJ, Swirsky D, Karadimitris A, Notaro R, Nafa K, Bessler M, Thaler HT, Castro-Malaspina H, Childs BH, Boulad F, Weiss M, Anagnostopoulos N, Kutlar A, Savage DG, Maziarz RT, Jhanwar S, Luzzatto L. Cytogenetic and morphological abnormalities in paroxysmal nocturnal haemoglobinuria. Br J Haematol 2001; 115:360-8. [PMID: 11703336 DOI: 10.1046/j.1365-2141.2001.03113.x] [Citation(s) in RCA: 35] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Paroxysmal nocturnal haemoglobinuria (PNH) is characterized by the expansion of a haematopoietic stem cell clone with a PIG-A mutation (the PNH clone) in an environment in which normal stem cells are lost or failing: it has been hypothesized that this abnormal marrow environment provides a relative advantage to the PNH clone. In patients with PNH, generally, the karyotype of bone marrow cells has been reported to be normal, unlike in myelodysplastic syndrome (MDS), another clonal condition in which cytogenetic abnormalities are regarded as diagnostic. In a retrospective review of 46 patients with a PNH clone, we found a karyotypic abnormality in 11 (24%). Upon follow-up, the proportion of cells with abnormal karyotype decreased significantly in seven of these 11 patients. Abnormal morphological bone marrow features reminiscent of MDS were common in PNH, regardless of the karyotype. However, none of our patients developed excess blasts or leukaemia. We conclude that in patients with PNH cytogenetically abnormal clones are not necessarily malignant and may not be predictive of evolution to leukaemia.
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Affiliation(s)
- D J Araten
- Department of Human Genetics, Memorial Sloan-Kettering Cancer Center, New York, USA
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36
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Tamayose K, Sugimoto K, Ando M, Oshimi K. Disappearance of chromosomal abnormalities and recovery of hematopoiesis after immunosuppressive therapy for hypoplastic refractory anemia with excess of blasts. Blood 2001; 97:2524. [PMID: 11307772 DOI: 10.1182/blood.v97.8.2524] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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Immunosuppressive therapy using antithymocyte globulin, cyclosporine, and danazol with or without human granulocyte colony-stimulating factor in children with acquired aplastic anemia. Blood 2000. [DOI: 10.1182/blood.v96.6.2049] [Citation(s) in RCA: 180] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Abstract
A prospective multicenter trial of 119 children 1 to 18 years of age with newly diagnosed aplastic anemia (AA) was conducted, comparing treatment using antithymocyte globulin (ATG), cyclosporine (CyA), and danazol (DAN) with or without rhG-CSF (400 μg/m2, day on days 1-90). All children with very severe AA received rhG-CSF (VSAA group, n = 50). The other children were randomized to receive ATG, CyA, DAN, and rhG-CSF (G-CSF+ group, n = 35) or ATG, CyA, and DAN without rhG-CSF (G-CSF− group, n = 34). After 6 months, the hematologic response rate was 71%, 55%, and 77% in the VSAA group, G-CSF+ group, and G-CSF− group, respectively. There was no difference in the incidence of febrile episodes and documented infections between the G-CSF+ and G-CSF− groups. Bone marrow transplantation (BMT) was attempted in 22 patients in whom initial immunosuppressive therapy (IST; n = 18) failed or in whom a relapse occurred after an initial response (n = 4). Nineteen of the 22 patients are alive and well after a median follow-up of 18 months (range, 3 to 66 months) since BMT. The probability of survival at 4 years was 83% ± 7% in the VSAA group, 91% ± 5% in the G-CSF+ group, and 93% ± 6% in the G-CSF− group. Myelodysplastic syndrome (MDS)/acute myeloid leukemia (AML) developed in one patient in each of the three groups; the overall risk for MDS/AML was 3% ± 2% at 4 years. Because the results of IST were encouraging, it is suggested that children with AA receive IST as first-line therapy if there is no human leukocyte antigen-matched sibling donor.
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38
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Immunosuppressive therapy using antithymocyte globulin, cyclosporine, and danazol with or without human granulocyte colony-stimulating factor in children with acquired aplastic anemia. Blood 2000. [DOI: 10.1182/blood.v96.6.2049.h8002049_2049_2054] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
A prospective multicenter trial of 119 children 1 to 18 years of age with newly diagnosed aplastic anemia (AA) was conducted, comparing treatment using antithymocyte globulin (ATG), cyclosporine (CyA), and danazol (DAN) with or without rhG-CSF (400 μg/m2, day on days 1-90). All children with very severe AA received rhG-CSF (VSAA group, n = 50). The other children were randomized to receive ATG, CyA, DAN, and rhG-CSF (G-CSF+ group, n = 35) or ATG, CyA, and DAN without rhG-CSF (G-CSF− group, n = 34). After 6 months, the hematologic response rate was 71%, 55%, and 77% in the VSAA group, G-CSF+ group, and G-CSF− group, respectively. There was no difference in the incidence of febrile episodes and documented infections between the G-CSF+ and G-CSF− groups. Bone marrow transplantation (BMT) was attempted in 22 patients in whom initial immunosuppressive therapy (IST; n = 18) failed or in whom a relapse occurred after an initial response (n = 4). Nineteen of the 22 patients are alive and well after a median follow-up of 18 months (range, 3 to 66 months) since BMT. The probability of survival at 4 years was 83% ± 7% in the VSAA group, 91% ± 5% in the G-CSF+ group, and 93% ± 6% in the G-CSF− group. Myelodysplastic syndrome (MDS)/acute myeloid leukemia (AML) developed in one patient in each of the three groups; the overall risk for MDS/AML was 3% ± 2% at 4 years. Because the results of IST were encouraging, it is suggested that children with AA receive IST as first-line therapy if there is no human leukocyte antigen-matched sibling donor.
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Abstract
Acquired, idiosyncratic aplastic anaemia (AA) is a rare but potentially fatal haematological disorder. Severe AA constitutes an acute medical emergency, and supportive therapy is needed to prevent overwhelming sepsis or a life threatening haemorrhage. Specific therapy for the disease includes the choice between allogeneic stem cell transplantation (SCT) from an HLA-identical sibling or immunosuppressive therapy with anti-thymocyte globulin (ATG) and cyclosporin A (CSA). Long-term cure rates of 75-90% are now achieved following HLA (human leukocyte antigen) identical sibling bone marrow transplant. The use of donors other than HLA-id siblings for transplantation in AA remains experimental. Transplantation offers the patient a chance of cure, whilst treatment with immunosuppressive therapy carries a long-term risk of relapse and clonal transformation. The haemopoietic growth factors, apart from granulocyte colony stimulating factor (G-CSF), have been shown to be potentially toxic when given to patients with AA. A short course of G-CSF may be useful to help treat severe infection, but its longer-term use with ATG and CSA remains controversial. Results from immunosuppressive treatment continue to improve with time, as a result of the additional use of CSA with ATG, the use of repeat courses of ATG for non-responders and improvements in the supportive care of patients.
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Affiliation(s)
- S B Killick
- Department of Haematology, St George's Hospital Medical School, Cranmer Terrace, London, SW17 ORE, UK
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40
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Affiliation(s)
- S E Ball
- Department of Haematology, St George's Hospital Medical School, Cranmer Terrace, London, UK.
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de-Medeiros CR, Ribeiro RC, Bittencourt MA, Zanis-Neto J, Pasquini R. Long-term outcome of 25 children and adolescents with severe aplastic anemia treated with antithymocyte globulin. Braz J Med Biol Res 2000; 33:553-8. [PMID: 10775887 DOI: 10.1590/s0100-879x2000000500010] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Severe aplastic anemia (SAA) is probably an immune-mediated disorder, and immunosuppressive therapy is recommended for patients with no available donor for bone marrow transplant. Between October 1984 and November 1987, 25 consecutive children and adolescents with SAA with no HLA-compatible marrow donor received equine antithymocyte globulin (ATG) (15 mg kg-1 day-1) for 10 days. The patients were evaluated 6 weeks, 6 months, and 12 months after starting ATG treatment. Thereafter, patients were evaluated yearly until July 1998. Median age was 10 years (range, 1.5-20 years), granulocyte counts on referral ranged from 0.032 to 1.4 x 10(9)/l (median 0.256 x 10(9)/l), and 12 patients had granulocyte counts <0.2 x 10(9)/l. At a median follow-up of 9.6 years (range, 8.6-11.8 years), 10 patients (40%) remained alive with good marrow function. No morphologic evidence of hematological clonal disorders has been observed, although two patients probably have acquired clonal chromosomal abnormalities (trisomy 8 and del(6)q21, respectively). Responses to ATG were observed between 6 weeks and 6 months from the start of treatment in 60% of evaluable patients. The response rate was not different in patients whose granulocyte count at diagnosis was <0.2 x 10(9)/l, or in those who were <10 years of age. This study supports the view that, when compared with supportive measures, ATG is an effective treatment for children or adolescents with SAA. Although these results are inferior to those reported for marrow transplantation or more intensive immunosuppressive regimens, these patients who responded to ATG are long-term survivors with stable peripheral blood counts and a low rate of relapse.
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Affiliation(s)
- C R de-Medeiros
- Departamento de Medicina Interna, Serviço de Transplante de Medula Ossea, Hospital das Clínicas, Universidade Federal do Paraná, Curitiba, PR, Brasil.
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42
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Piaggio G, Podestà M, Pitto A, Sessarego M, Figari O, Fugazza G, Benvenuto F, Bruno B, Van Lint MT, Truini M, Frassoni F, Bacigalupo A. Coexistence of normal and clonal haemopoiesis in aplastic anaemia patients treated with immunosuppressive therapy. Br J Haematol 1999; 107:505-11. [PMID: 10583249 DOI: 10.1046/j.1365-2141.1999.01729.x] [Citation(s) in RCA: 22] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Cytogenetic abnormalities and paroxysmal nocturnal haemoglobinuria (PNH) phenotype are frequent findings in aplastic anaemia patients treated with immunosuppressive therapy (IST). In this study we investigated whether the appearance of clonal haemopoiesis influences patient outcome and survival. 97 patients entered this study and were followed from the onset of the disease for a median follow-up (FU) of 53 months. 93% are alive, 56% achieved complete remission, 30% partial remission, both transfusion independent, and 14% did not respond. Three groups were identified: (A) patients without evidence of emerging clones (71/97); (B) patients who acquired chromosomal abnormalities (13/97); (C) patients who showed low expression of glycosyl phosphatidylinositol anchored proteins (GPI-AP) (PNH phenotype) at presentation or later (16/97). Three patients showed both PIG-AP deficiency and chromosomal abnormalities. The actuarial survival of patients without clonal haemopoiesis (n = 71) at 6 years was 95%, for patients with chromosomal abnormalities (n = 13), 88%, and for patients with PIG-AP deficiency (n = 16), 89%. There was no difference in the probability of becoming transfusion independent in the three groups (93%, 92% and 88% respectively). This study confirmed that a proportion of severe aplastic anaemia (SAA) patients exhibit clonal markers during the time after IST, often coexisting with cytogenetically or phenotypically normal haemopoiesis. There was no significant clinical impact of these abnormalities on transfusion independence and survival at the median follow-up of 4 years.
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Affiliation(s)
- G Piaggio
- Dipartimento di Ematologia, Ospedale S. Martino, Genova, Italy.
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