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Vojjala N, Roberson F, Yadav SK, Krishnamoorthy G. Ibrutinib-induced spinal haematoma in a patient with marginal zone lymphoma. BMJ Case Rep 2024; 17:e260598. [PMID: 39216882 DOI: 10.1136/bcr-2024-260598] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/04/2024] Open
Abstract
Bleeding diathesis is an uncommon side effect of ibrutinib use and is seen in less than 5% of the population. We describe a case of an elderly woman with ibrutinib-induced spontaneous major extradural haematoma presenting as acute compressive myelopathy. She is a known case of splenic marginal zone lymphoma with multiple extramedullary relapses and presented to the emergency department with acute-onset low backache, followed by urinary retention. MRI revealed extradural haemorrhage. After possible evaluation, she was diagnosed with ibrutinib-induced extradural haematoma.
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Affiliation(s)
- Nikhil Vojjala
- Internal Medicine, Trinity Health Oakland Hospital, Pontiac, Michigan, USA
| | - Fazela Roberson
- Ross University School of Medicine - Barbados Campus, Bridgetown, Barbados
| | - Sumeet Kumar Yadav
- Hospital Internal Medicine, Mayo Clinic Health System in Mankato, Mankato, Minnesota, USA
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2
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Gordon MJ, Ferrajoli A. Unusual complications in the management of chronic lymphocytic leukemia. Am J Hematol 2022; 97 Suppl 2:S26-S34. [PMID: 35491515 DOI: 10.1002/ajh.26585] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2022] [Revised: 04/20/2022] [Accepted: 04/25/2022] [Indexed: 02/04/2023]
Abstract
Chronic lymphocytic leukemia (CLL) is a common, indolent disease that typically presents with a proliferation of mature, immunologically dysfunctional CD5+ B-cells which preferentially occupy the bone marrow, peripheral blood and lymphoid organs. Immune dysfunction leads to an increase in autoimmune diseases which occur in approximately 10% of patients with CLL. Autoimmune cytopenias are the most common, but other organs may be affected as well. The treatment of these conditions typically depends on the extent of CLL and severity of symptoms, but generally consists of CLL-directed therapies, immunosuppression or both. CLL may also infiltrate extranodal sites in the body. Symptomatic extranodal CLL or extranodal disease which threatens normal organ function is an indication for initiation of CLL-directed therapy. The following review summarizes autoimmune and extranodal complications that can occur in patients with CLL and our suggested approach to their treatment.
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Affiliation(s)
- Max J Gordon
- MD Anderson Cancer Center, University of Texas, Houston, Texas, USA
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3
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Marini I, Uzun G, Jamal K, Bakchoul T. Treatment of drug-induced immune thrombocytopenias. Haematologica 2022; 107:1264-1277. [PMID: 35642486 PMCID: PMC9152960 DOI: 10.3324/haematol.2021.279484] [Citation(s) in RCA: 19] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2022] [Indexed: 01/19/2023] Open
Abstract
Several therapeutic agents can cause thrombocytopenia by either immune-mediated or non-immune-mediated mechanisms. Non-immune-mediated thrombocytopenia is due to direct toxicity of drug molecules to platelets or megakaryocytes. Immune-mediated thrombocytopenia, on the other hand, involves the formation of antibodies that react to platelet-specific glycoprotein complexes, as in classic drug-induced immune thrombocytopenia (DITP), or to platelet factor 4, as in heparin-induced thrombocytopenia (HIT) and vaccine-induced immune thrombotic thrombocytopenia (VITT). Clinical signs include a rapid drop in platelet count, bleeding or thrombosis. Since the patient's condition can deteriorate rapidly, prompt diagnosis and management are critical. However, the necessary diagnostic tests are only available in specialized laboratories. Therefore, the most demanding step in treatment is to identify the agent responsible for thrombocytopenia, which often proves difficult because many patients are taking multiple medications and have comorbidities that can themselves also cause thrombocytopenia. While DITP is commonly associated with an increased risk of bleeding, HIT and VITT have a high mortality rate due to the high incidence of thromboembolic complications. A structured approach to drug-associated thrombocytopenia/thrombosis can lead to successful treatment and a lower mortality rate. In addition to describing the treatment of DITP, HIT, VITT, and vaccine-associated immune thrombocytopenia, this review also provides the pathophysiological and clinical information necessary for correct patient management.
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Affiliation(s)
- Irene Marini
- Centre for Clinical Transfusion Medicine, Medical Faculty of Tübingen, University of Tübingen
| | - Gunalp Uzun
- Centre for Clinical Transfusion Medicine, Medical Faculty of Tübingen, University of Tübingen
| | - Kinan Jamal
- Centre for Clinical Transfusion Medicine, Medical Faculty of Tübingen, University of Tübingen
| | - Tamam Bakchoul
- Centre for Clinical Transfusion Medicine, Medical Faculty of Tübingen, University of Tübingen.
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Kuter DJ. Treatment of chemotherapy-induced thrombocytopenia in patients with non-hematologic malignancies. Haematologica 2022; 107:1243-1263. [PMID: 35642485 PMCID: PMC9152964 DOI: 10.3324/haematol.2021.279512] [Citation(s) in RCA: 35] [Impact Index Per Article: 17.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2022] [Indexed: 01/19/2023] Open
Abstract
Chemotherapy-induced thrombocytopenia (CIT) is a common complication of the treatment of non-hematologic malignancies. Many patient-related variables (e.g., age, tumor type, number of prior chemotherapy cycles, amount of bone marrow tumor involvement) determine the extent of CIT. CIT is related to the type and dose of chemotherapy, with regimens containing gemcitabine, platinum, or temozolomide producing it most commonly. Bleeding and the need for platelet transfusions in CIT are rather uncommon except in patients with platelet counts below 25x109/L in whom bleeding rates increase significantly and platelet transfusions are the only treatment. Nonetheless, platelet counts below 70x109/L present a challenge. In patients with such counts, it is important to exclude other causes of thrombocytopenia (medications, infection, thrombotic microangiopathy, post-transfusion purpura, coagulopathy and immune thrombocytopenia). If these are not present, the common approach is to reduce chemotherapy dose intensity or switch to other agents. Unfortunately decreasing relative dose intensity is associated with reduced tumor response and remission rates. Thrombopoietic growth factors (recombinant human thrombopoietin, pegylated human megakaryocyte growth and development factor, romiplostim, eltrombopag, avatrombopag and hetrombopag) improve pretreatment and nadir platelet counts, reduce the need for platelet transfusions, and enable chemotherapy dose intensity to be maintained. National Comprehensive Cancer Network guidelines permit their use but their widespread adoption awaits adequate phase III randomized, placebo-controlled studies demonstrating maintenance of relative dose intensity, reduction of platelet transfusions and bleeding, and possibly improved survival. Their potential appropriate use also depends on consensus by the oncology community as to what constitutes an appropriate pretreatment platelet count as well as identification of patient-related and treatment variables that might predict bleeding.
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Affiliation(s)
- David J Kuter
- Massachusetts General Hospital, Harvard Medical School, Boston, MA.
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5
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Porpaczy E, Jäger U. How I manage autoimmune cytopenias in patients with lymphoid cancer. Blood 2022; 139:1479-1488. [PMID: 34517415 PMCID: PMC11017954 DOI: 10.1182/blood.2019003686] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2020] [Accepted: 04/29/2021] [Indexed: 11/20/2022] Open
Abstract
Autoimmune conditions can occur in a temporary relationship with any malignant lymphoma. In many instances, treatment at diagnosis is not required, but symptomatic autoimmune conditions represent an indication for treatment, particularly in chronic lymphoproliferative diseases. Treatment is selected depending on the predominant condition: autoimmune disease (immunosuppression) or lymphoma (antilymphoma therapy). Steroids and anti-CD20 antibodies are effective against both conditions and may suppress the autoimmune complication for a prolonged period. The efficacy of B-cell receptor inhibitors has provided us with novel insights into the pathophysiology of antibody-producing B cells. Screening for underlying autoimmune conditions is part of the lymphoma workup, because other drugs, such as immunomodulators and checkpoint inhibitors, should be avoided or used with caution. In this article, we discuss diagnostic challenges and treatment approaches for different situations involving lymphomas and autoimmune cytopenias.
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Affiliation(s)
- Edit Porpaczy
- Department of Medicine I, Division of Hematology and Hemostaseology
| | - Ulrich Jäger
- Department of Medicine I, Division of Hematology and Hemostaseology
- Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria
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Kompotiatis P, Manohar S, Alkhateeb HB, Hogan WJ, Nath KA, Leung N. Hemoglobinuria in the Early Poststem-Cell-Transplant Period: Risk Factors and Association with Outcomes. KIDNEY360 2021; 2:1569-1575. [PMID: 35372983 PMCID: PMC8785790 DOI: 10.34067/kid.0002262021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/05/2021] [Accepted: 08/06/2021] [Indexed: 02/04/2023]
Abstract
Background Information on risk factors of hemoglobinuria after hematopoietic stem-cell transplant (HSCT) and its association with AKI, mortality, and engraftment is limited. Methods We conducted a retrospective cohort study on all consecutive adults that underwent HSCT from January 6, 1999, to November 6, 2017. The study included 6039 patients that underwent bone marrow transplantation (BMT), umbilical cord blood, and peripheral blood stem-cell transplantation (PBSCT). Results Early post-HSCT, AKI occurred in 393 (7%) patients, and 52 (0.9%) patients had post-HSCT hemoglobinuria. Post-HSCT hemoglobinuria was associated with graft type (BMT+Cord), underlying disease (lymphoma, acute leukemia), and fludarabine-based conditioning regimen. Post-HSCT hemoglobinuria was associated with early (48-72 hours) post-HSCT AKI. Graft type (BMT+Cord) was associated with AKI among patients with hemoglobinuria. AKI in patients with hemoglobinuria was associated with delayed platelet engraftment and delayed WBC engraftment but not 100-day mortality. Conclusion Close monitoring is recommended in this patient group to facilitate a good engraftment outcome.
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Affiliation(s)
| | - Sandhya Manohar
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, Minnesota
| | | | | | - Karl A. Nath
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, Minnesota
| | - Nelson Leung
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, Minnesota,Division of Hematology, Mayo Clinic, Rochester, Minnesota
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Effect of ibrutinib treatment on hemolytic anemia and acrocyanosis in cold agglutinin disease/cold agglutinin syndrome. Blood 2021; 138:2002-2005. [PMID: 34293088 DOI: 10.1182/blood.2021012039] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2021] [Accepted: 07/16/2021] [Indexed: 11/20/2022] Open
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Autoimmune Cytopenia in CLL: Prognosis and Management in the Era of Targeted Therapies. ACTA ACUST UNITED AC 2021; 27:286-296. [PMID: 34398555 DOI: 10.1097/ppo.0000000000000537] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
ABSTRACT Chronic lymphocytic leukemia (CLL) is frequently associated with autoimmune hemolytic anemia and immune thrombocytopenia and, less frequently, with pure red cell aplasia and immune neutropenia. The emergence of these complications is related to an intertwined and complex relationship between patient, disease, and treatment characteristics. The prognostic repercussion of autoimmune cytopenia (AIC) in patients with CLL mainly depends on its response to therapy. For patients with AIC and nonactive CLL, treatment is as in primary, uncomplicated AIC, keeping in mind that no response is an indication for CLL therapy. The success of treating active CLL-related AIC widely relies on a flexible strategy that should include initial therapy with corticosteroids and a rapid shift to effective CLL therapy in nonresponding patients. Targeted therapies (e.g., ibrutinib) that have already demonstrated to be effective in CLL-related AIC will likely offer a unique possibility of treating both AIC and CLL as a single target.
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Fang S, Yang F. Recurrent infection-induced autoimmune haemolytic anaemia complicated by pulmonary embolism: a case report and literature review. Clin Med (Lond) 2021; 21:e306-e308. [PMID: 34001586 DOI: 10.7861/clinmed.2021-0112] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
A 73-year-old woman presented with progressive dyspnoea up to type 1 respiratory failure. Laboratory values showed leucocytosis, reduced haemoglobin to 71 g/L, elevated indirect serum bilirubin and lactic dehydrogenase. Computed tomography pulmonary angiography (CTPA) revealed peripheral pulmonary embolism (PE). Echocardiography showed enlarged right ventricle, elevated estimated pulmonary arterial systolic pressure (57.2 mmHg) and normal left ventricular ejection fraction. The patient was diagnosed with autoimmune haemolytic anaemia (AIHA), which was induced by recurrent infections without standard treatment in the past year. AIHA is the cause of PE due to the absence of common predisposing factors and other thrombophilia. The patient became better after administration of glucocorticoids, intravenous immunoglobulin and rivaroxaban.
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Affiliation(s)
- Shu Fang
- Peking University First Hospital, Beijing, China
| | - Fan Yang
- Peking University First Hospital, Beijing, China
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10
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Tranekær S, Hansen DL, Frederiksen H. Epidemiology of Secondary Warm Autoimmune Haemolytic Anaemia-A Systematic Review and Meta-Analysis. J Clin Med 2021; 10:jcm10061244. [PMID: 33802848 PMCID: PMC8002719 DOI: 10.3390/jcm10061244] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2021] [Revised: 03/09/2021] [Accepted: 03/14/2021] [Indexed: 12/15/2022] Open
Abstract
Background: Warm autoimmune haemolytic anaemia (wAIHA) is a haemolytic disorder, most commonly seen among adults and is classified as either primary or secondary to an underlying disease. We describe the age and sex distribution and the proportion of secondary wAIHA. Method: We retrieved 2635 published articles, screened abstracts and titles, and identified 27 articles eligible for full-text review. From these studies, we extracted data regarding number of patients, sex distribution, age at diagnosis, number of patients with secondary wAIHA, and whether the patients were diagnosed through local or referral centres. All data were weighted according to the number of included patients in each study. Results: 27 studies including a total of 4311 patients with wAIHA, of which 66% were females, were included. The median age at diagnosis was 68.7 years, however, wAIHA affected all ages. The mean proportion of secondary wAIHA was 49%, most frequently secondary to systemic lupus erythematosus. The proportions of secondary wAIHA reported from primary vs. referral centres were 35% vs. 59%, respectively. Conclusion: This review consolidates previously reported gender distribution. The higher proportion of secondary wAIHA in referral centres suggests that the most severely affected patients are disproportionally more frequent in such facilities.
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Affiliation(s)
- Stinne Tranekær
- Haematological Research Unit, Department of Clinical Research, University of Southern, 5230 Odense M, Denmark; (S.T.); (D.L.H.)
- Department of Haematology, Odense University Hospital, 5000 Odense C, Denmark
| | - Dennis Lund Hansen
- Haematological Research Unit, Department of Clinical Research, University of Southern, 5230 Odense M, Denmark; (S.T.); (D.L.H.)
- Department of Haematology, Odense University Hospital, 5000 Odense C, Denmark
| | - Henrik Frederiksen
- Haematological Research Unit, Department of Clinical Research, University of Southern, 5230 Odense M, Denmark; (S.T.); (D.L.H.)
- Department of Haematology, Odense University Hospital, 5000 Odense C, Denmark
- Correspondence:
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11
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Kramer R, Zaremba A, Moreira A, Ugurel S, Johnson DB, Hassel JC, Salzmann M, Gesierich A, Weppler A, Spain L, Loquai C, Dudda M, Pföhler C, Hepner A, Long GV, Menzies AM, Carlino MS, Sachse MM, Lebbé C, Baroudjian B, Enokida T, Tahara M, Schlaak M, Hayani K, Bröckelmann PJ, Meier F, Reinhardt L, Friedlander P, Eigentler T, Kähler KC, Berking C, Zimmer L, Heinzerling L. Hematological immune related adverse events after treatment with immune checkpoint inhibitors. Eur J Cancer 2021; 147:170-181. [PMID: 33706206 DOI: 10.1016/j.ejca.2021.01.013] [Citation(s) in RCA: 41] [Impact Index Per Article: 13.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2020] [Revised: 12/09/2020] [Accepted: 01/12/2021] [Indexed: 12/21/2022]
Abstract
INTRODUCTION With the increasing use of checkpoint inhibitors, rare immune-related adverse events (irAE) are being identified. Haematological irAE (hem-irAE) are difficult to treat and have shown high mortality rates. In order to improve side-effect management for these potentially life-threatening events, we analysed frequency, severity and outcomes. PATIENTS AND METHODS Patients who developed hem-irAE while being treated with immune checkpoint inhibitors (ICI) therapy were retrospectively identified from 18 international cancer centres. RESULTS In total, more than 7626 patients treated with ICI were screened, and 50 patients with hem-irAE identified. The calculated incidence amounts to 0.6% and median onset was 6 weeks after the ICI initiation (range 1-128 weeks). Thrombocytopenia and leucopaenia were the most frequent hem-irAE with 34% (17/50) and 34% (17/50), respectively, followed by anaemia 28% (14/50), hemophagocytic lymphohistiocytosis (4% (2/50)), aplastic anaemia (2% (1/50)), acquired haemophilia A (2% (1/50)) and coagulation deficiency (2% (1/50)). Simultaneous thrombocytopenia and neutropenia occurred in two patients, concurrent anaemia and thrombocytopenia in one patient. Other than cessation of ICI (in 60%) and corticosteroids (in 78%), treatment included second-line immunosuppression in 24% of cases. Events resolved in 78% (39/50), while 18% (9/50) had persistent changes, and 2% (1/50) had fatal outcomes (agranulocytosis). CONCLUSION Hem-irAE can affect all haematopoietic blood cell lineages and may persist or even be fatal. Management may require immunosuppression beyond corticosteroids. Although these irAE are rare, treating physicians should be aware, monitor blood counts regularly and promptly act upon detection.
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Affiliation(s)
- Rafaela Kramer
- Department of Dermatology, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), Erlangen, Germany; Deutsches Zentrum Immuntherapie (DZI), Erlangen, Germany; Comprehensive Cancer Center Erlangen-European Metropolitan Area of Nürnberg (CCC ER-EMN), Erlangen, Germany
| | - Anne Zaremba
- Department of Dermatology, Venerology und Allergology, University Hospital Essen, Essen, Germany
| | - Alvaro Moreira
- Tisch Cancer Institute at the Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Selma Ugurel
- Department of Dermatology, Venerology und Allergology, University Hospital Essen, Essen, Germany
| | - Douglas B Johnson
- Vanderbilt University Medical Center, Department of Medicine, Division of Hematology and Oncology, Nashville, USA
| | - Jessica C Hassel
- Skin Cancer Center, Department of Dermatology and National Center for Tumor Diseases (NCT), University Hospital Heidelberg, Heidelberg, Germany
| | - Martin Salzmann
- Skin Cancer Center, Department of Dermatology and National Center for Tumor Diseases (NCT), University Hospital Heidelberg, Heidelberg, Germany
| | - Anja Gesierich
- Department of Dermatology, Venereology and Allergology, University Hospital Würzburg, Würzburg, Germany
| | - Alison Weppler
- Medical Oncology Department, Peter MacCallum Cancer Centre, Melbourne, Australia
| | - Lavinia Spain
- Medical Oncology Department, Peter MacCallum Cancer Centre, Melbourne, Australia
| | - Carmen Loquai
- Department of Dermatology, University Medical Center, Mainz, Germany
| | - Milena Dudda
- Department of Dermatology, University Medical Center, Mainz, Germany
| | - Claudia Pföhler
- Department of Dermatology, Saarland University Medical Center, Homburg/Saar, Germany
| | - Adriana Hepner
- Department of Medical Oncology, Melanoma Institute Australia, Sydney, Australia; Medical Oncology Service, Instituto do Cancer do Estado de Sao Paulo, Sao Paulo, Brazil
| | - Georgina V Long
- Melanoma Institute Australia, University of Sydney, Royal North Shore and Mater Hospitals, Sydney, NSW, Australia
| | - Alexander M Menzies
- Melanoma Institute Australia, University of Sydney, Royal North Shore and Mater Hospitals, Sydney, NSW, Australia
| | - Matteo S Carlino
- Westmead and Blacktown Hospitals, Melanoma Institute Australia and the University of Sydney, NSW, Australia
| | - Michael M Sachse
- Department of Dermatology, Allergology and Phlebology, Bremerhaven Reinkenheide Hospital, Bremerhaven, Germany
| | - Céleste Lebbé
- APHP, Department of Dermatology, Saint-Louis Hospital, Université de Paris, INSERM U976, Paris, France
| | - Barouyr Baroudjian
- APHP, Department of Dermatology, Saint-Louis Hospital, Université de Paris, INSERM U976, Paris, France
| | - Tomohiro Enokida
- Department of Head and Neck Medical Oncology, National Cancer Center Hospital East, Chiba, Japan
| | - Makoto Tahara
- Department of Head and Neck Medical Oncology, National Cancer Center Hospital East, Chiba, Japan
| | - Max Schlaak
- Department of Dermatology, Charité University Hospital, Berlin, Germany
| | - Kinan Hayani
- Department of Dermatology and Allergy, LMU, University Hospital, Munich, Germany
| | - Paul J Bröckelmann
- Department I of Internal Medicine, Centre of Integrated Oncology Aachen Bonn Cologne Duesseldorf (CIO ABCD), Faculty of Medicine and University Hospital of Cologne, University of Cologne, Cologne, Germany
| | - Friedegund Meier
- Skin Cancer Center at the University Cancer Centre Dresden and National Center for Tumor Diseases, Dresden, Germany; Department of Dermatology, University Hospital Carl Gustav Carus, TU Dresden, Germany
| | - Lydia Reinhardt
- Skin Cancer Center at the University Cancer Centre Dresden and National Center for Tumor Diseases, Dresden, Germany; Department of Dermatology, University Hospital Carl Gustav Carus, TU Dresden, Germany
| | - Philip Friedlander
- Tisch Cancer Institute at the Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Thomas Eigentler
- Department of Dermatology, University Hospital Tübingen, Germany
| | | | - Carola Berking
- Department of Dermatology, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), Erlangen, Germany; Deutsches Zentrum Immuntherapie (DZI), Erlangen, Germany; Comprehensive Cancer Center Erlangen-European Metropolitan Area of Nürnberg (CCC ER-EMN), Erlangen, Germany
| | - Lisa Zimmer
- Department of Dermatology, Venerology und Allergology, University Hospital Essen, Essen, Germany
| | - Lucie Heinzerling
- Department of Dermatology, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), Erlangen, Germany; Deutsches Zentrum Immuntherapie (DZI), Erlangen, Germany; Comprehensive Cancer Center Erlangen-European Metropolitan Area of Nürnberg (CCC ER-EMN), Erlangen, Germany; Department of Dermatology and Allergy, LMU, University Hospital, Munich, Germany.
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12
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Difficult Cases of Autoimmune Hemolytic Anemia: A Challenge for the Internal Medicine Specialist. J Clin Med 2020; 9:jcm9123858. [PMID: 33261016 PMCID: PMC7760866 DOI: 10.3390/jcm9123858] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2020] [Revised: 11/20/2020] [Accepted: 11/25/2020] [Indexed: 12/11/2022] Open
Abstract
Autoimmune hemolytic anemia (AIHA) is diagnosed in the presence of anemia, hemolysis, and direct antiglobulin test (DAT) positivity with monospecific antisera. Many confounders of anemia and hemolytic markers should be included in the initial workup (i.e., nutrients deficiencies, chronic liver or kidney diseases, infections, and cancers). Besides classical presentation, there are difficult cases that may challenge the treating physician. These include DAT negative AIHA, diagnosed after the exclusion of other causes of hemolysis, and supported by the response to steroids, and secondary cases (infections, drugs, lymphoproliferative disorders, immunodeficiencies, etc.) that should be suspected and investigated through careful anamnesis physical examination, and specific tests in selected cases. The latter include autoantibody screening in patients with signs/symptoms of systemic autoimmune diseases, immunoglobulins (Ig) levels in case of frequent infections or suspected immunodeficiency, and ultrasound/ computed tomography (CT) studies and bone marrow evaluation to exclude hematologic diseases. AIHA occurring in pregnancy is a specific situation, usually manageable with steroids and intravenous (iv) Ig, although refractory cases have been described. Finally, AIHA may complicate specific clinical settings, including intensive care unit (ICU) admission, reticulocytopenia, treatment with novel anti-cancer drugs, and transplant. These cases are often severe, more frequently DAT negative, and require multiple treatments in a short time.
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Defining autoimmune hemolytic anemia: a systematic review of the terminology used for diagnosis and treatment. Blood Adv 2020; 3:1897-1906. [PMID: 31235526 DOI: 10.1182/bloodadvances.2019000036] [Citation(s) in RCA: 55] [Impact Index Per Article: 13.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2019] [Accepted: 05/21/2019] [Indexed: 12/11/2022] Open
Abstract
The terminology applied to autoimmune hemolytic anemia (AIHA) seems inconsistent. We aimed to evaluate the consistency of definitions used for diagnosis and treatment. In this systematic review of literature from January 2006 to December 2015, we assessed heterogeneity in the definition of AIHA and its subtypes, refractory disease, disease phase, severity, criteria for treatment response, and response durability. A Medline search for anemia, hemolytic, autoimmune was supplemented with keyword searches. Main exclusions were conference abstracts, animal and non-English studies, and studies with <10 cases. Of 1371 articles retrieved, 1209 were excluded based on titles and abstracts. Two authors independently reviewed 10% and 16% of abstracts and full papers, respectively. After full-paper review, 84 studies were included. AIHA was most frequently (32 [52%] of 61) defined as hemolytic anemia with positive direct antiglobulin test (DAT) and exclusion of alternatives, but 10 of 32 also recognized DAT-negative AIHA. A lower threshold for diagnosis of DAT-negative AIHA was observed in literature on chronic lymphocytic leukemia. Definitions of anemia, hemolysis, and exclusion criteria showed substantial variation. Definitions of primary/secondary cold agglutinin disease/syndrome were not consistent. Forty-three studies provided criteria for treatment response, and other than studies from 1 center, these were almost entirely unique. Other criteria were rarely defined. Only 7, 0, 3, 2, 2, and 3 studies offered definitions of warm AIHA, paroxysmal cold hemoglobinuria, mixed AIHA, AIHA severity, disease phase, and refractory AIHA, respectively. Marked heterogeneity in the time period sampled indicates the need to standardize AIHA terminology.
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Fattizzo B, Barcellini W. Autoimmune Cytopenias in Chronic Lymphocytic Leukemia: Focus on Molecular Aspects. Front Oncol 2020; 9:1435. [PMID: 31998632 PMCID: PMC6967408 DOI: 10.3389/fonc.2019.01435] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2019] [Accepted: 12/02/2019] [Indexed: 01/12/2023] Open
Abstract
Autoimmune cytopenias, particularly autoimmune hemolytic anemia (AIHA) and immune thrombocytopenia (ITP), complicate up to 25% of chronic lymphocytic leukemia (CLL) cases. Their occurrence correlates with a more aggressive disease with unmutated VHIG status and unfavorable cytogenetics (17p and 11q deletions). CLL lymphocytes are thought to be responsible of a number of pathogenic mechanisms, including aberrant antigen presentation and cytokine production. Moreover, pathogenic B-cell lymphocytes may induce T-cell subsets imbalance that favors the emergence of autoreactive B-cells producing anti-red blood cells and anti-platelets autoantibodies. In the last 15 years, molecular insights into the pathogenesis of both primary and secondary AIHA/ITP has shown that autoreactive B-cells often display stereotyped B-cell receptor and that the autoantibodies themselves have restricted phenotypes. Moreover, a skewed T-cell repertoire and clonal T cells (mainly CD8+) may be present. In addition, an imbalance of T regulatory-/T helper 17-cells ratio has been involved in AIHA and ITP development, and correlates with various cytokine genes polymorphisms. Finally, altered miRNA and lnRNA profiles have been found in autoimmune cytopenias and seem to correlate with disease phase. Genomic studies are limited in these forms, except for recurrent mutations of KMT2D and CARD11 in cold agglutinin disease, which is considered a clonal B-cell lymphoproliferative disorder resulting in AIHA. In this manuscript, we review the most recent literature on AIHA and ITP secondary to CLL, focusing on available molecular evidences of pathogenic, clinical, and prognostic relevance.
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Affiliation(s)
- Bruno Fattizzo
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, University of Milan, Milan, Italy
| | - Wilma Barcellini
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
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Diagnosis and treatment of autoimmune hemolytic anemia in adults: Recommendations from the First International Consensus Meeting. Blood Rev 2019; 41:100648. [PMID: 31839434 DOI: 10.1016/j.blre.2019.100648] [Citation(s) in RCA: 249] [Impact Index Per Article: 49.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2019] [Revised: 11/21/2019] [Accepted: 11/25/2019] [Indexed: 12/15/2022]
Abstract
Autoimmune hemolytic anemias (AIHAs) are rare and heterogeneous disorders characterized by the destruction of red blood cells through warm or cold antibodies. There is currently no licensed treatment for AIHA. Due to the paucity of clinical trials, recommendations on diagnosis and therapy have often been based on expert opinions and some national guidelines. Here we report the recommendations of the First International Consensus Group, who met with the aim to review currently available data and to provide standardized diagnostic criteria and therapeutic approaches as well as an overview of novel therapies. Exact diagnostic workup is important because symptoms, course of disease, and therapeutic management relate to the type of antibody involved. Monospecific direct antiglobulin test is considered mandatory in the diagnostic workup, and any causes of secondary AIHA have to be diagnosed. Corticosteroids remain first-line therapy for warm-AIHA, while the addition of rituximab should be considered early in severe cases and if no prompt response to steroids is achieved. Rituximab with or without bendamustine should be used in the first line for patients with cold agglutinin disease requiring therapy. We identified a need to establish an international AIHA network. Future recommendations should be based on prospective clinical trials whenever possible.
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Haider MS, Khan SA, Nasiruddin, Shahid S. Autoimmune cytopenias in chronic lymphocytic leukemia. Pak J Med Sci 2019; 35:1334-1338. [PMID: 31489002 PMCID: PMC6717446 DOI: 10.12669/pjms.35.5.369] [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] [Indexed: 11/15/2022] Open
Abstract
Objective To determine the frequency of autoimmune cytopenias in chronic lymphocytic leukemia. Methods This cross sectional study was carried out at Department of Hematology, Army Medical College Rawalpindi, in collaboration with Military Hospital Rawalpindi and Armed Forces institute of Pathology Rawalpindi from 1st January 2018 to 1st October 2018. Sample size of 64 was calculated using WHO calculator. Age and gender of patients was noted. Frequency of autoimmune hemolytic anaemia, immune thrombocytopenic purpura, pure red cell aplasia and autoimmune agranulocytosis were determined in diagnosed patients of chronic lymphocytic leukemia by various laboratory tests in our study population. Results A total of 64 patients were included in the study, 53 (82.8%) were males and 11(17.2%) were females. Mean age of patients was 65 years. Autoimmune hemolytic anaemia was observed in 5/64 (7.8%) of patients. Immune thrombocytopenic purpura was seen in 2/64 (3.1%) patients. Autoimmune granuloytopenia and pure red cell aplasia were not seen in any patient. Conclusion Autoimmune hemolytic anaemia and immune thrombocytopenic purpura are the most common causes of immune cytopenias in patients of CLL. Immune cytopenias should always be identified by laboratory tests as their management differs from other cytopenias which occur due to various other causes.
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Affiliation(s)
- M Shabih Haider
- Dr. Mohammad Shabih Haider, MBBS, Department of Pathology (Haematology Section), Army Medical College, Rawalpindi, Pakistan
| | - Saleem Ahmed Khan
- Dr. Saleem Ahmed Khan, FCPS, Department of Pathology (Haematology Section), Army Medical College, Rawalpindi, Pakistan
| | - Nasiruddin
- Dr. Nasiruddin, FCPS, Department of Pathology (Haematology Section), Army Medical College, Rawalpindi, Pakistan
| | - Samra Shahid
- Dr. Samra Shahid FCPS, Department of Pathology (Haematology Section), Army Medical College, Rawalpindi, Pakistan
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17
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Chronic Lymphocytic Leukemia Presenting as a Subcortical Watershed Infarct. Case Rep Hematol 2019; 2019:2089359. [PMID: 30729050 PMCID: PMC6343168 DOI: 10.1155/2019/2089359] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2018] [Revised: 11/14/2018] [Accepted: 12/20/2018] [Indexed: 11/24/2022] Open
Abstract
Internal watershed infarcts (WI) involve white matter between deep and superficial arterial systems of middle cerebral artery. These infarcts are considered to be either from low blood flow or microembolism. Anemia is an extremely rare cause of watershed infarcts. Very few cases of hemolytic anemia causing watershed cerebral infarcts have been reported. Chronic lymphocytic leukemia (CLL) is frequently complicated with secondary autoimmune cytopenia such as autoimmune hemolytic anemia (AIHA), immune thrombocytopenia (ITP), and pure red cell aplasia. AIHA is present in about 7–10% of patients with CLL. AIHA from CLL presenting as WI is an extremely rare phenomenon with no previously published case reports to the best of our knowledge.
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Approach to pancytopenia: Diagnostic algorithm for clinical hematologists. Blood Rev 2018; 32:361-367. [DOI: 10.1016/j.blre.2018.03.001] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2017] [Revised: 12/01/2017] [Accepted: 03/02/2018] [Indexed: 11/22/2022]
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Schuh AH, Parry-Jones N, Appleby N, Bloor A, Dearden CE, Fegan C, Follows G, Fox CP, Iyengar S, Kennedy B, McCarthy H, Parry HM, Patten P, Pettitt AR, Ringshausen I, Walewska R, Hillmen P. Guideline for the treatment of chronic lymphocytic leukaemia: A British Society for Haematology Guideline. Br J Haematol 2018; 182:344-359. [PMID: 30009455 DOI: 10.1111/bjh.15460] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Affiliation(s)
- Anna H Schuh
- NIHR BRC Oxford Molecular Diagnostic Centre, Oxford University Hospitals NHS Trust and Department of Oncology, University of Oxford, John Radcliffe Hospital, Oxford, UK
| | - Nilima Parry-Jones
- Department of Haematology, Aneurin Bevan University Health Board, Abergavenny, UK
| | - Niamh Appleby
- NIHR BRC Oxford Molecular Diagnostic Centre, Oxford University Hospitals NHS Trust and Department of Oncology, University of Oxford, John Radcliffe Hospital, Oxford, UK
| | | | | | | | | | - Christopher P Fox
- Clinical Haematology, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | | | - Ben Kennedy
- Department of Haematology, University Hospital Leicester, Leicester, UK
| | - Helen McCarthy
- Haematology, Bournemouth and Christchurch Hospitals, Bournemouth, UK
| | - Helen M Parry
- NIHR-ACL Haematology, University of Birmingham, Birmingham, UK
| | | | | | | | - Renata Walewska
- Haematology, Bournemouth and Christchurch Hospitals, Bournemouth, UK
| | - Peter Hillmen
- Haematology, Leeds Teaching Hospital NHS Trust, Leeds, UK
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De Back TR, Kater AP, Tonino SH. Autoimmune cytopenias in chronic lymphocytic leukemia: a concise review and treatment recommendations. Expert Rev Hematol 2018; 11:613-624. [DOI: 10.1080/17474086.2018.1489720] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Affiliation(s)
- Tim R. De Back
- Department of Hematology and Lymphoma and Myeloma Center (LYMMCARE), Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - Arnon P. Kater
- Department of Hematology and Lymphoma and Myeloma Center (LYMMCARE), Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - Sanne H. Tonino
- Department of Hematology and Lymphoma and Myeloma Center (LYMMCARE), Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
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Hergott CB, Pozdnyakova O. Evans syndrome secondary to undiagnosed chronic lymphocytic leukemia in a patient with unexplained bleeding. Am J Hematol 2018; 93:978-979. [PMID: 29341268 DOI: 10.1002/ajh.25039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2018] [Accepted: 01/11/2018] [Indexed: 11/07/2022]
Affiliation(s)
| | - Olga Pozdnyakova
- Department of Pathology; Brigham and Women's Hospital; Boston Massachusetts
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22
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Chronic Lymphocytic Leukemia-associated Refractory Immune Thrombocytopenia Successfully Treated with Eltrombopag. TUMORI JOURNAL 2018. [DOI: 10.5301/tj.5000248] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
Chronic lymphocytic leukemia (CLL) may be associated with immune thrombocytopenia (ITP). The standard treatment for CLL-associated ITP is steroids. For refractory cases, various treatment strategies such as rituximab, splenectomy, and thrombopoietic mimetics are available. We report a patient with CLL who developed recurrent ITP and life-threatening pulmonary hemorrhage. Platelet counts remained extremely low despite massive platelet transfusion and treatment including steroids, immunoglobulin, and single-dose rituximab infusion. The bleeding stopped and platelet counts were increased to normal range 13 days after treatment with eltrombopag 25 mg per day. Our experience suggests that eltrombopag is an effective treatment option in CLL-associated, refractory ITP, especially during major bleeding, which requires relatively rapid improvement of thrombocytopenia.
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23
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Woyach JA. What is the optimal management of older CLL patients? Best Pract Res Clin Haematol 2018; 31:83-89. [PMID: 29452670 DOI: 10.1016/j.beha.2017.10.007] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2017] [Accepted: 10/26/2017] [Indexed: 11/19/2022]
Abstract
CLL is the most common leukemia in older adults with a median age at diagnosis of 71. Therefore, management of patients with this disease must take into account the older age of most patients and consequences of this in terms of functional status and organ function. This review will discuss the management of CLL with regards to observation prior to the initiation of therapy, functional status, and initial treatment. We will discuss criteria for the initiation of therapy, and how initial therapy is different between older and younger patients. Finally, we will discuss specific therapies including chemoimmunotherapy and newer targeted therapies that are being used widely in the older patient population.
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MESH Headings
- Age Factors
- Aged
- Aged, 80 and over
- Humans
- Immunotherapy/methods
- Leukemia, Lymphocytic, Chronic, B-Cell/metabolism
- Leukemia, Lymphocytic, Chronic, B-Cell/pathology
- Leukemia, Lymphocytic, Chronic, B-Cell/therapy
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Affiliation(s)
- Jennifer A Woyach
- The Ohio State University Division of Hematology, 445D Wiseman Hall CCC, 410 W 12th Ave, Columbus, OH 43210, USA.
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24
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Sato R, Jacob J, Gaballa S. Rapid flare of immune thrombocytopenia after stopping ibrutinib in a patient with chronic lymphocytic leukemia. Leuk Lymphoma 2017; 59:1738-1741. [PMID: 29081253 DOI: 10.1080/10428194.2017.1387907] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Affiliation(s)
- Rino Sato
- a Department of Internal Medicine , Thomas Jefferson University , Philadelphia , PA , USA
| | - Jillian Jacob
- b Department of Medical Oncology, Division of Hematologic Malignancies and Hematopoietic Stem Cell Transplantation , Thomas Jefferson University , Philadelphia , PA , USA
| | - Sameh Gaballa
- b Department of Medical Oncology, Division of Hematologic Malignancies and Hematopoietic Stem Cell Transplantation , Thomas Jefferson University , Philadelphia , PA , USA
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25
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Clinical and serological autoimmune complications in chronic lymphocytic leukemia. Wien Klin Wochenschr 2017; 129:552-557. [PMID: 28477093 DOI: 10.1007/s00508-017-1208-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2016] [Accepted: 04/12/2017] [Indexed: 10/19/2022]
Abstract
BACKGROUND Autoimmune disorders often develop during the course of chronic lymphocytic leukemia (CLL). The aim of our study was to investigate the incidence of autoimmune complications (AIC) and serological autoantibodies, and to assess the relationship of these to patient characteristics. METHODS We prospectively collected screenings of AIC and serological markers from a total of 192 patients. RESULTS AIC was observed in 18 (9.4%) patients. Autoimmune hemolytic anemia (AIHA) was observed in 8 patients. Autoimmune thrombocytopenia (AITP) was observed in 3 patients. Other various types of AIC were observed in the remaining 7 patients. Serological autoantibodies were positive in 17.2% of patients with CLL. The mean age of patients with AIC was higher than the control group (p = 0.036). Patients with AIC were mostly in advanced disease stage (p = 0.004), and they had received more first-line treatments than the control group (p = 0.003). Patients with AIC had a higher mean age and more advanced disease stage than patients with positive serological autoantibodies (p = 0.020 and p = 0.009; respectively). In addition, patients with AIC had also received more first-line treatment than the patients with positive serological autoantibodies (p = 0.015). Hematologic AIC was associated with older age, advanced disease stage, and treatment. Conversely, non-hematological AIC and serological autoantibodies are generally observed in early stages. CONCLUSIONS Our study has established a coexistence of CLL and autoimmune complications. Hematologists are usually familiar with AIHA and AITP, but less so with non-hematologic AIC. The latter complications should be carefully searched for, particularly in patients with early CLL.
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26
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Ibrutinib in previously treated chronic lymphocytic leukemia patients with autoimmune cytopenias in the RESONATE study. Blood Cancer J 2017; 7:e524. [PMID: 28157216 PMCID: PMC5386339 DOI: 10.1038/bcj.2017.5] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
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27
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Kipps TJ, Stevenson FK, Wu CJ, Croce CM, Packham G, Wierda WG, O'Brien S, Gribben J, Rai K. Chronic lymphocytic leukaemia. Nat Rev Dis Primers 2017; 3:16096. [PMID: 28102226 PMCID: PMC5336551 DOI: 10.1038/nrdp.2016.96] [Citation(s) in RCA: 293] [Impact Index Per Article: 41.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Chronic lymphocytic leukaemia (CLL) is a malignancy of CD5+ B cells that is characterized by the accumulation of small, mature-appearing lymphocytes in the blood, marrow and lymphoid tissues. Signalling via surface immunoglobulin, which constitutes the major part of the B cell receptor, and several genetic alterations play a part in CLL pathogenesis, in addition to interactions between CLL cells and other cell types, such as stromal cells, T cells and nurse-like cells in the lymph nodes. The clinical progression of CLL is heterogeneous and ranges from patients who require treatment soon after diagnosis to others who do not require therapy for many years, if at all. Several factors, including the immunoglobulin heavy-chain variable region gene (IGHV) mutational status, genomic changes, patient age and the presence of comorbidities, should be considered when defining the optimal management strategies, which include chemotherapy, chemoimmunotherapy and/or drugs targeting B cell receptor signalling or inhibitors of apoptosis, such as BCL-2. Research on the biology of CLL has profoundly enhanced our ability to identify patients who are at higher risk for disease progression and our capacity to treat patients with drugs that selectively target distinctive phenotypic or physiological features of CLL. How these and other advances have shaped our current understanding and treatment of patients with CLL is the subject of this Primer.
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Affiliation(s)
- Thomas J Kipps
- Division of Hematology-Oncology, Department of Medicine, Moores Cancer Centre, University of California, San Diego, 3855 Health Sciences Drive M/C 0820, La Jolla, California 92093, USA
| | - Freda K Stevenson
- Southampton Cancer Research UK Centre, Cancer Sciences Academic Unit, Faculty of Medicine, University of Southampton, Southampton, UK
| | - Catherine J Wu
- Dana-Farber Cancer Institute, Boston, Massachusetts, USA
| | - Carlo M Croce
- Department of Molecular Virology, Immunology and Medical Genetics, Ohio State University, Columbus, Ohio, USA
| | - Graham Packham
- Southampton Cancer Research UK Centre, Cancer Sciences Academic Unit, Faculty of Medicine, University of Southampton, Southampton, UK
| | - William G Wierda
- Department of Hematology, MD Anderson Cancer Centre, Houston, Texas, USA
| | - Susan O'Brien
- Division of Hematology, Department of Medicine, University of California, Irvine, California, USA
| | - John Gribben
- Department of Haemato-Oncology, Barts Cancer Institute, Queen Mary University of London, London, UK
| | - Kanti Rai
- CLL Research and Treatment Program, Feinstein Institute for Medical Research, Northwell Health, New Hyde Park, New York, USA
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28
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Podaza E, Sabbione F, Risnik D, Borge M, Almejún MB, Colado A, Fernández-Grecco H, Cabrejo M, Bezares RF, Trevani A, Gamberale R, Giordano M. Neutrophils from chronic lymphocytic leukemia patients exhibit an increased capacity to release extracellular traps (NETs). Cancer Immunol Immunother 2017; 66:77-89. [PMID: 27796477 PMCID: PMC11029506 DOI: 10.1007/s00262-016-1921-7] [Citation(s) in RCA: 44] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2016] [Accepted: 10/23/2016] [Indexed: 12/19/2022]
Abstract
Chronic lymphocytic leukemia (CLL) is characterized by immune defects that contribute to a high rate of infections and autoimmune cytopenias. Neutrophils are the first line of innate immunity and respond to pathogens through multiple mechanisms, including the release of neutrophil extracellular traps (NETs). These web-like structures composed of DNA, histones, and granular proteins are also produced under sterile conditions and play important roles in thrombosis and autoimmune disorders. Here we show that neutrophils from CLL patients are more prone to release NETs compared to those from age-matched healthy donors (HD). Increased generation of NETs was not due to higher levels of elastase, myeloperoxidase, or reactive oxygen species production. Instead, we found that plasma from CLL patients was able to prime neutrophils from HD to generate higher amounts of NETs upon activation. Plasmatic IL-8 was involved in the priming effect since its depletion reduced plasma capacity to enhance NETs release. Finally, we found that culture with NETs delayed spontaneous apoptosis and increased the expression of activation markers on leukemic B cells. Our study provides new insights into the immune dysregulation in CLL and suggests that the chronic inflammatory environment typical of CLL probably underlies this inappropriate neutrophil priming.
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Affiliation(s)
- Enrique Podaza
- Laboratorio de Inmunología Oncológica, Instituto de Medicina Experimental (CONICET), Academia Nacional de Medicina, Pacheco de Melo 3081, 1425, Buenos Aires, Argentina
| | - Florencia Sabbione
- Laboratorio de Inmunidad Innata, Instituto de Medicina Experimental (CONICET), Academia Nacional de Medicina, Buenos Aires, Argentina
| | - Denise Risnik
- Laboratorio de Inmunología Oncológica, Instituto de Medicina Experimental (CONICET), Academia Nacional de Medicina, Pacheco de Melo 3081, 1425, Buenos Aires, Argentina
| | - Mercedes Borge
- Laboratorio de Inmunología Oncológica, Instituto de Medicina Experimental (CONICET), Academia Nacional de Medicina, Pacheco de Melo 3081, 1425, Buenos Aires, Argentina
| | - María B Almejún
- Laboratorio de Inmunología Oncológica, Instituto de Medicina Experimental (CONICET), Academia Nacional de Medicina, Pacheco de Melo 3081, 1425, Buenos Aires, Argentina
| | - Ana Colado
- Laboratorio de Inmunología Oncológica, Instituto de Medicina Experimental (CONICET), Academia Nacional de Medicina, Pacheco de Melo 3081, 1425, Buenos Aires, Argentina
| | | | - María Cabrejo
- Servicio de Hematología, Sanatorio Municipal Dr. Julio Méndez, Buenos Aires, Argentina
| | - Raimundo F Bezares
- Servicio de Hematología, Hospital Municipal Dr. Teodoro Alvarez, Buenos Aires, Argentina
| | - Analía Trevani
- Laboratorio de Inmunidad Innata, Instituto de Medicina Experimental (CONICET), Academia Nacional de Medicina, Buenos Aires, Argentina
| | - Romina Gamberale
- Laboratorio de Inmunología Oncológica, Instituto de Medicina Experimental (CONICET), Academia Nacional de Medicina, Pacheco de Melo 3081, 1425, Buenos Aires, Argentina
| | - Mirta Giordano
- Laboratorio de Inmunología Oncológica, Instituto de Medicina Experimental (CONICET), Academia Nacional de Medicina, Pacheco de Melo 3081, 1425, Buenos Aires, Argentina.
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Immune Hemolytic Anemia (Paroxysmal Cold Hemoglobinuria) Preceding Burkitt Lymphoma in a 12-Year-Old Child. J Pediatr Hematol Oncol 2017; 39:e25-e26. [PMID: 27879544 DOI: 10.1097/mph.0000000000000714] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Autoimmune hemolytic anemia (AIHA) in childhood, including paroxysmal cold hemoglobinuria, is an uncommon, potentially life-threatening disorder. AIHA is a recognized complication of several varieties of lymphoproliferative disorders, including high-grade B-cell lymphoma, but it has not been associated with Burkitt lymphoma in people without an underlying immunodeficiency. When AIHA occurs in association with lymphoproliferative disorders, it may precede or accompany the diagnosis of malignant disease or herald relapse. We report a novel case of a previously healthy child diagnosed with paroxysmal cold hemoglobinuria 14 months preceding the development of Burkitt lymphoma.
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30
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Evers D, Zwaginga JJ, Tijmensen J, Middelburg RA, de Haas M, de Vooght KMK, van de Kerkhof D, Visser O, Péquériaux NCV, Hudig F, van der Bom JG. Treatments for hematologic malignancies in contrast to those for solid cancers are associated with reduced red cell alloimmunization. Haematologica 2016; 102:52-59. [PMID: 27634204 DOI: 10.3324/haematol.2016.152074] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2016] [Accepted: 09/09/2016] [Indexed: 01/29/2023] Open
Abstract
Red cell alloimmunization may induce severe hemolytic side effects. Identification of risk-modifying conditions will help tailor preventative strategies. This study aims to quantify the associations of hematologic malignancies and solid cancers with red cell alloimmunization in patients receiving red cell transfusions. We performed a nested multicenter case-control study in a source population of 24,063 patients receiving their first and subsequent red cell transfusions during an 8-year follow-up period. Cases (n=505), defined as patients developing a first transfusion-induced red cell alloantibody, were each compared with 2 non-alloimmunized controls (n=1010) who received a similar number of red cell units. Using multivariate logistic regression analyses, we evaluated the association of various malignancies and treatment regimens with alloimmunization during a delineated 5-week risk period. The incidence of alloimmunization among patients with acute (myeloid or lymphoid) leukemia and mature (B- or T-cell) lymphoma was significantly reduced compared to patients without these malignancies: adjusted relative risks (RR) with 95% confidence interval (CI) 0.36 (range 0.19-0.68) and 0.30 (range 0.12-0.81). Associations were primarily explained by immunosuppressive treatments [RR for (any type of) chemotherapy combined with immunotherapy 0.27 (95%CI: 0.09-0.83)]. Alloimmunization risks were similarly diminished in allogeneic or autologous stem cell transplanted patients (RR 0.34, 95%CI: 0.16-0.74), at least during the six months post transplant. Alloimmunization risks of patients with other hematologic diseases or solid cancers, and their associated treatment regimens were similar to risks in the general transfused population. Our findings suggest that, in contrast to malignancies in general, hemato-oncological patients treated with dose-intensive regimens have strongly diminished risk of red cell alloimmunization.
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Affiliation(s)
- Dorothea Evers
- Center for Clinical Transfusion Research, Sanquin Research, Leiden, the Netherlands.,Department of Immuno-hematology and Blood Transfusion, Leiden University Medical Center, the Netherlands
| | - Jaap Jan Zwaginga
- Center for Clinical Transfusion Research, Sanquin Research, Leiden, the Netherlands.,Department of Immuno-hematology and Blood Transfusion, Leiden University Medical Center, the Netherlands
| | - Janneke Tijmensen
- Center for Clinical Transfusion Research, Sanquin Research, Leiden, the Netherlands.,Department of Immuno-hematology and Blood Transfusion, Leiden University Medical Center, the Netherlands
| | - Rutger A Middelburg
- Center for Clinical Transfusion Research, Sanquin Research, Leiden, the Netherlands.,Department of Clinical Epidemiology, Leiden University Medical Center, the Netherlands
| | - Masja de Haas
- Center for Clinical Transfusion Research, Sanquin Research, Leiden, the Netherlands.,Department of Immuno-hematology and Blood Transfusion, Leiden University Medical Center, the Netherlands.,Department of Immunohematology Diagnostics, Sanquin, Amsterdam, the Netherlands
| | - Karen M K de Vooght
- Department of Clinical Chemistry and Hematology, University Medical Center, Utrecht, the Netherlands
| | - Daan van de Kerkhof
- Department of Clinical Chemistry and Hematology, Catharina Hospital, Eindhoven, the Netherlands
| | - Otto Visser
- Department of Hematology, VU Medical Center, Amsterdam, the Netherlands
| | - Nathalie C V Péquériaux
- Department of Clinical Chemistry and Hematology, Jeroen Bosch Hospital, 's-Hertogenbosch, the Netherlands
| | | | - Johanna G van der Bom
- Center for Clinical Transfusion Research, Sanquin Research, Leiden, the Netherlands .,Department of Clinical Epidemiology, Leiden University Medical Center, the Netherlands
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Scarfò L, Ferreri AJM, Ghia P. Chronic lymphocytic leukaemia. Crit Rev Oncol Hematol 2016; 104:169-82. [PMID: 27370174 DOI: 10.1016/j.critrevonc.2016.06.003] [Citation(s) in RCA: 102] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2015] [Revised: 05/01/2016] [Accepted: 06/14/2016] [Indexed: 01/11/2023] Open
Abstract
Chronic lymphocytic leukaemia (CLL) is the most common leukaemia among the adults in the Western World. CLL (and the corresponding nodal entity small lymphocytic lymphoma, SLL) is classified as a lymphoproliferative disorder characterised by the relentless accumulation of mature B-lymphocytes showing a peculiar immunophenotype in the peripheral blood, bone marrow, lymph nodes and spleen. CLL clinical course is very heterogeneous: the majority of patients follow an indolent clinical course with no or delayed treatment need and with a prolonged survival, while others experience aggressive disease requiring early treatment followed by frequent relapses. In the last decade, the improved understanding of CLL pathogenesis shed light on premalignant conditions (i.e., monoclonal B-cell lymphocytosis, MBL), defined new prognostic and predictive markers, improving patient stratification, but also broadened the therapeutic armamentarium with novel agents, targeting fundamental signaling pathways.
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Affiliation(s)
- Lydia Scarfò
- Department of Onco-Haematology, Division of Experimental Oncology, IRCCS San Raffaele Hospital, Milan, Italy; University Vita-Salute San Raffaele, Milan, Italy
| | - Andrés J M Ferreri
- Department of Onco-Haematology, Division of Experimental Oncology, IRCCS San Raffaele Hospital, Milan, Italy.
| | - Paolo Ghia
- Department of Onco-Haematology, Division of Experimental Oncology, IRCCS San Raffaele Hospital, Milan, Italy; University Vita-Salute San Raffaele, Milan, Italy
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Carli G, Visco C, Falisi E, Perbellini O, Novella E, Giaretta I, Ferrarini I, Sandini A, Alghisi A, Ambrosetti A, Rodeghiero F. Evans syndrome secondary to chronic lymphocytic leukaemia: presentation, treatment, and outcome. Ann Hematol 2016; 95:863-70. [PMID: 27001309 DOI: 10.1007/s00277-016-2642-x] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2015] [Accepted: 03/08/2016] [Indexed: 11/30/2022]
Abstract
Evans syndrome (ES) is defined by the combination (either simultaneous or sequential) of immune thrombocytopenia (ITP) and autoimmune haemolytic anaemia (AIHA). When related to secondary conditions, ES may arise in patients with chronic lymphocytic leukaemia (CLL), which is frequently associated to autoimmune cytopenias (AIC). We analysed 25 patients with ES secondary to CLL, which were identified from a large series of consecutive patients with CLL, diagnosed and followed up in two institutions. They represented 2.9 % of the whole series. Thirteen patients presented with concurrent ITP and AIHA (simultaneous ES), while others developed the two AIC sequentially. Occurrence of ES was associated with unfavourable biological prognostic factors like ZAP-70 expression, unmutated immunoglobulin heavy chain variable region gene status, 17-p13 deletion and TP53 gene mutations. Of note, the majority of patients with ES (66 %) had stereotyped B cell receptor configuration. Most patients had short-lasting remissions and required second-line treatments to control the autoimmune manifestations of ES. Patients with ES were associated with inferior survival compared to patients not developing AIC, especially when ES developed early in the course of CLL, although the reduced survival was not confirmed by multivariate analysis. In conclusion, ES secondary to CLL is a difficult-to-treat complication, characterised by adverse biological features and clinical outcome.
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Affiliation(s)
- Giuseppe Carli
- Department of Cell Therapy and Haematology, San Bortolo Hospital, Via Rodolfi 37, 36100, Vicenza, Italy
| | - Carlo Visco
- Department of Cell Therapy and Haematology, San Bortolo Hospital, Via Rodolfi 37, 36100, Vicenza, Italy.
| | - Erika Falisi
- Department of Cell Therapy and Haematology, San Bortolo Hospital, Via Rodolfi 37, 36100, Vicenza, Italy
| | - Omar Perbellini
- Department of Cell Therapy and Haematology, San Bortolo Hospital, Via Rodolfi 37, 36100, Vicenza, Italy
| | - Elisabetta Novella
- Department of Cell Therapy and Haematology, San Bortolo Hospital, Via Rodolfi 37, 36100, Vicenza, Italy
| | - Ilaria Giaretta
- Department of Cell Therapy and Haematology, San Bortolo Hospital, Via Rodolfi 37, 36100, Vicenza, Italy
| | - Isacco Ferrarini
- Department of Medicine, Section of Haematology, University of Verona, Verona, Italy
| | - Alessandra Sandini
- Department of Immunohaematology, Transfusion Medicine and Human Genetics, San Bortolo Hospital, Vicenza, Italy
| | - Alberta Alghisi
- Department of Immunohaematology, Transfusion Medicine and Human Genetics, San Bortolo Hospital, Vicenza, Italy
| | - Achille Ambrosetti
- Department of Medicine, Section of Haematology, University of Verona, Verona, Italy
| | - Francesco Rodeghiero
- Department of Cell Therapy and Haematology, San Bortolo Hospital, Via Rodolfi 37, 36100, Vicenza, Italy
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Abstract
Secondary autoimmune cytopenias in chronic lymphocytic leukemia are distinct clinical entities that require specific management. These autoimmune disorders have a complex pathogenesis that involves both the leukemic cells and the immune environment in which they exist. The mechanism is not the same in all cases, and to varying degrees involves the chronic lymphocytic leukemia (CLL) cells in antibody production, antigen presentation, and stimulation of T cells and bystander polyclonal B cells. Diagnosis of autoimmune cytopenias can be challenging as it is difficult to differentiate between autoimmunity and bone marrow failure due to disease progression. There is a need to distinguish these causes, as prognosis and treatment are not the same. Evidence regarding treatment of secondary autoimmune cytopenias is limited, but many effective options exist and treatment can be selected with severity of disease and patient factors in mind. With new agents to treat CLL coming into widespread clinical use, it will be important to understand how these will change the natural history and treatment of autoimmune cytopenias.
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Affiliation(s)
- Kerry A Rogers
- Division of Hematology, Department of Internal Medicine, The Ohio State University, Columbus, OH
| | - Jennifer A Woyach
- Division of Hematology, Department of Internal Medicine, The Ohio State University, Columbus, OH.
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35
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Romiplostim for the treatment of glioblastoma-related paraneoplastic autoimmune thrombocytopenia refractory to conventional therapy. Ann Hematol 2016; 95:665-6. [PMID: 26787417 DOI: 10.1007/s00277-016-2600-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2015] [Accepted: 01/12/2016] [Indexed: 10/22/2022]
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Autoimmune Hemolytic Anemia and Hodgkin's Disease: An Unusual Pediatric Association. Case Rep Pediatr 2016; 2016:4598587. [PMID: 26904342 PMCID: PMC4745911 DOI: 10.1155/2016/4598587] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2015] [Revised: 12/24/2015] [Accepted: 12/30/2015] [Indexed: 11/17/2022] Open
Abstract
Autoimmune hemolytic anemia (AIHA) is a recognized complication of lymphoproliferative disorders. AIHA associated with Hodgkin's disease (HD) is uncommon especially in the pediatric population. The diagnosis of AIHA is usually associated with HD at the time of initial presentation or during the course of disease, but it could precede it by years to months. In adults the association of AIHA and HD is more frequent in advanced stages and in the nodular sclerosis and mixed cellularity type HD. Warm immune hemolytic anemia is mainly controlled with steroids and chemotherapy. We report a case of a pediatric patient with direct antiglobulin positive test at the diagnosis of a late relapse of stage III B mixed cellularity type HD.
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37
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Rider TG, Grace RJ, Newman JA. Autoimmune haemolytic anaemia occurring during ibrutinib therapy for chronic lymphocytic leukaemia. Br J Haematol 2015. [DOI: 10.1111/bjh.13602] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Affiliation(s)
- Tom G. Rider
- Department of Haematology; Eastbourne District General Hospital; Eastbourne UK
| | - Richard J. Grace
- Department of Haematology; Eastbourne District General Hospital; Eastbourne UK
| | - Joel A. Newman
- Department of Haematology; Eastbourne District General Hospital; Eastbourne UK
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Shimada N, Yuji K, Ohno N, Koibuchi T, Oyaizu N, Uchimaru K, Tojo A. Treatment of chronic lymphocytic leukemia with bendamustine in an HIV-infected patient on antiretroviral therapy: a case report and review of the literature. Clin Case Rep 2015; 3:453-60. [PMID: 26185648 PMCID: PMC4498862 DOI: 10.1002/ccr3.244] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2014] [Revised: 01/28/2015] [Accepted: 02/20/2015] [Indexed: 12/19/2022] Open
Abstract
Few reports have described the coincidence of chronic lymphocytic leukemia (CLL) and HIV. We administered bendamustine to an HIV-positive refractory CLL patient and obtained a significant objective response. Our results indicate that bendamustine can be used in HIV-infected CLL patients. We also reviewed 12 cases of CLL with HIV infection.
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Affiliation(s)
- Naoki Shimada
- Promotion Plan for the Platform of Human Resource Development for Cancer, Research Hospital, The Institute of Medical Science, The University of Tokyo Tokyo, Japan
| | - Koichiro Yuji
- Department of Hematology/Oncology, Research Hospital, The Institute of Medical Science, The University of Tokyo Tokyo, Japan
| | - Nobuhiro Ohno
- Department of Hematology/Oncology, Research Hospital, The Institute of Medical Science, The University of Tokyo Tokyo, Japan
| | - Tomohiko Koibuchi
- Department of Infectious Diseases and Applied Immunology, Research Hospital, The Institute of Medical Science, The University of Tokyo Tokyo, Japan
| | - Naoki Oyaizu
- Department of Laboratory Medicine, Research Hospital, The Institute of Medical Science, The University of Tokyo Tokyo, Japan
| | - Kaoru Uchimaru
- Department of Hematology/Oncology, Research Hospital, The Institute of Medical Science, The University of Tokyo Tokyo, Japan
| | - Arinobu Tojo
- Department of Hematology/Oncology, Research Hospital, The Institute of Medical Science, The University of Tokyo Tokyo, Japan
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39
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Holbro A, Passweg JR. Management of hemolytic anemia following allogeneic stem cell transplantation. HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2015; 2015:378-384. [PMID: 26637746 DOI: 10.1182/asheducation-2015.1.378] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Abstract
Hemolytic anemia (HA) is a frequent condition with variable pathophysiology. Hematopoietic stem cell transplantation (HSCT) is unique because it is performed across the ABO blood group barrier. Thereby, there is a transfer of plasma, red blood cells, and immunocompetent cells from the donor to the recipient, possibly leading to HA, due to red blood cell incompatibility. The underlying disease, drugs (particularly those used for conditioning and immunosuppressants), infections, graft-versus-host disease, and autoimmune diseases may all contribute to the clinical and laboratory picture of HA. Additionally, transplantation-associated thrombotic microangiopathy (TA-TMA) may occur and is associated with significant morbidity and mortality. This review highlights the current knowledge on HA after allogeneic HSCT, particularly due to ABO incompatibility. We follow the timeline of the transplantation process and discuss investigations, differential diagnosis, and prophylactic measures including graft processing to avoid hemolysis in case of ABO incompatibility. Finally, current therapeutic approaches for both TA-TMA and post-HSCT autoimmune HA, which are associated with high morbidity and mortality, are discussed.
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Affiliation(s)
- Andreas Holbro
- Division of Hematology, Department of Internal Medicine, University Hospital, Basel, Switzerland; and Blood Transfusion Centre, Swiss Red Cross, Basel, Switzerland
| | - Jakob R Passweg
- Division of Hematology, Department of Internal Medicine, University Hospital, Basel, Switzerland; and
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40
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Visco C, Barcellini W, Maura F, Neri A, Cortelezzi A, Rodeghiero F. Autoimmune cytopenias in chronic lymphocytic leukemia. Am J Hematol 2014; 89:1055-62. [PMID: 24912821 DOI: 10.1002/ajh.23785] [Citation(s) in RCA: 76] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2014] [Revised: 05/28/2014] [Accepted: 06/06/2014] [Indexed: 12/20/2022]
Abstract
Chronic lymphocytic leukemia (CLL) is frequently complicated by secondary autoimmune cytopenias (AIC) represented by autoimmune hemolytic anemia (AIHA), immune thrombocytopenia (ITP), pure red cell aplasia, and autoimmune granulocytopenia. The distinction of immune cytopenias from cytopenias due to bone marrow infiltration, usually associated with a worse outcome and often requiring a different treatment, is mandatory. AIHA and ITP are more frequently found in patients with unfavorable biological risk factors for CLL. AIC secondary to CLL respond less favorably to standard treatments than their primary forms, and treating the underlying CLL with chemotherapy or monoclonal antibodies may ultimately be necessary.
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Affiliation(s)
- Carlo Visco
- Department of Cell Therapy and Hematology; Ospedale San Bortolo Vicenza
| | - Wilma Barcellini
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico; Milan
| | - Francesco Maura
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico; Milan
- Department of Clinical Sciences and Community Health; University of Milan; Milan
| | - Antonino Neri
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico; Milan
- Department of Clinical Sciences and Community Health; University of Milan; Milan
| | - Agostino Cortelezzi
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico; Milan
- Department of Clinical Sciences and Community Health; University of Milan; Milan
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41
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Cuneo A, Marchetti M, Barosi G, Billio A, Brugiatelli M, Ciolli S, Laurenti L, Mauro FR, Molica S, Montillo M, Zinzani P, Tura S. Appropriate use of bendamustine in first-line therapy of chronic lymphocytic leukemia. Recommendations from SIE, SIES, GITMO Group. Leuk Res 2014; 38:1269-77. [DOI: 10.1016/j.leukres.2014.06.017] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2014] [Revised: 06/08/2014] [Accepted: 06/28/2014] [Indexed: 01/09/2023]
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42
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Jolliffe E, Romeril K. Eltrombopag for resistant immune thrombocytopenia secondary to chronic lymphocytic leukaemia. Intern Med J 2014; 44:697-9. [DOI: 10.1111/imj.12468] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2013] [Accepted: 04/03/2014] [Indexed: 11/28/2022]
Affiliation(s)
- E. Jolliffe
- Wellington Blood and Cancer Centre; Capital and Coast District Health Board; Wellington New Zealand
| | - K. Romeril
- Wellington Blood and Cancer Centre; Capital and Coast District Health Board; Wellington New Zealand
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43
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Ghia P, Hallek M. Management of chronic lymphocytic leukemia. Haematologica 2014; 99:965-72. [PMID: 24881042 PMCID: PMC4040893 DOI: 10.3324/haematol.2013.096107] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2013] [Accepted: 04/23/2014] [Indexed: 12/22/2022] Open
Abstract
In the last decade, the management of chronic lymphocytic leukemia has undergone profound changes that have been driven by an improved understanding of the biology of the disease and the approval of several new drugs. Moreover, many novel drugs are currently under evaluation for rapid approval or have been approved by regulatory agencies, further broadening the available therapeutic armamentarium for patients with chronic lymphocytic leukemia. The use of novel biological and genetic parameters combined with a careful clinical evaluation allows us to dissect some of the heterogeneity of the disease and to distinguish patients with a very mild onset and course, who often will not need any treatment, from those with an intermediate prognosis and a third group with a very aggressive course (high-risk leukemia). On this background, it becomes increasingly challenging to select the right treatment strategy. In this paper, we describe our own approach to the management of different patients with chronic lymphocytic leukemia.
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Affiliation(s)
- Paolo Ghia
- Clinical Unit of Lymphoid Malignancies and Laboratory of B Cell Neoplasia, Department of Onco-Hematology and Division of Molecular Oncology, Università Vita-Salute San Raffaele, Fondazione Centro San Raffaele, IRCCS Istituto Scientifico San Raffaele, Milano, Italy
| | - Michael Hallek
- Department I Internal Medicine, Center for Integrated Oncology Köln-Bonn, Center of Excellence on Cellular Stress Responses in Aging-Associated Diseases, University of Cologne, Germany
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44
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Haddad H, Mohammad F, Dai Q. Bendamustine-induced immune hemolytic anemia in a chronic lymphocytic leukemia patient: A case report and review of the literature. Hematol Oncol Stem Cell Ther 2014; 7:162-4. [PMID: 24785506 DOI: 10.1016/j.hemonc.2014.04.001] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2014] [Revised: 03/24/2014] [Accepted: 04/07/2014] [Indexed: 11/26/2022] Open
Abstract
Bendamustine is an alkylating agent approved for the treatment of chronic lymphocytic leukemia (CLL) and B-cell non-Hodgkin lymphoma. There are scant reports on bendamustine-induced immune hemolytic anemia occurring mainly in CLL patients. We report a case of immune hemolytic anemia that developed after exposure to bendamustine in a 70-year-old female with CLL who was previously exposed to fludarabine. Previous exposure to fludarabine is a common finding in the majority of reported cases of bendamustine drug-induced immune hemolytic anemia (DIIHA), including our case. Bendamustine should be suspected as the cause of any hemolytic anemia that develops while on this drug, especially in CLL patients treated previously with fludarabine.
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Affiliation(s)
- Housam Haddad
- Staten Island University Hospital, 475 Seaview Ave, Staten Island, NY 10305, United States.
| | - Farhan Mohammad
- Staten Island University Hospital, 475 Seaview Ave, Staten Island, NY 10305, United States.
| | - Qun Dai
- Staten Island University Hospital, 475 Seaview Ave, Staten Island, NY 10305, United States.
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45
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Autrel-Moignet A, Lamy T. Autoimmune neutropenia. Presse Med 2014; 43:e105-18. [PMID: 24680423 DOI: 10.1016/j.lpm.2014.02.007] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2013] [Revised: 02/13/2014] [Accepted: 02/18/2014] [Indexed: 02/08/2023] Open
Abstract
Autoimmune neutropenia (AIN) is a rare entity caused by antibodies directed against neutrophil-specific antigens. It includes primary and secondary autoimmune neutropenia. Acute autoimmune neutropenia can be related to drug-induced mechanism or viral infections. Chronic autoimmune neutropenias occur in the context of autoimmune diseases, hematological malignancies, such as large granular lymphocyte leukemia, primary immune deficiency syndromes or solid tumors. The therapeutic management depends on the etiology. Granulocyte growth factor is the main therapeutic option, raising the question of their long-term utilization safety. Corticosteroids or immunosuppressive therapy are indicated in infection-related AIN or in case of symptomatic autoimmune disease or LGL leukemia.
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Affiliation(s)
| | - Thierry Lamy
- CHU de Rennes, service d'hématologie clinique, Rennes 35043, France; Université Rennes 1, Rennes 35043, France.
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46
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Butler MJ, Yin M, Quddus F. Isolated hemolytic anemia: an unusual manifestation of occult malignancy. Hematol Rep 2014; 6:5159. [PMID: 24711918 PMCID: PMC3977155 DOI: 10.4081/hr.2014.5159] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2013] [Revised: 12/24/2013] [Accepted: 01/12/2014] [Indexed: 01/28/2023] Open
Abstract
Hemolysis is an uncommon and usually late complication of malignancy, and very rarely the presenting feature. Cancer-associated hemolysis may be immune-mediated, or may result from thrombotic microangiopathy accompanied by thrombocytopenia. We describe an unusual case of isolated hemolysis in the setting of occult metastatic breast cancer. The patient initially presented with symptomatic anemia, with evidence of hemolysis but with negative direct antiglobulin testing and a normal platelet count. Subsequent investigation discovered metastatic adenocarcinoma of the breast involving bone marrow. Hemolysis worsened despite initial treatment with cytotoxic chemotherapy and a trial of corticosteroids, but later resolved with aromatase inhibitor therapy.
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Affiliation(s)
- Matthew J Butler
- Department of Internal Medicine, Geisinger Medical Center , Danville, PA, USA
| | - Ming Yin
- Department of Internal Medicine, Geisinger Medical Center , Danville, PA, USA
| | - Fahd Quddus
- Department of Hematology and Oncology, Geisinger Medical Center , Danville, PA, USA
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47
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Tandra P, Krishnamurthy J, Bhatt VR, Newman K, Armitage JO, Akhtari M. Autoimmune cytopenias in chronic lymphocytic leukemia, facts and myths. Mediterr J Hematol Infect Dis 2013; 5:e2013068. [PMID: 24363883 PMCID: PMC3867225 DOI: 10.4084/mjhid.2013.068] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2013] [Accepted: 10/31/2013] [Indexed: 12/21/2022] Open
Abstract
CLL has been defined as presence of more than 5000 small mature appearing monoclonal B lymphocytes with a specific immunophenotype in peripheral blood. It is a well-known fact that CLL is associated with autoimmune cytopenias. CLL cells are CD5(+) B lymphocytes, and usually are not the "guilty" cells which produce autoantibodies. T cell defect is another characteristic of CLL and the total number of T cells is increased, and there is inversion of the CD4/CD8 ratio. Autoimmune hemolytic anemia (AIHA) is the most common autoimmune complication of CLL and has been reported in 10-25% of CLL patients. However, the stage-adjusted estimated rate of AIHA in CLL is about 5%. Conversely, CLL is three times more common in patients who present with AIHA. Direct agglutinin test (DAT) is positive in 7-14% of CLL patients but AIHA may also occur in DAT negative patients. Autoimmune thrombocytopenia (AIT) is the second most common complication of CLL and has been reported in 2-3% of patients. DAT is positive in AIT but presence of antiplatelet antibodies is neither diagnostic nor reliable. Autoimmune neutropenia (AIN) and pure red cell aplasia (PRCA) are very rare complications of CLL and like other autoimmune complications of CLL may occur at any clinical stage. It is believed that most case reports of AIN and PRCA in CLL actually belong to large granular lymphocytic leukemia (LGL). Non-hematologic autoimmune complications of CLL including cold agglutinin disease (CAD), paraneoplastic pemphigus (PNP), acquired angioedema, and anti-myelin associated globulin are rare. Before starting any treatment, clinicians should distinguish between autoimmune cytopenias and massive bone marrow infiltration since autoimmune complications of CLL are not necessarily equal to advanced disease with poor prognosis. According to IWCLL guideline, steroids are the mainstay of treatment of simple autoimmunity. Intravenous immunoglobulin (IVIg), cyclosporine, and rituximab are used in complex, steroid refractory cases. Monotherapy with purine analogues and alkylating agents should be avoided as they may increase CLL associated autoimmune complications.
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Affiliation(s)
- Pavankumar Tandra
- Division of Hematology and Oncology, University of Nebraska Medical Center, Omaha, NE 68198, USA
| | - Jairam Krishnamurthy
- Division of Hematology and Oncology, University of Nebraska Medical Center, Omaha, NE 68198, USA
| | - Vijaya Raj Bhatt
- Division of Hematology and Oncology, University of Nebraska Medical Center, Omaha, NE 68198, USA
| | - Kam Newman
- Dr. Kam Newman, Section of Transfusion Medicine, Cleveland Clinic Foundation, 9500 Euclid Avenue 6-1, Cleveland, OH 44195, USA
| | - James O Armitage
- Division of Hematology and Oncology, University of Nebraska Medical Center, Omaha, NE 68198, USA
| | - Mojtaba Akhtari
- Division of Hematology and Oncology, University of Nebraska Medical Center, Omaha, NE 68198, USA
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48
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Treatment of chronic lymphocytic leukemia. Transfus Apher Sci 2013; 49:44-50. [PMID: 23932707 DOI: 10.1016/j.transci.2013.05.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
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49
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Short communication: bendamustine-related hemolytic anemia in chronic lymphocytic leukemia. Cancer Chemother Pharmacol 2013; 72:709-13. [PMID: 23907444 DOI: 10.1007/s00280-013-2243-5] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2013] [Accepted: 07/22/2013] [Indexed: 12/19/2022]
Abstract
PURPOSE Immune hemolytic anemia (IHA) may complicate the course of chronic lymphocytic leukemia (CLL), especially in patients with advanced disease, and as a complication of treatment with chlorambucil or fludarabine. Bendamustine, a novel agent with both alkylating and purine-analog properties, was approved in the USA for use in CLL in 2008. Since then, clinical data on its adverse events are accumulating. IHA related to bendamustine was seldom described and is thus reported and reviewed. METHODS We assessed five cases of CLL patients complicated by IHA, out of 31 treated with bendamustine for a relapse of their disease. Also reviewed are previous case reports in the literature. RESULTS AND CONCLUSIONS Bendamustine-related IHA is more common than suspected (16 %). No such cases were found in non-CLL patients. Personal history of fludarabine-triggered AIHA may be a risk factor for this complication (recorded in 4/5 patients, 80 %). The mechanism is thought to be related to the loss of T cell regulatory control as described for other agents. Physicians using bendamustine for the treatment for CLL should be aware of this complication.
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50
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Hemminki K, Liu X, Försti A, Ji J, Sundquist J, Sundquist K. Subsequent leukaemia in autoimmune disease patients. Br J Haematol 2013; 161:677-687. [PMID: 23565673 DOI: 10.1111/bjh.12330] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2012] [Accepted: 02/26/2013] [Indexed: 12/12/2022]
Abstract
Previous studies have shown that patients diagnosed with some autoimmune (AI) diseases are at an increased risk of leukaemia but limited data are available on survival. We systematically analysed the risks (standardized incidence ratio, SIR) and survival (hazard ratio, HR) in nine types of leukaemia among 402 462 patients hospitalized for any of 33 AI diseases and compared to persons not hospitalized for AI diseases. Risk for all leukaemia was increased after 13 AI diseases and survival was decreased after six AI diseases. SIRs were increased after all AI diseases for seven types of leukaemia, including SIR 1·69 (95% confidence interval (CI): 1·29-2·19) for acute lymphoblastic leukaemia (ALL), 1·85 (95% CI: 1·65-2·07) for acute myeloid leukaemia, 1·68 (95% CI: 1·37-2·04) for chronic myeloid leukaemia, 2·20 (95% CI: 1·69-2·81) for 'other myeloid leukaemia', 2·45 (95% 1·99-2·98) for 'other and unspecified leukaemia', 1·81 (95% CI: 1·11-2·81) for monocytic leukaemia, and 1·36 (95% CI: 1·08-1·69) for myelofibrosis. The HRs were increased for four types of leukaemia, most for myelofibrosis (1·74, 95% CI: 1·33-2·29) and ALL (1·42, 95% CI: 1·03-1·95). Some AI diseases, including rheumatoid arthritis, were associated with increased SIRs and HRs in many types of leukaemia. The present data showed increases in risk and decreases in survival for many types of leukaemia after various AI diseases. Leukaemia is a rare complication in AI disease but findings about this comorbidity at the time of leukaemia diagnosis may help to optimize the treatment and improve survival.
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Affiliation(s)
- Kari Hemminki
- Division of Molecular Genetic Epidemiology, German Cancer Research Centre (DKFZ), Heidelberg, Germany
- Centre for Primary Health Care Research, Lund University, Malmö, Sweden
| | - Xiangdong Liu
- Centre for Primary Health Care Research, Lund University, Malmö, Sweden
- College of Lab Medicine, Hebei North University, Zhangjiakou, China
| | - Asta Försti
- Division of Molecular Genetic Epidemiology, German Cancer Research Centre (DKFZ), Heidelberg, Germany
- Centre for Primary Health Care Research, Lund University, Malmö, Sweden
| | - Jianguang Ji
- Centre for Primary Health Care Research, Lund University, Malmö, Sweden
| | - Jan Sundquist
- Centre for Primary Health Care Research, Lund University, Malmö, Sweden
- Stanford Prevention Research Center, Stanford University School of Medicine, Stanford, CA, USA
| | - Kristina Sundquist
- Centre for Primary Health Care Research, Lund University, Malmö, Sweden
- Stanford Prevention Research Center, Stanford University School of Medicine, Stanford, CA, USA
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