Co-existent chronic lymphatic leukaemia with polycythaemia vera

Second Malignancies and Richter's Syndrome in Patients with Chronic Lymphocytic Leukemia

Second malignancies are frequent complications in patients with chronic lymphocytic leukemia (CLL). Patients with this leukemia may develop large cell lymphoma (LCL) known as Richter's syndrome (RS). RS occurs in CLL patients of about 3% and may develop in a single lymph node or more often in a group of nodes. However, in some patients extranodal localization of aggressive lymphoma in RS has been observed. Besides LCL, Hodgkin's disease, prolymphocytoid leukemia, multiple myeloma and acute lymphoblastic leukemia may also occur as RS variants. The origin of lymphoid cells in RS remains tentative. However, CLL and RS originate from the same clone for some patients, whereas, in other patients cells of aggressive lymphoma do not have the features of the same clone as the CLL cells. The prognosis of RS is poor. Survival in different studies will be usually 2-5 months. The secondary development or coexistence of myeloproliferative disorders or myelodysplastic syndrome and solid tumors have also been rarely documented in CLL patients. It is of great concern that therapy may further increase the risk of a second neoplasm. However, until now, there are no clear evidence that alkylating agents or purine nucleoside analogs may be associated with an increased incidence of second malignancies in patients with CLL. In this review, epidemiology, biology, clinical characteristic and treatment approaches in RS and other secondary neoplasms in patients with CLL are discussed.

The coexistence of chronic lymphocytic leukemia and myeloproliperative neoplasms: a retrospective multicentric GIMEMA experience

Although the coexistence of chronic lymphocytic leukemia (CLL) and myeloproliferative neoplasms (MPN) has been sporadically reported in the literature, no systematic studies on this disease association are available. We retrospectively analyzed 46 patients affected by CLL/MPN referred by 15 Italian GIMEMA centers. The aim of this retrospective multicenter study was to define the following: clinico-biological characteristics, possible familiarity, clinical course of both diseases, and influence of MPN chemotherapy on the course of CLL. Among 46 patients, 30 patients were males, 16 patients were females; median age was 71 years. Only one case had familiar CLL. Myeloproliferative disorders consisted of essential thrombocytemia in 18 cases, polycythemia vera in 10 cases, chronic myeloid leukemia in 9 cases, primary myelofibrosis in 6 cases, and MPN/myelodysplastic syndrome in 3 cases. The lymphoproliferative disorder was diagnosed as monoclonal B-cell lymphocytosis in 8 patients and as Binet Stage A CLL in 38 patients. After a median follow-up of 49 months, 9 patients experienced progressive CLL and only 6 patients required treatment after a median of 57.5 months. The biological profile confirmed a subset of low-risk CLL. Twenty patients received chemotherapy for MPN without influence on the course of CLL: lymphocyte counts remained unchanged after 3, 6, and 12 months of treatment. This series is the largest so far reported in literature. The diagnosis of concomitant CLL/MPN is a rare event and lymphoproliferative disorders present a clinical indolent course with a low-risk biological profile. MPN therapy does not interfere with the prognosis of patients with CLL.

Coexistence of chronic lymphocytic leukemia and essential thrombocythemia

The association of chronic lymphocytic leukemia (CLL) with essential thrombocythemia (ET) is an extremely rare event and until now 3 patients with such coexistence have been reported in the literature. We report a 77-year-old white woman in whom these two disorders were diagnosed concomitantly on the basis of peripheral blood count and cytology, bone marrow cytology and histology, immunophenotyping, as well as exclusion criteria. The diagnosis of ET was also supported by spontaneous in-vitro erythroid colony growth and by evaluation of thrombopoietin (TPO) serum level. Interphase FISH analysis allowed to detect 13q14.3 deletion in 98% of lymphocytes nuclei. In contrast this aberration was not observed in the megakaryocytes. The results of PCR analysis of IgG gene rearrangement showed distinct bands characteristic for monoclonal lymphoid population in bone marrow, peripheral blood and inguinal lymph node. The patient was started on hydroxyurea 1 g/day and normalization of the platelet count was achieved. Possible etiopathogenic relationships between both disorders and differential diagnosis of ET and reactive thrombocytosis (RT) are discussed.

Coexistent Polycythemia Vera and Chronic Lymphocytic Leukemia: Down-Regulation of Myeloid Clone by the Lymphoid Clone?

Coexistence of polycythemia vera (PV) and chronic lymphocytic leukemia (CLL) is a rare association. The clinical course in all cases has been remarkably mild, thus suggesting suppression and/or control of each disease by the other. We have studied a patient who exhibited a typical feature of PV for 6 years. After 3 years of remission, induced by (32)P, a mild form of PV reappeared in association with B-CLL. In order to investigate the possible influence of CLL to the mild expression of PV, we have performed several in vitro colony assays and the tumor necrosis factor (TNF) assay. Colony formation by patient's bone marrow hematopoietic progenitor cells showed "spontaneous" BFU-E and CFU-E. In addition, patient's plasma selectively inhibited growth of normal BFU-E and CFU-E colony formation. TNF bioactivity, analysed during the course of the disease, was reduced. These findings suggested the existence of an inhibitor of erythropoiesis that could be involved in a down regulation of the myeloid clone by the lymphoid clone in this patient.

The association of erythrocytosis and chronic lymphocytic leukemia

The authors report the clinical course of three patients with well-documented chronic lymphocytic leukemia (CLL) and concomitant erythrocytosis. Associated disorders included immune cytopenias, Hashimoto struma and Richter syndrome. Durable complete remissions of CLL have occurred in two patients. Inasmuch as a chance association of these two relatively rare hematologic disorders is unlikely, the available information suggests that a pluripotent stem cell with the capacity to differentiate into lymphoid and erythroid pathways is the most attractive hypothesis.

Acute lymphoblastic leukemia in a patient with longstanding polycythemia vera: cytogenetic analysis reveals two distinct abnormal clones

A 68-year-old female patient is described in whom acute lymphoblastic leukemia followed a long course of polycythemia vera. Chromosomal analysis of a peripheral blood specimen at the time of blastic transformation revealed two distinct clones: one characterized by a chromosomal abnormality frequently noted in polycythemia vera and the other by a rearrangement characteristically observed in lymphoid malignancies. These findings suggest the existence of two independent hematologic diseases: this phenomenon would not support the speculation from previous reports that lymphoproliferative disorders in patients with polycythemia vera arise from clonal evolution.

Erythremic [corrected] myelosis in chronic lymphocytic leukemia

Two patients who had both B-cell chronic lymphocytic leukemia (CLL) and dyserythropoiesis are described. One patient (Case 2) had both CLL and dyserythropoiesis. Erythrodysplasia developed in the other patient (Case 1) after treatment for CLL with alkylating agents and 2'-deoxycoformycin. The management of these patients and the possible mechanisms responsible for the development of dyserythropoiesis in CLL are discussed.

Frequent association of idiopathic myelofibrosis with plasma cell dyscrasias

In a retrospective analysis of 199 cases of myeloproliferative diseases a concomitant plasma cell dyscrasia was found in three out of 46 patients with idiopathic myelofibrosis. Chronic myeloid leukemia, polycythemia vera or unclassifiable myeloproliferative disorders were in no case associated with monoclonal gammopathy. One patient with idiopathic myelofibrosis had primarily coexistent IgG-lambda paraproteinemia and increasing osteolytic lesions; histologic evidence of multiple myeloma, however, was insufficient. In the second patient the interval between diagnosis of idiopathic myelofibrosis and IgG-kappa paraproteinemia was 11 years. After a stable period of 9 years' duration the paraprotein level rapidly increased, associated with depression of normal background immunoglobulins and progressive bone marrow failure. The exact nature of this patient's malignant plasma cell dyscrasia remained uncertain. In the third case benign monoclonal gammopathy of the IgM-lambda type was diagnosed 13 years after idiopathic myelofibrosis. A review of the literature confirms a remarkably high incidence of monoclonal gammopathies in idiopathic myelofibrosis. Benign monoclonal gammopathy seems to occur in at least 8% of the patients while only a few cases of concomitant multiple myeloma have been reported. It may be speculated that plasma cell dyscrasias in idiopathic myelofibrosis reflect involvement of the lymphoid lineage in the neoplastic stem cell disorder.

Development of polycythemia vera and chronic lymphocytic leukemia during the course of refractory idiopathic thrombocytopenic purpura

A case in which polycythemia vera and chronic lymphocytic leukemia (CLL) developed during the course of idiopathic thrombocytopenic purpura (ITP) is described. Observations in this case suggest that ITP was a pre-monitor of the clinical development of CLL and preceded the manifestation of polycythemia vera. The polycythemia was mild, requiring infrequent phlebotomies, and, as the CLL progressed, the requirement for phlebotomy diminished. Evidence of both CLL and myeloid proliferation, as well as severe immune thrombocytopenia, persisted throughout her course. Studies on lymphocytes revealed characteristics of those of CLL. Excellent therapeutic response of the CLL was observed with the use of vinblastine and steroids.

Polycythaemia rubra vera and hairy cell leukaemia in the same patient: studies on the spleen

The first association of polycythaemia rubra vera (PRV) and hairy cell leukaemia (HCL) is reported. The secretion by spleen cells in short term culture of IfGlambda to the exclusion kappa demonstrated that despite aberrant surface marker studies the HCL was a monoclonal tumour of B cells. Chromosomal studies on splenic cells were not able to demonstrate the common clonal origin of the two tumours.

Two additional cases of coexisting polycythaemia vera and chronic lymphocytic leukaemia

2 patients with coexistent polycythaemia vera and chronic lymphocytic leukaemia are described. A 61-year-old man presented with an increased packed cell volume (PCV) and a leucoerythroblastic blood picture, which was reversible upon treatment, neutrophil leucoytosis, bone marrow lymphocyte infiltration and splenomegaly, and subsequently developed lymphomas, blood lymphocytosis and thrombocytosis. The second case was a 58-year-old female presenting with increased PCV and leucocyte alkaline phosphatase score. She later had neutrophil leucocytosis, thrombocytosis, lymphocytosis, lymphomas and splenomegaly. These cases, together with 6 cases published by others, suggest that an association exists between the two diseases.

Development of chronic lymphocytic leukaemia in a patient with polycythaemia vera

A 73-year-old patient who had polycythaemia vera (PV), and who 6 years later developed chronic lymphocytic leukaemia (CCL) is described. 2 years after the appearance of CLL, the polycythaemic phase showed a remission following treatment with phlebotomy and busulfan. CLL did not make all the characteristics of PV disappear: leucocyte alkaline phosphatase and fibrosis of the bone marrow remained increased and the erythrocyte sedimentation rate remained low. The abnormal lymphocytes were B-cells and had the peculiarity that most of their nuclei showed a deep cleft, and some were bilobed. Chromosomal studies of the bone marrow showed the presence of a metacentric chromosome in the C-group, while the karyotype of the peripheral blood was normal. This case is described because of the rarity of the coexistence of these 2 diseases in the same patient.

Bone biopsy in haematological disorders

Bone marrow biopsies are now widely used in the investigation and follow-up of many diseases. Semi-thin sections of 8216 undecalcified biopsies of patients with haematological disorders were studied. Observations were made on the cytopenias and the myelodysplastic syndromes, the acute leukaemias the myeloproliferative disorders, Hodgkin's disease and the malignant lymphomas including multiple myeloma, hairy cell leukaemia and angioimmunoblastic lymphadenopathy. Bone marrow biopsies are essential for the differential diagnosis of most cytopenias and for the early recognition of fibrosis which most frequently occurred as a consequence of megakaryocytic proliferation in the myeloproliferative disorders. Different patterns of bone marrow involvement were found in the lymphoproliferative disorders and both their type and extent constituted factors of prognostic significance. A survey of the literature is given and the conclusion is drawn that bone marrow biopsies provide indispensible information for the diagnostic evaluation and the follow-up of patients with haematological disorders.

Simultaneous or spontaneous occurrence of lympho- and myeloproliferative disorders: a report of four cases

We describe four patients with mixed lympho- and myeloproliferative disorders. One patient had hairy cell leukaemia and acute myelomonocytic leukaemia, another lymphocytic lymphoma in leukaemic phase and chronic myelomonocytic leukaemia and the third patient had chronic lymphocytic leukaemia and polycythaemia rubra vera; none of these patients had received any prior therapy, and in two the diagnosis of the two malignancies was simultaneous. The fourth patient developed acute monocytic leukaemia 4 years after the diagnosis of chronic lymphocytic leukaemia after only 2 weeks of therapy with chlorambucil. The nuber of cases with concurrent or sequential but spontaneous occurrence of lympho- and myeloproliferative disorders reported so far is now 38. The questions relating to the pathogenesis of the two malignancies are discussed.

Dual presentation of polycythaemia vera and lymphatic leukaemia

A case is described in which polycythaemia vera was found to co-exist with chronic lymphatic leukaemia at the time of presentation. This case can be added to five other reported cases of an association between polycythaemia vera and well-differentiated lymphocytic neoplasia, and adds further emphasis to the tendency for dual presentation, which has now occurred in all but one of these cases. One explanation is that the association is due to chance, but the tendency for dual presentation raises the possibility that the overall picture reflects neoplastic involvement of stem cells with capacity to differentiate into the lymphoid as well as the erythroid, myeloid and megakaryocytic series.