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Monitoring of cytomegalovirus reactivation during induction and nontransplant consolidation of acute leukemia.

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Correspondence
Langerhans cell histiocytosis following acute leukemia
in an adult
To the editor: A 69-year-old man presents with cough and SOB approximately 3.5 years following diagnosis of a poorly differentiated acute lymphocytic leukemia (progenitor cell phenotype). By flow cytometry, the initial
leukemia in 1998 was positive for HLA-DR, CD34, and CD45 and negative
for lymphoid and myeloid markers including: CD3, CD5, CD7, CD19, CD10,
CD20, CD13, CD33, CD11b, and CD14; CD1a and S-100 protein staining
were not available on this sample. A pathologic diagnosis of a progenitor
cell leukemia most suggestive of acute lymphocytic leukemia was made.
The patient received induction therapy in November 1998 and achieved a
complete remission. Consolidation therapy was discontinued after one cycle
due to severe cytopenias. Maintenance therapy was discontinued after
6 months secondary to methotrexate-induced hepatoxicity.
Approximately 3.5 years after the initial diagnosis, the patient presented
with back pain and leg weakness and found to have a paraspinal mass with
cord compression. He underwent surgical resection followed by consolidative
radiation. The lesion (see Fig. 1) was composed of sheets of medium to
large sized mitotically active cells with relatively abundant cytoplasm. Occasional multinucleated tumor giant cells were also identified. The cell nuclei
were vesicular with irregular contour and occasional grooves. Considering
the remote history of a lymphocytic leukemia and the morphologic features
which raised the possibility of an epithelioid/dendritic cell neoplasm, a panel
of immunohistochemical stains was used to characterize the lesion. The
tumor cells were positive for vimentin, CD1a, S-100 protein, CD43 and
focally for keratins, CD45, CD68, and lysozyme. Negative immunostains
included EMA, Melan-A, CD3, CD20, CD21, CD35, Kappa and Lambda light
chains, and MPO. Leder’s histochemical stain was negative. Based on the
morphology and the immunohistochemical profile, a diagnosis of a dendritic
cell neoplasm most consistent with Langerhans cell sarcoma was rendered.
Electron microscopic studies were not performed. Bone marrow biopsy
revealed trilineage hematopoiesis with no evidence of leukemic involvement.
Approximately 2 months later, he developed a similar soft tissue mass
in the right upper chest extending into the right supraclavicular area.
Radiation treatment resulted in a complete clinical response in the chest
mass and he had no evidence of progression for 1 year. The patient
then developed shortness of breath and fevers. A CXR showed a right
Fig. 1. Infiltrate of atypical cells with occasional grooved nuclei and with scattered
multinucleated cells. Insert shows that the tumor cells are positive for CD1a. [Color
figure can be viewed in the online issue, which is available at www.interscience.
wiley.com.]
upper lobe infiltrate. A bronchoscopy was performed and biopsy specimens showed LCH. The patient was treated with a course of Cladribine,
but did not respond. The patient died from pulmonary complications of
LCH. The morphologic features of the para spinal lesion and the autopsy
lesions (in the lungs, thyroid, and multiple intra-abdominal lymph nodes)
were similar.
Langerhans cell histiocytosis (LCH) is a rare disorder involving the proliferation of the specialized langerhans histiocyte normally found primarily in the
skin. LCH affects children in 66–90% of case reports and has an incidence
in adults of 1–2 per million population based on case series [1–3]. LCH has
been associated with malignancy, including malignant lymphoma and solid
tumors in adults and children [3]. While LCH has been associated with acute
leukemia, a literature review reveals only 15 cases where LCH occurred after acute leukemia; all but one case were in children [4,5,6,11]. LCH, formerly histiocytosis X, is a clonal proliferative disease, however, the pathogenesis remains unclear [3]. The disease ranges in severity and presentation
and can affect virtually any organ system [2]. Diagnosis of LCH depends on
the identification of the tumor cells. These cells are antigen presenting and
express HLA-DR and CD1a. Langerhans cells have characteristic HX bodies
(Birbeck granules) in the cytoplasm [3].
LCH is associated with a variety of neoplasms and chemotherapy. In
one study of 47 patients over the age of 15, 17% had an associated
hematological or solid tumor [7]. Of the cases currently reviewed in the
literature, the relationship between malignancy and LCH remains unclear
as LCH may precede, develop concurrently, or as in this case, develop
after malignancy. The relationship between LCH and ALL may be
explained by several mechanisms including a chance occurrence, treatment induced effect, a common progenitor cell, or a cytokine-mediated
phenomenon.
A registry of patients in whom LCH was associated with malignancy was
established in 1991. LCH was most frequently associated with malignant
lymphoma, leukemia, and lung carcinoma. A series looking at LCH in adults
included an association with breast cancer as well [7]. The first review of the
registry, in 1994, included 91 patients with LCH associated with malignancy.
Of those 91 patients, five patients had LCH associated with ALL. In four of
the five cases, ALL preceded the diagnosis of LCH by 6–12 months [6]. A
later review of the registry included an additional seven cases of LCH preceded by ALL. In each of the seven cases, LCH was diagnosed while the
patients were receiving chemotherapy [5]. Only patients less than 18 years
of age at the time of diagnosis were included in the report, excluding two
patients with LCH associated with malignancy ages 75 and 79. The time
course in these cases suggests a chemotherapy-related pathogenesis of
LCH either by chemo induced mutagenesis or immunosuppression.
Raj et al. describe a case of a 7-year-old male who developed LCH 2
years after the completion of chemotherapy for ALL [8]. This time frame suggests that development of LCH was not related to immunosuppression. In
support of this hypothesis, Raj et al. demonstrated that the standard tests
for T- and B-cell function in their patient were normal [8].
More recent reports also support an alternative pathogenesis of LCH
developing after ALL. Feldman et al. report on two cases of LCH developing
after ALL in children. They demonstrate a clonal relationship between the
two neoplasms in each patient with identical T-cell receptor rearrangements
[9]. A follow-up study by Rodig et al. in these two patients investigating a
role for NOTCH1 did not show evidence to suggest that the lineage switch
was mediated through NOTCH1 down regulation [12]. However, progenitor
cells with lymphoid and dendric cell potential remains a likely mechanism for
the observed relationship of these two neoplasms. While NOTCH1 expression is known to influence cell fate, there are other epigenetic factors that
play a role including the cytokine environment. Interestingly, Ko et al.
describe two cases of LCH and T-lymphoblastic lymphoma in the same
lymph node both of which were CD561. The Feldman cases were also
CD561, although most LCH are not CD561 [9,10]. CD56 function in hematopoietic cells is unclear.
Much of the literature regarding LCH and malignancy relies on pediatric
populations. As noted by Tavernier et al., because adult patients with ALL
C 2009 Wiley-Liss, Inc.
V
American Journal of Hematology
693
http://www3.interscience.wiley.com/cgi-bin/jhome/35105
correspondence
have a poorer prognosis than children and have more comorbidities at the
time of diagnosis and treatment, subsequent development of second malignancies is likely underestimated [11]. Tavernier reports on at least one
other adult patient with ALL from the LALA-87 and LALA-94 trials who
subsequently developed LCH. In our case, the diagnosis of a Langerhans
cell tumor was based on morphologic features supported by immunohistochemical staining with CD1a and S-100. The pathological diagnosis rendered in this case was based on the criteria adopted by the International
Lymphoma Study Group [1]. Up to now, to the best of our knowledge,
there is only one other reported case of LCH developing in an adult after
diagnosis of ALL. While these cases may represent a chance occurrence,
given that the association of LCH and ALL has been explored in pediatric
populations and secondary malignancies in adults with ALL are likely
underestimated, further investigation of LCH and ALL in adults seems warranted. Further investigation of future cases with thorough investigation of
genetic mutations cell surface receptor expression may help elucidate the
pathogenesis of these cancers.
REBECCA HIRSH
DILIP GIRI
ROGERS GRIFFITH
RICHARD STONE
NEAL READY
Clinical Fellow Hematology Oncology
Columbia University Medical Center
Conflicts of interest: Nothing to report.
Published online 6 July 2009 in Wiley InterScience
(www.interscience.wiley.com).
DOI: 10.1002/ajh.21490
References
1. Pileri SA, Grogan TM, Harris NL, et al. Tumors of histiocytes and accessory
dendritic cells: An immunohistochemical approach to classification from the
International Lymphoma Study Group based on 61 cases. Histopathology
2002;41:1–29.
2. Baumgartner I, von Hochstetter A, Baumert B, et al. Langerhan’s cell histiocytosis in adults. Med Pediatr Oncol 1997;28:9–14.
3. Willman CL, Busque L, Griffith BB, et al. Langerhans’ cell histiocytosis (histiocytosis X)—A clonal proliferative disease. N Engl J Med 1994;331:154–160.
4. Egeler RM, Neglia JP, Puccetti DM, et al. Association of Langerhans cell
histiocytosis with malignant neoplasms. Cancer 1993;71:865–873.
5. Egeler RM, Neglia JP, Arico M, et al. The relation of Langerhans cell histiocytosis to acute leukemia, lymphomas, and other solid tumors: The LCH Malignancy Study Group of the Histiocyte Society. Hematol Oncol Clin North Am
1998;12:369–378.
6. Egeler RM, Neglia JP, Arico M, et al. Acute Leukemia in association with
Langerhans cell histiocytosis. Med Pediatr Oncol 1994;23:81–85.
7. Malpas JS, Norton AJ. Langerhans cell histiocytosis in the adult. Med Paediatr Oncol 1996;27:540–546.
8. Raj A, Bendon R, Moriarty T, et al. Langerhans cell histiocytosis following
acute lyphoblastic leukemia. Am J Hematol 2001;68:284–286.
9. Feldman A, Berthold F, Arceci RJ, et al. Clonal relationship between precursor T-lymphoblastic leukaemia/lymphoma and Langerhans-cell histiocytosis.
Lancet Oncol 2005;6:435–437.
10. Ko YH, Kim WS, Kim Y. Expression of CD56 antigen in Langerhans cell histiocytosis associated with T-lymphoblastic lymphoma in a same lymph node.
Virchows Arch 2006;448:90–94.
11. Tavernier E, Le QH, de Botton S, et al. Secondary or concomitant neoplasms among adults diagnosed with acute lymphoblastic leukemia and
treated according to the LALA-87 and LALA-94 trials. Cancer 2007;110:
2747–2755.
12. Rodig SJ, Payne EG, Degar BA, et al. Aggressive Langerhans cell histiocytosis following T-ALL: Clonal related neoplasms with persistent expression of
constitutively active NOTCH1. Am J Hematol 2008;83:116–121.
Treatment of multiple myeloma in patients
with Gaucher disease
munoglobulin profile and clonality for patients with GD older than 50 years
of age and every other year for patients younger than 50 years [4]. If
monoclonal protein (M-protein) is found, bone marrow biopsy and aspirate
should be performed, alongside with cytogenetic analysis of plasma cells.
However, it is not known which, if any, of the standard or investigational
protocols for treating myeloma in the general population can lead to reproducibly favorable outcomes in patients with GD. We present a case of myeloma in a patient with N370S/L444P GD, with details of the applied treatment and outcome. A critical review of published results of myeloma therapy in GD is also provided.
A Swedish male was splenectomized in 1958, at the age of 32 years, due
to massive splenomegaly and thrombocytopenia (platelet count 42 3 109/L).
Histopathology of the spleen disclosed GD. In 1986, at the age of 60 years,
the patient developed monoclonal gammopathy of undetermined significance
(MGUS) of IgG-lambda type. Fifteen years later, in 2001, he was referred to
hematologist because of serum M-protein increase to 34 g/L. Laboratory
investigations showed Hb 103 g/L, WBC 6.0 3 109/L, platelet count 139 3
109/L, b2-microglobulin 5.2 mg/L, and normal levels of serum albumin, creatinine, and calcium. Bone marrow (BM) examination disclosed 17% plasma
cells and 40% Gaucher cells. The cited plasma cell count is expressed as
the percentage of hematopoietic cells only; Gaucher cell burden was
assessed in the trephine biopsy, as the percentage of all nonfatty cells in
the BM. BM cytogenetics revealed t(11;14), and further immunohistochemistry confirmed that approximately 50% of plasma cells expressed cyclin-D1.
The patient had no skeletal pain, and skeletal X-ray did not show any
lesions typical for myeloma. The patient’s disease was classified as IgGlambda myeloma (stage I A), without indications for treatment.
Four years later, in 2005, the patient developed painful peripheral neuropathy in both legs and skin lesions diagnosed as leukocytoclastic vasculitis.
M-protein began to rise, reaching 49 g/L in December 2006, followed by the
progress of thrombocytopenia (platelet count 54 3 109/L). Possible relationship between patient’s myeloma and worsening of thrombocytopenia and peripheral neuropathy was considered, leading to a cautious initiation of oral
MP treatment: melphalan (20 mg/d, days 1–2; reduced 50%) and prednisone (150 mg/d, days 1–4) given every sixth week. After the first MP
course, 29% reduction of M-protein to 35 g/L was obtained but no further Mprotein regress was noted despite two more MP courses. The treatment had
no impact on the peripheral neuropathy or the skin lesions. Moreover, after
the third MP course the platelet count decreased permanently to 10–25 3
109/L and treatment was ceased. One year later, M-protein was stable (32
g/L) but the patient became transfusion-dependent for both platelets and
RBC. BM examination in February 2008 revealed dysplastic features in two
series (mild dyserythropoiesis and dysmyelopoiesis), which were however
not significant, with only 4% plasma cells. Cytogenetic investigation disclosed normal karyotype, but FISH was positive for t(11;14). The patient initially refused the proposed enzyme replacement therapy (ERT) with imiglucerase infusions, so the substrate reduction therapy with oral miglustat (300
mg/d) was administered. Miglustat was well tolerated but did not influence
the level of thrombocytopenia or anemia. After 10 weeks, the patient
changed his mind and treatment with imiglucerase (60 U/kg/14 d) was initiated. Nevertheless, combination therapy was continued in hope to achieve
as rapid reduction in the BM Gaucher cell burden as possible. In June 2008,
diagnosis of MDS RAEB-2 (refractory anemia with excess of blasts type 2)
was established based on significant dysplastic features in two hematopoietic series, 11–16% blasts in BM and 3% blasts in peripheral blood. At that
time, there were 13% plasma cells and 40% Gaucher cells in BM. Cytogenetic analysis of BM did not reveal any new abnormalities. Seven months after the initiation of GD therapy, the patient still remained transfusion-dependent. Shortly afterwards, transformation to acute myeloid leukemia occurred
and the patient deceased.
We think that melphalan treatment could have probably played a role in
the development of MDS in our patient. However, it is difficult to assess if it
was the only causative factor. It is known that concentration of glycosphingo-
To the editor: Several studies have reported an increased incidence of
multiple myeloma in patients with type 1 Gaucher disease (GD) [1–3].
Available data requires attention of all physicians dealing with GD to the
signs of myeloma in patients with GD. Current guidelines for the management of the hematological aspects of GD recommend annual control of im-
694
lipids other than glucocerebroside may be increased in GD. Some of these
lipids may be able to act as signaling molecules or transcription factors that
could conceivably alter early pluripotent hematopoietic stem cells in some
patients, which could result in the development of B-cell dyscrasias, MDS,
and leukemia.
American Journal of Hematology
correspondence
TABLE I. Published Reports on Results of Myeloma Therapy in Gaucher Disease
Sex/age
GD genotype
Sx
ERT
F/66
n.g.
N
N
F/58
N370S/L444P
Y
F/57
N370S/L444P
N
Myeloma type
Therapy
Response
IgG-kappa
MP
SD
N
IgG-lambda
N
Lambda light chain
MP
VAD
VAD
MEL200 and
APSCT
Progress after 4 MP
n.g.
CR
Relapse within
3 months after
APSCT
Died 3 months after
myeloma diagnosis
due to heart failure
M/55
n.g.
N
Y
Kappa light chain
(progression from MGUS)
M/61
n.g.
Y
Y
IgG-kappa
M/80
N370S/L444P
Y
N
IgG-lambda
(progression from MGUS)
DXM
Complications
Prolonged
pancytopenia
Miller et al. [5]
Harder et al. [6]
Cheung et al. [7]
Prolonged severe
thrombocytopenia;
renal failure
de Fost et al. [8]
MP (reduced)
Thalidomide
MP (reduced)
Reference
Favorable
SD
Unacceptable
pancytopenia
de Fost et al. [8]
Prolonged severe
thrombocytopenia;
myelodysplasia (?)
Machaczka
et al. [this report]
Sx, splenectomy; ERT, enzyme replacement therapy; Y, yes; N, no; n.g., not given; SD, stable disease; CR, complete response; MP, melphalan and prednisone; DXM,
dexamethason; VAD, vincristine, adriamycin, DXM; MEL200, conditioning with melphalan 200 mg/m2; APSCT, autologous peripheral stem cell transplantation.
There are virtually no published guidelines on optimal treatment strategies
in patients with GD who develop myeloma. We could identify only four published reports [5–8] including important details on the outcome of myeloma
therapy in a total of five patients with GD (Table I).
A striking observation is the serious and persistent myelotoxicity of melphalan-based regimens (even if dose-reduced), with only moderate and temporary efficacy at the same time. This is a surprising finding given that this
alkylating agent is otherwise considered safe and effective in myeloma therapy. We speculate that Gaucher cells in BM may have increased hematopoietic stem cells’ vulnerability to melphalan treatment in some unknown mechanism. Based on the same reports, VAD and Thalidomide were better tolerated and in two described cases produced remission [7,8]. The use of
newer myeloma agents (bortezomib, lenalidomide) have never been
reported in GD context. Bortezomib is the first agent targeting the proteasome, which results in the disruption of multiple pathways and checkpoints
in the cell cycle, ultimately leading to apoptosis. However, ER oxidative
stress due to protein misfolding and proteasome overload has been suggested as possible contribuent, the effect of which adds to GD-related
changes. Bortezomib might theoretically enhance this pathway and its own
toxicities might be increased in patients with GD.
The optimal myeloma therapy for advanced disease remains poorly
defined. In general population, consolidation with one or two cycles of
high-dose chemotherapy and autologous hematopoietic cell transplantation
(HCT) has been considered optimal treatment for advanced stage myeloma for patients younger than 65 years of age. Autologous HCT have
been previously successfully performed in patients with GD; however, difficulties with engraftment were described in recently published case of autologous HCT for relapsed non-Hodgkin’s lymphoma in 69-year-old male
with naı̈ve N370S/N370S GD [9]. Initiation of imiglucerase therapy has
effectively circumvented graft failure and the patient became transfusion
independent.
Long-lasting remissions and possible cures have been reported in myeloma patients who received allogeneic HCT. A graft-versus-myeloma
(GVM) effect of donor T-cells, the phenomenon which is absent after autologous HCT, may provide long-term disease control. Encouraging data on
nonmyeloablative HLA-identical sibling allogeneic HCT after autologous
HCT has been recently reported [10,11]. On the other hand, long-term follow-up results of allogeneic HCT in GD performed in Sweden in the preERT era (before 1991), revealed effective engraftment and durable curative
effect of allogeneic HCT on GD [12]. Our currently updated, but not published, data indicates that particularly favorable outcome can be achieved
in patients with GD who were transplanted from HLA-identical siblings. The
authors believe that, when discussing possible therapeutic options for
advanced stage myeloma in patients with GD, allogeneic HCT from HLAidentical sibling donor should be considered in eligible younger patients.
Such an approach has a curative potential in both entities: myeloma and
GD.
American Journal of Hematology
MGUS may emerge even in patients with clinically very mild GD. An intriguing question is whether early institution of ERT would prevent the development of MGUS in patients with GD. Yet, there is no evidence to support
this hypothesis. Brautbar et al. found a decrease in immunoglobulin levels
during ERT, although only in cases with a polyclonal gammopathy [13].
Results of the same study showed that in five patients with GD with
MGUS ERT does not eliminate or even decrease M-protein level once it
appears. However, data from the study published by de Fost et al. suggest
a beneficial effect of ERT in preventing the occurrence and the progression of gammopathies inclusive MGUS [8]. The question whether early
institution of ERT after MGUS detection can decrease the likelihood of
transformation to myeloma still remains open. Another important issue
relates to the role and the timing of ERT with regard to myeloma outcome
in previously naı̈ve patients with GD. Published cases of chemotherapy in
patients with GD suffering from different cancers suggest better tolerance
of cytotoxic drugs with less side effects when on ERT [8,14–18]. ERT may
attribute to a better tolerability of chemotherapy by reducing GD burden in
BM and improving function of macrophages (and in consequence of the
entire immune system). Therefore, we propose to initiate ERT directly after
establishing the diagnosis of myeloma in all naı̈ve patients with GD eligible
for myeloma therapy.
MACIEJ MACHACZKA1
RICHARD LERNER1
MONIKA KLIMKOWSKA 2
HANS HÄGGLUND1
1
Hematology Center, Karolinska University
Hospital Huddinge, Stockholm, Sweden
Department of Pathology, Karolinska University
Hospital Huddinge, Stockholm, Sweden
Conflicts of interest: Nothing to report.
Published online 6 July 2009 in Wiley InterScience
(www.interscience.wiley.com).
DOI: 10.1002/ajh.21492
2
References
1. Rosenbloom BE, Weinreb NJ, Zimran A, et al. Gaucher disease and cancer
incidence: A study from the Gaucher Registry. Blood 2005;105:4569–4572.
2. de Fost M, vom Dahl S, Weverling GJ, et al. Increased incidence of cancer in
adult Gaucher disease in Western Europe. Blood Cells Mol Dis 2006;36:53–
58.
3. Taddei TH, Kacena KA, Yang M, et al. The underrecognized progressive nature of N370S Gaucher disease and assessment of cancer risk in 403
patients. Am J Hematol 2009;84:208–214.
4. Hughes D, Cappellini MD, Berger M, et al. Recommendations for the management of the haematological and onco-haematological aspects of Gaucher
disease. Br J Haematol 2007;138:676–686.
695
correspondence
5. Miller W, Lamon JM, Tavassoli M, et al. Multiple myeloma complicating
Gaucher’s disease. West J Med 1982;136:122–128.
6. Harder H, Eucker J, Zang C, et al. Coincidence of Gaucher’s disease due to
1226G/1448C mutation and of an immunoglobulin G lambda multiple myeloma with Bence-Jones proteinuria. Ann Hematol 2000;79:640–643.
7. Cheung WY, Greenberg CR, Bernstein K, et al. Type I Gaucher disease following chemotherapy for light chain multiple myeloma. Intern Med 2007;
46:1255–1258.
8. de Fost M, Out TA, de Wilde FA, et al. Immunoglobulin and free light chain
abnormalities in Gaucher disease type I: Data from an adult cohort of 63
patients and review of the literature. Ann Hematol 2008;87:439–449.
9. Carreiro J, Balwani M, Grosskreutz C, et al. A case report of secondary autograft failure due to Gaucher disease. Am J Hematol 2008;83:937.
10. Bruno B, Rotta M, Patriarca F, et al. A comparison of allografting with autografting for newly diagnosed myeloma. N Eng J Med 2007;356:1110–1120.
11. Rotta M, Storer BE, Sahebi F, et al. Long-term outcome of patients with multiple myeloma after autologous hematopoietic cell transplantation and nonmyeloablative allografting. Blood 2009;113:3383–3391.
12. Ringden O, Groth CG, Erikson A, et al. Ten years’ experience of bone
marrow transplantation for Gaucher disease. Transplantation 1995;59:864–
870.
13. Brautbar A, Elstein D, Pines G, et al. Effect of enzyme replacement therapy
on gammopathies in Gaucher disease. Blood Cells Mol Dis 2004;32:214–
217.
14. Petrides PE, leCoutre P, Müller-Höcker J, et al. Coincidence of Gaucher’s disease due to a private mutation and Ph’ positive chronic myeloid leukaemia.
Am J Hematol 1998;59:87–90.
15. Böhm P, Kunz W, Horny H-P, Einsele H. Adult Gaucher disease in association
with primary malignant bone tumors. Cancer 2001;91:457–462.
16. Manz M, Riessen R, Poll L, et al. High-grade lymphoma mimicking bone crisis
in Gaucher’s disease. Br J Haematol 2001;113:191–193.
17. Brody JD, Advani R, Shin LK, et al. Splenic diffuse large B-cell lymphoma in
a patient with type 1 Gaucher disease: Diagnostic and therapeutic challenges.
Ann Hematol 2006;85:817–820.
18. Leone JP, Dudek AZ. Enzyme replacement therapy for Gaucher’s disease in
patient treated for non-small cell lung cancer. Anticancer Res 2008;28:3937–
3939.
Two cases of pegylated asparaginase-associated severe
and persistent hyperbilirubinemia
before the administration of second dose of pegaspargase) and reached its
highest at 10.2 mg/dL on day 33. Magnetic resonance cholangiopancreatography (MRCP) test on day 32 revealed hepatomegaly with diffuse hepatic steatosis without biliary dilatation or choledocholithiasis. Normalization of bilirubin level occurred on day 64. During the induction therapy,
she had well tolerated all six doses of L-asparaginase given as 6,000 IU/
m2/dose subcutaneously other than a local injection site reaction
observed with the sixth dose.
The second patient was an 81-year-old female with pre-B-cell ALL whose
total bilirubin level increased to 0.5–19.5 mg/dL following one dose of pegaspargase therapy. Pegaspargase was administered as 2,500 mg/m2 IV, in
combination with multiple chemotherapeutic agents, including vincristine,
daunorubicin, and corticosteroid. On day 34, total bilirubin level reached its
highest at 19.5 mg/dL. MRCP test on day 21 revealed diffuse hepatic steatosis without hepatomegaly, biliary dilatation, or choledocholithiasis. Complete
resolution of hyperbilirubinemia took place on day 77.
Although the incidence of mild to moderate hyperbilirubinemia is common with asparaginase therapy, mechanism for the associated hepatotoxicity is not yet clearly understood. To date, at least one case report and
a case series have described fatal hepatotoxicities associated with asparaginase therapy [2,3], and L-asparaginase was the associated agent in
each of these reported cases, with the exception of one patient who died
with a relapsed ALL 6 months after receiving a total of 10 doses of
pegaspargase at 6,000 IU/m2, which is more than twice the standard
dose; the cause of death in this patient, however, appears to be attributable to the relapsed disease rather than pegaspargase therapy. Aside
from the aforementioned case, to my knowledge, this is the first case series that describe potentially fatal hyperbilirubinemia associated with
pegaspargase therapy. Although I believe pegaspargase is the causative
agent for the severe hyperbilirubinemia in our patients, other concurrently
administered agents cannot be completely ruled out for the observed toxicity. Nevertheless, with the increasing use of pegaspargase, clinicians
should be aware of the potentially life-threatening hyperbilirubinemia, which
can persist for a prolonged period of time (upto 77 days) as we have
observed in our patients.
SARA KIM
To the editor: Pegaspargase is a PEGylated formulation of asparaginase
that was designed to prolong its serum half-life and to lower both the immunogenecity, and the adverse events of asparaginase (i.e. coagulopathy, pancreatitis, hyperglycemia, hepatotoxicity, and hypersensitivity reactions) [1].
Asparaginase can be isolated from Escherichia coli [L-asparaginase
(Elspar1); Pegaspargase (Oncaspar1)] or Erwinia chrysanthemia (Erwinia,
an investigational agent in U.S).
Here we report two patients with acute lymphocytic leukemia (ALL), both
of whom developed a prolonged and severe hyperbilirubinemia following
pegaspargase therapy (Table I).
The first patient was a 42-year-old female with pre-B-cell ALL, who underwent a consolidation therapy and developed a grade 4 hyperbilirubinemia after
receiving two doses of pegaspargase therapy as 2,000 mg/m2 IV. Concurrently
administered agents included vincristine, daunorubicin, and corticosteroid. Her
total bilirubin level was elevated to 0.6–2.6 mg/dL on day 17 (immediately
Department of Pharmacy, The Mount Sinai Medical Center
One Gustave L. Levy Place, Box 1211, New York
Conflicts of interest: Nothing to report.
Published online 6 July 2009 in Wiley InterScience
(www.interscience.wiley.com).
DOI: 10.1002/ajh.21493
References
1. Asselin BL, Whitin JC, Coppola DJ, et al. Comparative pharmacokinetic studies of the asparaginase preparations. J Clin Oncol 1993;11:1780–1786.
2. Sahoo S, Hart J. Histopathological features of L-asparaginase-induced liver
disease. Semin Liver Dis 2003;23:295–299.
3. Bodmer M, Sulz M, Stadlmann S, et al. Fatal liver failures in an adult patient
with acute lymphoblastic leukemia following treatment with L-asparaginase.
Digestion 2006;74:28–32.
TABLE I. Two Cases of Pegylated Asparaginase-Associated Hepatotoxity
LFTs (units)
Time
Case 1
8/6/08 (Day 1): first dose of pegaspargase
8/22/08 (Day 17): second dose of pegaspargase
9/7/08 (Day 33)
10/8/08 (Day 64)
Case 2
8/21/08 (Day 1): pegaspargase
9/23/08 (Day 34)
11/5/08 (Day 77)
T.bil/D.bil
(mg/dL)
ALT (U/L)
AST (U/L)
GGT (U/L)
ALP (U/L)
LDH (U/L)
0.6/0.1
2.6/1.9
10.2/8
1/0.5
22
201
72
55
18
97
143
53
27
1129
608
54
72
456
274
72
312
545
475
314
0.5/0.2
19.5/18.8
1/0.5
72
363
28
26
268
29
247
1533
n/a
124
1002
204
409
665
408
ALP, alkaline phosphatase; ALT, alannine transaminase; AST, aspartate transaminase; GGT, gamma-glutamyl-transferase; LDH, lactate dehydrogenase; D.bil, direct
bilirubin; T.bil, total bilirubin.
696
American Journal of Hematology
correspondence
Monitoring of cytomegalovirus reactivation during
induction and nontransplant consolidation
of acute leukemia
To the editor: Cytomegalovirus (CMV) reactivation in the bloodstream is a
relevant issue in hematologic patients who undergo hematopoietic stem cell
transplantation (HSCT), where the prevalence of CMV reactivation range is
between 30 and 70% [1]. This high prevalence reflects the degree of immunodeficiency associated with transplant procedures. Induction and nontransplant consolidation regimens for acute myeloid leukemia (AML) and acute
lymphoid leukemia (ALL) carry a high myelosuppressive and immunosuppressive potential. However, the prevalence of CMV reactivation in acute
leukemia not undergoing HSCT is currently unknown.
This study was based on 44 patients with AML and 13 patients with ALL,
who underwent a systematic screening for CMV reactivation by weekly CMV
pp65 antigen testing and CMV DNA PCR studies starting from the beginning
of induction until the last nontransplant consolidation course. Clinical
and molecular characteristics at diagnosis are reported in Table I. Induction
regimens for AML were idarubicin, cytarabine, etoposide (ICE) or mitoxantrone, cytarabine, etoposide (MICE) [2,3]. Nontransplant consolidation
was based on high dose Ara-C [4]. ALL were treated with a regimen based on
high doses of daunorubicin [5]. Overall, 57 patients with acute leukemia were
tested for CMV reactivation, with a total of 533 tests performed. Results of
CMV monitoring documented that reactivation of CMV was restricted to ALL.
Median number of tests for CMV monitoring, median testing interval from the
first to the last test, and median interval between single tests did not differ
between ALL and AML. Reactivation of CMV occurred in 2/13 (15.3%) ALL. At
the time of CMV reactivation and thereafter, none of the patients with ALL with
CMV reactivation showed clues of overt CMV disease. No patient with AML
developed CMV reactivation.
In an attempt to identify the mechanisms predisposing to CMV reactivation, we compared quantitative immunologic defects at diagnosis of ALL and
AML and during induction and nontransplant consolidation. Median duration
of severe lymphopenia and neutropenia did not differ between ALL and
AML. In a different clinical setting, i.e., chronic lymphocytic leukemia, CMV
reactivation has been shown to associate with low serum albumin at diagnosis [6]. Based on this, we analyzed serum levels of albumin and g-globulin
at diagnosis. Median serum albumin and g-globulin did not differ between
ALL and AML.
The results of our screening suggest that CMV monitoring is not routinely
required in the AML setting. Conversely, a fraction of patients with ALL
may undergo CMV reactivation. The occurrence of CMV reactivation in ALL
does not appear to be related to specific defects of immune function
detectable at diagnosis of leukemia, or arising during treatment. It is conceivable that differences between ALL and AML treatment regimens, and in particular the inclusion of prednisone during ALL induction regimen, may be relevant
for CMV reactivation in a fraction of ALL. The prevalence of CMV reactivation
in ALL is similar to that reported in chronic lymphocytic leukemia during treatment with alemtuzumab, a setting in which a regular CMV monitoring is strictly
indicated [7]. Based on this, a regular monitoring for CMV reactivation may be
potentially useful during induction and nontransplant consolidation of ALL.
MONIA LUNGHI
PAOLA RICCOMAGNO
LORENZO DE PAOLI
CHIARA VENDRAMIN
ANNARITA CONCONI
GIANLUCA GAIDANO
DAVIDE ROSSI
Division of Hematology, Amedeo Avogadro
University of Eastern Piedmont and Ospedale
Maggiore della Carità, Novara, Italy
Conflict of interest: Nothing to report.
Contract grant sponsors: Ricerca Sanitaria Finalizzata, Regione
Piemonte, Torino, Italy; Progetto Alfieri,
Fondazione CRT, Torino, Italy; Novara-AIL Onlus and
Associazione Franca Capurro per Novara Onlus, Novara, Italy
Published online 6 July 2009 in Wiley InterScience
(www.interscience.wiley.com).
DOI: 10.1002/ajh.21494
References
1. Meijer E, Boland GJ, Verdonck LF. Prevention of cytomegalovirus disease in
recipients of allogeneic stem cell transplants. Clin Mcrobiol Rev 2003;16:647–
657.
2. Suciu S, Mandelli F, de Witte T, et al. Allogeneic compared with autologous
stem cell transplantation in the treatment of patients younger than 46 years
TABLE I. Clinical and Molecular Characteristics
Characteristics at diagnosis
Age
Male:female
WHO classification
AML with recurrent cytogenetic abnormalities
AML with multilineage dysplasia
Therapy-related AML
AML, NOS
Precursor B-ALL
Precursor T-ALL
Karyotype
Low risk
Standard risk
High risk
Molecular features
AML/ETO
PML/RARa
MLL fusion
NPM mutations
FLT3 internal tandem duplication
BCR/ABL
E2A/PBX
ALL1/ENL
Blasts in peripheral blood (3 109/l)
Blasts in bone marrow (%)
Hb (g/dl)
Platelet count (3 109/l)
Grade 4 neutropenia
Albumin (g/l)
Gamma-globulin (g/l)
CMV serology positive
AML
ALL
61 (25th–75th: 46–69) year
28:16
48 (25th–75th: 38–60) year
8:5
9/44 (20.5%)
9/44 (20.5%)
1/44 (2.3%)
25/44 (56.8%)
na
na
na
na
na
na
12/13 (92.3%)
1/13 (7.7%)
8/44 (18.2%)
27/44 (61.4%)
9/44 (20.5%)
–
6/13 (46.2%)
7/13 (53.8%)
2/44 (4.5%)
6/44 (13.6%)
1/44 (2.3%)
2/10 (20.0%)
5/25 (20.0%)
0/44
na
na
45.0 (25th–75th: 6.1–90.0)
80.0 (25th–75th: 43.0–90.0)
8.4 (25th–75th: 6.8–10.2)
56 (25th–75th: 29–93)
39/44 (88.6%)
36.0 (25th–75th: 34.2–40.7)
12.5 (25th–75th: 10.0–14.7)
40/44 (90.9%)
na
na
na
na
na
5/13 (38.5%)
1/13 (7.6%)
1/13 (7.6%)
78.0 (25th–75th: 37.5–89.0)
95.0 (25th–75th: 90.0–95.0)
7.7 (25th–75th: 5.8–9.6)
32 (25th–75th: 10–57)
9/13 (69.2%)
40.0 (25th–75th: 36.0–41.5)
11.0 (25th–75th: 8.5–17.0)
10/13 (76.9%)
na, not applicable.
American Journal of Hematology
697
correspondence
3.
4.
5.
6.
7.
with acute myeloid leukemia (AML) in first complete remission (CR1): An
intention-to-treat analysis of the EORTC/GIMEMA AML-10 trial. Blood
2003;102:1232–1240.
Amadori S, Suciu S, Jehn U, et al.;EORTC/GIMEMA Leukemia Group. Use of
glycosylated recombinant human G-CSF (lenograstim) during and/or after
induction chemotherapy in patients 61 years of age and older with acute myeloid leukemia: Final results of AML-13, a randomized phase-3 study. Blood
2005;106:27–34.
Mayer RJ, Davis RB, Schiffer CA, et al. Intensive postremission chemotherapy in adults with acute myeloid leukemia. Cancer and Leukemia Group B. N
Engl J Med 1994;331:896–903.
Cimino G, Elia L, Mancini M, et al. Clinico-biologic features and treatment
outcome of adult pro-B-ALL patients enrolled in the GIMEMA 0496 study: Absence of the ALL1/AF4 and of the BCR/ABL fusion genes correlates with a
significantly better clinical outcome. Blood 2003;102:2014–2020.
Borthakur G, Lin E, Faderl S, et al. Low serum albumin level is associated
with cytomegalovirus reactivation in patients with chronic lymphoproliferative
diseases treated with alemtuzumab (Campath-1H)-based therapies. Cancer
2007;110:2478–2483.
O’Brien SM, Keating MJ, Mocarski ES. Updated guidelines on the management of cytomegalovirus reactivation in patients with chronic lymphocytic leukemia treated with alemtuzumab. Clin Lymphoma Myeloma 2006;7:125–130.
Thalidomide-induced pneumonitis in a patient with plasma
cell leukemia: No recurrence with subsequent
lenalidomide therapy
To the editor: Originally developed as a sleep-aid and antiemetic for
pregnant women, thalidomide was prescribed before adequate toxicity testing
had taken place. It was pulled from the market in the 1960s once it was recognized as a potent teratogen. However, thalidomide slowly re-entered clinical
practice and more recently has been broadly used in the treatment of multiple
myeloma [1,2] and plasma cell dyscrasias [3]. Toxicities consistently observed
with thalidomide-based therapies include neuropathy, constipation, and psychological disturbances. Without anticoagulant prophylaxis, thromboembolic
events are also observed [4–6]. Serious respiratory side effects have been
reported with thalidomide use, but these are rare. The most notable pulmonary toxicity reported has been from thromboembolic events resulting in pulmonary embolisms. In one study on thalidomide and dexamethasone treatment for multiple myeloma patients, 4% of participants experienced nonspecific dyspnea at a Grade 3 or 4 toxicity level [7]. Other pulmonary toxicities
have been discussed in the literature as case reports, where hypersensitivity
pneumonitis has been uncommonly reported [8–11]. Lenalidomide is an
immunomodulatory (IMiD) analog of thalidomide. It was designed to have
increased potency and fewer nonhematologic side effects compared with thalidomide. Myelosuppression is the most prominent toxicity of lenalidomide
[12,13]. Grade 3 or 4 pneumonitis appears to occur in up to 6% of patients,
although this may be under-reported [13,14]. To date, there has been one
case report of lenalidomide-induced hypersensitivity pneumonitis [15].
A 76-year-old woman presented to our hospital with severe shortness of
breath on mild exertion and increasing fatigue. Two months before she was
newly diagnosed with lambda-monotypic plasma cell leukemia and began
her first cycle of MPT therapy (melphalan 6 mg 3 7 days, prednisone 60 mg
3 7 days, and thalidomide 50 mg at bedtime daily). Aside from moderate
myelosuppression, she tolerated her first two cycles relatively well.
Ten days before her hospital admission, the patient presented to an
outpatient clinic with increasing shortness of breath and fatigue. Her oxygen
saturation was 95% on room air, and a CT scan at that time confirmed bilateral pulmonary infiltrates with multiple parenchymal nodules. As there was
concern at that point for thalidomide-induced pulmonary toxicity versus an
atypical infection, the decision was made to discontinue thalidomide and
start empirical antibiotic therapy. Although a formal evaluation was not performed, the patient appeared to have, at least, a partial response (according
to both International Myeloma Working Group and European Group for
Blood and Bone Marrow Transplant criteria) to therapy at the time of discontinuation of thalidomide. Whereas, a 70% reduction in her serum monoclonal
protein and an 82% reduction in her serum free light assay was noted.
On admission, the patient continued to have increasing fatigue and severe
shortness of breath. She reported a 12 pound weight loss in the past 2
months. At presentation her oxygen saturation was 89%, which recovered to
698
95% on 2 L oxygen. Physical exam revealed decreased breath sounds bibasilarly with crackles and rhonchi throughout the lung fields and 11 pitting
lower extremity edema bilaterally. Lower extremity Doppler exams were negative for deep vein thromboses. A CT angiogram was deferred by the
patient. A repeat CT scan showed an interval increase in her ground-glass
opacities. A bronchoalveolar lavage (BAL) sample contained 0% neutrophils,
38% lymphocytes, 37% monocytes, and 24% eosinophils. The infectious studies on the BAL specimen revealed a negative DFA for Pneumocystis carinii,
negative fungal cultures, and negative viral studies for RSV, adenovirus, influenza, parainfluenza, and CMV. A gram stain showed normal flora. The high
percentage of eosinophils in the BAL, along with the ground-glass opacity CT
findings and the absence of infectious etiology strongly supported the diagnosis of eosinophilic pneumonia, likely induced by the thalidomide.
The patient improved greatly during a 2-day hospital stay on steroid therapy (1 mg/kg of prednisone, with a plan to taper to 20 mg of prednisone, on
which she would remain for 4–6 weeks). On follow-up a week later, the
patient reported feeling very well and had been able to resume her previous
exercise tolerance.
The patient continued therapy for her plasma cell leukemia with melphalan
and prednisone (MP) only. After two cycles of MP, disease progression was
noted, evidenced by a rise of her monoclonal IgG lambda. Careful consideration was given to switching her therapy to a combination of lenalidomide
and dexamethasone. Given the structural similarity of thalidomide and lenalidomide and the overlap in some toxicity, there was a small but undocumented risk that she could experience an exacerbation of pneumonitis.
Lenalidomide plus dexamethasone (lenalidomide 15 mg daily for 3 weeks
along with dexamethasone 40 mg weekly) was started. Her second cycle on
this regimen utilized a dose-reduced level of lenalidomide of 5 mg due to
impaired renal function. During 4 cycles of this therapy, the patient achieved
transfusion-independence and had no signs of pulmonary toxicity.
Although pulmonary toxicity is a known side effect to thalidomide, there
is only one previous episode of documented lenalidomide-induced pneumonitits [15]. To our knowledge, this is the first report of lenalidomide use
following the development of thalidomide-induced pneumonitis. Careful
consideration is necessary when recommending the use of other IMiDs
following thalidomide-induced hypersensitivity.
JENNIFER PRETZ1
BRUNO C. MEDEIROS1,2
1
Division of Hematology, Department of Medicine,
Stanford University School of Medicine, Stanford, CA
2
Stanford Comprehensive Cancer Center, Stanford, CA.
Published online 16 July 2009 in Wiley InterScience
(www.interscience.wiley.com).
DOI: 10.1002/ajh.21495
Conflicts of interest: Nothing to report
References
1. Palumbo A, Bringhen S, Caravita T, et al. Oral melphalan and prednisone
chemotherapy plus thalidomide compared with melphalan and prednisone
alone in elderly patients with multiple myeloma: Randomised controlled trial.
Lancet 2006;367:825–831.
2. Facon T, Mary JY, Hulin C, et al. Melphalan and prednisone plus thalidomide
versus melphalan and prednisone alone or reduced-intensity autologous stem
cell transplantation in elderly patients with multiple myeloma (IFM 99-06): A
randomised trial. Lancet 2007;370:1209–1218.
3. Schwartz RN, Vozniak M. Current and emerging treatments for multiple myeloma. J Manag Care Pharm 2008;14:S12–S18.
4. Palumbo A, Facon T, Sonneveld P, et al. Thalidomide for treatment of multiple
myeloma: 10 years later. Blood 2008;111:3968–3977.
5. Ludwig H, Hajek R, Tothova E, et al. Thalidomide-dexamethasone compared
with melphalan-prednisolone in elderly patients with multiple myeloma. Blood
2009;113:3435–3442.
6. Palumbo A, Rajkumar SV, Dimopoulos MA, et al. Prevention of thalidomide- and
lenalidomide-associated thrombosis in myeloma.Leukemia 2008;22:414–423.
7. Rajkumar SV, Hayman S, Gertz MA, et al. Combination therapy with thalidomide plus dexamethasone for newly diagnosed myeloma. J Clin Oncol
2002;20:4319–4323.
8. Carrion Valero F, Bertomeu Gonzalez V. Lung toxicity due to thalidomide.
Arch Bronconeumol 2002;38:492–494.
9. Onozawa M, Hashino S, Sogabe S, et al. Side effects and good effects from
new chemotherapeutic agents. Case 2. Thalidomide-induced interstitial pneumonitis. J Clin Oncol 2005;23:2425–2426.
American Journal of Hematology
correspondence
WICO W. LAI2,3
BONNIE M. FONG4
SIDNEY TAM4
YOK-LAM KWONG1
10. Feaver AA, Mccune DE, Mysliwiec AG, Mysliwiec V. Thalidomide-induced
organizing pneumonia. South Med J 2006;99:1292–1294.
11. Tilluckdharry L, Dean R, Farver C, Ahmad M. Thalidomide-related eosinophilic
pneumonia: A case report and brief literature review. Cases J 2008;1:143–146.
12. Richardson PG, Blood E, Mitsiades CS, et al. A randomized phase 2 study of
lenalidomide therapy for patients with relapsed or relapsed and refractory
multiple myeloma. Blood 2006;108:3458–3464.
13. Hazarika M, Rock E, Williams G, et al. Lenalidomide in combination with
dexamethasone for the treatment of multiple myeloma after one prior therapy.
Oncologist 2008;13:1120–1127.
14. Rajkumar SV, Hayman SR, Lacy MQ, et al. Combination therapy with lenalidomide plus dexamethasone (Rev/Dex) for newly diagnosed myeloma. Blood
2005;106:4050–4053.
15. Thornburg A, Abonour R, Smith P, et al. Hypersensitivity pneumonitis-like syndrome associated with the use of lenalidomide. Chest 2007;131:1572–1574.
1
Department of Medicine, Queen Mary Hospital
Department of Ophthalmology, Queen Mary Hospital
3
Eye Institute, University of Hong Kong
4
Department of Clinical Biochemistry, Queen
Mary Hospital, Hong Kong, China
Charmaine Hon is currently at Hong Kong Ophthalmic Associates
Published online 16 July 2009 in Wiley InterScience
(www.interscience.wiley.com).
DOI: 10.1002/ajh.21505
2
References
Two cases of monocular visual loss during oral arsenic
trioxide therapy of acute promyelocytic leukemia
To the editor: Arsenic trioxide (As2O3) is a standard medication for relapsed
acute promyelocytic leukemia (APL). Visual problems have been detected in
environmental toxicology studies of arsenic exposure [1]. This may not be
surprising as arsenic can cause peripheral neuropathy [2] and also enters
the cerebrospinal fluid (CSF) [3]. In 100 APL patients receiving oral-As2O3,
two serious visual problems were observed, both in patients in complete
remission (CR) with normal platelet counts. However, both cases had other
major causative factors to blindness.
A 25-year-old man with APL in first CR received oral-As2O3 (10 mg/day)
and all-trans retinoic acid (ATRA, 45 mg/m2/day) maintenance (2 weeks every 2 months 3 2 years). After completion of maintenance, he complained
deterioration of right eye vision to light perception only, after a basketball
injury sustained during the last course of oral treatment. Fundoscopic examination showed a large retinal tear with total rhegmatogenous detachment.
He was treated with posterior vitrectomy, lensectomy, retinectomy, endolaser
photocoagulation, and silicone oil injection, without visual recovery. With
inductively-coupled plasma mass spectroscopy, [2] elemental arsenic in the
plasma, aqueous humor, and vitreous humor were found to be 115, 35, and
57 nmol/L, respectively.
A 35-year-old man with APL in relapse achieved second CR with oralAs2O3 (10 mg/day 3 30 days) followed by idarubicin consolidation (9 mg/
day 3 5 days). He was a chronic smoker (three packs/day) with a history of
right eye amaurosis fugax. Two days after chemotherapy, he developed sudden right eye blindness, due to central retinal artery occlusion. No source of
cardiac or carotid embolization was found. He was treated with anterior
chamber paracentesis, acetazolamide, and timolol eye drops, but optic atrophy ensued. The patient completed idarubicin consolidation and As2O3 1
ATRA maintenance without complications.
Acute visual loss during remission is unusual for patients with acute leukemia. However, both of our patients had clear anatomical causes for blindness. Furthermore, unilateral (rather than bilateral) blindness suggested a
limited role for systemic arsenic toxicity. Nevertheless, a weak contribution of
ocular arsenic toxicity should not be completely ruled out. Both As2O3 and
ATRA can increase intracranial pressure, resulting in pseudotumor cerebri
[4,5] and a secondary increase in intraocular pressure, which may augment
retinal injury. Also, As2O3 can cause vasoconstriction [6] and worsen retinal
artery occlusion. Finally, we documented for the first time that elemental arsenic enters the eye at 30–50% of the plasma level, a ratio comparable to
that in CSF. This may have direct retinal toxicity, especially with high peak
concentrations associated with intravenous-As2O3. For physicians prescribing long-term or intravenous As2O3, we recommend full ophthalmologic evaluation. The role of electroretinographic studies [7] for detecting subclinical
retinal toxicities in patients treated with As2O3 remains to be defined.
Acknowledgments
The S.K. Yee Medical Foundation provided oral arsenic trioxide free to the
patient.
WING-YAN AU1
CHARMAINE HON2
KIN YAU2,3
American Journal of Hematology
1. Kazi TG, Afridi HI, Kazi GH, et al. Evaluation of essential and toxic metals by
ultrasound-assisted acid leaching from scalp hair samples of children with
macular degeneration patients. Clin Chim Acta 2006;369:52–60.
2. Huang SY, Chang CS, Tang JL, et al. Acute and chronic arsenic poisoning
associated with treatment of acute promyelocytic leukaemia. Br J Haematol
1998;103:1092–1095.
3. Au WY, Tam S, Fong BM, Kwong YL. Determinants of cerebrospinal fluid arsenic concentration in patients with acute promyelocytic leukemia on oral arsenic trioxide therapy. Blood 2008;112:3587–3590.
4. de Botton S, Coiteux V, Chevret S, et al. Outcome of childhood acute promyelocytic leukemia with all-trans-retinoic acid and chemotherapy. J Clin Oncol
2004;22:1404–1412.
5. Galm O, Fabry U, Osieka R. Pseudotumor cerebri after treatment of relapsed
acute promyelocytic leukemia with arsenic trioxide. Leukemia 2000;14:343–
344.
6. Lagerkvist B, Linderholm H, Nordberg GF. Vasospastic tendency and Raynaud’s phenomenon in smelter workers exposed to arsenic. Environ Res
1986;39:465–474.
7. da Costa GM, dos Anjos LM, Souza GS, et al. Mercury toxicity in Amazon
gold miners: Visual dysfunction assessed by retinal and cortical electrophysiology. Environ Res 2008;107:98–107.
Successful discontinuation of anticoagulation
following eculizumab administration in
paroxysmal nocturnal hemoglobinuria
To the editor: Paroxysmal nocturnal hemoglobinuria (PNH) is a clonal hematopoietic stem cell disease that can present with bone marrow failure, hemolytic anemia, and thrombosis [1,2]. The disease originates from a multipotent
hematopoietic stem cell that acquires a PIG-A mutation [3,4]. Expansion
and differentiation of the PIG-A mutant stem cell leads to clinical manifestations of the disease. The PIG-A gene product is required for the biosynthesis of glycophosphatidylinositol anchors, a glycolipid moiety that attaches
dozens of proteins to the plasma membrane of cells. Consequently, the
PNH stem cell and all of its progeny have a deficiency or absence GPIanchored proteins (GPI-AP). Two of these GPI-AP, CD55, and CD59, are
complement regulatory proteins that are fundamental to the pathophysiology
of the disease [5,6]. CD55 inhibits C3 convertases and CD59 blocks formation of the membrane attack complex. The loss of these complement regulatory proteins renders PNH erythrocytes susceptible to intravascular and
extravascular hemolysis, but it is the intravascular hemolysis that contributes
to most of the morbidity and mortality of the disease [7]. Thrombosis is the
leading cause of death in PNH [8–10].
The etiology of thrombosis in PNH is multifactorial and believed to be
related to: (1) Intravascular hemolysis and nitric oxide scavenging causing
platelet activation and endothelial injury [7], (2) platelet microvesicle formation leading to accelerated thrombin generation [11], and (3) loss of the GPIanchored urokinase receptor perturbing fibrinolysis [12,13]. Venous thrombosis, with particular proclivity of abdominal and saggital veins, is most common but the risk of arterial thrombosis is also increased in PNH [8–10]. A
case of multiple cerebral arterial thromboses, upper extremity vein thrombosis, and Budd-Chiari syndrome with the onset of PNH recently was reported
demonstrating that thrombosis in PNH can affect both venous and arterial
systems [14]. The risk for thrombosis in PNH patients is highest in those
with large PNH granulocyte clones [9,15].
Eculizumab is a humanized monoclonal antibody that blocks the terminal
complement assembly [16]. In two phase III clinical trials, eculizumab administration resulted in marked reduction of intravascular hemolysis, a decrease
699
700
20
42
10
32
47
12
in transfusion requirements and improved quality of life [17,18]. There was
also 85% (1.07 vs. 7.37 events/100 patient-years) absolute reduction in
thrombosis rate while on eculizumab treatment [19]. These results suggest
chronic administration of eculizumab can significantly reduce the overall lifetime thromboembolic event rate. Nevertheless, a major unresolved issue in
the management of PNH patients on eculizumab is whether or not anticoagulation can be safely discontinued, especially in patients with previous
thrombotic events [20].
Here, we report successful discontinuation of anticoagulation after initiation of eculizumab in three young PNH patients with histories of extensive
thromboses.
Patient characteristics are shown in Table I. The first patient is a 34-yearold male with a 17-year history of classical PNH. For 12 years, his disease
Pulmonary emboli, portal vein,
splenic vein (status postsplenic
embolization), sagital vein, renal
and hepatic failure status
postliver transplant
CVA (right corona radiata punctate infarct)
Severe extensive dermal thromboses,
subacute left cerebellum ischemia
manifested with chronic hemolysis and occasional paroxysms of abdominal
pain and hemoglobinuria. The patient did not have any suitable donor for allogenic bone marrow transplantation. He was treated with folic acid supplementation and intermittent pulses of prednisone. Five years ago, he developed
splenic vein thrombosis with marked splenomegaly, gastric varices, and portal
vein occlusion with cavernous transformation. He was started on warfarin, but
his clinical condition progressively deteriorated in spite of anticoagulation. He
developed a sagittal vein thrombosis, which manifested as severe frontal and
3230/227
1248/326
Not available
12.16/2.36
Zero
Zero
retro-orbital headaches. New thrombi were also found in the infrahepatic and
retrohepatic inferior vena cava as well as the hepatic veins, which caused
3420
4120
97%
99%
7
9
22/Female
31/Male
2
3
LDH, lactate dehydrogenase; ECOG-PS, Eastern Cooperative Group performance status.
159,000
107,000
10.7
14.9
Zero
29/1.4
430–2300/161
154,000
10.4
3790
100%
17
34/Male
Patient
1
Duration of
PNH (years)
Age
(years)/Gender
TABLE I. Patients Characteristics
PNH granulocyte
(FLAER)
WBC 3 10
per liter
6
Hgb (g/dL)
(most recent)
Platelets counts
3 106 per liter
(most recent)
LDH (U/L)
before eculizumab/
most recent
d-Dimer
(mg/dL) before
eculizumab/most
recent
ECOG-PS
(current)
Site of thrombosis
Duration on
eculizumab
(months)
Duration off
anticoagulations
(months)
correspondence
hepatomegaly, caudate hypertrophy, and worsening ascites. Eventually, he
developed renal insufficiency and was placed on dialysis.
Eculizumab was initiated 32 months ago, which resulted in an immediate
reduction in intravascular hemolysis evidenced by a decrease in lactate dehydrogenase (LDH) to nearly normal levels and a decreased need for blood
transfusions. Breakthrough hemolysis occurred 1 week after each eculizumab
dose, most likely because of removal of the drug during weekly paracentesis.
Three months after initiation of eculizumab, the patient received a liver transplant. He required no dialysis after surgery, with a creatinine level of 1.1 mg/dL
by the time of discharge on post-transplant day 9. His liver function also slowly
improved, with a total bilirubin level of 0.8 mg/dL, an alanine aminotransferase
level of 44 U/L, and an international normalized ratio (INR) of 1.0 at discharge.
Treatment with eculizumab was continued during and after surgery and he has
had no evidence of overt hemolysis or complement-mediated breakthroughs.
He required no postoperative blood transfusions.
A routine follow-up abdominal CT scan after surgery revealed an asymptomatic lower extremity deep vein thrombosis that felt to be old; thus, his
anticoagulation was continued for 6 months. Because of the difficulty maintaining a therapeutic INR on warfarin and a history of PNH associated
thrombosis before eculizumab administration while on warfarin, the patient
insisted in discontinuing anticoagulation. He has not experienced any thrombotic event since then and his most recent d-dimer is within normal limit. He
continues to work full time and has an Eastern Cooperative Oncology Group
(ECOG) performance status of zero.
The second patient is a 22-year-old female with a 7-year history of PNH
which was complicated by multiple hemolytic episodes and red blood cell
transfusion dependence. In December 2003, she had a cerebral vascular
accident in the right corona radiate, associated with left-sided motor and
sensory deficits. Anticoagulation with warfarin initiated.
The patient was treated with eculizumab in August 2005 and has required
only one transfusion since starting the drug. Currently, she is transfusion independent with an LDH of 227 U/L compared with 3230 U/L before starting eculizumab. She and her parents were concerned about the risk of bleeding associated with lifelong anticoagulation and elected to discontinue warfarin 5 months
after starting eculizumab therapy. She has not developed any new thrombosis
since then and continues to work with an ECOG performance status of zero.
The third patient is a 31-year-old man with a 9-year history of PNH.
Initially, he had a few exacerbations of his disease but gradually the frequency of his flares increased. Approximately 1-year ago, he had an episode of severe dermal thromboses involving his ears as well as extensive
skin necrosis in the front and back of his chest and abdominal walls. A
punch biopsy showed occlusion of the small superficial vessels consistent
with microthrombi. Periodic acid-Schiff stain also highlighted the vascular
occlusion, in a fashion consistent with thrombi. The deeper sections also
showed more prominent changes of early epidermal necrosis, including
American Journal of Hematology
correspondence
an influx of neutrophils. Magnetic resonance angiogram of the brain
showed a small linear focus of enhancement involving the left cerebellum,
consistent with subacute ischemia. He was placed on anticoagulation with
low-molecular weight heparin and converted to warfarin therapy.
He was started on eculizumab in July 2008 while still taking warfarin. His
LDH decreased from 1248 U/L during the flare to 441 U/L within 2 weeks after initiation of eculizumab. Approximately 1 month after starting eculizumab,
he inquired about discontinuing his warfarin due to his passion for playing
basketball and other sports. Furthermore, he was requiring 15–20 mg of
warfarin daily to maintain his INR in therapeutic range. After much discussion with his doctor, he elected to come off of anticoagulation. He has not
reported any thrombotic event in the last 10 months. His d-dimer decreased
from 12.16 mg/L in June 2008 to 2.36 mg/L in December 2008. His ECOG
performance status is zero.
Before eculizumab, thrombosis was the leading cause of death from
PNH. Accordingly, many investigators recommended prophylactic anticoagulation for PNH patients with platelet counts of 100 3 109/L and no
contraindications to anticoagulation [15]. Virtually all PNH patients with
documented thrombosis are treated with lifelong anticoagulation. Recent
Phase III studies of eculizumab in PNH patients demonstrate that (1) eculizumab markedly reduces the thrombosis risk and (2) that prophylactic anticoagulation in PNH patients does little to reduce the risk for thrombosis in
PNH patients not on eculizumab. Specifically, the thromboembolism event
rate per 100 patient-years following eculizumab administration was reduced
from 7.4 events to 1.1 events, an 85% reduction. In antithrombotic-treated
patients, the thromboembolism event rate was also reduced (10.6 events
per 100 patient-years to 0.6 events per 100 patient-years) with eculizumab
treatment. Interestingly, the use of antithrombotic therapy before eculizumab did not appear to influence the thrombosis risk (7.4 events per 100
patient-years versus 10.6 events per 100 patient-years); furthermore, eculizumab markedly reduced the thrombosis risk regardless of whether or not
patients were receiving anticoagulation. Thus, a question of major clinical
importance is whether lifelong anticoagulation is necessary for PNH
patients who are well controlled on eculizumab therapy.
Here, we report withdrawal of anticoagulation in three young PNH patients
after eculizumab therapy. All three patients had severe thrombotic events
before initiation of eculizumab. All of them have active life styles that make lifelong anticoagulation inconvenient and chose to discontinue warfarin after careful discussion with their treating physician. Currently all three patients are
transfusion independent on eculizumab and have remained free of thrombosis
from 10 to 42 months after stopping anticoagulation.
Ideally, the decision of whether or not it is safe to withdraw anticoagulation in PNH patients on eculizumab should be answered in a randomized controlled clinical trial. Given the rarity of PNH, it is unlikely that
such a trial will ever be performed; thus, the best attempts to answer this
question may come from registry data. Our data suggest that it may be
safe to withdraw anticoagulation in PNH patients on eculizumab; however,
more experience and longer follow-up is necessary before recommending
withdrawal of anticoagulation in all PNH patients. Until then, careful
discussion with the patient concerning the potential risks and benefits of
lifelong anticoagulation should occur.
ASHKAN EMADI
ROBERT A. BRODSKY
Department of Internal Medicine, Division of Hematology, Johns Hopkins
University, Baltimore, MD
Conflicts of interest: Nothing to report.
Published online 25 July 2009 in Wiley InterScience
(www.interscience.wiley.com).
DOI: 10.1002/ajh.21506
Conflict of interest: Dr. Brodsky serves on the international
advisory board for Alexion Pharmaceuticals and declares
no other competing financial interests.
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Complete resolution of leukemia cutis with sorafenib in an
acute myeloid leukemia patient with FLT3-ITD mutation
To the editor: Sorafenib, a small molecule tyrosine kinase inhibitor, has
shown efficacy in suppressing leukemic cells in mouse myeloid leukemia
models with FLT3 gene internal tandem duplication (FLT3-ITD) [1]. Significant activity for sorafenib has also been reported in a phase I clinical trial in
patients with relapsed or refractory acute myeloid leukemia (AML) with
FLT3-ITD [1]. We present a case of AML with FLT3-ITD in hematologic
remission who developed leukemia cutis, which completely resolved after
treatment with sorafenib alone.
A 73-year old male, known to have mitral valve prolapse with 41 mitral regurgitation, presented to the hospital for evaluation of right upper quadrant pain. He
was treated with IV antibiotics for suspected cholecystitis with gallstones and
elevated serum levels of liver enzymes. His white blood cell count was 6300/lL,
and a peripheral blood smear showed lymphocytosis. His hemoglobin was 13
g/dL, hematocrit 38%, and platelet count 58,000/lL. His serum lactate dehydrogenase was of 11,000 U/L, and the serum alkaline phosphatase level was
437U/L. A bone marrow aspirate and biopsy were performed, and flow cytometric analysis of the aspirate detected abnormal cells comprising 75% of white
blood cells. The leukemic cells expressed the immature marker, CD123, but
lacked CD34 and CD117. Expression of CD33, CD11b, and HLA-DR by these
701
correspondence
Fig. 1.
Leukemia cutis before sorafenib.
blasts confirmed the diagnosis of immature monocytic, CD11bpos AML [2]. The
blasts lacked lymphoid antigens as well as the mature monocytic marker, CD14.
The bone marrow biopsy was hypercellular (100%) with extensive replacement of
hematopoietic tissue by blasts, consistent with AML. Cytogenetic analysis of this
bone marrow revealed a karyotype of 47, XY, 18[11]/46, X,-Y, 18[4]/46, XY [5].
Polymerase chain reaction analysis of cDNA detected FLT3-ITD positivity. Therefore, a diagnosis of FLT3-ITDpos AML was made. Due to his cardiac comorbidities,
he was treated with azacitidine, 125 mg/m2/day rapid intravenous injection for 5
days. His bone marrow became markedly hypoplastic, and his hospital course
was complicated by enterococcus sepsis. His bone marrow recovered 6 weeks
after treatment, and the patient was discharged. He returned for follow-up 3 days
later with skin eruptions on his trunk, flanks, inguinal area, and upper thighs [Fig.
1]. A bone marrow biopsy was hypercellular (80–90%) with trilineage hematopoiesis, and no morphologic evidence of AML. Cytogenetic analysis of the aspirate
revealed 20 normal metaphases, and flow cytometry failed to detect leukemic
blasts. However, a skin punch biopsy of one of numerous pale pink, papular
lesions revealed leukemia cutis [Fig. 2]. By immunohistochemistry, the skin lesion
cells were CD4pos, CD33pos, CD68pos, and CD56pos, negative for lymphoid
markers, CD3 and CD20. A myeloperoxidase stain highlighted only scattered
granulocytes. This immunohistochemical profile was consistent with monocytic
leukemia, reminiscent of the patient’s initial diagnosis. Since his leukemia was
FLT3-ITDpos, he was treated with sorafenib, 400 mg orally twice daily. The leukemic skin lesions began to resolve within 3 days after treatment, and complete resolution was observed after 10 days of treatment with sorafenib [Fig. 3].
Patients with AML (20–30%) are found to have FLT3-ITD transcripts
where the juxtamembrane domain of the FLT-3 receptor tyrosine kinase is
duplicated [3], and patients with this mutation have a high risk of relapse,
even after allogeneic stem cell transplantation [1,4–7]. Sorafenib was
recently found to inhibit proliferation and induce apoptosis in FLT3-ITDpos
AML blasts at concentrations that are easily achievable in vivo [7]. This
effect is thought to be mediated by activation of the Bim and bcl-2 mediated
intrinsic apoptotic pathway leading to regression of the leukemic clone [8].
This is the first clinical report of successful treatment with sorafenib of leukemia cutis in a patient with FLT3-ITDpos AML.
SUNG HO LEE
ELISABETH PAIETTA
JANIS RACEVSKIS
PETER H. WIERNIK
Department of Medical Oncology, New York Medical College, Bronx, New York
Published online 25 July 2009 in Wiley InterScience
(www.interscience.wiley.com).
DOI: 10.1002/ajh.21511
Conflict of interest: Nothing to report.
702
Fig. 2. Skin punch biopsy: (A) 320 H&E. (B) CD33 Stain. (C) 34 H&E. (D)
3100 H&E.
Fig. 3.
10 days after sorafenib.
References
1. Zhang W, Konopleva M, Shi YX, et al. Mutant FLT3: A direct target of sorafenib in acute myelogenous leukemia. J Natl Cancer Inst 2008;100:184–198.
2. Paietta E, Andersen J, Yunis J, et al. Acute myeloid leukemia expressing the
leucocyte integrin CD11b—A new leukemic syndrome with poor prognosis:
Result of an ECOG database analysis. Br J Haematol 1998;100:265–272.
3. Nakao M, Yokota S, Iwai T, et al. Internal tandem duplication of the flt3 gene
found in acute myeloid leukemia. Leukemia 1996;10:1911–1918.
4. Kottaridis PD, Gale RE, Frew ME, et al. The presence of a FLT3 internal tandem duplication in patients with acute myeloid leukemia (AML) adds important
prognostic information to cytogenetic risk group and response to the first
cycle of chemotherapy: Analysis of 854 patients from the United Kingdom
medical research council AML 10 and 12 trials. Blood 2001;98:1752–1759.
5. Safaian NN, Czibere A, Bruns I, et al. Sorafenib (Nexavar1) induces molecular remission and regression of extramedullary disease in a patient with FLT3ITD acute myeloid leukemia. Leuk Res 2009;33:348–350.
6. Metzelder S, Wang Y, Wollmer E, et al. Compassionate use of sorafenib in
FLT3-ITD-positive acute myeloid leukemia: Sustained regression before and
after allogenic stem cell transplantation. Blood 2009;113:6567–6571.
7. Hu S, Niu H, Minkin P, et al. Comparison of antitumor effects of multitargeted
tyrosine kinase inhibitors in acute myelogenous leukemia. Mol Cancer Ther
2008;7:1110–1120.
8. Zhang W, Konopleva M, Ruvolo VR, et al. Sorafenib induces apoptosis of
AML cells via Bim-mediated activation of the intrinsic apoptotic pathway.
Leukemia 2008;22:808–818.
American Journal of Hematology
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