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For personal use only. 1996 88: 4725-4726 Development of paroxysmal nocturnal hemoglobinuria after chemotherapy [letter] F Hakim, R Childs, J Balow, K Cowan, J Zujewski and R Gress Updated information and services can be found at: http://www.bloodjournal.org/content/88/12/4725.citation.full.html Articles on similar topics can be found in the following Blood collections Information about reproducing this article in parts or in its entirety may be found online at: http://www.bloodjournal.org/site/misc/rights.xhtml#repub_requests Information about ordering reprints may be found online at: http://www.bloodjournal.org/site/misc/rights.xhtml#reprints Information about subscriptions and ASH membership may be found online at: http://www.bloodjournal.org/site/subscriptions/index.xhtml Blood (print ISSN 0006-4971, online ISSN 1528-0020), is published weekly by the American Society of Hematology, 2021 L St, NW, Suite 900, Washington DC 20036. Copyright 2011 by The American Society of Hematology; all rights reserved. From www.bloodjournal.org by guest on November 20, 2014. For personal use only. CORRESPONDENCE ~~ ~ Development of Paroxysmal Nocturnal Hemoglobinuria After Chemotherapy To the Editors: Paroxysmal nocturnal hemoglobinuria (PNH) has recently been linked to mutations in pluripotent hematopoietic cells of the pig-A gene. the enzyme necessary for glycosylphosphatidylinositol (GPI) anchors for several important cell surface proteins.' PNH symptoms result when those clones lacking all GPI-anchored proteins become the dominant populations. The sensitivity to complement-mediated hemolysis characteristic of PNH is related to the lack of three complement defense proteins: membrane inhibitor of reactive lysis (CDS9). decay-accelerating factor (CDSS), and C8 binding protein. The tendency toward thromboses is attributed to a lack of CD59 on platelets and a lack of urokinase plasminogen activator receptor on monocytes. rendering clots more stable.' Although the mechanisms leading to hemolysis are now better understood, the frequency of the pig-A mutation within the hematopoietic progenitor pool and the factors promoting the expansion of the mutant clones remain unknown. It has been proposed that the pig-A mutation is relatively common, but that the resultant clones are small and undetectable unless selected.' Recent reports have focused on such selective pressures. Hertenstein et al' described a transient expansion of lymphocytes lacking GPI-anchored proteins after treatment with the CAMPATH reagent, anti-CD52. This antibody treatment had apparently provided a selective pressure, enabling the expansion of a pre-existing population of lymphocytes lacking a functional transcript of the pig-A gene, hence lacking all GPI-anchored proteins. Studies linking aplastic anemia (AA) and PNH have suggested that the autoimmune attack in the former may provide a selective pressure against normal clones, because clones lacking GPI-anchored proteins are found in AA patients before the development of PNH.'.',' We propose that chemotherapy, transplantation, or other treatments that result in a major expansion of limited numbers of hematopoietic progenitors may be cofactors in the expansion of GPI-anchored, protein-negative clones. Because hematopoietic cells are typically very sensitive to chemotherapy. the bone marrow of patients receiving dose-intensive chemotherapy repeatedly undergoes severe depletion followed by cytokine-driven expansion. This therapy produces a severe reduction in the number of hematopoietic progenitors." Under these conditions, expansion of previously small numbers of pig-A mutated clones may occur. Although the prior therapy for the patients of Hertenstein et al' was not specified, their identification as non-Hodgkin's lymphoma patients refractory to other treatment suggests prior chemotherapy. Similarly, Paloczi et al' have reported the presence of significant T- and B-cell populations lacking the GPI-anchored proteins CDSS and CD59 in the period after marrow transplantation, wherein a small number of hematopoietic progenitors must rapidly expand. In this context, we report on a 4 I -year-old stage IV breast cancer patient who developed hemoglobinuric acute renal failure (ARF) while being monitored in a trial of weekly treatments with MDXH2I0, a bispecific antibody targeting FcyR 1 (CD64) receptors on monocytes and erbB-2 receptors on tumor cells. This patient had previously received dose-intensive chemotherapy and hormonal therapy, but had no prior history of renal insufficiency or hemolysis. Diagnostic evaluation was remarkable for hemoglobinuria and an magnetic resonance imaging (MRI) scan suggestive of iron deposition in the cortex (Fig I ) . The hematocrit was reduced during this episode and transient thrombocytopenia was noted. Flow cytometric analysis before MDXH2I0 treatments had identified a lack ofexpression of CD66b and CD14, two GPI-anchored proteins. on 50% of her granulocytes and monocytes, respectively (Fig 2); these proportions remained unchanged during 8 weekly MDXH2lO infusions. Subsequent to ARF, populations lacking CD59 were identified in several lineages, suggesting a diagnosis of PNH. Individuals diagnosed with PNH have been found to lack GPI-anchored proteins in greater than 85% of their cells.' With less than 50% of the leucocytes lacking GPI-anchored proteins, the patient we describe might have been at a subclinical stage of PNH development. The patient subsequently developed deep venous thromboses, consistent with PNH, before death from metastatic cancer. No recent study has evaluated the development of PNH, or more specifically, the frequency of hematopoietic lineages lacking GPIanchored proteins, after myeloablative therapy. A flow cytometric survey of GPI-anchored protein expression in postchemotherapy patients could provide new information concerning the frequency of &-A mutations and the course of development of PNH. F. Hakim R. Childs J. Balow K. Cowan J. Zujewski R. Gress National Cancer Institute NIDDK Rerhesda, MD Fig 1. MRI of renal cortex. Axial spin echo (A) Tl-weighted and (E) TP-weighted images. Renal cortex on TP-weighted image shows decreased intensity consistent with iron deposition (arrow). Blood, Vol 88, No 12 (December 151, 1996: pp 4725-4731 4725 From www.bloodjournal.org by guest on November 20, 2014. For personal use only. CORRESPONDENCE 4726 3 Y 8 EO -p0 $g In W l 0 w a "01 w 4 0 4 CD59 FlTC 0259 ilTC REFERENCES I . Rosse WF, Ware RE: The molecular basis of paroxysmal nocturnal hemoglobinuria. Blood 86:3277, 1995 2. Young NS: The problem of clonality in aplastic anemia: Dr. Dameshek's riddle, restated. Blood 79:1385. 1992 3. Hertenstein B, Wagner B, Bunjes D, Duncker C. Raghavachar A, Arnold R, Heimpel H, Schrezenmeier H: Emergence of CD52-, Phosphatidylinositolglycan-anchor-deficientT lymphocytes after in vivo application of Campath-IH for refractory B-cell non-Hodgkin lymphoma. Blood 86:1487, 1995 4. Griscelli-Bennaceur A, Gluckman E, Scrobohaci ML, Jonveaux P.Vu T, Bazarbachi A, Carosetta ED, Sigaux F, Socie G: Aplastic anemia and paroxysmal nocturnal hemoglobinuria: Search for a pathogenetic link. Blood 85:1354, 1995 CD53 FlTC Fig 2. cytometric Flow analysis of gated granuloa normal donorshowed a cyte populations from (A) single CD66b' population, whereas (B) the patient's granulocytes, before of startthe MDXH2lO treatment, intosplit CD66b' and CD66b populations. Similarly, (C) monocytes on(gated SSC and CD64b.'9h')split into CD14' and CD14- populations. After acute renal failure, (D) granulocytes, (E) monocytes, and (F) lymphocytes were found t o contain CD59' and CD59- subpopulations. Notein (E) that the same monocytes lack both CD14 and CD59. S . Schrezenmeir H. Hertenstein B, Wagner B, Raghavachar A, Heimpel H: A pathogenetic link between aplastic anemia and paroxysmalnocturnal hemoglobinuria is suggested by a highfrequency of aplastic anemia patients with a deficiency of phosphatidylinositol glycan anchored proteins. Exp Hematol 23531, 1995 6. Schwartz GN, Hakim F, Zujewski J, Szabo JM. Cepeda R, Riseberg D. Warren MK, Mackall CL, Setzer A, Noone M, Cowan K. O'Shaughnessy J, Cress RE: Early suppressive effects of chemotherapy and cytokine treatment on committed versus primitive hematopoietic progenitors. Br J Haematol 92537, 1996 7. Paloczi K. Mihalik R, Remenyi P, Milosevits J, Petranyi GC. Demeter J: GPI-linked molecules of lymphoid cells of allogeneic BMT patients. lmmunol Today 16302. 1995