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O'Neill C, Nwachukwu N, Vergara-Lluri M, Hagiya A, O'Connell CL. Clinical and pathological features of clonal cytopenia of undetermined significance presenting with isolated thrombocytopenia (CCUS-IT). Eur J Haematol 2024; 112:594-600. [PMID: 38088145 DOI: 10.1111/ejh.14149] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2023] [Revised: 11/22/2023] [Accepted: 11/27/2023] [Indexed: 03/19/2024]
Abstract
BACKGROUND Clonal cytopenia of undetermined significance (CCUS) is defined as somatic mutations of myeloid malignancy-associated genes in the blood or bone marrow with one or more persistent unexplained cytopenias that do not meet diagnostic criteria for a defined myeloid neoplasm. CCUS with isolated thrombocytopenia (CCUS-IT) is rare. METHODS This is a retrospective case series of patients with prolonged isolated thrombocytopenia, a pathogenic mutation on a myeloid molecular panel, and a bone marrow biopsy with morphologic atypia below the WHO-defined diagnostic threshold for dysplasia. RESULTS Five male patients were identified with a median age at CCUS-IT diagnosis of 61 years (56-74). Median duration of thrombocytopenia prior to CCUS-IT diagnosis was 4 years (3-12), and median platelet count at CCUS-IT diagnosis was 41 × 103 /μL (26-80). All patients had megakaryocytic hyperplasia and megakaryocytes with hyperchromasia and high nuclear-cytoplasmic ratio. Pathogenic SRSF2 mutations were identified in all 5 patients with median variant allele frequency of 36% (28%-50%). Three patients were treated with IVIg and/or steroids with no response; one of three responded to thrombopoietin receptor agonists. Three patients progressed to MDS and one to AML. DISCUSSION We describe the clinicopathological features of CCUS-IT which can mimic immune thrombocytopenia.
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Affiliation(s)
- Caitlin O'Neill
- Jane Anne Nohl Division of Hematology, Keck School of Medicine of the University of Southern California, Los Angeles, California, USA
| | - Nneka Nwachukwu
- Jane Anne Nohl Division of Hematology, Keck School of Medicine of the University of Southern California, Los Angeles, California, USA
| | - Maria Vergara-Lluri
- Department of Pathology, Hematopathology Section, Keck School of Medicine of the University of Southern California, Los Angeles, California, USA
| | - Ashley Hagiya
- Department of Pathology, Hematopathology Section, Keck School of Medicine of the University of Southern California, Los Angeles, California, USA
| | - Casey L O'Connell
- Jane Anne Nohl Division of Hematology, Keck School of Medicine of the University of Southern California, Los Angeles, California, USA
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2
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Kaastrup K, Gillberg L, Mikkelsen SU, Ørskov AD, Schöllkopf C, Mortensen BK, Porse B, Hansen JW, Grønbæk K. LEP promoter methylation in the initiation and progression of clonal cytopenia of undetermined significance and myelodysplastic syndrome. Clin Epigenetics 2023; 15:91. [PMID: 37237325 DOI: 10.1186/s13148-023-01505-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2022] [Accepted: 05/13/2023] [Indexed: 05/28/2023] Open
Abstract
BACKGROUND Idiopathic non-clonal cytopenia (ICUS) and clonal cytopenia (CCUS) are common in the elderly population. While these entities have similar clinical presentations with peripheral blood cytopenia and less than 10% bone marrow dysplasia, their malignant potential is different and the biological relationship between these disorders and myeloid neoplasms such as myelodysplastic syndrome (MDS) is not fully understood. Aberrant DNA methylation has previously been described to play a vital role in MDS and acute myeloid leukemia (AML) pathogenesis. In addition, obesity confers a poorer prognosis in MDS with inferior overall survival and a higher rate of AML transformation. In this study, we measured DNA methylation of the promoter for the obesity-regulated gene LEP, encoding leptin, in hematopoietic cells from ICUS, CCUS and MDS patients and healthy controls. We investigated whether LEP promoter methylation is an early event in the development of myeloid neoplasms and whether it is associated with clinical outcome. RESULTS We found that blood cells of patients with ICUS, CCUS and MDS all have a significantly hypermethylated LEP promoter compared to healthy controls and that LEP hypermethylation is associated with anemia, increased bone marrow blast percentage, and lower plasma leptin levels. MDS patients with a high LEP promoter methylation have a higher risk of progression, shorter progression-free survival, and inferior overall survival. Furthermore, LEP promoter methylation was an independent risk factor for the progression of MDS in a multivariate Cox regression analysis. CONCLUSION In conclusion, hypermethylation of the LEP promoter is an early and frequent event in myeloid neoplasms and is associated with a worse prognosis.
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Affiliation(s)
- Katja Kaastrup
- The Epi-/Genome Lab, Department of Hematology, Rigshospitalet, Ole Maaløes Vej 5, 2200, Copenhagen, Denmark
- Department of Hematology, Rigshospitalet, Copenhagen, Denmark
- Biotech Research and Innovation Centre (BRIC), University of Copenhagen, Copenhagen, Denmark
- The Novo Nordisk Foundation for Stem Cell Research, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Linn Gillberg
- The Epi-/Genome Lab, Department of Hematology, Rigshospitalet, Ole Maaløes Vej 5, 2200, Copenhagen, Denmark
- Biotech Research and Innovation Centre (BRIC), University of Copenhagen, Copenhagen, Denmark
| | - Stine U Mikkelsen
- The Epi-/Genome Lab, Department of Hematology, Rigshospitalet, Ole Maaløes Vej 5, 2200, Copenhagen, Denmark
- Department of Hematology, Rigshospitalet, Copenhagen, Denmark
- Biotech Research and Innovation Centre (BRIC), University of Copenhagen, Copenhagen, Denmark
- The Novo Nordisk Foundation for Stem Cell Research, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Andreas D Ørskov
- Department of Hematology, Rigshospitalet, Copenhagen, Denmark
- Department of Hematology, Zealand University Hospital, Roskilde, Denmark
| | | | - Bo K Mortensen
- Department of Hematology, Herlev Hospital, Herlev, Denmark
| | - Bo Porse
- Biotech Research and Innovation Centre (BRIC), University of Copenhagen, Copenhagen, Denmark
- The Novo Nordisk Foundation for Stem Cell Research, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
- The Finsen Laboratory, Rigshospitalet, Faculty of Health Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Jakob W Hansen
- The Epi-/Genome Lab, Department of Hematology, Rigshospitalet, Ole Maaløes Vej 5, 2200, Copenhagen, Denmark
- Department of Hematology, Rigshospitalet, Copenhagen, Denmark
- Biotech Research and Innovation Centre (BRIC), University of Copenhagen, Copenhagen, Denmark
- The Novo Nordisk Foundation for Stem Cell Research, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Kirsten Grønbæk
- The Epi-/Genome Lab, Department of Hematology, Rigshospitalet, Ole Maaløes Vej 5, 2200, Copenhagen, Denmark.
- Department of Hematology, Rigshospitalet, Copenhagen, Denmark.
- Biotech Research and Innovation Centre (BRIC), University of Copenhagen, Copenhagen, Denmark.
- The Novo Nordisk Foundation for Stem Cell Research, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark.
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3
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van Zeventer IA, de Graaf AO, Salzbrunn JB, Nolte IM, Kamphuis P, Dinmohamed A, van der Reijden BA, Schuringa JJ, Jansen JH, Huls G. Evolutionary landscape of clonal hematopoiesis in 3,359 individuals from the general population. Cancer Cell 2023:S1535-6108(23)00132-0. [PMID: 37146604 DOI: 10.1016/j.ccell.2023.04.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2022] [Revised: 01/05/2023] [Accepted: 04/07/2023] [Indexed: 05/07/2023]
Abstract
Knowledge about evolution of clonal hematopoiesis, which may drive malignant progression, is crucial for clinical decision-making. We investigated the landscape of clonal evolution by error-corrected sequencing on 7,045 sequential samples from 3,359 individuals in the prospective population-based Lifelines cohort, with a special focus on cytosis and cytopenia. Spliceosome (SRSF2/U2AF1/SF3B1) and JAK2 mutated clones show highest growth rates over a median 3.6-year period, while clone sizes for DNMT3A and TP53 increase only marginally, independent of cytosis or cytopenia. Nevertheless, large differences are observed between individuals carrying the same mutation, indicative of modulation by non-mutation-related factors. Clonal expansion is not dependent on classical cancer risk factors (e.g., smoking). Risk for incident myeloid malignancy diagnosis is highest for JAK2, spliceosome, or TP53 mutations and absent for DNMT3A, and it is mostly preceded by cytosis or cytopenia. The results provide important insight into high-risk evolutionary patterns to guide monitoring of "CHIP" and "CCUS."
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Affiliation(s)
- Isabelle A van Zeventer
- Department of Hematology, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | - Aniek O de Graaf
- Department of Laboratory Medicine, Laboratory of Hematology, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Jonas B Salzbrunn
- Department of Hematology, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | - Ilja M Nolte
- Department of Epidemiology, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | - Priscilla Kamphuis
- Department of Hematology, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | - Avinash Dinmohamed
- Department of Research and Development, Netherlands Comprehensive Cancer Organization, Utrecht, the Netherlands; Department of Public Health, Erasmus Medical Center Rotterdam, Rotterdam, the Netherlands; Department of Hematology, Amsterdam UMC, Cancer Center Amsterdam, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
| | - Bert A van der Reijden
- Department of Laboratory Medicine, Laboratory of Hematology, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Jan Jacob Schuringa
- Department of Hematology, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | - Joop H Jansen
- Department of Laboratory Medicine, Laboratory of Hematology, Radboud University Medical Center, Nijmegen, the Netherlands.
| | - Gerwin Huls
- Department of Hematology, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands.
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4
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Inflammatory Cytokine Profiles Do Not Differ Between Patients With Idiopathic Cytopenias of Undetermined Significance and Myelodysplastic Syndromes. Hemasphere 2022; 6:e0713. [PMID: 35495296 PMCID: PMC9038488 DOI: 10.1097/hs9.0000000000000713] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2021] [Accepted: 03/18/2022] [Indexed: 02/03/2023] Open
Abstract
Immune dysregulation has been highlighted as a key player in the pathogenesis of myelodysplastic syndromes (MDS), but little is known about cytokine profiles in patients with unexplained cytopenia with or without mutations in MDS-associated genes (clonal cytopenias of undetermined significance [CCUS] and idiopathic cytopenias of undetermined significance [ICUS], respectively), which often precede MDS. Here, we study the cytokine profiles in 111 patients with ICUS (N = 41), CCUS (N = 30), lower-risk MDS (LR-MDS; N = 22) and higher-risk MDS (HR-MDS; N = 18), and in healthy elderly controls (N = 21). Twenty cytokines were examined in blood plasma at time of diagnosis using Luminex assays and enzyme linked immunosorbent assays. The cytokine levels were compared between patient groups, and in patients versus controls. Associations between cytokines and MDS-associated mutations were evaluated. An aberrant cytokine profile was observed in all patient groups relative to healthy elderly controls. Patients had significantly higher levels of IL-6 (P< 0 .001), tumor necrosis factor α (P < 0.001), IL-10 (P < 0.001), and C-X-C motif chemokine 10 (P < 0.001) and lower levels of transforming growth factor beta 1 (P < 0.001), CCL5/regulated on activation normal T-cell expressed and secreted (P < 0.001), and S100A4 (P < 0.001) compared with healthy controls. Survival was significantly shorter in CCUS and MDS patients with a high systemic inflammatory cytokine load (median overall survival [OS] 21 months) compared with those with low-moderate systemic inflammatory cytokine load (median OS 64 months; P < 0.0001). These data suggest that patients with ICUS and CCUS have cytokine levels as abnormal as in LR-MDS. Indeed, high cytokine levels are present before MDS is diagnosed and cytokine levels are elevated irrespective of the presence or size of the myeloid clones. Cytokines may have a prognostic impact at a very early premalignant stage of myeloid disorders.
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5
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A predictive model for bone marrow disease in cytopenia based on noninvasive procedures. Blood Adv 2022; 6:3541-3550. [PMID: 35427424 PMCID: PMC9198925 DOI: 10.1182/bloodadvances.2021006649] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2021] [Accepted: 04/01/2022] [Indexed: 11/20/2022] Open
Abstract
Bone marrow specimens are the core of the diagnostic work-up of patients with cytopenia. To explore whether next-generation sequencing (NGS) could be used to rule out malignancy without bone marrow specimens, we incorporated NGS in a model to predict presence of disease in the bone marrow of patients with unexplained cytopenia. We analyzed the occurrence of mutations in 508 patients with cytopenia, referred for primary work-up of a suspected hematological malignancy from 2015-2020. We divided patients into a discovery (n = 340) and validation (n = 168) cohort. Targeted sequencing, bone marrow biopsy and complete blood count were performed in all patients. Mutations were identified in 267 (53%) and abnormal bone marrow morphology in 188 (37%) patients. Patients with isolated neutropenia had the lowest frequency of both mutations (21%) and abnormal bone marrow morphology (5%). The median number of mutations per patient was two in patients with abnormal bone marrow morphology, compared to zero in patients with a non-diagnostic bone marrow (P < 0.001). In a multivariable logistic regression, mutations in TET2, SF3B1, U2AF1, TP53 and RUNX1 were significantly associated with abnormal bone marrow morphology. In the validation cohort, a model combining mutational status and clinical data identified 34 patients (20%) without abnormal bone marrow morphology with a sensitivity of 100% (95%-CI: 93%-100%). Overall, we show that NGS combined with clinical data can predict the presence of abnormal bone marrow morphology in patients with unexplained cytopenia and thus can be used to assess the need of a bone marrow biopsy.
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6
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Breinholt MF, Nielsen K, Schejbel L, Fassi DE, Schöllkopf C, Novotny GW, Mortensen BK, Ahmad A, Høgdall E, Nørgaard P. The value of next-generation sequencing in routine diagnostics and management of patients with cytopenia. Int J Lab Hematol 2022; 44:531-537. [PMID: 35142436 DOI: 10.1111/ijlh.13802] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2021] [Revised: 12/28/2021] [Accepted: 01/17/2022] [Indexed: 01/19/2023]
Abstract
INTRODUCTION We performed a single-center study of real-world health data to investigate the direct clinical consequence of targeted next-generation sequencing (NGS) results integrated in the clinicopathological evaluation of patients with cytopenia suspected of myelodysplastic syndrome (MDS). METHODS The study included 87 newly referred patients, who had a bone marrow examination, which included targeted NGS analysis. NGS was requested at the discretion of either examining pathologist or hematologist. Data were collected retrospectively from patient files including pathology reports with integrated NGS results. RESULTS The NGS results had a diagnostic impact in 67 cases (77%) when combining both histopathological and final clinical evaluation and provided prognostic value in 19 cases (22%). NGS supported a confident or tentative histopathological diagnosis in 52 cases (60%). Twenty cases (23%) had a final diagnosis of either Clonal Cytopenia of Undetermined Significance (CCUS) or Idiopathic Cytopenia of Undetermined Significance (ICUS). In 4 cases, NGS results affected the choice of principal treatment strategy, including considerations of allotransplantation. Twenty-one patients (24%) could be discharged to primary care physician. CONCLUSION In a multidisciplinary clinicopathological real-world setting, NGS analysis of bone marrow samples from selected patients contributed substantially to the diagnostic evaluation and management of patients with cytopenia suspected of MDS. Consequently, we have now included NGS analysis in most routine bone marrow examinations from patients with MDS or unexplained cytopenia.
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Affiliation(s)
| | - Kåre Nielsen
- Department of Pathology, Zealand University Hospital, Roskilde, Denmark
| | - Lone Schejbel
- Department of Pathology, Herlev og Gentofte Hospital, Herlev, Denmark
| | - Daniel El Fassi
- Department of Hematology, Herlev og Gentofte Hospital, Herlev, Denmark.,Department of Hematology, Rigshospitalet, Copenhagen, Denmark.,Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Claudia Schöllkopf
- Department of Hematology, Herlev og Gentofte Hospital, Herlev, Denmark.,Department of Hematology, Rigshospitalet, Copenhagen, Denmark
| | - Guy Wayne Novotny
- Department of Pathology, Herlev og Gentofte Hospital, Herlev, Denmark
| | - Bo Kok Mortensen
- Department of Hematology, Herlev og Gentofte Hospital, Herlev, Denmark.,Department of Hematology, Rigshospitalet, Copenhagen, Denmark
| | - Azhar Ahmad
- Department of Hematology, Herlev og Gentofte Hospital, Herlev, Denmark.,Department of Hematology, Rigshospitalet, Copenhagen, Denmark
| | - Estrid Høgdall
- Department of Pathology, Herlev og Gentofte Hospital, Herlev, Denmark
| | - Peter Nørgaard
- Department of Pathology, Herlev og Gentofte Hospital, Herlev, Denmark
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7
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Murakami K, Yamaguchi Y, Kida Y, Morikawa Y, Ujiie H, Sugahara H, Nannya Y, Ogawa S, Kanakura Y. Clonal Cytopenia of Undetermined Significance in a Patient with Congenital Wilms' Tumor 1 and Acquired DNMT3A Gene Mutations. Intern Med 2021; 60:3785-3788. [PMID: 34053991 PMCID: PMC8710374 DOI: 10.2169/internalmedicine.7571-21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Congenital mutations of the Wilms' tumor 1 (WT1) gene can lead to various abnormalities, including renal/gonadal developmental disorders and cardiac malformations. Although there have been many reports of somatic WT1 mutations in patients with acute myeloid leukemia and myelodysplastic syndrome, congenital WT1 mutations have not been reported in hematological disorders. We herein report a patient with early-onset clonal cytopenia of undetermined significance that was associated with a congenital mutation of WT1 and an acquired mutation of DNMT3A [encoding DNA (cytosine-5)-methyltransferase 3A].
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Affiliation(s)
- Ken Murakami
- Department of Hematology, Sumitomo Hospital, Japan
| | | | - Yuko Kida
- Department of Hematology, Sumitomo Hospital, Japan
| | | | | | | | - Yasuhito Nannya
- Department of Pathology and Tumor Biology, Graduate School of Medicine, Kyoto University, Japan
| | - Seishi Ogawa
- Department of Pathology and Tumor Biology, Graduate School of Medicine, Kyoto University, Japan
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8
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Peripheral blood cytopenias in the aging general population and risk of incident hematological disease and mortality. Blood Adv 2021; 5:3266-3278. [PMID: 34459888 DOI: 10.1182/bloodadvances.2021004355] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2021] [Accepted: 05/03/2021] [Indexed: 11/20/2022] Open
Abstract
Peripheral blood cytopenias may precede the development of hematological malignancies and frequently pose clinical challenges in the older population. The natural course of (mild) cytopenias during aging and their association with hematological disorders in community-dwelling individuals are not well studied. Within the population-based Lifelines cohort (n = 167729), we studied changes in peripheral blood counts, occurrence of cytopenias, and associated hematological outcomes in the context of aging. Development of hematological malignancies and (cause-specific) mortality were evaluated by linkage to nationwide registries. Anemia and thrombocytopenia emerged with older age, in line with a general age-related decline in these blood counts. For neutropenia, no increase in prevalence with older age was observed. Using standard reference limits to define cytopenias, anemia (hazard ratio [HR], 1.84; 95% confidence interval [CI], 1.59-2.12), thrombocytopenia (HR, 1.58; 95% CI, 1.32-1.89), and, especially the concomitant presence of anemia and thrombocytopenia (HR, 4.75; 95% CI, 2.98-7.55) were associated with inferior overall survival. Only a minor proportion of deaths was explained by diagnosed hematological malignancies, with the majority attributable to other causes. Neutropenia, either isolated (HR, 0.88; 95% CI, 0.73-1.06) or combined with another cytopenia, did not affect overall survival. For individuals aged ≥60 years, 5-year cumulative incidence of hematological malignancies was 0.60% (95% CI, 0.50-0.70), with higher incidences among those with anemia (P < .001) or thrombocytopenia (P < .001) but not neutropenia (P = .201). Highest cumulative incidences of diagnoses and mortality from hematological malignancies were observed in individuals with >1 cytopenia. We conclude that anemia and thrombocytopenia, but not neutropenia, are associated with inferior overall survival of community-dwelling individuals. Hematological malignancies develop in a small fraction of these cases.
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9
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Incidence and Prognosis of Clonal Hematopoiesis in patients with Chronic Idiopathic Neutropenia. Blood 2021; 138:1249-1257. [PMID: 34166485 DOI: 10.1182/blood.2021010815] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2021] [Accepted: 06/05/2021] [Indexed: 11/20/2022] Open
Abstract
The incidence and prognosis of clonal hematopoiesis in patients with isolated neutropenia among patients with idiopathic cytopenia of undetermined significance (ICUS), known as ICUS-N or chronic idiopathic neutropenia (CIN) patients, is poorly defined. In the present study we sought to investigate the frequency and clinical significance of mutations of genes implicated in myeloid malignancies using next generation sequencing, in CIN patients (n=185) with a long follow-up. We found that 21/185 patients (11.35%) carried totally 25 somatic mutations in 6 genes with median variant allele frequency (VAF) 12.75%. The most frequently mutated genes were DNMT3A and TET2 involving more than 80% of patients followed by IDH1/2, SRSF2 and ZRSR2. The frequency of transformation to a myeloid malignancy was low in the total group of patients (5/185 patients; 2.70%). However, from the transformed patients four belonged to the clonal (4/21; 19.05%) and one to the non-clonal (1/164; 0.61%) group, indicating that the presence of mutation(s) confers a relative risk for transformation 31.24 (P = 0.0017). The VAF of the mutant clones in the transformed patients was higher than 10% in all cases and the genes most frequently associated with malignant transformation were the SRSF2 and IDH1. No significant differences were identified between clonal and non-clonal groups in the severity of neutropenia. Patients with clonal disease were older compared to non-clonal patients. These data contribute to the better understanding of the heterogeneous entities underlying ICUS and highlight the importance of the mutation analysis for the diagnosis and prognosis of patients with unexplained neutropenias.
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10
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Gotschalck MA, Nørgaard M, Risbo N, Christiansen CF, Bahmanyar S, Ghanima W, Alam N, Frederiksen H, Nielson CM, Sørensen HT. Predictors for and outcomes after bone marrow biopsy in Scandinavian patients with chronic immune thrombocytopenia. Eur J Haematol 2021; 107:145-156. [PMID: 33851445 DOI: 10.1111/ejh.13635] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2021] [Revised: 04/09/2021] [Accepted: 04/10/2021] [Indexed: 11/26/2022]
Abstract
OBJECTIVES To examine predictors for bone marrow biopsy (BMB) and the outcome following BMB in patients with chronic immune thrombocytopenia (cITP). METHODS We identified patients diagnosed with cITP during 2009-2017 and obtained information on BMB, cITP treatment and subsequent thrombotic events, hospitalized bleeding, hematological cancer, and death using data from population-based healthcare databases and medical records in Denmark, Norway, and Sweden. RESULTS Among 4471 adults (≥18 years) with cITP, 1683 (37.6%) underwent BMB before cITP diagnosis, while cumulative BMB incidence after cITP diagnosis date was 3.1% at 1 year and 7.5% at 5 years. Predictors of having a BMB after cITP diagnosis included older age, male sex, low baseline platelet count, splenectomy, and number of cITP treatments. Compared with patients without BMB, patients with BMB had higher rates of thrombotic events (1 year adjusted hazard ratio [HR] 1.53 [95% CI, 0.92-2.54]), hospitalized bleeding episodes (1 year adjusted HR 1.72 [95% CI, 1.15-2.58]), hematological cancer (1 year adjusted HR 35.26 [95% CI 17.67-70.34]), and all-cause mortality (1 year adjusted HR 1.97 [95% CI, 1.44-2.68]). CONCLUSION Patients who undergo BMB after cITP diagnosis represent a subset of patients with more severe disease and increased rates of complications as well as hematological malignancies.
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Affiliation(s)
- Madeleine Andersson Gotschalck
- Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus N, Denmark.,Department of Clinical Medicine, Aarhus University, Aarhus N, Denmark
| | - Mette Nørgaard
- Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus N, Denmark.,Department of Clinical Medicine, Aarhus University, Aarhus N, Denmark
| | - Nickolaj Risbo
- Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus N, Denmark.,Department of Clinical Medicine, Aarhus University, Aarhus N, Denmark
| | - Christian Fynbo Christiansen
- Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus N, Denmark.,Department of Clinical Medicine, Aarhus University, Aarhus N, Denmark
| | - Shahram Bahmanyar
- Department of Medicine, Clinical Epidemiology Unit & Center for Pharmacoepidemiology, Karolinska Institutet, Solna, Sweden
| | - Waleed Ghanima
- Department of Medicine, Østfold Hospital Trust, Oslo, Norway.,Department of Hematology, Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Naufil Alam
- Center for Observational Research, Amgen Ltd, Uxbridge, UK
| | - Henrik Frederiksen
- Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus N, Denmark.,Department of Clinical Medicine, Aarhus University, Aarhus N, Denmark.,Department of Hematology, Odense University Hospital, Odense, Denmark
| | - Carrie M Nielson
- Center for Observational Research, Amgen Inc, Thousand Oaks, CA, USA
| | - Henrik Toft Sørensen
- Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus N, Denmark.,Department of Clinical Medicine, Aarhus University, Aarhus N, Denmark
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11
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Schejbel L, Novotny GW, Breinholt MF, El Fassi D, Schöllkopf C, Hogdall E, Nørgaard P. Improved Variant Detection in Clinical Myeloid NGS Testing by Supplementing a Commercial Myeloid NGS Assay with Custom or Extended Data Filtering and Accessory Fragment Analysis. Mol Diagn Ther 2021; 25:251-266. [PMID: 33687704 DOI: 10.1007/s40291-021-00519-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/15/2021] [Indexed: 12/20/2022]
Abstract
BACKGROUND Commercial myeloid next-generation sequencing (NGS) panels may facilitate uniform generation of raw data between laboratories. However, different strategies for data filtering and variant annotation may contribute to differences in variant detection and reporting. Here, we present how custom data filtering or the use of Oncomine extended data filtering improve detection of clinically relevant mutations with the Oncomine Myeloid Research Assay. METHODS The study included all patient samples (n = 264) analyzed during the first-year, single-site, clinical use of the Ion Torrent Oncomine Myeloid Research Assay. In data analysis, the default analysis filter was supplemented with our own data filtering algorithm in order to detect additional clinically relevant mutations. In addition, we developed a sensitive supplementary test for the ASXL1 c.1934dupG p.Gly646fs mutation by fragment analysis. RESULTS Using our custom filter chain, we found 96 different reportable variants that were not detected by the default filter chain. Twenty-six of these were classified as variants of strong or potential clinical significance (tier I/tier II variants), and the custom filtering discovered otherwise undetected tier I/tier II variants in 25 of 132 patients with clinically relevant mutations (19%). The remaining 70 variants not detected by the default filter chain were classified as variants of unknown significance. Among these were several unique variants with possible pathogenic potential judged by bioinformatic predictions. The recently launched Oncomine 5.14 extended filter algorithm detects most but not all of the tier I/tier II variants that were not detected by the default filter. The supplementary fragment analysis for the ASXL1 c.1934dupG p.Gly646fs confidently detected a variant allele frequency of down to 4.8% (SD 0.83%). The assay also detected the ASXL1 c.1900_1922del23 mutation. CONCLUSION Detection of clinically relevant variants with the Oncomine Myeloid Research NGS assay can be significantly improved by supplementing the default filter chain with custom data filtering or the recently launched Oncomine 5.14 extended filter algorithm. Our accessory fragment analysis facilitates easy testing for frequent ASXL1 mutations that are poorly or not covered by the NGS assay.
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Affiliation(s)
- Lone Schejbel
- Department of Pathology, Herlev and Gentofte Hospital, Borgmester Ib Juuls Vej 73, 2730, Herlev, Denmark.
| | - Guy Wayne Novotny
- Department of Pathology, Herlev and Gentofte Hospital, Borgmester Ib Juuls Vej 73, 2730, Herlev, Denmark
| | - Marie Fredslund Breinholt
- Department of Pathology, Herlev and Gentofte Hospital, Borgmester Ib Juuls Vej 73, 2730, Herlev, Denmark
| | - Daniel El Fassi
- Department of Hematology, Herlev and Gentofte Hospital, Herlev, Denmark
| | | | - Estrid Hogdall
- Department of Pathology, Herlev and Gentofte Hospital, Borgmester Ib Juuls Vej 73, 2730, Herlev, Denmark
| | - Peter Nørgaard
- Department of Pathology, Herlev and Gentofte Hospital, Borgmester Ib Juuls Vej 73, 2730, Herlev, Denmark
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12
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Jajosky AN, Sadri N, Meyerson HJ, Oduro KA, Kelkar A, Fitzgerald B, Tomlinson B, Moore EM, Beck RC. Clonal cytopenia of undetermined significance (CCUS) with dysplasia is enriched for MDS-type molecular findings compared to CCUS without dysplasia. Eur J Haematol 2021; 106:500-507. [PMID: 33386622 DOI: 10.1111/ejh.13574] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2020] [Revised: 12/17/2020] [Accepted: 12/21/2020] [Indexed: 12/17/2022]
Abstract
OBJECTIVES Although morphologic dysplasia is not typically considered a feature of CCUS, we have consistently observed low-level bone marrow (BM) dysplasia among CCUS patients. We sought to determine whether sub-diagnostic BM dysplasia in CCUS patients is associated with other clinico-pathologic findings of myelodysplastic syndrome (MDS). METHODS We identified 49 CCUS patients, 25 with sub-diagnostic dysplasia (CCUS-D), and 24 having no dysplasia (CCUS-ND). We compared the clinical, histologic, and laboratory findings of CCUS-D and CCUS-ND patients to 49 MDS patients, including blood cell counts, BM morphology, flow cytometry, cytogenetics, and results of next-generation sequencing. RESULTS No statistically significant differences were observed between CCUS-D and CCUS-ND patients in the degree of cytopenias, BM cellularity, myeloid-to-erythroid ratio, or the presence of flow cytometric abnormalities. However, compared to CCUS-ND, CCUS-D patients exhibited increased mutations in myeloid malignancy-associated genes, including non-TET2/DNMT3A/ASXL1 variants, spliceosome (SF3B1, SRSF2, ZRSR2, or U2AF1) variants, and IDH2/RUNX1/CBL variants. CCUS-D patients were also enriched for higher variant allele frequencies and co-mutation of TET2/DNMT3A/ASXL1 with other genes. CONCLUSIONS CCUS-D patients exhibit a molecular (but not clinical) profile more similar to MDS patients than CCUS-ND, suggesting CCUS-D may represent a more immediate precursor to MDS and may warrant closer clinical follow-up.
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Affiliation(s)
- Audrey N Jajosky
- Department of Pathology and Laboratory Medicine, University Hospitals of Cleveland/Case Western Reserve University School of Medicine, Cleveland, OH, USA
| | - Navid Sadri
- Department of Pathology and Laboratory Medicine, University Hospitals of Cleveland/Case Western Reserve University School of Medicine, Cleveland, OH, USA
| | - Howard J Meyerson
- Department of Pathology and Laboratory Medicine, University Hospitals of Cleveland/Case Western Reserve University School of Medicine, Cleveland, OH, USA
| | - Kwadwo A Oduro
- Department of Pathology and Laboratory Medicine, University Hospitals of Cleveland/Case Western Reserve University School of Medicine, Cleveland, OH, USA
| | - Ashwin Kelkar
- Case Western Reserve University School of Medicine, Cleveland, OH, USA
| | - Brynn Fitzgerald
- Case Western Reserve University School of Medicine, Cleveland, OH, USA
| | - Benjamin Tomlinson
- Division of Hematology and Oncology, Department of Medicine, University Hospitals of Cleveland/Case Western Reserve University School of Medicine, Cleveland, OH, USA
| | - Erika M Moore
- Department of Pathology and Laboratory Medicine, University Hospitals of Cleveland/Case Western Reserve University School of Medicine, Cleveland, OH, USA
| | - Rose C Beck
- Department of Pathology and Laboratory Medicine, University Hospitals of Cleveland/Case Western Reserve University School of Medicine, Cleveland, OH, USA
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13
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Garcia‐Manero G, Chien KS, Montalban‐Bravo G. Myelodysplastic syndromes: 2021 update on diagnosis, risk stratification and management. Am J Hematol 2020; 95:1399-1420. [PMID: 32744763 DOI: 10.1002/ajh.25950] [Citation(s) in RCA: 104] [Impact Index Per Article: 26.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2020] [Revised: 07/30/2020] [Accepted: 07/30/2020] [Indexed: 12/12/2022]
Abstract
DISEASE OVERVIEW The myelodysplastic syndromes (MDS) are a very heterogeneous group of myeloid disorders characterized by peripheral blood cytopenias and increased risk of transformation to acute myelogenous leukemia (AML). Myelodysplastic syndromes occur more frequently in older males and in individuals with prior exposure to cytotoxic therapy. DIAGNOSIS Diagnosis of MDS is based on morphological evidence of dysplasia upon visual examination of a bone marrow aspirate and biopsy. Information obtained from additional studies such as karyotype, flow cytometry and molecular genetics is usually complementary and may help refine diagnosis. RISK-STRATIFICATION Prognosis of patients with MDS can be calculated using a number of scoring systems. In general, all these scoring systems include analysis of peripheral cytopenias, percentage of blasts in the bone marrow and cytogenetic characteristics. The most commonly accepted system is the Revised International Prognostic Scoring System (IPSS-R). Somatic mutations can help define prognosis and therapy. RISK-ADAPTED THERAPY Therapy is selected based on risk, transfusion needs, percent of bone marrow blasts, cytogenetic and mutational profiles, comorbidities, potential for allogeneic stem cell transplantation (alloSCT) and prior exposure to hypomethylating agents (HMA). Goals of therapy are different in lower-risk patients than in higher-risk individuals and in those with HMA failure. In lower-risk MDS, the goal is to decrease transfusion needs and transformation to higher risk disease or AML, as well as to improve survival. In higher-risk disease, the goal is to prolong survival. In 2020, we witnessed an explosion of new agents and investigational approaches. Current available therapies include growth factor support, lenalidomide, HMAs, intensive chemotherapy and alloSCT. Novel therapeutics approved in 2020 are luspatercept and the oral HMA ASTX727. At the present time, there are no approved interventions for patients with progressive or refractory disease particularly after HMA-based therapy. Options include participation in a clinical trial, cytarabine-based therapy or alloSCT.
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Affiliation(s)
- Guillermo Garcia‐Manero
- Section of MDS, Department of Leukemia University of Texas MD Anderson Cancer Center Houston Texas USA
| | - Kelly S. Chien
- Section of MDS, Department of Leukemia University of Texas MD Anderson Cancer Center Houston Texas USA
| | - Guillermo Montalban‐Bravo
- Section of MDS, Department of Leukemia University of Texas MD Anderson Cancer Center Houston Texas USA
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14
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Skibenes ST, Clausen I, Raaschou-Jensen K. Next-generation sequencing in hypoplastic bone marrow failure: What difference does it make? Eur J Haematol 2020; 106:3-13. [PMID: 32888355 DOI: 10.1111/ejh.13513] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2020] [Revised: 08/25/2020] [Accepted: 08/26/2020] [Indexed: 12/16/2022]
Abstract
Hypoplastic bone marrow failure is a diagnostic feature of multiple haematological disorders, which also share a substantial overlap of clinical symptoms. Hence, discrimination of underlying disorders in patients presenting with hypoplastic bone marrow failure remains a major challenge in the clinic. Recent next-generation sequencing (NGS) studies have broadened our understanding of the varying molecular mechanisms and advanced diagnostics of disorders exhibiting hypoplastic bone marrow failure. In this article, we present a literature review of NGS studies of haematological disorders associated with hypoplastic bone marrow failure and highlight the relevance of NGS for improved clinical diagnostics and decision-making.
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Affiliation(s)
- Sofie T Skibenes
- Department of Hematology, Odense University Hospital, Odense, Denmark
| | - Ida Clausen
- Department of Hematology, Odense University Hospital, Odense, Denmark
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15
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Dimopoulos K, Hansen OK, Sjö LD, Saft L, Schjødt IM, Werner Hansen J, Grønbæk K. The diagnostic and prognostic role of flow cytometry in idiopathic and clonal cytopenia of undetermined significance (ICUS/CCUS): A single-center analysis of 79 patients. CYTOMETRY. PART B, CLINICAL CYTOMETRY 2020; 98:250-258. [PMID: 31479199 PMCID: PMC7318231 DOI: 10.1002/cyto.b.21842] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/05/2019] [Revised: 07/26/2019] [Accepted: 08/20/2019] [Indexed: 01/22/2023]
Abstract
OBJECTIVE The aim of this study was to evaluate the diagnostic and prognostic role of multiparameter flow cytometry (FC) in patients with idiopathic cytopenia of undetermined significance (ICUS) and clonal cytopenia of undetermined significance (CCUS). METHODS We performed FC using a standardized panel and two different diagnostic algorithms (Ogata, Wells) in a well-characterized cohort of 79 patients with ICUS/CCUS and compared it with a retrospective blinded morphological evaluation and data from targeted next-generation DNA sequencing of 20 myelodysplastic syndrome (MDS)-related genes. RESULTS Our data show that FC has low sensitivity in distinguishing CCUS from ICUS patients (40.5% for Ogata score and 59.5% for Wells score). The Wells score was suggestive of dysplasia in ICUS/CCUS patients with concurrent morphological signs of dysplasia in the bone marrow (following re-evaluation by two hematopathologists) and in CCUS patients with a higher mutational burden. Eight patients with ICUS/CCUS from our cohort progressed to another myeloid malignancy (MDS, acute myeloid leukemia, or chronic myelomonocytic leukemia), all showing flow cytometric signs of dysplasia. CONCLUSION FC performs poorly in diagnosing CCUS versus ICUS. However, it can potentially provide prognostic information in cytopenic patients by identifying a subgroup of patients with a higher grade of dysplasia, higher mutational burden, and higher risk of progression and, together with mutational screening, also identify a group of patients who might require morphological reassessment of dysplastic changes in their bone marrow.
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Affiliation(s)
- Konstantinos Dimopoulos
- Department of HematologyRigshospitalet, University Hospital of CopenhagenCopenhagenDenmark
- Department of Clinical BiochemistryRigshospitalet, University Hospital of CopenhagenCopenhagenDenmark
- Biotech Research and Innovation Centre (BRIC)University of CopenhagenDenmark
| | | | - Lene Dissing Sjö
- Department of PathologyRigshospitalet, University Hospital of CopenhagenCopenhagenDenmark
| | - Leonie Saft
- Department of PathologyKarolinska University HospitalSolnaStockholmSweden
| | - Ida Marianne Schjødt
- Department of Clinical BiochemistryRigshospitalet, University Hospital of CopenhagenCopenhagenDenmark
| | - Jakob Werner Hansen
- Department of HematologyRigshospitalet, University Hospital of CopenhagenCopenhagenDenmark
- Biotech Research and Innovation Centre (BRIC)University of CopenhagenDenmark
- Novo Nordisk Foundation Center for Stem Cell Biology, DanStem, Faculty of Health and Medical SciencesUniversity of CopenhagenCopenhagenDenmark
| | - Kirsten Grønbæk
- Department of HematologyRigshospitalet, University Hospital of CopenhagenCopenhagenDenmark
- Biotech Research and Innovation Centre (BRIC)University of CopenhagenDenmark
- Novo Nordisk Foundation Center for Stem Cell Biology, DanStem, Faculty of Health and Medical SciencesUniversity of CopenhagenCopenhagenDenmark
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16
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Pine AB, Chokr N, Stahl M, Steensma DP, Sekeres MA, Litzow MR, Luger SM, Stone RM, Greenberg PL, Bejar R, Bewersdorf JP, Gore SD, Zeidan AM. Wide variation in use and interpretation of gene mutation profiling panels among health care providers of patients with myelodysplastic syndromes: results of a large web-based survey. Leuk Lymphoma 2020; 61:1455-1464. [DOI: 10.1080/10428194.2020.1723013] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Affiliation(s)
- Alexander B. Pine
- Department of Internal Medicine, Section of Hematology, Yale School of Medicine, New Haven, CT, USA
| | - Nora Chokr
- Department of Medicine, Yale School of Medicine/Waterbury Hospital, Waterbury, CT, USA
- State University of New York, Downstate Medical Center College of Medicine, Brooklyn, NY, USA
| | - Maximilian Stahl
- Department of Medicine, Section of Hematologic Oncology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - David P. Steensma
- Division of Hematological Malignancies, Dana Farber Cancer Institute, Boston, MA, USA
| | - Mikkael A. Sekeres
- Department of Hematology and Medical Oncology, Cleveland Clinic, Cleveland, OH, USA
| | - Mark R. Litzow
- Division of Hematology and Oncology, Department of Internal Medicine, Mayo Clinic, Rochester, MN, USA
| | - Selina M. Luger
- Department of Medicine, Division of Hematology-Oncology, University of Pennsylvania, Philadelphia, PA, USA
| | - Richard M. Stone
- Division of Hematological Malignancies, Dana Farber Cancer Institute, Boston, MA, USA
| | | | - Rafael Bejar
- Moores Cancer Center, University of California San Diego, La Jolla, CA, USA
| | - Jan P. Bewersdorf
- Department of Internal Medicine, Section of Hematology, Yale School of Medicine, New Haven, CT, USA
| | - Steven D. Gore
- Department of Internal Medicine, Section of Hematology, Yale School of Medicine, New Haven, CT, USA
| | - Amer M. Zeidan
- Department of Internal Medicine, Section of Hematology, Yale School of Medicine, New Haven, CT, USA
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17
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Ravindran A, He R, Ketterling RP, Jawad MD, Chen D, Oliveira JL, Nguyen PL, Viswanatha DS, Reichard KK, Hoyer JD, Go RS, Shi M. The significance of genetic mutations and their prognostic impact on patients with incidental finding of isolated del(20q) in bone marrow without morphologic evidence of a myeloid neoplasm. Blood Cancer J 2020; 10:7. [PMID: 31974359 PMCID: PMC6978416 DOI: 10.1038/s41408-020-0275-8] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2019] [Revised: 12/25/2019] [Accepted: 01/03/2020] [Indexed: 12/22/2022] Open
Abstract
Patients with a sole del(20q) chromosomal abnormality and without morphologic features of a myeloid neoplasm (MN) have shown variable clinical outcomes. To explore the potential risk stratification markers in this group of patients, we evaluated their genetic mutational landscape by a 35-gene MN-focused next-generation sequencing (NGS) panel and examined the association of mutations to progression of MNs. Our study included 56 patients over a 10-year period with isolated del(20q), of whom 23 (41.1%) harbored at least one mutation. With a median follow-up of 32.6 months (range: 0.1−159.1), 9 of 23 patients with mutation(s) progressed to MNs, while all 33 patients without mutations did not progress to MN. Kaplan−Meier survival analysis demonstrated the presence of mutation(s) as a significant risk factor for progression to MN (P < 0.0001). MN progression was strongly associated with the presence of non-DNMT3A/TET2/ASXL1 epigenetic modifiers and nonspliceosome mutations (P = 0.003). There was no significant difference among patients with and without MN progression with respect to the number of mutations, variant allele frequency, percentage of del(20q), and other clinical/laboratory variables. This study illustrates the underlying genetic heterogeneity and complexity of isolated del(20q), and underscores the prognostic value of NGS mutational analysis in these cases.
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Affiliation(s)
- Aishwarya Ravindran
- Division of Hematopathology, Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, USA
| | - Rong He
- Division of Hematopathology, Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, USA
| | - Rhett P Ketterling
- Division of Laboratory Genetics and Genomics, Mayo Clinic, Rochester, MN, USA
| | - Majd D Jawad
- Division of Hematology, Mayo Clinic, Rochester, MN, USA
| | - Dong Chen
- Division of Hematopathology, Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, USA
| | - Jennifer L Oliveira
- Division of Hematopathology, Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, USA
| | - Phuong L Nguyen
- Division of Hematopathology, Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, USA
| | - David S Viswanatha
- Division of Hematopathology, Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, USA
| | - Kaaren K Reichard
- Division of Hematopathology, Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, USA
| | - James D Hoyer
- Division of Hematopathology, Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, USA
| | - Ronald S Go
- Division of Hematology, Mayo Clinic, Rochester, MN, USA
| | - Min Shi
- Division of Hematopathology, Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, USA.
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18
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Gillberg L, Ørskov AD, Nasif A, Ohtani H, Madaj Z, Hansen JW, Rapin N, Mogensen JB, Liu M, Dufva IH, Lykkesfeldt J, Hajkova P, Jones PA, Grønbæk K. Oral vitamin C supplementation to patients with myeloid cancer on azacitidine treatment: Normalization of plasma vitamin C induces epigenetic changes. Clin Epigenetics 2019; 11:143. [PMID: 31623675 PMCID: PMC6798470 DOI: 10.1186/s13148-019-0739-5] [Citation(s) in RCA: 41] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2019] [Accepted: 09/05/2019] [Indexed: 02/07/2023] Open
Abstract
Background Patients with haematological malignancies are often vitamin C deficient, and vitamin C is essential for the TET-induced conversion of 5-methylcytosine (5mC) to 5-hydroxymethylcytosine (5hmC), the first step in active DNA demethylation. Here, we investigate whether oral vitamin C supplementation can correct vitamin C deficiency and affect the 5hmC/5mC ratio in patients with myeloid cancers treated with DNA methyltransferase inhibitors (DNMTis). Results We conducted a randomized, double-blinded, placebo-controlled pilot trial (NCT02877277) in Danish patients with myeloid cancers performed during 3 cycles of DNMTi-treatment (5-azacytidine, 100 mg/m2/d for 5 days in 28-day cycles) supplemented by oral dose of 500 mg vitamin C (n = 10) or placebo (n = 10) daily during the last 2 cycles. Fourteen patients (70%) were deficient in plasma vitamin C (< 23 μM) and four of the remaining six patients were taking vitamin supplements at inclusion. Global DNA methylation was significantly higher in patients with severe vitamin C deficiency (< 11.4 μM; 4.997 vs 4.656% 5mC relative to deoxyguanosine, 95% CI [0.126, 0.556], P = 0.004). Oral supplementation restored plasma vitamin C levels to the normal range in all patients in the vitamin C arm (mean increase 34.85 ± 7.94 μM, P = 0.0004). We show for the first time that global 5hmC/5mC levels were significantly increased in mononuclear myeloid cells from patients receiving oral vitamin C compared to placebo (0.037% vs − 0.029%, 95% CI [− 0.129, − 0.003], P = 0.041). Conclusions Normalization of plasma vitamin C by oral supplementation leads to an increase in the 5hmC/5mC ratio compared to placebo-treated patients and may enhance the biological effects of DNMTis. The clinical efficacy of oral vitamin C supplementation to DNMTis should be investigated in a large randomized, placebo-controlled clinical trial. Trial registration ClinicalTrials.gov, NCT02877277. Registered on 9 August 2016, retrospectively registered.
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Affiliation(s)
- Linn Gillberg
- Department of Haematology, Rigshospitalet, Copenhagen Biocenter, Building 2, 3rd floor, Ole Maaløes Vej 5, DK-2200, Copenhagen, Denmark.,Biotech Research and Innovation Centre (BRIC), Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Andreas D Ørskov
- Department of Haematology, Rigshospitalet, Copenhagen Biocenter, Building 2, 3rd floor, Ole Maaløes Vej 5, DK-2200, Copenhagen, Denmark.,Biotech Research and Innovation Centre (BRIC), Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Ammar Nasif
- MRC London Institute of Medical Sciences (LMS), Imperial College, London, UK
| | | | | | - Jakob W Hansen
- Department of Haematology, Rigshospitalet, Copenhagen Biocenter, Building 2, 3rd floor, Ole Maaløes Vej 5, DK-2200, Copenhagen, Denmark.,Biotech Research and Innovation Centre (BRIC), Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark.,The Danish Stem Cell Center (Danstem), Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Nicolas Rapin
- Biotech Research and Innovation Centre (BRIC), Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Johanne B Mogensen
- Department of Haematology, Rigshospitalet, Copenhagen Biocenter, Building 2, 3rd floor, Ole Maaløes Vej 5, DK-2200, Copenhagen, Denmark.,Biotech Research and Innovation Centre (BRIC), Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Minmin Liu
- Van Andel Research Institute, Grand Rapids, MI, USA
| | - Inge H Dufva
- Department of Haematology, Herlev University Hospital, Copenhagen, Denmark
| | - Jens Lykkesfeldt
- Department of Veterinary and Animal Sciences, Faculty of Health and Medical Sciences, University of Copenhagen, Frederiksberg, Denmark
| | - Petra Hajkova
- MRC London Institute of Medical Sciences (LMS), Imperial College, London, UK
| | | | - Kirsten Grønbæk
- Department of Haematology, Rigshospitalet, Copenhagen Biocenter, Building 2, 3rd floor, Ole Maaløes Vej 5, DK-2200, Copenhagen, Denmark. .,Biotech Research and Innovation Centre (BRIC), Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark. .,The Danish Stem Cell Center (Danstem), Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark.
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19
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Bewersdorf JP, Ardasheva A, Podoltsev NA, Singh A, Biancon G, Halene S, Zeidan AM. From clonal hematopoiesis to myeloid leukemia and what happens in between: Will improved understanding lead to new therapeutic and preventive opportunities? Blood Rev 2019; 37:100587. [DOI: 10.1016/j.blre.2019.100587] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2019] [Revised: 06/22/2019] [Accepted: 07/02/2019] [Indexed: 02/08/2023]
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20
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Chokr N, Pine AB, Bewersdorf JP, Shallis RM, Stahl M, Zeidan AM. Getting personal with myelodysplastic syndromes: is now the right time? Expert Rev Hematol 2019; 12:215-224. [PMID: 30977414 PMCID: PMC6540985 DOI: 10.1080/17474086.2019.1592673] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2018] [Accepted: 03/06/2019] [Indexed: 12/24/2022]
Abstract
INTRODUCTION Commonly used scoring systems rely on blood counts, histological and cytological examination of bone marrow and peripheral blood as well as cytogenetic assessments to estimate prognosis of patients with myelodysplastic syndromes (MDS) and guide therapy decisions. Next-generation sequencing (NGS) has identified recurrent genetic abnormalities in up to 90% of patients with MDS and may provide important information regarding the pathogenesis of the disease, diagnostic and prognostic evaluation, and therapy selection. Areas covered: Herein, the authors review the role of NGS in diagnosis, treatment, and prognosis of MDS at various disease stages, and discuss advantages and caveats of incorporating molecular genetics in routine management of MDS. While a vast majority of patients harbor recurrent mutations implicated in MDS pathogenesis, similar mutations can be detected in otherwise healthy individuals with other hematologic malignancies. Besides establishing a diagnosis, NGS may be used to monitor minimal residual disease following treatment. Expert opinion: As more targeted therapies become available, assessment of genetic mutations will become central to individualized therapy selection and may improve diagnostic accuracy and further guide management for each patient. However, multiple challenges remain before NGS can be incorporated into routine clinical practice.
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Affiliation(s)
- Nora Chokr
- Section of Hematology, Department of Internal Medicine, Yale University School of Medicine, New Haven, USA
| | - Alexander B. Pine
- Section of Hematology, Department of Internal Medicine, Yale University School of Medicine, New Haven, USA
| | - Jan Philipp Bewersdorf
- Section of Hematology, Department of Internal Medicine, Yale University School of Medicine, New Haven, USA
| | - Rory M. Shallis
- Section of Hematology, Department of Internal Medicine, Yale University School of Medicine, New Haven, USA
| | - Maximilian Stahl
- Section of Hematology, Department of Internal Medicine, Yale University School of Medicine, New Haven, USA
| | - Amer M. Zeidan
- Section of Hematology, Department of Internal Medicine, Yale University School of Medicine, New Haven, USA
- Cancer Outcomes, Public Policy, and Effectiveness Research (COPPER) Center, Yale University, New Haven, USA
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21
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Rasmussen KD, Berest I, Keβler S, Nishimura K, Simón-Carrasco L, Vassiliou GS, Pedersen MT, Christensen J, Zaugg JB, Helin K. TET2 binding to enhancers facilitates transcription factor recruitment in hematopoietic cells. Genome Res 2019; 29:564-575. [PMID: 30796038 PMCID: PMC6442383 DOI: 10.1101/gr.239277.118] [Citation(s) in RCA: 54] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2018] [Accepted: 02/19/2019] [Indexed: 12/17/2022]
Abstract
The epigenetic regulator TET2 is frequently mutated in hematological diseases. Mutations have been shown to arise in hematopoietic stem cells early in disease development and lead to altered DNA methylation landscapes and an increased risk of hematopoietic malignancy. Here, we show by genome-wide mapping of TET2 binding sites in different cell types that TET2 localizes to regions of open chromatin and cell-type-specific enhancers. We find that deletion of Tet2 in native hematopoiesis as well as fully transformed acute myeloid leukemia (AML) results in changes in transcription factor (TF) activity within these regions, and we provide evidence that loss of TET2 leads to attenuation of chromatin binding of members of the basic helix-loop-helix (bHLH) TF family. Together, these findings demonstrate that TET2 activity shapes the local chromatin environment at enhancers to facilitate TF binding and provides an example of how epigenetic dysregulation can affect gene expression patterns and drive disease development.
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Affiliation(s)
- Kasper D Rasmussen
- Biotech Research and Innovation Centre (BRIC), Faculty of Health and Medical Sciences, University of Copenhagen, 2200 Copenhagen, Denmark
- The Novo Nordisk Foundation Center for Stem Cell Biology (Danstem), Faculty of Health and Medical Sciences, University of Copenhagen, 2200 Copenhagen, Denmark
| | - Ivan Berest
- European Molecular Biology Institute, Structural and Computational Unit, 69115 Heidelberg, Germany
| | - Sandra Keβler
- Biotech Research and Innovation Centre (BRIC), Faculty of Health and Medical Sciences, University of Copenhagen, 2200 Copenhagen, Denmark
- The Novo Nordisk Foundation Center for Stem Cell Biology (Danstem), Faculty of Health and Medical Sciences, University of Copenhagen, 2200 Copenhagen, Denmark
| | - Koutarou Nishimura
- Biotech Research and Innovation Centre (BRIC), Faculty of Health and Medical Sciences, University of Copenhagen, 2200 Copenhagen, Denmark
- Cell Biology Program, Memorial Sloan Kettering Cancer Center, New York, New York 10065, USA
| | - Lucía Simón-Carrasco
- Biotech Research and Innovation Centre (BRIC), Faculty of Health and Medical Sciences, University of Copenhagen, 2200 Copenhagen, Denmark
- The Novo Nordisk Foundation Center for Stem Cell Biology (Danstem), Faculty of Health and Medical Sciences, University of Copenhagen, 2200 Copenhagen, Denmark
| | - George S Vassiliou
- Wellcome Trust Sanger Institute, Wellcome Trust Genome Campus, Cambridge CB2 0XY, United Kingdom
- Department of Haematology, Cambridge University Hospitals NHS Trust, Cambridge CB2 0PT, United Kingdom
| | - Marianne T Pedersen
- Biotech Research and Innovation Centre (BRIC), Faculty of Health and Medical Sciences, University of Copenhagen, 2200 Copenhagen, Denmark
- The Novo Nordisk Foundation Center for Stem Cell Biology (Danstem), Faculty of Health and Medical Sciences, University of Copenhagen, 2200 Copenhagen, Denmark
| | - Jesper Christensen
- Biotech Research and Innovation Centre (BRIC), Faculty of Health and Medical Sciences, University of Copenhagen, 2200 Copenhagen, Denmark
- The Novo Nordisk Foundation Center for Stem Cell Biology (Danstem), Faculty of Health and Medical Sciences, University of Copenhagen, 2200 Copenhagen, Denmark
| | - Judith B Zaugg
- European Molecular Biology Institute, Structural and Computational Unit, 69115 Heidelberg, Germany
| | - Kristian Helin
- Biotech Research and Innovation Centre (BRIC), Faculty of Health and Medical Sciences, University of Copenhagen, 2200 Copenhagen, Denmark
- The Novo Nordisk Foundation Center for Stem Cell Biology (Danstem), Faculty of Health and Medical Sciences, University of Copenhagen, 2200 Copenhagen, Denmark
- Cell Biology Program, Memorial Sloan Kettering Cancer Center, New York, New York 10065, USA
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Shin DY, Park JK, Li CC, Park HS, Moon SY, Kim SM, Im K, Chang YH, Yoon SS, Lee DS. Replicative senescence of hematopoietic cells in patients with idiopathic cytopenia of undetermined significance. Leuk Res 2019; 79:22-26. [PMID: 30831479 DOI: 10.1016/j.leukres.2019.02.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2018] [Revised: 01/08/2019] [Accepted: 02/17/2019] [Indexed: 11/30/2022]
Abstract
We hypothesized that a subset of idiopathic cytopenia of undetermined significance (ICUS) is associated with an increased autonomous proliferation with exhaustion of hematopoiesis. The aim of this study was to investigate the cell turnover rate and replicative history of the bone marrow cells of ICUS patients. To this end, we examined telomere length (TL), proliferation, and apoptosis of the bone marrow cells of ICUS patients and healthy controls (HCs) using telomere quantitative fluorescence in situ hybridization and immunohistochemical staining for Ki-67 and cleaved caspase-3. We also performed targeted sequencing of 88 myeloid-associated genes. A total of 37 patients with ICUS were enrolled in this study, with a median age of 66 years (range: 31-83). TLs were significantly shorter in patients with ICUS than in the HCs (8.8, interquartile range [IQR] 6.8-12.1 vs 18.4, IQR 14.4-22.0, p < 0.0001). Proliferation (Ki-67-positive) and apoptosis (cleaved caspase-3-positive) were significantly increased in patients with ICUS compared to HCs (median = 20.0% vs 5.0%, p = 0.0003; 45.0% vs 22.5%, p = 0.0005, respectively). The shortening of TL and the increased proliferation and apoptotic activity was also prominent in patients with ICUS without mutation and dysplasia than in HCs (p < 0.0001, p < 0.0001, and p = 0.0093, respectively). TL was not associated with mutational profile and clinical characteristics as well in patients with ICUS. To our knowledge, this is the first study to show that ICUS is associated with premature replicative senescence with increased proliferation and apoptosis of bone marrow cells. Further study is needed to address the cause of replicative exhaustion in ICUS patients.
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Affiliation(s)
- Dong-Yeop Shin
- Division of Hematology and Medical Oncology, Department of Internal Medicine, Seoul National University Hospital, Seoul, South Korea; Biomedical Research Institute, Seoul National University Hospital, Seoul, South Korea
| | - Jin Kyun Park
- Division of Rheumatology, Department of Internal Medicine, Seoul National University Hospital, Seoul, South Korea
| | - Chih Chiao Li
- Department of Laboratory Medicine, Seoul National University Hospital, Seoul, South Korea
| | - Hee Sue Park
- Department of Laboratory Medicine, Chungbuk National University Hospital, Cheongju, South Korea
| | - Soo Young Moon
- Department of Laboratory Medicine, Pusan National University Hospital, Busan, South Korea
| | - Sung-Min Kim
- Cancer Research Institute, Seoul National University College of Medicine, Seoul, South Korea
| | - Kyongok Im
- Cancer Research Institute, Seoul National University College of Medicine, Seoul, South Korea
| | - Yoon Hwan Chang
- Department of Laboratory Medicine, Korea Cancer Center Hospital, Seoul, South Korea
| | - Sung-Soo Yoon
- Division of Hematology and Medical Oncology, Department of Internal Medicine, Seoul National University Hospital, Seoul, South Korea; Cancer Research Institute, Seoul National University College of Medicine, Seoul, South Korea
| | - Dong-Soon Lee
- Department of Laboratory Medicine, Seoul National University Hospital, Seoul, South Korea; Cancer Research Institute, Seoul National University College of Medicine, Seoul, South Korea.
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23
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Shin DY, Park JK, Kim SM, Im K, Kim JA, Kim SY, Hwang SM, Yoon SS, Lee DS. ASXL1 is a molecular predictor in idiopathic cytopenia of undetermined significance. Leuk Lymphoma 2018; 60:756-763. [DOI: 10.1080/10428194.2018.1492129] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Affiliation(s)
- Dong-Yeop Shin
- Division of Hematology and Medical Oncology, Department of Internal Medicine, Seoul National University Hospital, Seoul, South Korea
- Biomedical Research Institute, Seoul National University Hospital, Seoul, South Korea
| | - Jin-Kyun Park
- Division of Rheumatology, Department of Internal Medicine, Seoul National University Hospital, Seoul, South Korea
| | - Sung-Min Kim
- Cancer Research Institute, Seoul National University College of Medicine, Seoul, South Korea
| | - Kyongok Im
- Cancer Research Institute, Seoul National University College of Medicine, Seoul, South Korea
| | - Jung-Ah Kim
- Department of Laboratory Medicine, Chung-Ang University Hospital, Seoul, South Korea
| | - Sun Young Kim
- Department of Laboratory Medicine, Chungnam National University School of Medicine, Daejeon, South Korea
| | - Sang Mee Hwang
- Department of Laboratory Medicine, Seoul National University Bundang Hospital, Seongnam, South Korea
| | - Sung-Soo Yoon
- Division of Hematology and Medical Oncology, Department of Internal Medicine, Seoul National University Hospital, Seoul, South Korea
- Cancer Research Institute, Seoul National University College of Medicine, Seoul, South Korea
| | - Dong-Soon Lee
- Cancer Research Institute, Seoul National University College of Medicine, Seoul, South Korea
- Department of Laboratory Medicine, Chung-Ang University Hospital, Seoul, South Korea
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Johansen MM, Andersen MA, Grønbaek K, Hansen JW. Long-term clinical outcomes of patients with hematologically unexplained cytopenia after routine assessment: A single center study. Eur J Haematol 2018; 101:595-603. [PMID: 30027609 DOI: 10.1111/ejh.13146] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2018] [Revised: 07/11/2018] [Accepted: 07/12/2018] [Indexed: 12/29/2022]
Abstract
OBJECTIVE We investigated mortality and long-term development of malignant hematological disease, cancer, liver-, renal-, and rheumatic disease in patients with unexplained cytopenia (UC). METHODS We screened all patients referred to the outpatient clinic at the Department of Hematology, Rigshospitalet, Copenhagen, with a suspected myeloid neoplasm from June 2009 to the end of 2012. Through registry linkage, we obtained information on hospital-based ICD-10 diagnoses and survival. We estimated cumulative incidences of disease and hazard ratios of all-cause mortality using the Aalen-Johansen estimator and Cox regression. We compared incidences and mortality with a control cohort. RESULTS Among 1820 referrals, 221 had UC. The UC group had a 5-year cumulative incidence of malignant hematological disease of 8.91% (CI 95%: 4.98-12.84) compared to 0.93(CI 95%: 0.32-1.55) in the matched controls. In addition, UC patients had higher incidences of cancer, liver, and rheumatic disease. Mortality was higher in UC patients compared to the matched controls with a HR of 1.43 [P = 0.038, CI 95%: 1.02-2.00] adjusted for comorbidity, sex, and age. Most of the mortality and morbidity were ascribed to patients 50 years or older. CONCLUSIONS Unexplained cytopenia patients had a higher incidence of malignant hematological-, cancer-, liver-, and rheumatic disease and increased mortality compared to the general population.
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Affiliation(s)
- Morten Munk Johansen
- Department of Hematology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Michael Asger Andersen
- Department of Hematology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Kirsten Grønbaek
- Department of Hematology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Jakob Werner Hansen
- Department of Hematology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
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Montalban-Bravo G, Garcia-Manero G. Myelodysplastic syndromes: 2018 update on diagnosis, risk-stratification and management. Am J Hematol 2018; 93:129-147. [PMID: 29214694 DOI: 10.1002/ajh.24930] [Citation(s) in RCA: 123] [Impact Index Per Article: 20.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2017] [Accepted: 10/02/2017] [Indexed: 12/12/2022]
Abstract
DISEASE OVERVIEW The myelodysplastic syndromes (MDS) are a very heterogeneous group of myeloid disorders characterized by peripheral blood cytopenias and increased risk of transformation to acute myelogenous leukemia (AML). MDS occurs more frequently in older males and in individuals with prior exposure to cytotoxic therapy. DIAGNOSIS Diagnosis of MDS is based on morphological evidence of dysplasia upon visual examination of a bone marrow aspirate and biopsy. Information obtained from additional studies such as karyotype, flow cytometry or molecular genetics is usually complementary and may help refine diagnosis. RISK-STRATIFICATION Prognosis of patients with MDS can be calculated using a number of scoring systems. In general, all these scoring systems include analysis of peripheral cytopenias, percentage of blasts in the bone marrow and cytogenetic characteristics. The most commonly used system is probably the International Prognostic Scoring System (IPSS). IPSS is now replaced by the revised IPSS-R score. Although not systematically incorporated into new validated prognostic systems, somatic mutations can help define prognosis and should be considered as new prognostic factors. RISK-ADAPTED THERAPY Therapy is selected based on risk, transfusion needs, percent of bone marrow blasts and cytogenetic and mutational profiles. Goals of therapy are different in lower risk patients than in higher risk. In lower risk, the goal is to decrease transfusion needs and transformation to higher risk disease or AML, as well as to improve survival. In higher risk, the goal is to prolong survival. Current available therapies include growth factor support, lenalidomide, hypomethylating agents, intensive chemotherapy and allogeneic stem cell transplantation. The use of lenalidomide has significant clinical activity in patients with lower risk disease, anemia and a chromosome 5 alteration. 5-azacitidine and decitabine have activity in both lower and higher-risk MDS. 5-azacitidine has been shown to improve survival in higher risk MDS. A number of new molecular lesions have been described in MDS that may serve as new therapeutic targets or aid in the selection of currently available agents. Additional supportive care measures may include the use of prophylactic antibiotics and iron chelation. MANAGEMENT OF PROGRESSIVE OR REFRACTORY DISEASE At the present time there are no approved interventions for patients with progressive or refractory disease particularly after hypomethylating based therapy. Options include participation in a clinical trial or cytarabine based therapy and stem cell transplantation.
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Abstract
INTRODUCTION Patients presenting with idiopathic cytopenia with non-diagnostic marrow morphology and a normal karyotype pose a diagnostic and therapeutic challenge. Additional diagnostic information from mutation analysis could provide important clinical insights. However, one has to be cautious during such diagnostic interpretations in view of the recent documentation of clonal somatic mutations in healthy elder individuals. Whether to regard clonality synonymous with malignant proliferation or a manifestation of ageing process is to be judged carefully. Areas covered: The review covers defining criteria and diagnostic work up for Idiopathic cytopenia of undetermined significance (ICUS), Clonal cytopenia of undetermined significance (CCUS), Clonal hematopoiesis of indeterminate potential (CHIP). It also presents the results from previous reports on this subject. In addition the evolution and potential impact of these entities is discussed. Expert commentary: Current evidence does not support the use of somatic mutations as presumptive evidence of myelodysplastic syndrome (MDS). Including CCUS under the category of MDS requires further insight on natural disease course. Longitudinal follow up study on ICUS, CCUS, CHIP may eventually identify the pathological significance of the clonal mutations. An absence of mutation however may still be useful as good predictor of not having MDS.
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Affiliation(s)
- Mili Jain
- a Pathology Department , King George's Medical University , Lucknow , Uttar Pradesh , India
| | - Anil Tripathi
- a Pathology Department , King George's Medical University , Lucknow , Uttar Pradesh , India
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Leinøe E, Zetterberg E, Kinalis S, Østrup O, Kampmann P, Norström E, Andersson N, Klintman J, Qvortrup K, Nielsen FC, Rossing M. Application of whole-exome sequencing to direct the specific functional testing and diagnosis of rare inherited bleeding disorders in patients from the Öresund Region, Scandinavia. Br J Haematol 2017; 179:308-322. [PMID: 28748566 PMCID: PMC5655919 DOI: 10.1111/bjh.14863] [Citation(s) in RCA: 44] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2017] [Accepted: 06/20/2017] [Indexed: 01/19/2023]
Abstract
Rare inherited bleeding disorders (IBD) are a common cause of bleeding tendency. To ensure a correct diagnosis, specialized laboratory analyses are necessary. This study reports the results of an upfront diagnostic strategy using targeted whole exome sequencing. In total, 156 patients with a significant bleeding assessment tool score participated in the study, of which a third had thrombocytopenia. Eighty‐seven genes specifically associated with genetic predisposition to bleeding were analysed by whole exome sequencing. Variants were classified according to the five‐tier scheme. We identified 353 germline variants. Eight patients (5%) harboured a known pathogenic variant. Of the 345 previously unknown variants, computational analyses predicted 99 to be significant. Further filtration according to the Mendelian inheritance pattern, resulted in 59 variants being predicted to be clinically significant. Moreover, 34% (20/59) were assigned as novel class 4 or 5 variants upon targeted functional testing. A class 4 or 5 variant was identified in 30% of patients with thrombocytopenia (14/47) versus 11% of patients with a normal platelet count (12/109) (P < 0·01). An IBD diagnosis has a major clinical impact. The genetic investigations detailed here extricated our patients from a diagnostic conundrum, thus demonstrating that continuous optimization of the diagnostic work‐up of IBD is of great benefit.
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Affiliation(s)
- Eva Leinøe
- Department of Haematology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Eva Zetterberg
- Department of Haematology, Coagulation Unit, Skaane University Hospital, Lund, Sweden
| | - Savvas Kinalis
- Centre for Genomic Medicine, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Olga Østrup
- Centre for Genomic Medicine, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Peter Kampmann
- Department of Haematology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Eva Norström
- Department of Translational Medicine, Lund University, Skaane University Hospital, Lund, Sweden
| | - Nadine Andersson
- Department of Haematology, Coagulation Unit, Skaane University Hospital, Lund, Sweden
| | - Jenny Klintman
- Department of Haematology, Coagulation Unit, Skaane University Hospital, Lund, Sweden
| | - Klaus Qvortrup
- Department of Biomedical Sciences, Core Facility for Integrated Microscopy (CFIM), University of Copenhagen, Copenhagen, Denmark
| | - Finn Cilius Nielsen
- Centre for Genomic Medicine, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Maria Rossing
- Centre for Genomic Medicine, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
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Hansen JW, Sandholdt H, Siersma V, Ørskov AD, Holmberg S, Bjerrum OW, Hasselbalch HC, Olivarius NDF, Grønbaek K, Andersen CL. Anemia is present years before myelodysplastic syndrome diagnosis: Results from the pre-diagnostic period. Am J Hematol 2017; 92:E130-E132. [PMID: 28383148 DOI: 10.1002/ajh.24757] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2017] [Accepted: 04/03/2017] [Indexed: 11/09/2022]
Affiliation(s)
- Jakob Werner Hansen
- Department of Hematology; Rigshospitalet, University of Copenhagen; Copenhagen Denmark
| | - Håkon Sandholdt
- The Research Unit for General Practice and Section of General Practice, Department of Public Health; University of Copenhagen; Copenhagen Denmark
| | - Volkert Siersma
- The Research Unit for General Practice and Section of General Practice, Department of Public Health; University of Copenhagen; Copenhagen Denmark
| | - Andreas Due Ørskov
- Department of Hematology; Rigshospitalet, University of Copenhagen; Copenhagen Denmark
| | - Staffan Holmberg
- Department of Hematology; Herlev Hospital, University of Copenhagen; Copenhagen Denmark
| | - Ole Weis Bjerrum
- Department of Hematology; Rigshospitalet, University of Copenhagen; Copenhagen Denmark
| | - Hans Carl Hasselbalch
- Department of Hematology; Roskilde Hospital, University of Copenhagen; Copenhagen Denmark
| | - Niels de Fine Olivarius
- The Research Unit for General Practice and Section of General Practice, Department of Public Health; University of Copenhagen; Copenhagen Denmark
| | - Kirsten Grønbaek
- Department of Hematology; Rigshospitalet, University of Copenhagen; Copenhagen Denmark
| | - Christen Lykkegaard Andersen
- Department of Hematology; Rigshospitalet, University of Copenhagen; Copenhagen Denmark
- The Research Unit for General Practice and Section of General Practice, Department of Public Health; University of Copenhagen; Copenhagen Denmark
- Department of Hematology; Roskilde Hospital, University of Copenhagen; Copenhagen Denmark
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