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Patnaik MM, Tefferi A. Chronic myelomonocytic leukemia: 2024 update on diagnosis, risk stratification and management. Am J Hematol 2024; 99:1142-1165. [PMID: 38450850 PMCID: PMC11096042 DOI: 10.1002/ajh.27271] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2024] [Accepted: 02/09/2024] [Indexed: 03/08/2024]
Abstract
DISEASE OVERVIEW Chronic myelomonocytic leukemia (CMML) is a clonal hematopoietic stem cell disorder with overlapping features of myelodysplastic syndromes and myeloproliferative neoplasms, characterized by prominent monocytosis and an inherent risk for leukemic transformation (~15%-20% over 3-5 years). DIAGNOSIS Newly revised diagnostic criteria include sustained (>3 months) peripheral blood (PB) monocytosis (≥0.5 × 109/L; monocytes ≥10% of leukocyte count), consistent bone marrow (BM) morphology, <20% BM or PB blasts (including promonocytes), and cytogenetic or molecular evidence of clonality. Cytogenetic abnormalities occur in ~30% of patients, while >95% harbor somatic mutations: TET2 (~60%), SRSF2 (~50%), ASXL1 (~40%), RAS pathway (~30%), and others. The presence of ASXL1 and DNMT3A mutations and absence of TET2 mutations negatively impact overall survival (ASXL1WT/TET2MT genotype being favorable). RISK STRATIFICATION Several risk models serve similar purposes in identifying high-risk patients that are considered for allogeneic stem cell transplant (ASCT) earlier than later. Risk factors in the Mayo Molecular Model (MMM) include presence of truncating ASXL1 mutations, absolute monocyte count >10 × 109/L, hemoglobin <10 g/dL, platelet count <100 × 109/L, and the presence of circulating immature myeloid cells; the resulting 4-tiered risk categorization includes high (≥3 risk factors), intermediate-2 (2 risk factors), intermediate-1 (1 risk factor), and low (no risk factors); the corresponding median survivals were 16, 31, 59, and 97 months. CMML is also classified as being "myeloproliferative (MP-CMML)" or "myelodysplastic (MD-CMML)," based on the presence or absence of leukocyte count of ≥13 × 109/L. TREATMENT ASCT is the only treatment modality that secures cure or long-term survival and is appropriate for MMM high/intermediate-2 risk disease. Drug therapy is currently not disease-modifying and includes hydroxyurea and hypomethylating agents; a recent phase-3 study (DACOTA) comparing hydroxyurea and decitabine, in high-risk MP-CMML, showed similar overall survival at 23.1 versus 18.4 months, respectively, despite response rates being higher for decitabine (56% vs. 31%). UNIQUE DISEASE ASSOCIATIONS These include systemic inflammatory autoimmune diseases, leukemia cutis and lysozyme-induced nephropathy; the latter requires close monitoring of renal function during leukocytosis and is a potential indication for cytoreductive therapy.
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Affiliation(s)
- Mrinal M Patnaik
- Division of Hematology, Department of Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Ayalew Tefferi
- Division of Hematology, Department of Medicine, Mayo Clinic, Rochester, Minnesota, USA
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Patwardhan PP, Aarabi M, Aggarwal N. Genomics of myelodysplastic/myeloproliferative neoplasm. Semin Diagn Pathol 2023; 40:195-201. [PMID: 37105794 DOI: 10.1053/j.semdp.2023.04.005] [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: 04/07/2023] [Accepted: 04/10/2023] [Indexed: 04/29/2023]
Abstract
Myelodysplastic/ Myeloproliferative neoplasms (MDS/MPN) demonstrate overlapping pathologic and molecular features of myelodysplastic (MDS) and myeloproliferative (MPN) neoplasms. Diagnosis is difficult based on morphology alone, requiring exclusion of various non-neoplastic causes for CBC abnormalities and morphologic findings and other myeloid neoplasms. Identifying a clonal abnormality by cytogenetics or molecular studies has vastly improved our ability to diagnose MDS/MPN and has been incorporated in the different classification schemas. Currently two separate classification systems are in use- The 5th edition WHO and international consensus classification. The two competing classifications emphasize genetic work-up and are similar on many levels; however, they do introduce diagnostic dilemma when diagnosing certain entities such as chronic myelomonocytic leukemia in the presence of NPM1 mutations. The genetic profile overlaps among different subentities; however, the combination and the incidence of mutations; together with the clinical features and morphology helps in further subclassification. In this review, we discuss the advances in molecular characterization of MDS/MPN. We attempt to summarize the differences between the various classification schemes, and highlight the changes made in the diagnostic criteria.
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Affiliation(s)
| | - Mahmoud Aarabi
- UPMC Medical Genetics & Genomics Laboratories, UPMC Magee-Womens Hospital, Pittsburgh, PA, 15213, United States of America; Departments of Pathology, and Obstetrics, Gynecology and Reproductive Sciences, University of Pittsburgh School of Medicine, Pittsburgh, PA, 15213, United States of America
| | - Nidhi Aggarwal
- University of Pittsburgh School of Medicine, Pittsburgh, PA, United States of America.
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Impact of Mutational Status and Prognostic Factors on Survival in Chronic Myelomonocytic Leukemia With Systemic Inflammation and Autoimmune Disorders. Hemasphere 2023; 7:e847. [PMID: 36844177 PMCID: PMC9953038 DOI: 10.1097/hs9.0000000000000847] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2022] [Accepted: 01/12/2023] [Indexed: 02/25/2023] Open
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Epigenetic regulation in hematopoiesis and its implications in the targeted therapy of hematologic malignancies. Signal Transduct Target Ther 2023; 8:71. [PMID: 36797244 PMCID: PMC9935927 DOI: 10.1038/s41392-023-01342-6] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2022] [Revised: 01/03/2023] [Accepted: 01/19/2023] [Indexed: 02/18/2023] Open
Abstract
Hematologic malignancies are one of the most common cancers, and the incidence has been rising in recent decades. The clinical and molecular features of hematologic malignancies are highly heterogenous, and some hematologic malignancies are incurable, challenging the treatment, and prognosis of the patients. However, hematopoiesis and oncogenesis of hematologic malignancies are profoundly affected by epigenetic regulation. Studies have found that methylation-related mutations, abnormal methylation profiles of DNA, and abnormal histone deacetylase expression are recurrent in leukemia and lymphoma. Furthermore, the hypomethylating agents and histone deacetylase inhibitors are effective to treat acute myeloid leukemia and T-cell lymphomas, indicating that epigenetic regulation is indispensable to hematologic oncogenesis. Epigenetic regulation mainly includes DNA modifications, histone modifications, and noncoding RNA-mediated targeting, and regulates various DNA-based processes. This review presents the role of writers, readers, and erasers of DNA methylation and histone methylation, and acetylation in hematologic malignancies. In addition, this review provides the influence of microRNAs and long noncoding RNAs on hematologic malignancies. Furthermore, the implication of epigenetic regulation in targeted treatment is discussed. This review comprehensively presents the change and function of each epigenetic regulator in normal and oncogenic hematopoiesis and provides innovative epigenetic-targeted treatment in clinical practice.
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Nie Y, Shao L, Zhang H, He CK, Li H, Zou J, Chen L, Ji H, Tan H, Lin Y, Ru K. Mutational landscape of chronic myelomonocytic leukemia in Chinese patients. Exp Hematol Oncol 2022; 11:32. [PMID: 35610628 PMCID: PMC9128105 DOI: 10.1186/s40164-022-00284-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2022] [Accepted: 05/02/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Chronic myelomonocytic leukemia (CMML) is a rare and heterogeneous hematological malignancy. It has been shown that the molecular abnormalities such as ASXL1, TET2, SETBP1, and SRSF2 mutations are common in Caucasian population. METHODS We retrospectively analyzed 178 Chinese CMML patients. The targeted next generation sequencing (NGS) was used to evaluate 114 gene variations, and the prognostic factors for OS were determined by COX regression analysis. RESULTS The CMML patients showed a unique mutational spectrum, including TET2 (36.5%), NRAS (31.5%), ASXL1 (28.7%), SRSF2 (24.7%), and RUNX1 (21.9%). Of the 102 patients with clonal analysis, the ancestral events preferentially occurred in TET2 (18.5%), splicing factors (16.5%), RAS (14.0%), and ASXL1 (7.8%), and the subclonal genes were mainly ASXL1, TET2, and RAS. In addition, the secondary acute myeloid leukemia (sAML) transformed from CMML often had mutations in DNMT3A, ETV6, FLT3, and NPM1, while the primary AML (pAML) demonstrated more mutations in CEBPA, DNMT3A, FLT3, IDH1/2, NPM1, and WT1. It was of note that a series of clones were emerged during the progression from CMML to AML, including DNMT3A, FLT3, and NPM1. By univariate analysis, ASXL1 mutation, intermediate- and high-risk cytogenetic abnormality, CMML-specific prognostic scoring system (CPSS) stratifications (intermediate-2 and high group), and treatment options (best supportive care) predicted for worse OS. Multivariate analysis revealed a similar outcome. CONCLUSIONS The common mutations in Chinese CMML patients included epigenetic modifiers (TET2 and ASXL1), signaling transduction pathway components (NRAS), and splicing factor (SRSF2). The CMML patients with DNMT3A, ETV6, FLT3, and NPM1 mutations tended to progress to sAML. ASXL1 mutation and therapeutic modalities were independent prognostic factors for CMML.
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Affiliation(s)
- Yanbo Nie
- Sino-US Diagnostics Lab, Tianjin Enterprise Key Laboratory of AI-aided Hematopathology Diagnosis, Tianjin, 300385, China
| | - Liang Shao
- Department of Hematology, Zhongnan Hospital of Wuhan University, Wuhan, 430071, China
| | - Hong Zhang
- Sino-US Diagnostics Lab, Tianjin Enterprise Key Laboratory of AI-aided Hematopathology Diagnosis, Tianjin, 300385, China
| | | | - Hongyu Li
- Sino-US Diagnostics Lab, Tianjin Enterprise Key Laboratory of AI-aided Hematopathology Diagnosis, Tianjin, 300385, China
| | - Junyan Zou
- Sino-US Diagnostics Lab, Tianjin Enterprise Key Laboratory of AI-aided Hematopathology Diagnosis, Tianjin, 300385, China
| | - Long Chen
- Sino-US Diagnostics Lab, Tianjin Enterprise Key Laboratory of AI-aided Hematopathology Diagnosis, Tianjin, 300385, China
| | - Huaiyue Ji
- Sino-US Diagnostics Lab, Tianjin Enterprise Key Laboratory of AI-aided Hematopathology Diagnosis, Tianjin, 300385, China
| | - Hao Tan
- Sino-US Diagnostics Lab, Tianjin Enterprise Key Laboratory of AI-aided Hematopathology Diagnosis, Tianjin, 300385, China
| | - Yani Lin
- Sino-US Diagnostics Lab, Tianjin Enterprise Key Laboratory of AI-aided Hematopathology Diagnosis, Tianjin, 300385, China.
| | - Kun Ru
- Sino-US Diagnostics Lab, Tianjin Enterprise Key Laboratory of AI-aided Hematopathology Diagnosis, Tianjin, 300385, China.
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Enjeti AK, Agarwal R, Blombery P, Chee L, Chua CC, Grigg A, Hamad N, Iland H, Lane S, Perkins A, Singhal D, Tate C, Tiong IS, Ross DM. Panel-based gene testing in myelodysplastic/myeloproliferative neoplasm- overlap syndromes: Australasian Leukaemia and Lymphoma Group (ALLG) consensus statement. Pathology 2022; 54:389-398. [DOI: 10.1016/j.pathol.2022.03.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2021] [Revised: 03/20/2022] [Accepted: 03/23/2022] [Indexed: 11/30/2022]
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Patnaik MM, Tefferi A. Chronic myelomonocytic leukemia: 2022 update on diagnosis, risk stratification, and management. Am J Hematol 2022; 97:352-372. [PMID: 34985762 DOI: 10.1002/ajh.26455] [Citation(s) in RCA: 32] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2021] [Accepted: 01/03/2022] [Indexed: 12/19/2022]
Abstract
DISEASE OVERVIEW Chronic myelomonocytic leukemia (CMML) is a clonal hematopoietic stem cell disorder with overlapping features of myelodysplastic syndromes and myeloproliferative neoplasms, with an inherent risk for leukemic transformation (~15% over 3-5 years). DIAGNOSIS Diagnosis is based on the presence of sustained (>3 months) peripheral blood monocytosis (≥1 × 109 /L; monocytes ≥10%), usually with accompanying bone marrow dysplasia. Clonal cytogenetic abnormalities occur in ~30% of patients, while >90% have somatic gene mutations. Mutations involving TET2 (~60%), SRSF2 (~50%), ASXL1 (~40%), and the oncogenic RAS pathway (~30%) are frequent, while the presence of ASXL1 and DNMT3A mutations and the absence of TET2 mutations negatively impact overall survival. RISK-STRATIFICATION Molecularly integrated prognostic models include the Groupe Français des Myélodysplasies, Mayo Molecular Model (MMM), and the CMML specific prognostic model. Risk factors incorporated into the MMM include presence of truncating ASXL1 mutations, absolute monocyte count >10 × 109 /L, hemoglobin <10 g/dL, platelet count <100 × 109 /L, and the presence of circulating immature myeloid cells. The MMM stratifies CMML patients into four groups: high (≥3 risk factors), intermediate-2 (2 risk factors), intermediate-1 (1 risk factor), and low (no risk factors), with median survivals of 16, 31, 59, and 97 months, respectively. RISK-ADAPTED THERAPY Hypomethylating agents such as 5-azacitidine and decitabine are commonly used, with overall response rates of ~40%-50% and complete remission rates of ~7%-17%; with no impact on mutational allele burdens. Allogeneic stem cell transplant is the only potentially curative option but is associated with significant morbidity and mortality.
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Affiliation(s)
- Mrinal M. Patnaik
- Division of Hematology, Department of Medicine Mayo Clinic Rochester Minnesota USA
| | - Ayalew Tefferi
- Division of Hematology, Department of Medicine Mayo Clinic Rochester Minnesota USA
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8
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Xie Z, Campestri G, Lasho T, Finke C, Li M, Binder M, Fernandez J, Olteanu H, Reichard KK, Ketterling R, Litzow M, Tefferi A, Mangaonkar A, Gangat N, Aref AK, Patnaik MM. Clonal compositions involving epigenetic regulator and splicing mutations in CHIP, CCUS, MDS, and CMML. Leuk Res 2022; 116:106818. [DOI: 10.1016/j.leukres.2022.106818] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2022] [Revised: 02/15/2022] [Accepted: 02/19/2022] [Indexed: 10/19/2022]
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Abstract
Chronic myelomonocytic leukemia (CMML) is a rare and challenging type of myeloproliferative neoplasm. Poor prognosis and high mortality, associated predominantly with progression to secondary acute myeloid leukemia (sAML), is still an unsolved problem. Despite a growing body of knowledge about the molecular repertoire of this disease, at present, the prognostic significance of CMML-associated mutations is controversial. The absence of available CMML cell lines and the small number of patients with CMML make pre-clinical testing and clinical trials complicated. Currently, specific therapy for CMML has not been approved; most of the currently available therapeutic approaches are based on myelodysplastic syndrome (MDS) and other myeloproliferative neoplasm (MNP) studies. In this regard, the development of the robust CMML animal models is currently the focus of interest. This review describes important studies concerning animal models of CMML, examples of methodological approaches, and the obtained hematologic phenotypes.
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10
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Park HS, Son BR, Shin KS, Byeon S, Kim HK, Yang Y, Jeong Y, Han HS, Lee KH, Kwon J. The Prognostic Ability of RAS Pathway-Related Gene Mutations in Patients with Myeloid Neoplasms Treated with Hypomethylating Agents. Acta Haematol 2021; 144:649-659. [PMID: 34233332 DOI: 10.1159/000516793] [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: 01/26/2021] [Accepted: 04/23/2021] [Indexed: 11/19/2022]
Abstract
INTRODUCTION This study aimed to identify genetic predictors of treatment response and survival in patients with myeloid neoplasms treated with hypomethylating agents (HMAs). METHODS We performed next-generation sequencing on bone marrow aspiration samples of 59 patients diagnosed with acute myeloid leukemia (AML), myelodysplastic syndrome with excess blasts-2, or chronic myelomonocytic leukemia and treated with decitabine or azacitidine as a frontline therapy. RESULTS A single gene with the most common mutations was TP53 (14 of 59 patients), and mutations in RAS pathway-related genes including KRAS, NRAS, FLT3, PTPN11, CBL, and KIT were found in 28.8% of patients. The overall response rate to HMAs was 33.9%. Predictive factors for a poor response were an age >75 years (p = 0.007), 3 or more gene mutations (p = 0.004), mutations in RAS pathway-related genes (p = 0.033), and a mutated NRAS gene (p = 0.042). An age >75 years (hazard ratio 2.946), diagnosis of AML (hazard ratio 2.915), and mutations in NRAS (hazard ratio 4.440) were identified as poor prognostic factors for survival. CONCLUSION In conclusion, mutations in RAS pathway-related genes were predictors of a poor response to HMAs. Particularly, mutated NRAS was associated with inferior survival rates.
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MESH Headings
- Aged
- Aged, 80 and over
- Antimetabolites, Antineoplastic/therapeutic use
- Decitabine/therapeutic use
- Female
- Humans
- Leukemia, Myeloid, Acute/drug therapy
- Leukemia, Myeloid, Acute/genetics
- Leukemia, Myeloid, Acute/mortality
- Leukemia, Myelomonocytic, Chronic/drug therapy
- Leukemia, Myelomonocytic, Chronic/genetics
- Leukemia, Myelomonocytic, Chronic/mortality
- Male
- Middle Aged
- Mutation
- Myelodysplastic Syndromes/drug therapy
- Myelodysplastic Syndromes/genetics
- Myelodysplastic Syndromes/mortality
- Prognosis
- Proportional Hazards Models
- Proto-Oncogene Proteins c-kit/genetics
- Proto-Oncogene Proteins p21(ras)/genetics
- Signal Transduction/genetics
- Survival Rate
- Tumor Suppressor Protein p53/genetics
- fms-Like Tyrosine Kinase 3/genetics
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Affiliation(s)
- Hee Sue Park
- Laboratory Medicine, Chungbuk National University College of Medicine, Cheongju, Republic of Korea
- Laboratory Medicine, Chungbuk National University Hospital, Cheongju, Republic of Korea
| | - Bo Ra Son
- Laboratory Medicine, Chungbuk National University College of Medicine, Cheongju, Republic of Korea
- Laboratory Medicine, Chungbuk National University Hospital, Cheongju, Republic of Korea
| | - Kyeong Seob Shin
- Laboratory Medicine, Chungbuk National University College of Medicine, Cheongju, Republic of Korea
- Laboratory Medicine, Chungbuk National University Hospital, Cheongju, Republic of Korea
| | - Seonggyu Byeon
- Internal Medicine, Chungbuk National University College of Medicine, Cheongju, Republic of Korea
- Internal Medicine, Chungbuk National University Hospital, Cheongju, Republic of Korea
| | - Hee Kyung Kim
- Internal Medicine, Chungbuk National University College of Medicine, Cheongju, Republic of Korea
- Internal Medicine, Chungbuk National University Hospital, Cheongju, Republic of Korea
| | - Yaewon Yang
- Internal Medicine, Chungbuk National University College of Medicine, Cheongju, Republic of Korea
- Internal Medicine, Chungbuk National University Hospital, Cheongju, Republic of Korea
| | - Yusook Jeong
- Internal Medicine, Chungbuk National University College of Medicine, Cheongju, Republic of Korea
- Internal Medicine, Chungbuk National University Hospital, Cheongju, Republic of Korea
| | - Hye Sook Han
- Internal Medicine, Chungbuk National University College of Medicine, Cheongju, Republic of Korea
- Internal Medicine, Chungbuk National University Hospital, Cheongju, Republic of Korea
| | - Ki Hyeong Lee
- Internal Medicine, Chungbuk National University College of Medicine, Cheongju, Republic of Korea
- Internal Medicine, Chungbuk National University Hospital, Cheongju, Republic of Korea
| | - Jihyun Kwon
- Internal Medicine, Chungbuk National University College of Medicine, Cheongju, Republic of Korea
- Internal Medicine, Chungbuk National University Hospital, Cheongju, Republic of Korea
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11
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Chan O, Renneville A, Padron E. Chronic myelomonocytic leukemia diagnosis and management. Leukemia 2021; 35:1552-1562. [PMID: 33714974 DOI: 10.1038/s41375-021-01207-3] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2020] [Revised: 01/23/2021] [Accepted: 02/18/2021] [Indexed: 01/31/2023]
Abstract
Chronic myelomonocytic leukemia (CMML) is a rare, heterogeneous myeloid malignancy classified as a myelodysplastic syndromes/myeloproliferative neoplasm (MDS/MPN) overlap syndrome by the World Health Organization (WHO). Its initial presentation can be incidental or associated with myelodysplastic or myeloproliferative symptoms and up to 20% of patients harbor a concurrent inflammatory or autoimmune condition. Persistent monocytosis is the hallmark of CMML but diagnosis can be challenging. Increased understanding of human monocyte subsets, chromosomal abnormalities, and somatic gene mutations have led to more accurate diagnosis and improved prognostication. A number of risk stratification systems have been developed and validated but using those that incorporate molecular information such as CMML Prognostic Scoring System (CPSS)-Mol, Mayo Molecular, and Groupe Francophone des Myelodysplasies (GFM) are preferred. Symptom-directed approaches forms the basis of CMML management. Outcomes vary substantially depending on risk ranging from observation for a number of years to rapidly progressive disease and acute myeloid leukemia (AML) transformation. Patients who are low risk but with symptoms from cytopenias or proliferative features such as splenomegaly may be treated with hypomethylating agents (HMAs) or cytoreductive therapy, respectively, with the goal of durable symptoms control. Allogeneic hematopoietic cell transplantation should be considered for intermediate to high risk patients. The lack of effective pharmaceutical options has generated interest in novel therapeutics for this disease, and early phase clinical trial results are promising.
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Affiliation(s)
- Onyee Chan
- Department of Malignant Hematology, Moffitt Cancer Center, Tampa, FL, USA
| | | | - Eric Padron
- Department of Malignant Hematology, Moffitt Cancer Center, Tampa, FL, USA.
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12
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Carr RM, Vorobyev D, Lasho T, Marks DL, Tolosa EJ, Vedder A, Almada LL, Yurcheko A, Padioleau I, Alver B, Coltro G, Binder M, Safgren SL, Horn I, You X, Solary E, Balasis ME, Berger K, Hiebert J, Witzig T, Buradkar A, Graf T, Valent P, Mangaonkar AA, Robertson KD, Howard MT, Kaufmann SH, Pin C, Fernandez-Zapico ME, Geissler K, Droin N, Padron E, Zhang J, Nikolaev S, Patnaik MM. RAS mutations drive proliferative chronic myelomonocytic leukemia via a KMT2A-PLK1 axis. Nat Commun 2021; 12:2901. [PMID: 34006870 PMCID: PMC8131698 DOI: 10.1038/s41467-021-23186-w] [Citation(s) in RCA: 34] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2020] [Accepted: 04/20/2021] [Indexed: 12/24/2022] Open
Abstract
Proliferative chronic myelomonocytic leukemia (pCMML), an aggressive CMML subtype, is associated with dismal outcomes. RAS pathway mutations, mainly NRASG12D, define the pCMML phenotype as demonstrated by our exome sequencing, progenitor colony assays and a Vav-Cre-NrasG12D mouse model. Further, these mutations promote CMML transformation to acute myeloid leukemia. Using a multiomics platform and biochemical and molecular studies we show that in pCMML RAS pathway mutations are associated with a unique gene expression profile enriched in mitotic kinases such as polo-like kinase 1 (PLK1). PLK1 transcript levels are shown to be regulated by an unmutated lysine methyl-transferase (KMT2A) resulting in increased promoter monomethylation of lysine 4 of histone 3. Pharmacologic inhibition of PLK1 in RAS mutant patient-derived xenografts, demonstrates the utility of personalized biomarker-driven therapeutics in pCMML.
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MESH Headings
- Animals
- Cell Cycle Proteins/genetics
- Cell Cycle Proteins/metabolism
- GTP Phosphohydrolases/genetics
- GTP Phosphohydrolases/metabolism
- Gene Expression Profiling/methods
- Gene Expression Regulation, Leukemic
- Histone-Lysine N-Methyltransferase/genetics
- Histone-Lysine N-Methyltransferase/metabolism
- Kaplan-Meier Estimate
- Leukemia, Myelomonocytic, Chronic/genetics
- Leukemia, Myelomonocytic, Chronic/metabolism
- Leukemia, Myelomonocytic, Chronic/therapy
- Membrane Proteins/genetics
- Membrane Proteins/metabolism
- Mice, Inbred C57BL
- Mice, Knockout
- Mice, Transgenic
- Mutation
- Myeloid-Lymphoid Leukemia Protein/genetics
- Myeloid-Lymphoid Leukemia Protein/metabolism
- Protein Serine-Threonine Kinases/genetics
- Protein Serine-Threonine Kinases/metabolism
- Proto-Oncogene Proteins/genetics
- Proto-Oncogene Proteins/metabolism
- Signal Transduction/genetics
- Stem Cell Transplantation/methods
- Transplantation, Homologous
- Exome Sequencing/methods
- Xenograft Model Antitumor Assays/methods
- Polo-Like Kinase 1
- Mice
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Affiliation(s)
- Ryan M Carr
- Division of Hematology, Department of Internal Medicine, Mayo Clinic, MN, USA
- Schulze Center for Novel Therapeutics, Division of Oncology Research, Mayo Clinic, MN, USA
| | - Denis Vorobyev
- INSERM U981, Gustave Roussy Cancer Center, Villejuif, France
| | - Terra Lasho
- Division of Hematology, Department of Internal Medicine, Mayo Clinic, MN, USA
| | - David L Marks
- Schulze Center for Novel Therapeutics, Division of Oncology Research, Mayo Clinic, MN, USA
| | - Ezequiel J Tolosa
- Schulze Center for Novel Therapeutics, Division of Oncology Research, Mayo Clinic, MN, USA
| | - Alexis Vedder
- Chemical Biology and Molecular Medicine Program, Moffitt Cancer Center, Tampa, FL, USA
| | - Luciana L Almada
- Schulze Center for Novel Therapeutics, Division of Oncology Research, Mayo Clinic, MN, USA
| | - Andrey Yurcheko
- INSERM U981, Gustave Roussy Cancer Center, Villejuif, France
| | | | - Bonnie Alver
- Molecular Pharmacology and Experimental Therapeutics, Mayo Clinic, MN, USA
| | - Giacomo Coltro
- Division of Hematology, Department of Internal Medicine, Mayo Clinic, MN, USA
| | - Moritz Binder
- Division of Hematology, Department of Internal Medicine, Mayo Clinic, MN, USA
| | - Stephanie L Safgren
- Schulze Center for Novel Therapeutics, Division of Oncology Research, Mayo Clinic, MN, USA
| | - Isaac Horn
- Schulze Center for Novel Therapeutics, Division of Oncology Research, Mayo Clinic, MN, USA
| | - Xiaona You
- McArdle Laboratory for Cancer Research, University of Wisconsin-Madison, Madison, WI, USA
| | - Eric Solary
- INSERM U1170 and Department of Hematology, Gustave Roussy Cancer Center, Villejuif, France
| | - Maria E Balasis
- Chemical Biology and Molecular Medicine Program, Moffitt Cancer Center, Tampa, FL, USA
| | - Kurt Berger
- London Regional Transgenic and Gene Targeting Facility, Lawson Health Research Institute University of Western Ontario, London, ON, Canada
| | - James Hiebert
- Division of Hematology, Department of Internal Medicine, Mayo Clinic, MN, USA
| | - Thomas Witzig
- Division of Hematology, Department of Internal Medicine, Mayo Clinic, MN, USA
| | - Ajinkya Buradkar
- Division of Hematology, Department of Internal Medicine, Mayo Clinic, MN, USA
| | - Temeida Graf
- 5TH Department of Internal Medicine I, Division of Hematology and Hemostaseology, Medical University of Vienna, Vienna, Austria
| | - Peter Valent
- 5TH Department of Internal Medicine I, Division of Hematology and Hemostaseology, Medical University of Vienna, Vienna, Austria
- Ludwig Boltzmann Institute for Hematology and Hemostaseology, Medical University of Vienna, Vienna, Austria
| | | | - Keith D Robertson
- Molecular Pharmacology and Experimental Therapeutics, Mayo Clinic, MN, USA
| | - Matthew T Howard
- Department of Laboratory Medicine and Pathology, Mayo Clinic, MN, USA
| | - Scott H Kaufmann
- Division of Hematology, Department of Internal Medicine, Mayo Clinic, MN, USA
| | - Christopher Pin
- London Regional Transgenic and Gene Targeting Facility, Lawson Health Research Institute University of Western Ontario, London, ON, Canada
| | | | | | - Nathalie Droin
- INSERM U1170 and Department of Hematology, Gustave Roussy Cancer Center, Villejuif, France
| | - Eric Padron
- Chemical Biology and Molecular Medicine Program, Moffitt Cancer Center, Tampa, FL, USA
| | - Jing Zhang
- McArdle Laboratory for Cancer Research, University of Wisconsin-Madison, Madison, WI, USA
| | - Sergey Nikolaev
- INSERM U981, Gustave Roussy Cancer Center, Villejuif, France.
| | - Mrinal M Patnaik
- Division of Hematology, Department of Internal Medicine, Mayo Clinic, MN, USA.
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13
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Tremblay D, Rippel N, Feld J, El Jamal SM, Mascarenhas J. Contemporary Risk Stratification and Treatment of Chronic Myelomonocytic Leukemia. Oncologist 2021; 26:406-421. [PMID: 33792103 PMCID: PMC8100553 DOI: 10.1002/onco.13769] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2021] [Accepted: 03/25/2021] [Indexed: 12/19/2022] Open
Abstract
Chronic myelomonocytic leukemia (CMML) is a hematologic malignancy characterized by absolute monocytosis, one or more lineage dysplasia, and proliferative features including myeloid hyperplasia, splenomegaly, and constitutional symptoms. Because of vast clinical heterogeneity in presentation and course, risk stratification is used for a risk-adapted treatment strategy. Numerous prognostic scoring systems exist, some of which incorporate mutational information. Treatment ranges from observation to allogeneic hematopoietic stem cell transplantation. Therapies include hydroxyurea for cytoreduction, hypomethylating agents, and the JAK1/2 inhibitor ruxolitinib to address splenomegaly and constitutional symptoms. Recently, oral decitabine with cedazuridine was approved and represents a convenient treatment option for CMML patients. Although novel therapeutics are in development for CMML, further work is needed to elucidate possible targets unique to the CMML clone. In this review, we will detail the pathophysiology, risk stratification, available treatment modalities, and novel therapies for CMML, and propose a modern treatment algorithm. IMPLICATIONS FOR PRACTICE: Chronic myelomonocytic leukemia (CMML) is a clinically heterogenous disease, which poses significant management challenges. The diagnosis of CMML requires bone marrow biopsy and aspirate with thorough evaluation. Risk stratification and symptom assessment are essential to designing an effective treatment plan, which may include hypomethylating agents (HMAs) in intermediate or high-risk patients. The recently approved oral decitabine/cedazuridine provides a convenient alternative to parenteral HMAs. Ruxolitinib may be effective in ameliorating proliferative symptoms and splenomegaly. Allogeneic stem cell transplantation remains the only treatment with curative potential; however, novel therapies are in clinical development which may significantly alter the therapeutic landscape of CMML.
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Affiliation(s)
- Douglas Tremblay
- Tisch Cancer Institute, Icahn School of Medicine at Mount SinaiNew YorkNew YorkUSA
| | - Noa Rippel
- Department of Medicine, Icahn School of Medicine at Mount SinaiNew YorkNew YorkUSA
| | - Jonathan Feld
- Tisch Cancer Institute, Icahn School of Medicine at Mount SinaiNew YorkNew YorkUSA
| | - Siraj M. El Jamal
- Department of Pathology, Molecular and Cell‐Based Medicine, Icahn School of Medicine at Mount SinaiNew YorkNew YorkUSA
| | - John Mascarenhas
- Tisch Cancer Institute, Icahn School of Medicine at Mount SinaiNew YorkNew YorkUSA
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14
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Kwon J. Diagnosis and treatment of chronic myelomonocytic leukemia. Blood Res 2021; 56:S5-S16. [PMID: 33935030 PMCID: PMC8094002 DOI: 10.5045/br.2021.2020321] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2020] [Revised: 01/20/2021] [Accepted: 03/09/2021] [Indexed: 12/14/2022] Open
Abstract
Chronic myelomonocytic leukemia (CMML) is a clonal disorder of hematopoietic cells and is a complex of heterogeneous conditions with both myeloproliferative and myelodysplastic features. The diagnosis of CMML is made using morphologic criteria including monocyte-dominant leukocytosis, dysplastic changes, and increased blasts in the bone marrow. Recently, the identification of monocyte subtypes in peripheral blood using multiparameter flow cytometry has been actively studied. Chromosomal abnormalities are the basis of CMML risk stratification, and mutations in several genes including ASXL1 are known to be important not only for the diagnosis and treatment of this disease but also for predicting its prognosis. The standard treatment principles for CMML have not yet been clearly defined; however, hypomethylating agents are mainly considered the frontline therapy in most cases. Although allogeneic hematopoietic stem cell transplantation has limited applications owing to its toxicity, it still plays an important role as the only curative treatment option. Researchers are continuing to develop new drugs for CMML treatment and to prove their clinical usefulness. This review summarizes what is known to date on the diagnosis, treatment, and prognostic factors of CMML and presents future directions by analyzing recent research trends.
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Affiliation(s)
- Jihyun Kwon
- Division of Hematology and Oncology, Department of Internal Medicine, Chungbuk National University College of Medicine, Chungbuk National University Hospital, Cheongju, Korea
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15
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Jian J, Qiao Y, Li Y, Guo Y, Ma H, Liu B. Mutations in chronic myelomonocytic leukemia and their prognostic relevance. Clin Transl Oncol 2021; 23:1731-1742. [PMID: 33861431 DOI: 10.1007/s12094-021-02585-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2020] [Accepted: 03/06/2021] [Indexed: 12/19/2022]
Abstract
Chronic myelomonocytic leukemia (CMML) is a hematologic malignancy that overlaps with myeloproliferative neoplasms (MPN) and myelodysplastic syndromes (MDS) and tends to transform into acute myeloid leukemia (AML). Among cases of CMML, > 90% have gene mutations, primarily involving TET2 (~ 60%), ASXL1 (~ 40%), SRSF2 (~ 50%), and the RAS pathways (~ 30%). These gene mutations are associated with both the clinical phenotypes and the prognosis of CMML, special CMML variants and pre-phases of CMML. Cytogenetic abnormalities and the size of genome are also associated with prognosis. Meanwhile, cases with ASXL1, DNMT3A, NRAS, SETBP1, CBL and RUNX1 mutations may have inferior prognoses, but only ASXL1 mutations were confirmed to be independent predictors of the patient outcome and were included in three prognostic models. Novel treatment targets related to the various gene mutations are emerging. Therefore, this review provides new insights to explore the correlations among gene mutations, clinical phenotypes, prognosis, and novel drugs in CMML.
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Affiliation(s)
- J Jian
- The First Clinical Medical College, Lanzhou University, Lanzhou, Gansu, China
| | - Y Qiao
- Institute of Hematology, Xi'an Central Hospital, Xi'an, Shaanxi, China
| | - Y Li
- The First Clinical Medical College, Lanzhou University, Lanzhou, Gansu, China
| | - Y Guo
- The First Clinical Medical College, Lanzhou University, Lanzhou, Gansu, China
| | - H Ma
- The First Clinical Medical College, Lanzhou University, Lanzhou, Gansu, China. .,Department of Hematology, The First Affiliated Hospital, Lanzhou University, 1 Donggangxilu street, Lanzhou, Gansu, China.
| | - B Liu
- The First Clinical Medical College, Lanzhou University, Lanzhou, Gansu, China. .,Department of Hematology, The First Affiliated Hospital, Lanzhou University, 1 Donggangxilu street, Lanzhou, Gansu, China.
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16
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Genomic Landscape and Risk Stratification in Chronic Myelomonocytic Leukemia. Curr Hematol Malig Rep 2021; 16:247-255. [PMID: 33660195 DOI: 10.1007/s11899-021-00613-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/04/2021] [Indexed: 12/19/2022]
Abstract
PURPOSE The advent of next-generation sequencing has allowed for the annotation of a vast array of recurrent somatic mutations across human malignancies, ushering in a new era of precision oncology. Chronic myelomonocytic leukemia is recognized as a myelodysplastic/myeloproliferative neoplasm and displays heterogenous clinical and genetic features. Herein, we review what is currently understood regarding the genomic landscape of this disease and discuss how somatic mutations have impacted current risk stratification methods. RECENT FINDINGS Genomic studies in chronic myelomonocytic leukemia have identified a characteristic spectrum of cytogenetic and molecular abnormalities. Chromosomal abnormalities are detected in ~30% of patients and somatic gene mutations in up to 90% of patients, most commonly in TET2, SRSF2, and ASXL1. While cytogenetic abnormalities have long been known to impact the prognosis of myeloid neoplasms, recent studies have identified that somatic mutations impact prognosis independent of cytogenetic and clinical variables. This is best exemplified by mutations in ASXL1, which have been uniformly associated with inferior survival. These findings have led to the development of three molecularly inspired prognostic models, in an attempt to more accurately prognosticate in the disease. Our understanding of the genomic landscape of chronic myelomonocytic leukemia continues to evolve, with somatic mutations demonstrating an expanding role in diagnosis, risk stratification, and therapeutic decision-making. Given these findings, molecular profiling by next-generation sequencing should be considered standard of care in all patients.
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17
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Feusier JE, Arunachalam S, Tashi T, Baker MJ, VanSant-Webb C, Ferdig A, Welm BE, Rodriguez-Flores JL, Ours C, Jorde LB, Prchal JT, Mason CC. Large-Scale Identification of Clonal Hematopoiesis and Mutations Recurrent in Blood Cancers. Blood Cancer Discov 2021; 2:226-237. [PMID: 34027416 DOI: 10.1158/2643-3230.bcd-20-0094] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Clonal hematopoiesis of indeterminate potential (CHIP) is characterized by detectable hematopoietic-associated gene mutations in a person without evidence of hematologic malignancy. We sought to identify additional cancer-presenting mutations useable for CHIP detection by performing a data mining analysis of 48 somatic mutation studies reporting mutations at diagnoses of 7,430 adult and pediatric patients with hematologic malignancies. Following extraction of 20,141 protein-altering mutations, we identified 434 significantly recurrent mutation hotspots, 364 of which occurred at loci confidently assessable for CHIP. We then performed an additional large-scale analysis of whole exome sequencing data from 4,538 persons belonging to three non-cancer cohorts for clonal mutations. We found the combined cohort prevalence of CHIP with mutations identical to those reported at blood cancer mutation hotspots to be 1.8%, and that some of these CHIP mutations occurred in children. Our findings may help to improve CHIP detection and pre-cancer surveillance for both children and adults.
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Affiliation(s)
- Julie E Feusier
- Department of Pediatrics, Division of Pediatric Hematology and Oncology, University of Utah, Salt Lake City, UT, USA.,Department of Human Genetics, University of Utah, Salt Lake City, UT, USA
| | - Sasi Arunachalam
- Department of Pediatrics, Division of Pediatric Hematology and Oncology, University of Utah, Salt Lake City, UT, USA.,Huntsman Cancer Institute, University of Utah, Salt Lake City, UT, USA.,Department of Oncological Sciences, University of Utah, Salt Lake City, UT, USA
| | - Tsewang Tashi
- Huntsman Cancer Institute, University of Utah, Salt Lake City, UT, USA.,Division of Hematology and Hematologic Malignancies, University of Utah, Salt Lake City, UT, USA.,VA Medical Center, Salt Lake City, UT, USA
| | - Monika J Baker
- Department of Pediatrics, Division of Pediatric Hematology and Oncology, University of Utah, Salt Lake City, UT, USA
| | - Chad VanSant-Webb
- Department of Pediatrics, Division of Pediatric Hematology and Oncology, University of Utah, Salt Lake City, UT, USA
| | - Amber Ferdig
- Department of Pediatrics, Division of Pediatric Hematology and Oncology, University of Utah, Salt Lake City, UT, USA
| | - Bryan E Welm
- Huntsman Cancer Institute, University of Utah, Salt Lake City, UT, USA.,Department of Surgery, University of Utah, Salt Lake City, UT, USA
| | | | - Christopher Ours
- Department of Pediatrics, Division of Pediatric Hematology and Oncology, University of Utah, Salt Lake City, UT, USA
| | - Lynn B Jorde
- Department of Human Genetics, University of Utah, Salt Lake City, UT, USA
| | - Josef T Prchal
- Huntsman Cancer Institute, University of Utah, Salt Lake City, UT, USA.,Division of Hematology and Hematologic Malignancies, University of Utah, Salt Lake City, UT, USA.,VA Medical Center, Salt Lake City, UT, USA
| | - Clinton C Mason
- Department of Pediatrics, Division of Pediatric Hematology and Oncology, University of Utah, Salt Lake City, UT, USA
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18
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Kuykendall AT, Tokumori FC, Komrokji RS. Traipsing Through Muddy Waters: A Critical Review of the Myelodysplastic Syndrome/Myeloproliferative Neoplasm (MDS/MPN) Overlap Syndromes. Hematol Oncol Clin North Am 2021; 35:337-352. [PMID: 33641873 DOI: 10.1016/j.hoc.2020.12.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Myelodysplastic syndrome/Myeloproliferative neoplasms (MDS/MPNs) are molecularly complex, clinically heterogeneous diseases that exhibit proliferative and dysplastic features. Diagnostic criteria use clinical, pathologic, and genomic features to distinguish between disease entities, though considerable clinical and genetic overlap persists. MDS/MPNs are associated with a poor prognosis, save for MDS/MPN with ring sideroblasts and thrombocytosis, which can behave more indolently. The current treatment approach is risk-adapted and symptom-directed and largely extrapolated from experience in MDS or MPN. Gene sequencing has demonstrated frequent mutations involving signaling, epigenetic, and splicing pathways, which present numerous therapeutic opportunities for clinical investigation.
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Affiliation(s)
- Andrew T Kuykendall
- Moffitt Cancer Center, 12902 USF Magnolia Drive, CSB 7th Floor, Tampa, FL 33612, USA.
| | - Franco Castillo Tokumori
- University of South Florida, 17 Davis Boulevard, Suite 308, Tampa, FL 33606, USA. https://twitter.com/CTFrancoMD
| | - Rami S Komrokji
- Moffitt Cancer Center, 12902 USF Magnolia Drive, CSB 7th Floor, Tampa, FL 33612, USA. https://twitter.com/Ramikomrokji
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19
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Hasserjian RP, Buckstein R, Patnaik MM. Navigating Myelodysplastic and Myelodysplastic/Myeloproliferative Overlap Syndromes. Am Soc Clin Oncol Educ Book 2021; 41:328-350. [PMID: 34010050 DOI: 10.1200/edbk_320113] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Myelodysplastic syndromes (MDS) and MDS/myeloproliferative neoplasms (MPNs) are clonal diseases that differ in morphologic diagnostic criteria but share some common disease phenotypes that include cytopenias, propensity to acute myeloid leukemia evolution, and a substantially shortened patient survival. MDS/MPNs share many clinical and molecular features with MDS, including frequent mutations involving epigenetic modifier and/or spliceosome genes. Although the current 2016 World Health Organization classification incorporates some genetic features in its diagnostic criteria for MDS and MDS/MPNs, recent accumulation of data has underscored the importance of the mutation profiles on both disease classification and prognosis. Machine-learning algorithms have identified distinct molecular genetic signatures that help refine prognosis and notable associations of these genetic signatures with morphologic and clinical features. Combined geno-clinical models that incorporate mutation data seem to surpass the current prognostic schemes. Future MDS classification and prognostication schema will be based on the portfolio of genetic aberrations and traditional features, such as blast count and clinical factors. Arriving at these systems will require studies on large patient cohorts that incorporate advanced computational analysis. The current treatment algorithm in MDS is based on patient risk as derived from existing prognostic and disease classes. Luspatercept is newly approved for patients with MDS and ring sideroblasts who are transfusion dependent after erythropoietic-stimulating agent failure. Other agents that address red blood cell transfusion dependence in patients with lower-risk MDS and the failure of hypomethylating agents in higher-risk disease are in advanced testing. Finally, a plethora of novel targeted agents and immune checkpoint inhibitors are being evaluated in combination with a hypomethylating agent backbone to augment the depth and duration of response and, we hope, improve overall survival.
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Affiliation(s)
| | - Rena Buckstein
- Division of Hematology/Oncology, Sunnybrook Odette Cancer Center, Toronto, Ontario, Canada
| | - Mrinal M Patnaik
- Division of Hematology, Department of Internal Medicine, Mayo Clinic, MN
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20
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Abstract
In recent years CMML has received increased attention as the most commonly observed MDS/MPN overlap syndrome. Renewed interest has occurred in part due to widespread adoption of next-generation sequencing panels that help render the diagnosis in the absence of morphologic dysplasia. Although most CMML patients exhibit somatic mutations in epigenetic modifiers, spliceosome components, transcription factors and signal transduction genes, it is increasingly clear that a small subset harbors an inherited predisposition to CMML and other myeloid neoplasms. More intriguing is the fact that the mutational spectrum observed in CMML is found in other types of myeloid leukemias, begging the question of how similar genetic backgrounds can lead to such divergent clinical phenotypes. In this review we present a contemporary snapshot of the genetic complexity inherent to CMML, explore the relationship between genotype-phenotype and present a stepwise model of CMML pathogenesis and progression.
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Affiliation(s)
- Ami B Patel
- Division of Hematology and Hematologic Malignancies, University of Utah, Salt Lake City, UT, USA.,Huntsman Cancer Institute, University of Utah, Salt Lake City, UT, USA
| | - Michael W Deininger
- Division of Hematology and Hematologic Malignancies, University of Utah, Salt Lake City, UT, USA.,Huntsman Cancer Institute, University of Utah, Salt Lake City, UT, USA
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21
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Thomopoulos TP, Bouhla A, Papageorgiou SG, Pappa V. Chronic myelomonocytic leukemia - a review. Expert Rev Hematol 2020; 14:59-77. [PMID: 33275852 DOI: 10.1080/17474086.2021.1860004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
INTRODUCTION Chronic myelomonocytic leukemia (CMML) is a clonal myeloid neoplasm, denoted by overlapping myelodysplastic and myeloproliferative features, with poor overall survival and high transformation rate to acute myeloid leukemia. AREAS COVERED This review, following a thorough Medline search of pertinent published literature, discusses the diagnostic criteria, the pathogenesis, and the complex genetic landscape of the disease. Prognostication, response criteria, therapeutic management of patients, efficacy of established and novel treatment modalities are thoroughly reviewed. EXPERT OPINION Cytogenetic abnormalities and mutations in genes involved in epigenetic and transcriptional regulation, and cell-signaling are abundant in CMML and implicated in its complex pathogenesis. As presence of these mutations carry a prognostic impact, they are increasingly incorporated in risk-stratification schemes. Novel response criteria have been proposed, considering the unique features of the disease. Although allogeneic hematopoietic stem cell transplantation remains the only treatment with curative intent, it is reserved for a minority of patients; therefore, there is an unmet need for optimizing treatment modalities, such as hypomethylating agents, and introducing novel agents, which could substantially improve survival and quality of life of CMML patients. Clinical trials dedicated specifically to CMML are needed to explore the efficacy and safety of novel treatment modalities.
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Affiliation(s)
- Thomas P Thomopoulos
- 2 Department of Internal Medicine - Propaedeutic and Research Unit, National and Kapodistrian University of Athens, Medical School, University General Hospital "Attikon" , Athens, Greece
| | - Anthi Bouhla
- 2 Department of Internal Medicine - Propaedeutic and Research Unit, National and Kapodistrian University of Athens, Medical School, University General Hospital "Attikon" , Athens, Greece
| | - Sotirios G Papageorgiou
- 2 Department of Internal Medicine - Propaedeutic and Research Unit, National and Kapodistrian University of Athens, Medical School, University General Hospital "Attikon" , Athens, Greece
| | - Vasiliki Pappa
- 2 Department of Internal Medicine - Propaedeutic and Research Unit, National and Kapodistrian University of Athens, Medical School, University General Hospital "Attikon" , Athens, Greece
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22
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Patnaik MM, Lasho TL. Genomics of myelodysplastic syndrome/myeloproliferative neoplasm overlap syndromes. HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2020; 2020:450-459. [PMID: 33275756 PMCID: PMC7727543 DOI: 10.1182/hematology.2020000130] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/13/2023]
Abstract
Myelodysplastic syndrome (MDS)/myeloproliferative neoplasm (MPN) overlap syndromes are uniquely classified neoplasms occurring in both children and adults. This category consists of 5 neoplastic subtypes: chronic myelomonocytic leukemia (CMML), juvenile myelomonocytic leukemia (JMML), BCR-ABL1-negative atypical chronic myeloid leukemia (aCML), MDS/MPN-ring sideroblasts and thrombocytosis (MDS/MPN-RS-T), and MDS/MPN-unclassifiable (U). Cytogenetic abnormalities and somatic copy number variations are uncommon; however, >90% patients harbor gene mutations. Although no single gene mutation is specific to a disease subtype, certain mutational signatures in the context of appropriate clinical and morphological features can be used to establish a diagnosis. In CMML, mutated coexpression of TET2 and SRSF2 results in clonal hematopoiesis skewed toward monocytosis, and the ensuing acquisition of driver mutations including ASXL1, NRAS, and CBL results in overt disease. MDS/MPN-RS-T demonstrates features of SF3B1-mutant MDS with ring sideroblasts (MDS-RS), with the development of thrombocytosis secondary to the acquisition of signaling mutations, most commonly JAK2V617F. JMML, the only pediatric entity, is a bona fide RASopathy, with germline and somatic mutations occurring in the oncogenic RAS pathway giving rise to disease. BCR-ABL1-negative aCML is characterized by dysplastic neutrophilia and is enriched in SETBP1 and ETNK1 mutations, whereas MDS/MPN-U is the least defined and lacks a characteristic mutational signature. Molecular profiling also provides prognostic information, with truncating ASXL1 mutations being universally detrimental and germline CBL mutations in JMML showing spontaneous regression. Sequencing information in certain cases can help identify potential targeted therapies (IDH1, IDH2, and splicing mutations) and should be a mainstay in the diagnosis and management of these neoplasms.
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Affiliation(s)
- Mrinal M Patnaik
- Division of Hematology, Department of Internal Medicine, Mayo Clinic, Rochester, MN
| | - Terra L Lasho
- Division of Hematology, Department of Internal Medicine, Mayo Clinic, Rochester, MN
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23
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Prasad R, Yen TJ, Bellacosa A. Active DNA demethylation-The epigenetic gatekeeper of development, immunity, and cancer. ADVANCED GENETICS (HOBOKEN, N.J.) 2020; 2:e10033. [PMID: 36618446 PMCID: PMC9744510 DOI: 10.1002/ggn2.10033] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 07/06/2020] [Revised: 10/16/2020] [Accepted: 10/16/2020] [Indexed: 01/11/2023]
Abstract
DNA methylation is a critical process in the regulation of gene expression with dramatic effects in development and continually expanding roles in oncogenesis. 5-Methylcytosine was once considered to be an inherited and stably repressive epigenetic mark, which can be only removed by passive dilution during multiple rounds of DNA replication. However, in the past two decades, physiologically controlled DNA demethylation and deamination processes have been identified, thereby revealing the function of cytosine methylation as a highly regulated and complex state-not simply a static, inherited signature or binary on-off switch. Alongside these fundamental discoveries, clinical studies over the past decade have revealed the dramatic consequences of aberrant DNA demethylation. In this review we discuss DNA demethylation and deamination in the context of 5-methylcytosine as critical processes for physiological and physiopathological transitions within three states-development, immune maturation, and oncogenic transformation; and we describe the expanding role of DNA demethylating drugs as therapeutic agents in cancer.
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Affiliation(s)
- Rahul Prasad
- Cancer Epigenetics and Cancer Biology Programs, Fox Chase Cancer CenterPhiladelphiaPennsylvaniaUSA
| | - Timothy J. Yen
- Cancer Epigenetics and Cancer Biology Programs, Fox Chase Cancer CenterPhiladelphiaPennsylvaniaUSA
| | - Alfonso Bellacosa
- Cancer Epigenetics and Cancer Biology Programs, Fox Chase Cancer CenterPhiladelphiaPennsylvaniaUSA
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24
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Jiang Z, Sun X, Wu Z, Alhatem A, Zheng R, Liu D, Wang Y, Kumar D, Xia C, You B, Wang H, Liu C, Jiang JG. Cytogenetic and molecular landscape and its potential clinical significance in Hispanic CMML patients from Puerto Rico. Oncotarget 2020; 11:4411-4420. [PMID: 33315966 PMCID: PMC7720771 DOI: 10.18632/oncotarget.27824] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2020] [Accepted: 11/12/2020] [Indexed: 12/21/2022] Open
Abstract
Chronic myelomonocytic leukemia (CMML) is a clonal hematopoietic neoplasm that exhibits myelodysplastic and myeloproliferative characteristics with heterogeneous clinical and pathological features. There are limited publications on the ethnic and racial disparity of cytogenetics and genomics in CMML patients. This study aims to define the cytogenetic and molecular landscape in Hispanic CMML patients from Puerto Rico and explore its possible clinical significance. One hundred and eleven (111) Hispanic CMML patients from Puerto Rico were diagnosed in our institute from 2009 to 2018. Karyotypes were available in one hundred and seven (107) patients. Seventeen (17) patients had abnormal karyotypes (17/107, 16%). Compared to previously published data, Hispanic CMML patients in this study had significantly lower rates of overall cytogenetic abnormalities (16% vs 27-28%, p < 0.05) and trisomy 8 (2% vs 7%, p < 0.05). Among one hundred and eleven (111) Hispanic CMML patients, 40-gene myeloid molecular profile tests were performed in fifty-six (56) CMML patients. Gene mutations were identified in fifty-four (54) patients (96%). The most frequent mutated genes were: TET2, SRSF2, ASXL1, ZRSR2, DNMT3A, NRAS, CBL, and RUNX1. Twenty-nine (29) out of fifty-six (56) patients (29/56, 52%) had mutated TET2/wild type ASXL1 (muTET2/wtASXL1). Previous studies indicated that mutated ASXL1, DNMT3A, NRAS, RUNX1, and SETBP1 may associate with an unfavorable prognosis and muTET2/wtASXL1 may associate with a favorable prognosis in CMML patients. Compared to previously published data, Hispanic CMML patients from Puerto Rico in this study had significantly lower mutation rates in ASXL1 and SETBP1, and a higher rate of muTET2/wtASXL1. The findings raise the possibility of a favorable prognosis in Hispanic CMML patients.
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Affiliation(s)
- Zeju Jiang
- Department of Pathology, Immunology & Laboratory Medicine, Rutgers New Jersey Medical School, Newark, NJ 07103, USA.,Jiangxi Medical College, Nanchang University, Nanchang 330006, Jiangxi, China
| | - Xinlai Sun
- Department of Pathology, Immunology & Laboratory Medicine, Rutgers New Jersey Medical School, Newark, NJ 07103, USA
| | - Zhao Wu
- Neogenomics, Carlsbad, CA 92008, USA
| | - Albert Alhatem
- Department of Pathology, Immunology & Laboratory Medicine, Rutgers New Jersey Medical School, Newark, NJ 07103, USA
| | - Ruifang Zheng
- Department of Pathology, Immunology & Laboratory Medicine, Rutgers New Jersey Medical School, Newark, NJ 07103, USA
| | - Dongfang Liu
- Department of Pathology, Immunology & Laboratory Medicine, Rutgers New Jersey Medical School, Newark, NJ 07103, USA
| | - Yaqun Wang
- Department of Biostatistics, Rutgers School of Public Health and Rutgers Cancer Institute of New Jersey, New Brunswick, NJ 08901, USA
| | - Dibyendu Kumar
- Institute of Genomics Medicine, New Jersey Medical School, Rutgers University, Newark, NJ 07103, USA
| | - Changqing Xia
- Institute of Genomics Medicine, New Jersey Medical School, Rutgers University, Newark, NJ 07103, USA
| | - Bei You
- Department of Pathology, Immunology & Laboratory Medicine, Rutgers New Jersey Medical School, Newark, NJ 07103, USA
| | - He Wang
- Department of Pathology and Laboratory Medicine, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ 08903, USA
| | - Chen Liu
- Department of Pathology, School of Medicine, Yale University, New Haven, CT 06520, USA
| | - Jie-Gen Jiang
- Department of Pathology, Immunology & Laboratory Medicine, Rutgers New Jersey Medical School, Newark, NJ 07103, USA.,Institute of Genomics Medicine, New Jersey Medical School, Rutgers University, Newark, NJ 07103, USA
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25
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Sanz GF, Ibañez M, Mora E. Are next-generation sequencing results knocking on Heaven's door for transplantation planning in chronic myelomonocytic leukemia? Haematologica 2020; 105:530-533. [PMID: 32115412 DOI: 10.3324/haematol.2019.240853] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Affiliation(s)
- Guillermo F Sanz
- Department of Hematology, Hospital Universitario y Politécnico La Fe, Valencia.,Instituto de Investigación Sanitaria La Fe, Valencia.,Department of Medicine, University of Valencia, Valencia.,Centro de Investigación Biomédica en Red de Cáncer, CIBERONC, Instituto de Salud Carlos III, Madrid
| | - Mariam Ibañez
- Department of Hematology, Hospital Universitario y Politécnico La Fe, Valencia.,Instituto de Investigación Sanitaria La Fe, Valencia.,Centro de Investigación Biomédica en Red de Cáncer, CIBERONC, Instituto de Salud Carlos III, Madrid.,Departamento de Ciencias Biomédicas, Facultad de Ciencias de la Salud, Universidad CEU Cardenal Herrera, Valencia, Spain
| | - Elvira Mora
- Department of Hematology, Hospital Universitario y Politécnico La Fe, Valencia.,Instituto de Investigación Sanitaria La Fe, Valencia
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Effective drug treatment identified by in vivo screening in a transplantable patient-derived xenograft model of chronic myelomonocytic leukemia. Leukemia 2020; 34:2951-2963. [PMID: 32576961 PMCID: PMC7116758 DOI: 10.1038/s41375-020-0929-3] [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: 12/20/2019] [Revised: 06/03/2020] [Accepted: 06/11/2020] [Indexed: 12/13/2022]
Abstract
To establish novel and effective treatment combinations for chronic myelomonocytic leukemia (CMML) preclinically, we hypothesized that supplementation of CMML cells with the human oncogene Meningioma 1 (MN1) promotes expansion and serial transplantability in mice, while maintaining the functional dependencies of these cells on their original genetic profile. Using lentiviral expression of MN1 for oncogenic supplementation and transplanting transduced primary mononuclear CMML cells into immunocompromised mice, we established three serially transplantable CMML-PDX models with disease-related gene mutations that recapitulate the disease in vivo. Ectopic MN1 expression was confirmed to enhance the proliferation of CMML cells, which otherwise did not engraft upon secondary transplantation. Furthermore, MN1-supplemented CMML cells were serially transplantable into recipient mice up to 5 generations. This robust engraftment enabled an in vivo RNA interference screening targeting CMML-related mutated genes including NRAS, confirming that their functional relevance is preserved in the presence of MN1. The novel combination treatment with azacitidine and the MEK-inhibitor trametinib additively inhibited ERK-phosphorylation and thus depleted the signal from mutated NRAS. The combination treatment significantly prolonged survival of CMML mice compared to single-agent treatment. Thus, we identified the combination of azacitidine and trametinib as an effective treatment in NRAS-mutated CMML and propose its clinical development.
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27
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Song J, Hussaini M, Qin D, Zhang X, Shao H, Zhang L, Gajzer D, Basra P, Moscinski L, Zhang H. Comparison of SF3B1/DNMT3A Comutations With DNMT3A or SF3B1 Mutation Alone in Myelodysplastic Syndrome and Clonal Cytopenia of Undetermined Significance. Am J Clin Pathol 2020; 154:48-56. [PMID: 32112088 DOI: 10.1093/ajcp/aqaa016] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
OBJECTIVES To compare the clinical significance of SF3B1/DNMT3A Comutations with SF3B1 or DNMT3A mutation alone in myelodysplastic syndrome (MDS) and clonal cytopenia of undetermined significance (CCUS). METHODS We identified and compared 31 patients with only DNMT3A mutation, 48 patients with only SF3B1 mutation, and 16 patients with only SF3B1/DNMT3A comutations. RESULTS SF3B1/DNMT3A comutations were found to be more common in MDS, whereas DNMT3A mutation alone was more common in CCUS. The patients with SF3B1/DNMT3A comutations were less likely to have poor cytogenetics than patients with DNMT3A mutation alone. Patients with SF3B1/DNMT3A comutations showed significantly longer median survival time and better overall survival than patients with DNMT3A mutation alone. CONCLUSIONS Patients with SF3B1/DNMT3A comutations appear to have better clinical outcomes than patients with isolated DNMT3A mutation. These findings suggest that the favorable prognosis of SF3B1 mutation in is not abrogated by the concurrent presence of a DNMT3A mutation.
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Affiliation(s)
- Jinming Song
- Department of Hematopathology and Lab Medicine, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL
| | - Mohammad Hussaini
- Department of Hematopathology and Lab Medicine, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL
| | - Dahui Qin
- Department of Hematopathology and Lab Medicine, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL
| | - Xiaohui Zhang
- Department of Hematopathology and Lab Medicine, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL
| | - Haipeng Shao
- Department of Hematopathology and Lab Medicine, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL
| | - Ling Zhang
- Department of Hematopathology and Lab Medicine, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL
| | - David Gajzer
- Department of Hematopathology and Lab Medicine, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL
| | - Pukhraz Basra
- Department of Hematopathology and Lab Medicine, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL
| | - Lynn Moscinski
- Department of Hematopathology and Lab Medicine, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL
| | - Hailing Zhang
- Department of Hematopathology and Lab Medicine, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL
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28
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Patnaik MM, Tefferi A. Chronic Myelomonocytic leukemia: 2020 update on diagnosis, risk stratification and management. Am J Hematol 2020; 95:97-115. [PMID: 31736132 DOI: 10.1002/ajh.25684] [Citation(s) in RCA: 87] [Impact Index Per Article: 21.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2019] [Accepted: 11/13/2019] [Indexed: 12/12/2022]
Abstract
DISEASE OVERVIEW Chronic myelomonocytic leukemia (CMML) is a clonal hematopoietic stem cell disorder with overlapping features of myelodysplastic syndromes and myeloproliferative neoplasms, with an inherent risk for leukemic transformation (~15% over 3-5 years). DIAGNOSIS Diagnosis is based on the presence of sustained (>3 months) peripheral blood monocytosis (≥1 × 109 /L; monocytes ≥10%), along with bone marrow dysplasia. Clonal cytogenetic abnormalities occur in ~ 30% of patients, while >90% have gene mutations. Mutations involving TET2 (~60%), SRSF2 (~50%), ASXL1 (~40%) and the oncogenic RAS pathway (~30%) are frequent; while the presence of ASXL1 and DNMT3A mutations and the absence of TET2 mutations negatively impact over-all survival. RISK STRATIFICATION Molecularly integrated prognostic models include; the Groupe Français des Myélodysplasies (GFM), Mayo Molecular Model (MMM) and the CMML specific prognostic model (CPSS-Mol). Risk factors incorporated into the MMM include presence of nonsense or frameshift ASXL1 mutations, absolute monocyte count>10 × 109 /L, hemoglobin <10 g/dL, platelet count <100 × 109 /L and the presence of circulating immature myeloid cells. The MMM stratifies CMML patients into four groups; high (≥3 risk factors), intermediate-2 (2 risk factors), intermediate-1 (1 risk factor) and low (no risk factors), with median survivals of 16, 31, 59 and 97 months, respectively. RISK-ADAPTED THERAPY Hypomethylating agents such as 5-azacitidine and decitabine are commonly used, with overall response rates of ~40%-50% and complete remission rates of ~7%-17%; with no impact on mutational allele burdens. Allogeneic stem cell transplant is the only potentially curative option, but is associated with significant morbidity and mortality.
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Affiliation(s)
- Mrinal M. Patnaik
- Division of Hematology, Department of MedicineMayo Clinic Rochester Minnesota
| | - Ayalew Tefferi
- Division of Hematology, Department of MedicineMayo Clinic Rochester Minnesota
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29
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Moving towards a uniform risk stratification system in CMML - How far are we? Best Pract Res Clin Haematol 2019; 33:101131. [PMID: 32460982 DOI: 10.1016/j.beha.2019.101131] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2019] [Revised: 11/29/2019] [Accepted: 12/02/2019] [Indexed: 11/20/2022]
Abstract
Many prognostic scoring systems have been developed for chronic myelomonocytic leukemia (CMML). Although these efforts have been informative, no single model has been considered the consensus for CMML prognostication and all models are only moderately prognostic. CMML clinical models utilize mainly hematology and morphology parameters to estimate risk. A better understanding of cytogenetics and the genomic landscape of CMML have resulted in integrated risk models such as CMML Prognostic Scoring System (CPSS)-Mol and Mayo Molecular that may provide better prognostic accuracy for an individual patient. For example, frameshift/nonsense ASXL1 mutations have been consistently shown to confer inferior outcomes leading to its incorporation into some of the major risk classification systems. Prognostication in the setting of therapeutic interventions such as hypomethylating agents and allogeneic hematopoietic cell transplantation have also garnered considerable interest. Despite having many validated risk models available, not a single system is universally adopted. Herein, we will provide an overview of how these systems evolved and progress toward a uniform system.
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30
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Chronic Myelomonocytic Leukemia: Insights into Biology, Prognostic Factors, and Treatment. Curr Oncol Rep 2019; 21:101. [DOI: 10.1007/s11912-019-0855-6] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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31
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Palomo L, Ibáñez M, Abáigar M, Vázquez I, Álvarez S, Cabezón M, Tazón-Vega B, Rapado I, Fuster-Tormo F, Cervera J, Benito R, Larrayoz MJ, Cigudosa JC, Zamora L, Valcárcel D, Cedena MT, Acha P, Hernández-Sánchez JM, Fernández-Mercado M, Sanz G, Hernández-Rivas JM, Calasanz MJ, Solé F, Such E. Spanish Guidelines for the use of targeted deep sequencing in myelodysplastic syndromes and chronic myelomonocytic leukaemia. Br J Haematol 2019; 188:605-622. [PMID: 31621063 PMCID: PMC7064979 DOI: 10.1111/bjh.16175] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2019] [Revised: 07/04/2019] [Accepted: 07/06/2019] [Indexed: 12/20/2022]
Abstract
The landscape of medical sequencing has rapidly changed with the evolution of next generation sequencing (NGS). These technologies have contributed to the molecular characterization of the myelodysplastic syndromes (MDS) and chronic myelomonocytic leukaemia (CMML), through the identification of recurrent gene mutations, which are present in >80% of patients. These mutations contribute to a better classification and risk stratification of the patients. Currently, clinical laboratories include NGS genomic analyses in their routine clinical practice, in an effort to personalize the diagnosis, prognosis and treatment of MDS and CMML. NGS technologies have reduced the cost of large-scale sequencing, but there are additional challenges involving the clinical validation of these technologies, as continuous advances are constantly being made. In this context, it is of major importance to standardize the generation, analysis, clinical interpretation and reporting of NGS data. To that end, the Spanish MDS Group (GESMD) has expanded the present set of guidelines, aiming to establish common quality standards for the adequate implementation of NGS and clinical interpretation of the results, hoping that this effort will ultimately contribute to the benefit of patients with myeloid malignancies.
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Affiliation(s)
- Laura Palomo
- Josep Carreras Leukaemia Research Institute, ICO Badalona-Hospital Germans Trias i Pujol, Universitat Autònoma de Barcelona, Sadalona, Spain
| | - Mariam Ibáñez
- Department of Haematology, Hospital Universitari i Politècnic La Fe, València, Spain.,Centro de Investigacion Biomédica en Red de Cáncer (CIBERONC), Instituto Carlos III, Madrid, Spain.,Departamento de Ciencias Biomédicas, Facultad de Ciencias de la Salud, Universidad CEU Cardenal Herrera, València, Spain
| | - María Abáigar
- Institute of Biomedical Research of Salamanca (IBSAL), Cancer Research Centre (IBMCC-CIC; Univ. of Salamanca-CSIC), Salamanca, Spain
| | - Iria Vázquez
- Haematological Diseases Laboratory, CIMA LAB Diagnostics, University of Navarra, Pamplona, Spain.,Navarra Institute for Health Research (IdiSNA), Pamplona, Spain
| | - Sara Álvarez
- NIMGenetics, Genómica y Medicina, S.L., Madrid, Spain
| | - Marta Cabezón
- Haematology Service, ICO Badalona-Hospital Germans Trias i Pujol, Josep Carreras Leukaemia Research Institute, Badalona, Spain
| | - Bárbara Tazón-Vega
- Department of Haematology, Vall d'Hebron Institute of Oncology, Vall d'Hebron University Hospital, Barcelona, Spain.,Department of Medicine, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Inmaculada Rapado
- Haematology Department, Hospital Universitario 12 de Octubre, Madrid, Spain.,Haematological Malignancies Clinical Research Unit, CNIO, Madrid, Spain.,Centro de investigación Biomédica en Red Cáncer (CIBERONC), Madrid, Spain
| | - Francisco Fuster-Tormo
- Josep Carreras Leukaemia Research Institute, ICO Badalona-Hospital Germans Trias i Pujol, Universitat Autònoma de Barcelona, Sadalona, Spain
| | - José Cervera
- Department of Haematology, Hospital Universitari i Politècnic La Fe, València, Spain.,Centro de Investigacion Biomédica en Red de Cáncer (CIBERONC), Instituto Carlos III, Madrid, Spain.,Genetics Unit, Hospital Universitario y Politécnico La Fe, Valencia, Spain
| | - Rocío Benito
- Institute of Biomedical Research of Salamanca (IBSAL), Cancer Research Centre (IBMCC-CIC; Univ. of Salamanca-CSIC), Salamanca, Spain
| | - María J Larrayoz
- Haematological Diseases Laboratory, CIMA LAB Diagnostics, University of Navarra, Pamplona, Spain.,Navarra Institute for Health Research (IdiSNA), Pamplona, Spain
| | | | - Lurdes Zamora
- Haematology Service, ICO Badalona-Hospital Germans Trias i Pujol, Josep Carreras Leukaemia Research Institute, Badalona, Spain
| | - David Valcárcel
- Department of Haematology, Vall d'Hebron Institute of Oncology, Vall d'Hebron University Hospital, Barcelona, Spain.,Department of Medicine, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - María T Cedena
- Haematology Department, Hospital Universitario 12 de Octubre, Madrid, Spain.,Haematological Malignancies Clinical Research Unit, CNIO, Madrid, Spain.,Centro de investigación Biomédica en Red Cáncer (CIBERONC), Madrid, Spain
| | - Pamela Acha
- Josep Carreras Leukaemia Research Institute, ICO Badalona-Hospital Germans Trias i Pujol, Universitat Autònoma de Barcelona, Sadalona, Spain
| | - Jesús M Hernández-Sánchez
- Institute of Biomedical Research of Salamanca (IBSAL), Cancer Research Centre (IBMCC-CIC; Univ. of Salamanca-CSIC), Salamanca, Spain.,University of Salamanca (USAL), Salamanca, Spain
| | - Marta Fernández-Mercado
- Haematological Diseases Laboratory, CIMA LAB Diagnostics, University of Navarra, Pamplona, Spain.,Advanced Genomics Laboratory, Centre for Applied Medical Research (CIMA), University of Navarra, Haemato-Oncology, Pamplona, Spain.,Biomedical Engineering Department, School of Engineering, University of Navarra, San Sebastian, Spain
| | - Guillermo Sanz
- Department of Haematology, Hospital Universitari i Politècnic La Fe, València, Spain.,Centro de Investigacion Biomédica en Red de Cáncer (CIBERONC), Instituto Carlos III, Madrid, Spain
| | - Jesús M Hernández-Rivas
- Institute of Biomedical Research of Salamanca (IBSAL), Cancer Research Centre (IBMCC-CIC; Univ. of Salamanca-CSIC), Salamanca, Spain.,University of Salamanca (USAL), Salamanca, Spain.,Hospital Universitario de Salamanca, Salamanca, Spain
| | - María J Calasanz
- Haematological Diseases Laboratory, CIMA LAB Diagnostics, University of Navarra, Pamplona, Spain.,Navarra Institute for Health Research (IdiSNA), Pamplona, Spain
| | - Francesc Solé
- Josep Carreras Leukaemia Research Institute, ICO Badalona-Hospital Germans Trias i Pujol, Universitat Autònoma de Barcelona, Sadalona, Spain
| | - Esperanza Such
- Department of Haematology, Hospital Universitari i Politècnic La Fe, València, Spain.,Centro de Investigacion Biomédica en Red de Cáncer (CIBERONC), Instituto Carlos III, Madrid, Spain.,Departamento de Ciencias Biomédicas, Facultad de Ciencias de la Salud, Universidad CEU Cardenal Herrera, València, Spain
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32
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Prognostic significance of DNMT3A alterations in Middle Eastern papillary thyroid carcinoma. Eur J Cancer 2019; 117:133-144. [DOI: 10.1016/j.ejca.2019.05.025] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2019] [Revised: 05/16/2019] [Accepted: 05/22/2019] [Indexed: 12/24/2022]
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33
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Hwang SM, Kim SM, Nam Y, Kim J, Kim S, Ahn YO, Park Y, Yoon SS, Shin S, Kwon S, Lee DS. Targeted sequencing aids in identifying clonality in chronic myelomonocytic leukemia. Leuk Res 2019; 84:106190. [PMID: 31377458 DOI: 10.1016/j.leukres.2019.106190] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2019] [Revised: 07/10/2019] [Accepted: 07/12/2019] [Indexed: 11/19/2022]
Abstract
Chronic myelomonocytic leukemia (CMML) typically shows monocytosis in the peripheral blood (PB), which must be differentiated from reactive monocytosis. To determine the clonality of CMML, we performed molecular and cytogenetic analysis in Korean patients. To investigate whether monocytes in the PB harbored clonal mutational changes, we performed single-cell sequencing after selecting monocytes, neutrophils, and lymphocytes by morphology-aided laser microdissection. Targeted sequencing was performed in 35 patients with CMML with 41 bone marrow samples. Single-cell analysis was performed in two cases. Most (94.3%) patients harbored at least one variant, in genes considered as potential therapeutic targets, while cytogenetic aberrations occurred in only 28.6% of cases. ASXL1 (54.3%), SRSF2 (37.1%), NRAS (31.4%), and TET2 (25.7%) were frequently mutated, with lower frequencies of TET2 mutation and higher frequencies of NRAS, DNMT3A (17.1%), and NPM1 (11.4%) mutations compared to in previous studies of Caucasians. Patients with SETBP1 mutation and those with more than two variants showed poorer survival than those without mutation (P < 0.001 and P = 0.007, respectively). Most (70.8%) variants were detected at diagnosis and follow-up with no significant differences in variant allele frequency, warranting sequencing during follow-up if diagnostic samples were unavailable. Single-cell analysis revealed clonal monocytes with mutations, and the same mutations were also identified in lymphocytes and neutrophils. Targeted sequencing aided in clonality detection in most patients with CMML and single-cell sequencing facilitated identification of clonal monocytes and the co-existence of mutations in non-myeloid cells, suggesting that certain mutations are acquired by pluripotent stem cells.
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Affiliation(s)
- Sang Mee Hwang
- Department of Laboratory Medicine, Seoul National University Bundang Hospital, Seongnam, Republic of Korea; Department of Laboratory Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Sung-Min Kim
- Cancer Research Institute, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Youngwon Nam
- Department of Laboratory Medicine, Seoul National University Bundang Hospital, Seongnam, Republic of Korea; Department of Laboratory Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Jinhyun Kim
- Department of Electrical and Computer Engineering, Seoul National University, Seoul, Republic of Korea
| | - Sungsik Kim
- Interdisciplinary Program for Bioengineering, Seoul National University, Seoul, Republic of Korea
| | - Yong-Oon Ahn
- Cancer Research Institute, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Yong Park
- Department of Internal Medicine, Korea University College of Medicine, Seoul, Republic of Korea
| | - Sung-Soo Yoon
- Cancer Research Institute, Seoul National University College of Medicine, Seoul, Republic of Korea; Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Sue Shin
- Department of Laboratory Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea; Department of Laboratory Medicine, Seoul National University Boramae Hospital, Seoul, Republic of Korea
| | - Sunghoon Kwon
- Department of Electrical and Computer Engineering, Seoul National University, Seoul, Republic of Korea
| | - Dong Soon Lee
- Department of Laboratory Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea; Cancer Research Institute, Seoul National University College of Medicine, Seoul, Republic of Korea.
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34
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Coston T, Pophali P, Vallapureddy R, Lasho TL, Finke CM, Ketterling RP, Carr R, Binder M, Mangaonkar AA, Gangat N, Al‐Kali A, Litzow M, Zblewski D, Pardanani A, Tefferi A, Patnaik MM. Suboptimal response rates to hypomethylating agent therapy in chronic myelomonocytic leukemia; a single institutional study of 121 patients. Am J Hematol 2019; 94:767-779. [PMID: 30964202 DOI: 10.1002/ajh.25488] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2019] [Revised: 04/03/2019] [Accepted: 04/04/2019] [Indexed: 12/21/2022]
Abstract
Hypomethylating agents (HMA) are currently the only FDA approved therapy for patients with chronic myelomonocytic leukemia (CMML). In the current retrospective study, we assessed response rates as adjudicated by the IWG (International Working Group) MDS (myelodysplastic syndrome) and MDS/MPN myeloproliferative neoplasm overlap syndrome response criteria, in 121 CMML patients treated with Azacitidine (AZA, n = 56) and Decitabine (DAC, n = 65). The overall response rates were 41% by the IWG MDS (AZA- 45%, DAC-39%), and 56% by the IWG MDS/MPN (AZA-56%, DAC-58%) response criteria, with CR (complete remission) rates of <20% for both agents, by both criteria. There were no significant differences in response rates between proliferative and dysplastic CMML. Moreover, 29% of CMML patients in a CR with HMA progressed to AML (blast transformation), underscoring the limited impact of these agents on disease biology. Progression after HMA response was associated with a median overall-survival (OS) of 8 months, while median OS in patients with primary HMA failure was 4 months. Lower serum LDH levels (<250 Units/L) were associated with HMA responses by both criteria; while ASXL1 and TET2 mutational status had no impact. HMA treated patients had a longer median OS (31 vs 18 months; P = .01), in comparison to those treated with conventional care regimens (excluding observation only patients), without any differences between AZA vs DAC (P = .37). In conclusion, this study highlights the inadequacies of HMA therapy in CMML, retrospectively validates the IWG MDS/MPN response criteria and underscores the need for newer, rationally derived therapies.
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Affiliation(s)
- Tucker Coston
- Division of Hematology, Department of Internal MedicineMayo Clinic Rochester Minnesota
| | - Prateek Pophali
- Division of Hematology, Department of Internal MedicineMayo Clinic Rochester Minnesota
| | - Rangit Vallapureddy
- Division of Hematology, Department of Internal MedicineMayo Clinic Rochester Minnesota
| | - Terra L. Lasho
- Division of Hematology, Department of Internal MedicineMayo Clinic Rochester Minnesota
| | - Christy M. Finke
- Division of Hematology, Department of Internal MedicineMayo Clinic Rochester Minnesota
| | - Rhett P. Ketterling
- Division of Hematopathology, Department of Laboratory MedicineMayo Clinic Rochester Minnesota
| | - Ryan Carr
- Division of Hematology, Department of Internal MedicineMayo Clinic Rochester Minnesota
| | - Moritz Binder
- Division of Hematology, Department of Internal MedicineMayo Clinic Rochester Minnesota
| | | | - Naseema Gangat
- Division of Hematology, Department of Internal MedicineMayo Clinic Rochester Minnesota
| | - Aref Al‐Kali
- Division of Hematology, Department of Internal MedicineMayo Clinic Rochester Minnesota
| | - Mark Litzow
- Division of Hematology, Department of Internal MedicineMayo Clinic Rochester Minnesota
| | - Darci Zblewski
- Division of Hematology, Department of Internal MedicineMayo Clinic Rochester Minnesota
| | - Animesh Pardanani
- Division of Hematology, Department of Internal MedicineMayo Clinic Rochester Minnesota
| | - Ayalew Tefferi
- Division of Hematology, Department of Internal MedicineMayo Clinic Rochester Minnesota
| | - Mrinal M. Patnaik
- Division of Hematology, Department of Internal MedicineMayo Clinic Rochester Minnesota
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Abstract
PURPOSE OF REVIEW The goal of this review is to provide a practical and comprehensive update on changes in the classification of chronic myelomonocytic leukemia (CMML) and a summary of the most recent developments in our understanding of its genomic landscape, prognostic models, and therapeutic approaches. RECENT FINDINGS The 2017 revision of the World Health Organization (WHO) classification includes substantial changes to the subclassification CMML. The clinical utility of the newly revised subclassification scheme is discussed. In addition, we provide an overview of the genetic changes involved in the pathogenesis of CMML and discuss the clinical utility of the more recently developed molecularly integrated prognostic models and their management and therapeutic implications. Finally, we provide an overview of the currently available treatment options for patients with CMML. The classification of CMML as well as our understanding of its genomic landscape and optimal treatment approaches has advanced significantly over the past decade but remains in flux.
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Affiliation(s)
- Sanam Loghavi
- Department of Hematopathology, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd. Unit 0072, Houston, TX, 77030, USA.
| | - Joseph D Khoury
- Department of Hematopathology, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd. Unit 0072, Houston, TX, 77030, USA.
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36
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Arber DA, Orazi A. Update on the pathologic diagnosis of chronic myelomonocytic leukemia. Mod Pathol 2019; 32:732-740. [PMID: 30723295 DOI: 10.1038/s41379-019-0215-y] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2018] [Revised: 01/03/2019] [Accepted: 01/12/2019] [Indexed: 12/15/2022]
Abstract
The diagnostic criteria for chronic myelomonocytic leukemia were recently revised in the 2016 World Health Organization classification update and include new and revised subtypes. In addition, molecular genetic studies have provided new insights into the prognosis and diagnosis of this myeloid neoplasm. This review summarizes the 2016 changes to the diagnostic criteria, discusses potential future changes that may impact diagnosis and provides an overview of recent advances in the diagnosis and prognosis determination of chronic myelomonocytic leukemia.
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Affiliation(s)
- Daniel A Arber
- Department of Pathology, University of Chicago, Chicago, IL, USA.
| | - Attilio Orazi
- Department of Pathology, Texas Tech Health Sciences Center, El Paso, TX, USA
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37
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Patnaik MM, Pophali PA, Lasho TL, Finke CM, Horna P, Ketterling RP, Gangat N, Mangaonkar AA, Pardanani A, Tefferi A. Clinical correlates, prognostic impact and survival outcomes in chronic myelomonocytic leukemia patients with the JAK2V617F mutation. Haematologica 2019; 104:e236-e239. [PMID: 30606787 DOI: 10.3324/haematol.2018.208082] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Affiliation(s)
| | | | | | | | - Pedro Horna
- Division of Hematopathology, Department of Laboratory Medicine and Pathology
| | - Rhett P Ketterling
- Division of Cytogenetics, Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, USA
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39
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Pophali P, Horna P, Lasho TL, Finke CM, Ketterling RP, Gangat N, Nagorney D, Tefferi A, Patnaik MM. Splenectomy in patients with chronic myelomonocytic leukemia: Indications, histopathological findings and clinical outcomes in a single institutional series of thirty-nine patients. Am J Hematol 2018; 93:1347-1357. [PMID: 30105755 PMCID: PMC6196105 DOI: 10.1002/ajh.25246] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2018] [Revised: 08/03/2018] [Accepted: 08/06/2018] [Indexed: 12/13/2022]
Abstract
In a 28-year period, 39 (7%) patients with chronic myelomonocytic leukemia (CMML) (median age 66 years, 64% male) underwent a splenectomy at our institution. Primary indications for splenectomy were refractory thrombocytopenia (36%), progressive spleen related symptoms (33%), emergent splenectomy for splenic rupture (21%), refractory anemia (8%), and prior to allogeneic stem cell transplant (3%). Eleven (28%) patients had anemia at the time of splenectomy, of which 3 (27%) were autoimmune. The median time to splenectomy from CMML diagnosis was 6 months (0-40); perioperative morbidity and mortality rates were 43% and 13%, while the median postsplenectomy survival was 25 months (11-38). Durable remission in spleen related symptoms, thrombocytopenia, complications from splenic rupture, and anemia were achieved in 85%, 50%, 62%, and 21% of patients, respectively. Perioperative morbidity (n = 30) included infections/sepsis in 6 (20%), intraabdominal bleeding in 4 (13%), venous thromboembolism (VTE) in 3 (10%), and acute lung injury in 2 (7%) patients. The median duration of hospital stay was 6 days (1-25), with 5 deaths occurring secondary to respiratory failure (n = 2), multiorgan dysfunction (n = 2) and hemorrhagic shock (n = 1). There was no difference in overall survival between CMML patients that underwent splenectomy, in comparison to those that did not. Unlike in myelofibrosis, portal hypertension was not an indication for splenectomy and no patients developed post-splenectomy thrombocytosis. In conclusion, apart from being a lifesaving emergent modality in the event of splenic rupture, splenectomy has an important palliative role in patients with CMML, with significant and durable improvements in spleen related symptoms and refractory cytopenias.
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Affiliation(s)
- Prateek Pophali
- Division of Hematology, Department of Internal Medicine,
Mayo Clinic, Rochester, MN
| | - Pedro Horna
- Division of Hematopathology, Department of Laboratory
Medicine, Mayo Clinic, Rochester, MN
| | - Terra L. Lasho
- Division of Hematology, Department of Internal Medicine,
Mayo Clinic, Rochester, MN
| | - Christy M. Finke
- Division of Hematology, Department of Internal Medicine,
Mayo Clinic, Rochester, MN
| | - Rhett P. Ketterling
- Division of Hematopathology, Department of Laboratory
Medicine, Mayo Clinic, Rochester, MN
| | - Naseema Gangat
- Division of Hematology, Department of Internal Medicine,
Mayo Clinic, Rochester, MN
| | - David Nagorney
- Department of General Surgery, Mayo Clinic, Rochester,
MN
| | - Ayalew Tefferi
- Division of Hematology, Department of Internal Medicine,
Mayo Clinic, Rochester, MN
| | - Mrinal M. Patnaik
- Division of Hematology, Department of Internal Medicine,
Mayo Clinic, Rochester, MN
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Geevarghese A, Mascarenhas J. Evolving Understanding of Chronic Myelomonocytic Leukemia: Implications for Future Treatment Paradigms. CLINICAL LYMPHOMA MYELOMA & LEUKEMIA 2018; 18:519-527. [PMID: 29891120 DOI: 10.1016/j.clml.2018.05.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/03/2018] [Revised: 04/26/2018] [Accepted: 05/14/2018] [Indexed: 11/29/2022]
Abstract
Chronic myelomonocytic leukemia (CMML) is a relatively uncommon hematologic malignancy that manifests as peripheral monocytosis, has varying degrees of bone marrow dysplasia, and is associated with poor outcomes. Despite a growing appreciation of the pathobiologic mechanisms driving CMML, current therapies have not clearly demonstrated any survival benefit. The complex pathobiology of CMML highlights the intricate aberrantly activated cellular pathways that influence disease phenotype and limit current treatment options. Understanding of these oncogenic pathways may provide novel mechanism-based treatment strategies that may ultimately offer better outcomes for patients. We reviewed the current diagnostic, prognostic, and molecular understandings, and we assessed the current and future treatment options for CMML.
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Affiliation(s)
- Anita Geevarghese
- Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY
| | - John Mascarenhas
- Myeloproliferative Disorders Clinical Research Program, Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY.
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41
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Patnaik MM, Tefferi A. Chronic myelomonocytic leukemia: 2018 update on diagnosis, risk stratification and management. Am J Hematol 2018; 93:824-840. [PMID: 29878489 DOI: 10.1002/ajh.25104] [Citation(s) in RCA: 88] [Impact Index Per Article: 14.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2018] [Accepted: 04/02/2018] [Indexed: 12/20/2022]
Abstract
DISEASE OVERVIEW Chronic myelomonocytic leukemia (CMML) is a clonal hematopoietic stem cell disorder with overlapping features of myelodysplastic syndromes and myeloproliferative neoplasms, with an inherent risk for leukemic transformation (∼15%-20% over 3-5 years). DIAGNOSIS Diagnosis is based on the presence of sustained (>3 months) peripheral blood monocytosis (≥1 × 109 /L; monocytes ≥10%), along with bone marrow dysplasia. Clonal cytogenetic abnormalities occur in ∼ 30% of patients, while >90% have gene mutations. Mutations involving TET2 (∼60%), SRSF2 (∼50%), ASXL1 (∼40%) and the oncogenic RAS pathway (∼30%) are frequent; while the presence of ASXL1 and DNMT3A mutations and the absence of TET2 mutations negatively impact over-all survival. RISK STRATIFICATION Molecularly integrated prognostic models include; the Groupe Français des Myélodysplasies (GFM), Mayo Molecular Model (MMM), and the CMML specific prognostic model (CPSS-Mol). Risk factors incorporated into the MMM include presence of nonsense or frameshift ASXL1 mutations, absolute monocyte count > 10 × 109 /L, hemoglobin <10 gm/dL, platelet count <100 × 109 /L and the presence of circulating immature myeloid cells. The MMM stratifies CMML patients into 4 groups; high (≥3 risk factors), intermediate-2 (2 risk factors), intermediate-1 (1 risk factor), and low (no risk factors), with median survivals of 16, 31, 59, and 97 months, respectively. RISK-ADAPTED THERAPY Hypomethylating agents such as 5-azacitidine and decitabine are commonly used, with overall response rates of ∼30%-40% and complete remission rates of ∼7%-17%; with no impact on mutational allele burdens. Allogeneic stem cell transplant is the only potentially curative option, but is associated with significant morbidity and mortality.
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Affiliation(s)
- Mrinal M. Patnaik
- Division of Hematology, Department of MedicineMayo ClinicRochester Minnesota
| | - Ayalew Tefferi
- Division of Hematology, Department of MedicineMayo ClinicRochester Minnesota
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Liu H, Cheng J, Zhao L, Xu Q, Xue M, Zhang S, Liu B. Outcome of patient with high-risk chronic myelomonocytic leukemia, treated with decitabine prior to transformation to acute myeloid leukemia: A case report. Oncol Lett 2018; 15:7132-7138. [PMID: 29731877 PMCID: PMC5921036 DOI: 10.3892/ol.2018.8236] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2017] [Accepted: 01/29/2018] [Indexed: 11/23/2022] Open
Abstract
The present study describes a patient with high-risk chronic myelomonocytic leukemia (CMML), for whom decitabine therapy achieved partial remission, prior to a sudden transformation to acute myeloid leukemia (AML) and an inferior outcome. The 53-year-old male reported easily bruising for 5 months. Examination indicated a diagnosis of CMML. Chromosome analysis identified a 48, XY, +8, +21 karyotype, classifying the patient as high-risk, according to a clinical/molecular CPSS (CPSS-Mol) model. Gene sequencing detected a mutation in DNA methyltransferase 3α, which is relatively rarely identified in CMML and has recently been reported to have an independent prognostic impact on overall survival time. Partial remission was achieved with decitabine treatment, and hematologic improvement was observed subsequent to 2 cycles of treatment. However, a sudden transformation to AML led to fatality of the patient. This case suggests that decitabine may be an effective therapeutic for high-risk CMML; however, the response may be temporary, and the ultimate outcome may be extremely poor. Therefore, novel treatment strategies of CMML, including combination therapies with decitabine, or targeted drugs, including Janus kinase inhibitors or granulocyte-macrophage colony stimulating factor monoclonal antibodies, require investigation.
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Affiliation(s)
- Huan Liu
- The First Clinical Medical College, Lanzhou University, Lanzhou, Gansu 730000, P.R. China
| | - Juan Cheng
- Department of Hematology, The First Affiliated Hospital of Lanzhou University, Lanzhou, Gansu 730000, P.R. China
| | - Long Zhao
- Department of Hematology, The First Affiliated Hospital of Lanzhou University, Lanzhou, Gansu 730000, P.R. China
| | - Qian Xu
- The First Clinical Medical College, Lanzhou University, Lanzhou, Gansu 730000, P.R. China
| | - Mingming Xue
- The First Clinical Medical College, Lanzhou University, Lanzhou, Gansu 730000, P.R. China
| | - Shuling Zhang
- The First Clinical Medical College, Lanzhou University, Lanzhou, Gansu 730000, P.R. China
| | - Bei Liu
- Department of Hematology, The First Affiliated Hospital of Lanzhou University, Lanzhou, Gansu 730000, P.R. China
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Duchmann M, Yalniz FF, Sanna A, Sallman D, Coombs CC, Renneville A, Kosmider O, Braun T, Platzbecker U, Willems L, Adès L, Fontenay M, Rampal R, Padron E, Droin N, Preudhomme C, Santini V, Patnaik MM, Fenaux P, Solary E, Itzykson R. Prognostic Role of Gene Mutations in Chronic Myelomonocytic Leukemia Patients Treated With Hypomethylating Agents. EBioMedicine 2018; 31:174-181. [PMID: 29728305 PMCID: PMC6013781 DOI: 10.1016/j.ebiom.2018.04.018] [Citation(s) in RCA: 59] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2018] [Accepted: 04/20/2018] [Indexed: 12/02/2022] Open
Abstract
Somatic mutations contribute to the heterogeneous prognosis of chronic myelomonocytic leukemia (CMML). Hypomethylating agents (HMAs) are active in CMML, but analyses of small series failed to identify mutations predicting response or survival. We analyzed a retrospective multi-center cohort of 174 CMML patients treated with a median of 7 cycles of azacitidine (n = 68) or decitabine (n = 106). Sequencing data before treatment initiation were available for all patients, from Sanger (n = 68) or next generation (n = 106) sequencing. Overall response rate (ORR) was 52%, including complete response (CR) in 28 patients (17%). In multivariate analysis, ASXL1 mutations predicted a lower ORR (Odds Ratio [OR] = 0.85, p = 0.037), whereas TET2mut/ASXL1wt genotype predicted a higher CR rate (OR = 1.18, p = 0.011) independently of clinical parameters. With a median follow-up of 36.7 months, overall survival (OS) was 23.0 months. In multivariate analysis, RUNX1mut (Hazard Ratio [HR] = 2.00, p = .011), CBLmut (HR = 1.90, p = 0.03) genotypes and higher WBC (log10(WBC) HR = 2.30, p = .005) independently predicted worse OS while the TET2mut/ASXL1wt predicted better OS (HR = 0.60, p = 0.05). CMML-specific scores CPSS and GFM had limited predictive power. Our results stress the need for robust biomarkers of HMA activity in CMML and for novel treatment strategies in patients with myeloproliferative features and RUNX1 mutations. TET2mut/ASXL1wt genotype predicts higher complete response rate and prolonged survival in CMML with hypomethylating agents. Conversely, RUNX1mut and CBLmut genotypes are associated with poorer outcome, independently of higher leukocyte count. CPSS and GFM prognostic scores showed modest performance when calculated at initiation of hypomethylating agents.
Somatic mutations contribute to the heterogeneous prognosis of chronic myelomonocytic leukemia (CMML). Hypomethylating agents (HMAs) are active in CMML. Response and survival in MDS and AML patients treated with HMAs is difficult to predict. We explore the predictive role of recurrent somatic mutations in a large retrospective cohort of 174 HMA-treated CMMLs. Consistent with MDS studies, we report a higher response rate in TET2mut/ASXL1wt patients. We also identify a CMML-specific molecular pattern (RUNX1mut or CBLmut) associated with shorter survival. Our results can inform treatment decision in CMML, for instance by using HMAs prior to transplant in TET2mut/ASXL1wt patients.
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Affiliation(s)
| | | | - Alessandro Sanna
- MDS Unit-Hematology, Università di Firenze AOU careggi, Firenze, Italy
| | - David Sallman
- Malignant Hematology Department, H. Lee Moffitt Cancer Center, Tampa, FL, USA
| | - Catherine C Coombs
- Department of Medicine, Leukemia Service, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Aline Renneville
- Laboratory of Hematology, Biology and Pathology Center, CHRU of Lille, Lille, France
| | - Olivier Kosmider
- Laboratory of Hematology, Cochin Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Thorsten Braun
- Department of Hematology, Avicenne Hospital, Assistance Publique-Hôpitaux de Paris, Bobigny, France
| | - Uwe Platzbecker
- Department of Hematology and Oncology, University Hospital Carl Gustav Carus, Dresden, Germany
| | - Lise Willems
- Department of Hematology, Cochin Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Lionel Adès
- Department of Hematology, St Louis Hospital, Assistance Publique-Hôpitaux de Paris, University Paris Diderot, Paris, France
| | - Michaela Fontenay
- Laboratory of Hematology, Cochin Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Raajit Rampal
- Department of Medicine, Leukemia Service, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Eric Padron
- Malignant Hematology Department, H. Lee Moffitt Cancer Center, Tampa, FL, USA
| | - Nathalie Droin
- INSERM U1170, Gustave Roussy Cancer Center, Villejuif, France
| | - Claude Preudhomme
- Laboratory of Hematology, Biology and Pathology Center, CHRU of Lille, Lille, France
| | - Valeria Santini
- MDS Unit-Hematology, Università di Firenze AOU careggi, Firenze, Italy
| | | | - Pierre Fenaux
- Department of Hematology, St Louis Hospital, Assistance Publique-Hôpitaux de Paris, University Paris Diderot, Paris, France
| | - Eric Solary
- INSERM U1170, Gustave Roussy Cancer Center, Villejuif, France; Department of Hematology, Gustave Roussy Cancer Center, University Paris Sud, Villejuif, France
| | - Raphael Itzykson
- Department of Hematology, St Louis Hospital, Assistance Publique-Hôpitaux de Paris, University Paris Diderot, Paris, France; INSERM/CNRS UMR 944/7212, Saint-Louis Institute, Paris, France.
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44
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Blast phase chronic myelomonocytic leukemia: Mayo-MDACC collaborative study of 171 cases. Leukemia 2018; 32:2512-2518. [PMID: 29749401 PMCID: PMC6202273 DOI: 10.1038/s41375-018-0143-8] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2018] [Revised: 04/04/2018] [Accepted: 04/10/2018] [Indexed: 11/16/2022]
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45
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Diagnostic, Prognostic, and Predictive Utility of Recurrent Somatic Mutations in Myeloid Neoplasms. CLINICAL LYMPHOMA MYELOMA & LEUKEMIA 2018; 17S:S62-S74. [PMID: 28760304 DOI: 10.1016/j.clml.2017.02.015] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/09/2017] [Accepted: 02/28/2017] [Indexed: 02/02/2023]
Abstract
The classification and risk stratification of myeloid neoplasms, including acute myeloid leukemia, myelodysplastic syndromes, myelodysplastic syndromes/myeloproliferative neoplasms, and myeloproliferative neoplasms, have increasingly been guided by molecular genetic abnormalities. Gene expression analysis and next-generation sequencing have led to the ever increasing discovery of somatic gene mutations in myeloid neoplasms. Mutations have been identified in genes involved in epigenetic modification, RNA splicing, transcription factors, DNA repair, and the cohesin complex. These new somatic/acquired gene mutations have refined the classification of myeloid neoplasms and have been incorporated into the 2016 update of the World Health Organization (WHO) classification and the National Comprehensive Cancer Network guidelines. They have also been helpful in the development of new targeted therapeutic agents. In the present review, we describe the clinical utility of recently identified, clinically important gene mutations in myeloid neoplasms, including those incorporated in the 2016 update of the WHO classification.
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46
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Patnaik MM, Rangit Vallapureddy, Lasho TL, Hoversten KP, Finke CM, Ketterling RP, Hanson CA, Gangat N, Tefferi A, Pardanani A. A comparison of clinical and molecular characteristics of patients with systemic mastocytosis with chronic myelomonocytic leukemia to CMML alone. Leukemia 2018; 32:1850-1856. [DOI: 10.1038/s41375-018-0121-1] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2018] [Revised: 03/07/2018] [Accepted: 03/14/2018] [Indexed: 01/07/2023]
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47
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Hoversten K, Vallapureddy R, Lasho T, Finke C, Ketterling R, Hanson C, Gangat N, Tefferi A, Patnaik MM. Nonhepatosplenic extramedullary manifestations of chronic myelomonocytic leukemia: clinical, molecular and prognostic correlates. Leuk Lymphoma 2018; 59:2998-3001. [PMID: 29582697 DOI: 10.1080/10428194.2018.1452212] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Affiliation(s)
| | | | - Terra Lasho
- b Division of Hematology , Mayo Clinic , Rochester , MN , USA
| | - Christy Finke
- b Division of Hematology , Mayo Clinic , Rochester , MN , USA
| | - Rhett Ketterling
- c Department of Laboratory Medicine and Pathology , Division of Cytogenetics, Mayo Clinic , Rochester , MN , USA
| | - Curtis Hanson
- d Department of Laboratory Medicine and Pathology , Mayo Clinic , Rochester , MN , USA
| | - Naseema Gangat
- b Division of Hematology , Mayo Clinic , Rochester , MN , USA
| | - Ayalew Tefferi
- b Division of Hematology , Mayo Clinic , Rochester , MN , USA
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48
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Patnaik MM, Vallapureddy R, Lasho TL, Hoversten KP, Finke CM, Ketterling R, Hanson C, Gangat N, Tefferi A. EZH2 mutations in chronic myelomonocytic leukemia cluster with ASXL1 mutations and their co-occurrence is prognostically detrimental. Blood Cancer J 2018; 8:12. [PMID: 29358618 PMCID: PMC5802714 DOI: 10.1038/s41408-017-0045-4] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2017] [Accepted: 11/29/2017] [Indexed: 12/17/2022] Open
Affiliation(s)
- Mrinal M Patnaik
- Division of Hematology, Department of Internal Medicine, Mayo Clinic, Rochester, MN, USA.
| | - Rangit Vallapureddy
- Division of Hematology, Department of Internal Medicine, Mayo Clinic, Rochester, MN, USA
| | - Terra L Lasho
- Division of Hematology, Department of Internal Medicine, Mayo Clinic, Rochester, MN, USA
| | - Katherine P Hoversten
- Division of Hematology, Department of Internal Medicine, Mayo Clinic, Rochester, MN, USA
| | - Christy M Finke
- Division of Hematology, Department of Internal Medicine, Mayo Clinic, Rochester, MN, USA
| | - Rhett Ketterling
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, USA
| | - Curtis Hanson
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, USA
| | - Naseema Gangat
- Division of Hematology, Department of Internal Medicine, Mayo Clinic, Rochester, MN, USA
| | - Ayalew Tefferi
- Division of Hematology, Department of Internal Medicine, Mayo Clinic, Rochester, MN, USA
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49
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Patnaik MM, Vallapureddy R, Yalniz FF, Hanson CA, Ketterling RP, Lasho TL, Finke C, Al-Kali A, Gangat N, Tefferi A. Therapy related-chronic myelomonocytic leukemia (CMML): Molecular, cytogenetic, and clinical distinctions from de novo CMML. Am J Hematol 2018; 93:65-73. [PMID: 29023992 DOI: 10.1002/ajh.24939] [Citation(s) in RCA: 40] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2017] [Revised: 10/05/2017] [Accepted: 10/08/2017] [Indexed: 12/30/2022]
Abstract
Therapy related myeloid neoplasms (t-MN) including therapy related myelodysplastic syndromes (t-MDS) and acute myeloid leukemia (t-AML) are associated with aggressive disease biologies and poor outcomes. In this large (n = 497) and informative (inclusive of molecular and cytogenetic information) chronic myelomonocytic leukemia (CMML) patient cohort, we demonstrate key biological insights and an independent prognostic impact for t-CMML. T-CMML was diagnosed in 9% of patients and occurred approximately 7 years after exposure to prior chemotherapy and/or radiation therapy. In comparison to de novo CMML, t-CMML patients had higher LDH levels, higher frequency of karyotypic abnormalities and had higher risk cytogenetic stratification. There were no differences in the distribution of gene mutations and unlike t-MDS/AML, balanced chromosomal translocations, abnormalities of chromosome 11q23 (1%) and Tp53 mutations (<2%) were uncommon. Molecularly integrated CMML prognostic models were not effective in risk stratifying t-CMML patients and responses to hypomethylating agents were dismal with no complete responses. Median overall (OS) and leukemia free survival (LFS) was shorter for t-CMML in comparison to d-CMML (Median OS 10.9 vs 26 months and median LFS 50 vs 127 months) and t-CMML independently and adversely impacted OS (P = .0001 HR 2.1 95% CI 1.4-3.0). This prognostic impact was retained in the context of the Mayo Molecular Model (P = .001, HR 2.4, 95% CI 1.5-3.7) and the GFM prognostic model (P < .0001, HR 2.15, 95% CI 1.5-3.7). In summary, we highlight the unique genetics and independent prognostic impact of t-CMML, warranting its inclusion as a separate entity in the classification schema for both CMML and t-MN.
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Affiliation(s)
| | | | | | | | | | - Terra L. Lasho
- Division of Hematology; Mayo Clinic; Rochester Minnesota
| | - Christy Finke
- Division of Hematology; Mayo Clinic; Rochester Minnesota
| | - Aref Al-Kali
- Division of Hematology; Mayo Clinic; Rochester Minnesota
| | - Naseema Gangat
- Division of Hematology; Mayo Clinic; Rochester Minnesota
| | - Ayalew Tefferi
- Division of Hematology; Mayo Clinic; Rochester Minnesota
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50
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Tefferi A, Shah S, Mudireddy M, Lasho TL, Barraco D, Hanson CA, Ketterling RP, Elliott MA, Patnaik MS, Pardanani A, Gangat N. Monocytosis is a powerful and independent predictor of inferior survival in primary myelofibrosis. Br J Haematol 2017; 183:835-838. [PMID: 29265333 DOI: 10.1111/bjh.15061] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Affiliation(s)
- Ayalew Tefferi
- Division of Hematology, Department of Internal Medicine, Mayo Clinic, Rochester, MN, USA
| | - Sahrish Shah
- Division of Hematology, Department of Internal Medicine, Mayo Clinic, Rochester, MN, USA
| | - Mythri Mudireddy
- Division of Hematology, Department of Internal Medicine, Mayo Clinic, Rochester, MN, USA
| | - Terra L Lasho
- Division of Hematology, Department of Internal Medicine, Mayo Clinic, Rochester, MN, USA
| | - Daniela Barraco
- Division of Hematology, Department of Internal Medicine, Mayo Clinic, Rochester, MN, USA
| | - Curtis A Hanson
- Division ofHematopathology, Department of Laboratory Medicine, Mayo Clinic, Rochester, MN, USA
| | - Rhett P Ketterling
- Division ofCytogenetics, Department of Laboratory Medicine, Mayo Clinic, Rochester, MN, USA
| | - Michelle A Elliott
- Division of Hematology, Department of Internal Medicine, Mayo Clinic, Rochester, MN, USA
| | - Mrinal S Patnaik
- Division of Hematology, Department of Internal Medicine, Mayo Clinic, Rochester, MN, USA
| | - Animesh Pardanani
- Division of Hematology, Department of Internal Medicine, Mayo Clinic, Rochester, MN, USA
| | - Naseema Gangat
- Division of Hematology, Department of Internal Medicine, Mayo Clinic, Rochester, MN, USA
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