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Silzle T, Blum S, Kasprzak A, Nachtkamp K, Rudelius M, Hildebrandt B, Götze KS, Gattermann N, Lauseker M, Germing U. The Absolute Monocyte Count at Diagnosis Affects Prognosis in Myelodysplastic Syndromes Independently of the IPSS-R Risk Score. Cancers (Basel) 2023; 15:3572. [PMID: 37509235 PMCID: PMC10377210 DOI: 10.3390/cancers15143572] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2023] [Revised: 07/04/2023] [Accepted: 07/09/2023] [Indexed: 07/30/2023] Open
Abstract
The absolute monocyte count (AMC) is associated with mortality in a variety of medical conditions. Its prognostic impact in myelodysplastic syndromes (MDSs) is less well studied. Therefore, we investigated its potential prognostic value in a cohort from the Düsseldorf MDS registry in relationship to the revised international prognostic scoring system (IPSS-R). An AMC below the population's median (<0.2 × 109/L) was associated with several adverse disease features such as lower haemoglobin levels, lower count of neutrophils and platelets, and a higher percentage of blasts in the bone marrow. MDS patients with an AMC < 0.2 × 109/L had a significantly higher risk of progression into acute myeloid leukemia (AML). In a univariate, proportional hazards model the effect of the AMC as a continuous variable was modelled via p-splines. We found a U-shaped effect with the lowest hazard around 0.3 × 109/L. Accordingly, an AMC within the last quartile of the population (0.4 × 109/L) was associated with a reduced overall survival independently of IPSS-R, but not with the risk of secondary AML. Considering monocytopenia as a risk factor for AML progression in MDS may provide an additional argument for allogeneic transplantation or the use of hypomethylating agents in patients who are not clear candidates for those treatments according to current prognostic scoring systems and/or recommendations. Further studies are needed to assess the prognostic impact of the AMC in the context of prognostic scoring systems, considering the molecular risk profile, and to identify the mechanisms responsible for the higher mortality in MDS patients with a subtle monocytosis.
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Affiliation(s)
- Tobias Silzle
- Department of Medical Oncology and Hematology, Cantonal Hospital St. Gallen, 9007 St. Gallen, Switzerland
| | - Sabine Blum
- Service and Central Laboratory of Hematology, University Hospital of Lausanne and Lausanne University, 1011 Lausanne, Switzerland
| | - Annika Kasprzak
- Department of Hematology, Oncology, and Clinical Immunology, Heinrich Heine University Düsseldorf, 40225 Düsseldorf, Germany
| | - Kathrin Nachtkamp
- Department of Hematology, Oncology, and Clinical Immunology, Heinrich Heine University Düsseldorf, 40225 Düsseldorf, Germany
| | - Martina Rudelius
- Institute of Pathology, Faculty of Medicine, LMU Munich, 80337 Munich, Germany
| | - Barbara Hildebrandt
- Department of Human Genetics, Heinrich Heine University Düsseldorf, 40225 Düsseldorf, Germany
| | - Katharina S. Götze
- Department of Internal Medicine III, Klinikum Rechts der Isar, Technical University of Munich, 81675 Munich, Germany
| | - Norbert Gattermann
- Department of Hematology, Oncology, and Clinical Immunology, Heinrich Heine University Düsseldorf, 40225 Düsseldorf, Germany
| | - Michael Lauseker
- Institute for Medical Information Processing, Biometry and Epidemiology, Faculty of Medicine, LMU Munich, 81377 Munich, Germany
| | - Ulrich Germing
- Department of Hematology, Oncology, and Clinical Immunology, Heinrich Heine University Düsseldorf, 40225 Düsseldorf, Germany
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2
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Lucero J, Al-Harbi S, Yee KWL. Management of Patients with Lower-Risk Myelodysplastic Neoplasms (MDS). Curr Oncol 2023; 30:6177-6196. [PMID: 37504319 PMCID: PMC10377892 DOI: 10.3390/curroncol30070459] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2023] [Revised: 06/15/2023] [Accepted: 06/25/2023] [Indexed: 07/29/2023] Open
Abstract
Myelodysplastic neoplasms (MDS) are a heterogenous group of clonal hematologic disorders characterized by morphologic dysplasia, ineffective hematopoiesis, and cytopenia. In the past year, the classification of MDS has been updated in the 5th edition of the World Health Organization (WHO) Classification of Haematolymphoid Tumours and the International Consensus Classification (ICC) of Myeloid Neoplasms and Acute Leukemia with incorporation of morphologic, clinical, and genomic data. Furthermore, the more comprehensive International Prognostic Scoring System-Molecular (IPSS-M) allows for improved risk stratification and prognostication. These three developments allow for more tailored therapeutic decision-making in view of the expanding treatment options in MDS. For patients with lower risk MDS, treatment is aimed at improving cytopenias, usually anemia. The recent approval of luspatercept and decitabine/cedazuridine have added on to the current armamentarium of erythropoietic stimulating agents and lenalidomide (for MDS with isolated deletion 5q). Several newer agents are being evaluated in phase 3 clinical trials for this group of patients, such as imetelstat and oral azacitidine. This review provides a summary of the classification systems, the prognostic scores and clinical management of patients with lower risk MDS.
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Affiliation(s)
- Josephine Lucero
- Division of Medical Oncology and Hematology, Princess Margaret Cancer Centre, University Health Network, 700 University Avenue, 6th Floor, Toronto, ON M5G 1Z5, Canada
| | - Salman Al-Harbi
- Division of Medical Oncology and Hematology, Princess Margaret Cancer Centre, University Health Network, 700 University Avenue, 6th Floor, Toronto, ON M5G 1Z5, Canada
| | - Karen W L Yee
- Division of Medical Oncology and Hematology, Princess Margaret Cancer Centre, University Health Network, 700 University Avenue, 6th Floor, Toronto, ON M5G 1Z5, Canada
- Division of Hematology, University of Toronto, Toronto, ON M5S 3H2, Canada
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3
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Gurbuxani S, Hochman MJ, DeZern AE, Shimamura A. The Times, They Are A-Changing: The Impact of Next-Generation Sequencing on Diagnosis, Classification, and Prognostication of Myeloid Malignancies With Focus on Myelodysplastic Syndrome, AML, and Germline Predisposition. Am Soc Clin Oncol Educ Book 2023; 43:e390026. [PMID: 37307513 DOI: 10.1200/edbk_390026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Abstract
Myeloid malignancies are a manifestation of clonal expansion of hematopoietic cells driven by somatic genetic alterations that may arise in a potential background of deleterious germline variants. As next-generation sequencing technology has become more accessible, real-world experience has allowed integration of molecular genomic data with morphology, immunophenotype, and conventional cytogenetics to refine our understanding of myeloid malignancies. This has prompted revisions in the classification and the prognostication schema of myeloid malignancies and germline predisposition to hematologic malignancies. This review provides an overview of significant changes in the recently published classifications of AML and myelodysplastic syndrome, emerging prognostic scoring, and the role of germline deleterious variants in predisposing to MDS and AML.
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Affiliation(s)
| | - Michael J Hochman
- Johns Hopkins University School of Medicine, The Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins, Baltimore, MD
| | - Amy E DeZern
- Johns Hopkins University School of Medicine, The Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins, Baltimore, MD
| | - Akiko Shimamura
- Dana Farber/Boston Children's Cancer and Blood Disorders Center, Harvard Medical School, Boston, MA
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Wang C, Sallman DA. Current Therapeutic Landscape in Lower Risk Myelodysplastic Syndromes. Curr Treat Options Oncol 2023; 24:387-408. [PMID: 36966266 DOI: 10.1007/s11864-023-01062-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/19/2023] [Indexed: 03/27/2023]
Abstract
OPINION STATEMENT Lower risk myelodysplastic syndromes are typically characterized by an indolent disease course with a relatively low risk of transformation into acute myeloid leukemia. These patients are classically identified using the revised International Prognostic Scoring System and most likely its molecular version in the near future which may change the paradigm of treatment. The overall goals of care are symptomatic control to reduce transfusion requirements and improve quality of life. Symptomatic anemia is the most common indication to initiate disease-specific therapies after the optimization of supportive measures. Currently, erythropoiesis-stimulating agents remain the standard upfront therapy for anemia, and patients with del(5q) cytogenetic changes can benefit from lenalidomide monotherapy. Other therapeutic options after failure of upfront treatment include luspatercept, hypomethylating agents, and immunosuppressive therapies after taking into account of individualized disease features. Allogeneic hematopoietic stem cell transplant is the only potentially curative option and is usually reserved for medically fit patients with severe symptomatic cytopenias who failed all standard options and/or the disease is progressing toward higher risk categories. Fortunately, novel investigational therapies are rapidly emerging by targeting different biological processes contributing to MDS pathogenesis, and eligible patients should be managed in clinical trials if available.
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Affiliation(s)
- Chen Wang
- Department of Internal Medicine, University of South Florida, Morsani College of Medicine, Tampa, FL, USA
- Department of Malignant Hematology, H. Lee Moffitt Cancer Center and Research Institute, 12902 Magnolia Drive, Tampa, FL, 33612, USA
| | - David A Sallman
- Department of Malignant Hematology, H. Lee Moffitt Cancer Center and Research Institute, 12902 Magnolia Drive, Tampa, FL, 33612, USA.
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5
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Park HS, Son BR, Kwon J. Usefulness of Genetic Aberration and Shorter Telomere Length in Myelodysplastic Syndrome: A Pilot Study. Lab Med 2023; 54:199-205. [PMID: 36125233 DOI: 10.1093/labmed/lmac100] [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: 11/13/2022] Open
Abstract
OBJECTIVE We aimed to evaluate the clinical usefulness of genetic aberration and shorter telomere length (TL) in individuals with myelodysplastic syndrome (MDS). METHODS A targeted sequencing panel with 49 genes and TL measurement by quantitative real-time polymerase chain reaction were performed for 46 subjects. RESULTS According to the revised International Prognostic Scoring System (IPSS-R) subtypes, the mutation frequency was 33.3%, 57.9%, and 100% in the very low/low, intermediate, and very high/high risk groups, respectively. A shorter telomere was detected in 43.5%. We defined group 1 as IPSS-R-high or -very high risk, group 2 as having 1 or more genetic aberrations, group 3 as having a shorter TL, and group 4 as having a longer TL than the age-matched reference. Group 1 and group 2 showed an adverse prognosis. The TL was not strongly correlated with MDS prognosis. However, it may be related to a poor long-term prognosis. CONCLUSION Genetic variation and shorter TL may be helpful in reclassifying non-high-risk groups.
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Affiliation(s)
- Hee Sue Park
- Laboratory Medicine, Chungbuk National University Hospital, Cheongju, South Korea.,Laboratory Medicine, Chungbuk National University College of Medicine, Cheongju, South Korea
| | - Bo Ra Son
- Laboratory Medicine, Chungbuk National University Hospital, Cheongju, South Korea.,Laboratory Medicine, Chungbuk National University College of Medicine, Cheongju, South Korea
| | - Jihyun Kwon
- Internal Medicine, Chungbuk National University Hospital, Cheongju, South Korea.,Internal Medicine, Chungbuk National University College of Medicine, Cheongju, South Korea
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Wang C, Sallman DA. Therapeutic approaches for the management of higher risk myelodysplastic syndromes. Leuk Lymphoma 2023; 64:511-524. [PMID: 36433645 DOI: 10.1080/10428194.2022.2140287] [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: 11/28/2022]
Abstract
The heterogeneous nature of myelodysplastic syndromes (MDS) demands a risk-adapted therapeutic approach, and higher risk MDS, characterized by an increased risk of transformation into acute myeloid leukemia and inferior survival, is typically defined based on an integrated assessment of cytopenias, bone marrow blast percentage, and cytogenetic findings using the revised International Prognostic Scoring System. Incorporating mutational data could further refine the risk assessment and identify those with higher-than-expected disease risk. The principal therapeutic goal in this disease subset is to modify the natural history and prolong survival. Allogeneic stem cell transplant, the only potentially curative treatment, should be offered to eligible patients. Hypomethylating agents are the only approved treatment with unsatisfactory response rates and duration, and patients who failed prior hypomethylating agents unfortunately have dismal outcomes with urgent need of novel therapeutic agents. In this review, we provide the therapeutic landscape in higher risk MDS based on the current evidence and discuss the investigational treatment options under development.
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Affiliation(s)
- Chen Wang
- Department of Internal Medicine, University of South Florida, Morsani College of Medicine, Tampa, FL, USA
- Department of Malignant Hematology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA
| | - David A Sallman
- Department of Malignant Hematology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA
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Hoff FW, Madanat YF. Molecular Drivers of Myelodysplastic Neoplasms (MDS)-Classification and Prognostic Relevance. Cells 2023; 12:627. [PMID: 36831294 PMCID: PMC9954608 DOI: 10.3390/cells12040627] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2023] [Revised: 02/12/2023] [Accepted: 02/13/2023] [Indexed: 02/17/2023] Open
Abstract
Myelodysplastic neoplasms (MDS) form a broad spectrum of clonal myeloid malignancies arising from hematopoietic stem cells that are characterized by progressive and refractory cytopenia and morphological dysplasia. Recent advances in unraveling the underlying pathogenesis of MDS have led to the identification of molecular drivers and secondary genetic events. With the overall goal of classifying patients into relevant disease entities that can aid to predict clinical outcomes and make therapeutic decisions, several MDS classification models (e.g., French-American-British, World Health Organization, and International Consensus Classification) as well as prognostication models (e.g., International Prognostic Scoring system (IPSS), the revised IPSS (IPSS-R), and the molecular IPSS (IPSS-M)), have been developed. The IPSS-M is the first model that incorporates molecular data for individual genes and facilitates better prediction of clinical outcome parameters compared to older versions of this model (i.e., overall survival, disease progression, and leukemia-free survival). Comprehensive classification and accurate risk prediction largely depend on the integration of genetic mutations that drive the disease, which is crucial to improve the diagnostic work-up, guide treatment decision making, and direct novel therapeutic options. In this review, we summarize the most common cytogenetic and genomic drivers of MDS and how they impact MDS prognosis and treatment decisions.
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Affiliation(s)
- Fieke W. Hoff
- Department of Internal Medicine, UT Southwestern Medical Center, Dallas, TX 75390-8565, USA
- Harold C. Simmons Comprehensive Cancer Center, UT Southwestern Medical Center, Dallas, TX 75390-8565, USA
| | - Yazan F. Madanat
- Department of Internal Medicine, UT Southwestern Medical Center, Dallas, TX 75390-8565, USA
- Harold C. Simmons Comprehensive Cancer Center, UT Southwestern Medical Center, Dallas, TX 75390-8565, USA
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8
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Park HS, Im K, Shin D, Yoon S, Kwon S, Kim SW, Lee DS. Telomere integrated scoring system of myelodysplastic syndrome. J Clin Lab Anal 2023; 37:e24839. [PMID: 36658792 PMCID: PMC9978071 DOI: 10.1002/jcla.24839] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2022] [Revised: 12/05/2022] [Accepted: 12/30/2022] [Indexed: 01/21/2023] Open
Abstract
INTRODUCTION Recently, multigene target sequencing is widely performed for the purpose of prognostic prediction and application of targeted therapy. Here, we proposed a new scoring system that encompasses gene variations, telomere length, and Revised International Prognostic Scoring System (IPSS-R) together in Asian myelodysplastic syndrome. METHODS We developed a new scoring model of these variables: age ≥ 65 years + IPSS-R score + ASXL1 mutation + TP53 mutation + Telomere length (<5.37). According to this new scoring system, patients were divided into four groups: very good score cutoff (≤3.0), good (3.0-4.5), poor (4.5-7.0), and very poor (>7.0). RESULTS The median OS was 170.1, 100.4, 46.0, and 12.0 months for very good, good, poor, and very poor, retrospectively (p < 0.001). Meanwhile, according to the conventional IPSS-R scoring system, the median OS was 141.3, 50.2, 93.0, 36.0, and 16.2 months for very low, low, intermediate, high, and very high, retrospectively (p < 0.001). CONCLUSIONS The newly developed model incorporating molecular variations and TL yielded more clear separations of the survival curves. By adding the presence of gene mutation and telomere length to the existing IPSS-R, its predictive ability can be further improved in myelodysplastic syndrome.
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Affiliation(s)
- Hee Sue Park
- Department of Laboratory MedicineChungbuk National University HospitalCheongju‐siKorea,Department of Laboratory MedicineChungbuk National University College of MedicineCheongju‐siKorea
| | - Kyongok Im
- Institute of Reproductive Medicine and Population Medical Research CenterSeoul National UniversitySeoulKorea,School of Health and Environmental Science, College of Health ScienceKorea UniversitySeoulKorea
| | - Dong‐Yeop Shin
- Department of Internal MedicineSeoul National University HospitalSeoulKorea
| | - Sung‐Soo Yoon
- Department of Internal MedicineSeoul National University HospitalSeoulKorea,Department of Internal MedicineSeoul National University College of MedicineSeoulKorea
| | - Sunghoon Kwon
- Department of Electrical and Computer EngineeringSeoul National UniversitySeoulKorea,Bio‐MAX InstituteSeoul National UniversitySeoulKorea
| | - Suhng Wook Kim
- School of Health and Environmental Science, College of Health ScienceKorea UniversitySeoulKorea,BK21 FOUR R&E Center for Learning Health SystemsKorea UniversitySeoulKorea
| | - Dong Soon Lee
- Department of Laboratory MedicineSeoul National University College of MedicineSeoulKorea
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9
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Garcia-Manero G. Current status of phase 3 clinical trials in high-risk myelodysplastic syndromes: pitfalls and recommendations. Lancet Haematol 2023; 10:e71-e78. [PMID: 36215988 DOI: 10.1016/s2352-3026(22)00265-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2022] [Revised: 07/22/2022] [Accepted: 08/10/2022] [Indexed: 11/05/2022]
Abstract
Single-agent hypomethylating agents remain the cornerstone of treatment for patients with high-risk myelodysplastic syndromes. Although these agents have clinical activity and can improve the overall survival of these patients, their impact on the natural history of myelodysplastic syndromes is only partial. Therefore, we need either newer agents or combinations that could have a greater impact on the survival of our patients. Over the past decade there has been an increased effort in drug development for myelodysplastic syndromes. Hypomethylating agent combinations that have been explored over the past decade include agents that block mutant TP53, NEDD inhibitors, BCL-2 inhibitors, and antibodies such as sabatolimab or magrolimab. Despite initial encouraging results, two registration trials from 2021 and 2022 have not been successful in improving outcomes when compared with single-agent hypomethylating agents. Here, I summarise the current status of ongoing phase 3 trials for patients with untreated high-risk myelodysplastic syndromes and provide some suggestions for future designs.
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Affiliation(s)
- Guillermo Garcia-Manero
- Section of Myelodysplastic Syndromes, Department of Leukemia, MD Anderson Cancer Center, University of Texas, Houston, TX, USA.
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10
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Xie Z, Chen EC, Stahl M, Zeidan AM. Prognostication in myelodysplastic syndromes (neoplasms): Molecular risk stratification finally coming of age. Blood Rev 2022; 59:101033. [PMID: 36357283 DOI: 10.1016/j.blre.2022.101033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2022] [Revised: 11/01/2022] [Accepted: 11/02/2022] [Indexed: 11/06/2022]
Abstract
Accurate risk prognostication is central to the management of myelodysplastic syndromes, given the widely heterogeneous clinical outcomes of these bone marrow failure disorders. Over the past decade, the rapidly expanding compendium of molecular lesions in myelodysplastic syndrome (MDS) has offered unprecedented insight into MDS pathobiology. Recently, molecular prognostic models such as the Molecular International Prognostic Scoring System (IPSS-M) have leveraged the wellspring of genetic data to improve upon traditional risk models such as the Revised IPSS (IPSS-R), but also added substantial complexity. In this review, we highlight early MDS prognostic models, the significant advancements in MDS genomics since then, and the recent advent of molecular based prognostic models. We conclude by discussing important opportunities and challenges in the management of MDS as we arrive at the molecular frontier.
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11
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Snow A, Zeidner JF. The development of pevonedistat in myelodysplastic syndrome (MDS) and acute myeloid leukemia (AML): hope or hype? Ther Adv Hematol 2022; 13:20406207221112899. [PMID: 35898435 PMCID: PMC9310330 DOI: 10.1177/20406207221112899] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2022] [Accepted: 06/24/2022] [Indexed: 11/24/2022] Open
Abstract
Myelodysplastic syndrome (MDS) is a clonal hematopoietic stem cell disorder clinically defined by cytopenias, bone marrow failure, and an increased risk of progressing to acute myeloid leukemia (AML). Traditionally, first-line treatment for patients with higher-risk MDS has been hypomethylating agents (HMAs). However, these agents have modest clinical activity as single agents. A one-size-fits-all treatment paradigm is insufficient for such a heterogeneous disease in the modern era of precision medicine. Several new agents have been developed for MDS with the hopes of improving clinical outcomes and survival. Pevonedistat is a first-in-class, novel inhibitor of neuronal precursor cell-expressed developmentally down-regulated protein-8 (NEDD8) activating enzyme (NAE) blocking the neddylation pathway leading to downstream effects on the ubiquitin-proteosome pathway. Pevonedistat ultimately leads to apoptosis and inhibition of the cell cycle in cancer cells. Studies have demonstrated the safety profile of pevonedistat, leading to the development of multiple trials investigating combination strategies with pevonedistat in MDS and AML. In this review, we summarize the preclinical and clinical rationale for pevonedistat in MDS and AML, review the clinical data of this agent alone and in combination with HMAs to date, and highlight potential future directions for this agent in myeloid malignancies.
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Affiliation(s)
- Anson Snow
- Lineberger Comprehensive Cancer Center,
University of North Carolina School of Medicine
- Division of Hematology, Department of Medicine,
University of North Carolina School of Medicine, Chapel Hill, NC, USA
| | - Joshua F. Zeidner
- Lineberger Comprehensive Cancer Center,
University of North Carolina School of Medicine
- Division of Hematology, Department of Medicine,
University of North Carolina School of Medicine, 170 Manning Drive, POB, 3rd
Floor, CB #7305, Chapel Hill, NC 27599, USA
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12
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Qu B, Han X, Zhao L, Zhang F, Gao Q. Relationship of HIF‑1α expression with apoptosis and cell cycle in bone marrow mesenchymal stem cells from patients with myelodysplastic syndrome. Mol Med Rep 2022; 26:239. [PMID: 35642674 PMCID: PMC9185697 DOI: 10.3892/mmr.2022.12755] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2020] [Accepted: 02/21/2022] [Indexed: 11/09/2022] Open
Abstract
Myelodysplastic syndrome (MDS) is a group of abnormal clonal disorders with ineffective hematopoiesis, which are incurable with conventional therapy. Of note, MDS features an abnormal bone marrow microenvironment, which is related to its incidence. The hypoxia-inducible factor-1α (HIF-1α) transcriptional signature is generally activated in bone marrow stem/progenitor cells of patients with MDS. To analyze the expression of HIF-1α in bone marrow mesenchymal stem cells (BM-MSCs) and the apoptosis and cell cycle features associated with the disease, BM-MSCs were obtained from 40 patients with a definitive diagnosis of MDS and 20 subjects with hemocytopenia but a negative diagnosis of MDS as a control group. Reverse transcription-quantitative PCR and western blot analyses were used to measure HIF-1α expression in cells from the two groups and apoptosis and cell cycle were also analyzed and compared between the groups using flow cytometry assays. BM-MSCs from both the control group and the MDS group exhibited a fibroblast-like morphology, had similar growth cycles and were difficult to passage stably. It was observed that BM-MSCs from the MDS group had significantly higher HIF-1α expression levels than the control group (P<0.05). Furthermore, the BM-MSCs from the MDS group had a higher proportion of cells in early apoptosis (5.22±1.34 vs. 2.04±0.08%; P<0.0001) and late apoptosis (3.38±0.43 vs. 1.23±0.11%; P<0.01) and exhibited cell cycle arrest. This may be a noteworthy aspect of the pathogenesis of MDS and may be related to high HIF-1α expression under a hypoxic state in the bone marrow microenvironment. Furthermore, the expression of HIF-1α in bone marrow tissue sections from patients with MDS in the International Prognostic Scoring System (IPSS) lower-risk group was higher than that from patients with MDS in the IPSS high-risk group. These results revealed the role of HIF-1α as a central pathobiology mediator of MDS and an effective therapeutic target for a broad spectrum of patients with MDS, particularly for patients in the lower-risk group.
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Affiliation(s)
- Beibei Qu
- Department of Hematology, Jiading District Central Hospital, Affiliated Shanghai University of Medicine and Health Sciences, Shanghai 201800, P.R. China
| | - Xiuhua Han
- Department of Hematology, Jiading District Central Hospital, Affiliated Shanghai University of Medicine and Health Sciences, Shanghai 201800, P.R. China
| | - Lan Zhao
- Department of Hematology, Jiading District Central Hospital, Affiliated Shanghai University of Medicine and Health Sciences, Shanghai 201800, P.R. China
| | - Feifei Zhang
- Department of Hematology, Jiading District Central Hospital, Affiliated Shanghai University of Medicine and Health Sciences, Shanghai 201800, P.R. China
| | - Qingmei Gao
- Department of Hematology, Jiading District Central Hospital, Affiliated Shanghai University of Medicine and Health Sciences, Shanghai 201800, P.R. China
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13
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Ball S, Komrokji RS, Sallman DA. Prognostic scoring systems and risk stratification in myelodysplastic syndrome: focus on integration of molecular profile. Leuk Lymphoma 2021; 63:1281-1291. [PMID: 34933652 DOI: 10.1080/10428194.2021.2018579] [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] [Indexed: 10/19/2022]
Abstract
Myelodysplastic syndromes (MDS) form a clinically and molecularly heterogeneous disease group. Precise risk stratification remains crucial for choosing optimal management strategies. Several conventional prognostic scoring systems have been developed and validated in the MDS population. These risk models divide patients into prognostic subgroups based on clinical and cytogenetic characteristics. Lack of dynamicity, variable risk estimate across models, and heterogeneity within intermediate-risk group are the limitations of traditional models like IPSS-R, with questionable relevance of these scoring systems in treated MDS patients. Recent progress in next-generation sequencing techniques has improved understanding of the distribution and prognostic importance of recurrent genetic mutations in MDS. Early studies have suggested that incorporating mutations in risk stratification could supplement IPSS-R in further refining the model's performance in predicting overall survival and risk of transformation to acute myeloid leukemia and should translate into a molecularly driven prognostication approach in the near future.
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Affiliation(s)
- Somedeb Ball
- Department of Malignant Hematology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA
| | - Rami S Komrokji
- Department of Malignant Hematology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA
| | - David A Sallman
- Department of Malignant Hematology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA
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14
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Kaka S, Jahangirnia A, Beauregard N, Davis A, Tinmouth A, Chin-Yee N. Red blood cell transfusion in myelodysplastic syndromes: A systematic review. Transfus Med 2021; 32:3-23. [PMID: 34927286 DOI: 10.1111/tme.12841] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2021] [Revised: 11/06/2021] [Accepted: 11/11/2021] [Indexed: 11/28/2022]
Abstract
Patients with myelodysplastic syndrome (MDS) frequently receive red blood cell (RBC) transfusions for anaemia resulting from ineffective erythropoiesis. While RBC transfusions may rapidly increase haemoglobin values, their impact on clinical and health services outcomes in MDS patients has not previously been summarized. We conducted a systematic review of the literature to evaluate risks and benefits of RBC transfusions in MDS patients. We searched electronic databases (MEDLINE, Embase, CENTRAL, CINAHL) from inception through June 4, 2021 to identify studies reporting data on RBC transfusions in MDS patients. Full text publications that assessed RBC transfusions as an intervention and reported at least one clinical, laboratory, or healthcare outcome associated with transfusion were included. Study characteristics, transfusion information and transfusion-related outcomes were extracted and reported. We identified 1243 original studies, of which 38 met eligibility requirements and were included. Fourteen reported on survival following diagnosis of MDS, with the majority reporting poorer survival among patients receiving or requiring more frequent transfusions. Nine reported on transfusion-related iron overload and its complications. Other outcomes included rates of allo/autoimmunization and adverse transfusion reactions, and healthcare costs incurred by patients with a greater transfusion burden. Only two studies reported on symptom relief following transfusion. This review underscores transfusion dependence as a negative prognostic factor for MDS patients and highlights the paucity of evidence surrounding quality of life and symptom-related outcomes following RBC transfusions in this population. Further study of patient-important outcomes associated with transfusion in MDS patients is warranted to improve therapeutic recommendations and inform resource allocation.
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Affiliation(s)
- Shaima Kaka
- Faculty of Medicine, University of Ottawa/The Ottawa Hospital, Ottawa, Ontario, Canada
| | - Ashkan Jahangirnia
- Faculty of Medicine, University of Ottawa/The Ottawa Hospital, Ottawa, Ontario, Canada
| | | | - Alexandra Davis
- Faculty of Medicine, University of Ottawa/The Ottawa Hospital, Ottawa, Ontario, Canada
| | - Alan Tinmouth
- Faculty of Medicine, University of Ottawa/The Ottawa Hospital, Ottawa, Ontario, Canada.,The Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Nicolas Chin-Yee
- University of Toronto, Toronto, Ontario, Canada.,Department of Medicine, St. Michael's Hospital, Unity Health Toronto, Toronto, Ontario, Canada
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15
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DeZern AE. Lower risk but high risk. HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2021; 2021:428-434. [PMID: 34889376 PMCID: PMC8791100 DOI: 10.1182/hematology.2021000277] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/04/2023]
Abstract
Risk stratification is crucial to the appropriate management of most cancers, but in patients with myelodysplastic syndromes (MDS), for whom expected survival can vary from a few months to more than a decade, accurate disease prognostication is especially important. Currently, patients with MDS are often grouped into higher-risk (HR) vs lower-risk (LR) disease using clinical prognostic scoring systems, but these systems have limitations. Factors such as molecular genetic information or disease characteristics not captured in the International Prognostic Scoring System-Revised (IPSS-R) can alter risk stratification and identify a subset of patients with LR-MDS who actually behave more like those with HR-MDS. This review describes the current identification and management of patients with LR-MDS whose condition is likely to behave in a less favorable manner than predicted by the IPSS-R.
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Affiliation(s)
- Amy E. DeZern
- Correspondence Amy E. DeZern, Division of Hematologic Malignancies, Sidney Kimmel Cancer Center at Johns Hopkins, 1650 Orleans St, CRBI Room 3M87, Baltimore, MD 21287-0013; e-mail:
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16
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Diagnostic and Prognostic Implications of Caspase-1 and PD-L1 Co-Expression Patterns in Myelodysplastic Syndromes. Cancers (Basel) 2021; 13:cancers13225712. [PMID: 34830867 PMCID: PMC8616142 DOI: 10.3390/cancers13225712] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2021] [Revised: 11/07/2021] [Accepted: 11/11/2021] [Indexed: 11/25/2022] Open
Abstract
Simple Summary Myelodysplastic syndromes (MDS) originate from mutated hematopoietic stem and progenitor cells. Despite recent advances in genetics, the mechanisms involved in clonal progression remain largely unknown. We performed an exploratory, case-control study to identify immune-related biomarkers with diagnostic and prognostic utility. Our study suggests a combined Casp1/PD-L1 assessment to distinguish reactive conditions from lower- and higher-risk MDS. These immune-related biomarkers may help to personalize immuno-therapies but require further validation in prospective studies. Abstract Background: The inflammasome plays an essential role in lower risk MDS and immune subversion, with the up-regulation of immune checkpoint molecules in the progression to higher-risk disease. In this study, we explored the utility of immune-related biomarkers for the diagnosis and prognosis of MDS. Methods: We performed an exploratory, case-control study with 20 randomly selected MDS patients and nine controls with non-inflammatory (n = 3) and inflammatory conditions (n = 6). Patients were stratified in groups of lower (n = 10) and higher risk (n = 10) using IPSS-R. For the exploration of inflammasome and immune checkpoint activities, the expression of caspase-1 (Casp1), programmed cell death protein 1 (PD-1) and its ligand (PD-L1) were assessed in bone marrow samples using immunohistochemistry. Results: In multivariate analysis, we observed significant differences for Casp1 but not PD1/PD-L1 expression in our four conditions (p = 0.003). We found a discordant co-expression of Casp1/PD-L1 in MDS (rho = −0.41, p = 0.07) compared with a concordant co-expression in controls (rho = 0.64, p = 0.06). Neutrophil counts correlated directly with Casp1 (rho = 0.57, p = 0.009) but inversely with PD-L1 expression (rho = −0.58, p = 0.007). Conclusion: We identified characteristic discordant co-expression patterns in lower- (Casp1high/PD-L1low) and higher-risk MDS (Casp1low/PD-L1high), contrasting with concordant patterns in the non-inflammatory (Casp1low/PD-L1low) and inflammatory conditions (Casp1high/PD-L1high). Further validation is warranted in larger, prospective studies.
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17
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Shallis RM, Zeidan AM. Management of the Older Patient with Myelodysplastic Syndrome. Drugs Aging 2021; 38:751-767. [PMID: 34342860 DOI: 10.1007/s40266-021-00881-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/11/2021] [Indexed: 01/19/2023]
Abstract
No two diagnoses of myelodysplastic syndrome are genuinely alike, owing to differing and dynamic mutational topography and epigenetic aberrancy. Consequently, no two patients with myelodysplastic syndrome are identical and disease-specific and patient-specific factors are considered in formulating the optimal treatment, which includes few that are disease modifying. Age itself should not be an absolute contraindication to therapy, including intensive therapy such as allogeneic hematopoietic stem cell transplantation, which is the only curative therapy. However, age associates with an increased prevalence of frailty and comorbidities that must be considered and may preclude a path to cure. Palliative therapies are the mainstay for many patients with myelodysplastic syndrome, which is a disease of older adults with the majority of patients diagnosed at age ≥ 75 years. The older patient requires heightened attention to end organ function/reserve and drug-drug interactions as well as insurance, income, cost, and socioeconomic and psychosocial issues that influence management. Many prior studies have included relatively younger populations or have not specifically performed high-quality subgroup analyses of older patients. In this review, we discuss the available standard-of-care therapies for myelodysplastic syndrome as they specifically relate to the older population and assess the emerging therapeutics that may further the pursuit for personalized treatment and improve both the outcomes and quality of life of the older patient with myelodysplastic syndrome.
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Affiliation(s)
- Rory M Shallis
- Section of Hematology, Department of Internal Medicine, Yale University School of Medicine and Yale Cancer Center, Yale University, 333 Cedar Street, PO Box 208028, New Haven, CT, 06520-8028, USA
| | - Amer M Zeidan
- Section of Hematology, Department of Internal Medicine, Yale University School of Medicine and Yale Cancer Center, Yale University, 333 Cedar Street, PO Box 208028, New Haven, CT, 06520-8028, USA.
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18
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Volpe VO, Garcia-Manero G, Komrokji RS. Myelodysplastic Syndromes: A New Decade. CLINICAL LYMPHOMA MYELOMA & LEUKEMIA 2021; 22:1-16. [PMID: 34544674 DOI: 10.1016/j.clml.2021.07.031] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/10/2021] [Revised: 07/27/2021] [Accepted: 07/29/2021] [Indexed: 10/20/2022]
Abstract
Myelodysplastic syndromes (MDS) are a group of heterogeneous clonal hematopoietic stem cell disorders. The 2020 Surveillance, Epidemiology, and End Results data demonstrates the incidence rate of MDS increases with age especially in those greater than 70 years of age. Risk stratification that impact prognosis, survival, and rate of acute myeloid leukemia (AML) transformation in MDS is largely dependent on revised International Prognostic Scoring System along with molecular genetic testing as a supplement. Low risk MDS typically have a more indolent disease course in which treatment is only initiated to ameliorate symptoms of cytopenias. In many, anemia is the most common cytopenia requiring treatment and erythroid stimulating agents, are considered first line. In contrast, high risk MDS tend to behave more aggressively for which treatment should be initiated rapidly with Hypomethylating Agents (HMA) being in the frontline. In those with high risk MDS and eligible, evaluation for allogeneic stem cell transplant should be considered as this is the only potential curative option for MDS. With the use of molecular genetic testing, a personalized approach to therapy in MDS has ensued. As the treatment landscape in MDS continues to flourish with novel targeted agents, we ambitiously seek to improve survival rates especially among the relapsed/refractory and transplant ineligible.
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Affiliation(s)
- Virginia O Volpe
- Department of Malignant Hematology, H. Lee Moffitt Cancer Center, Tampa, FL
| | | | - Rami S Komrokji
- Department of Malignant Hematology, H. Lee Moffitt Cancer Center, Tampa, FL.
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19
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Platzbecker U, Kubasch AS, Homer-Bouthiette C, Prebet T. Current challenges and unmet medical needs in myelodysplastic syndromes. Leukemia 2021; 35:2182-2198. [PMID: 34045662 PMCID: PMC8324480 DOI: 10.1038/s41375-021-01265-7] [Citation(s) in RCA: 44] [Impact Index Per Article: 14.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2021] [Revised: 04/01/2021] [Accepted: 04/26/2021] [Indexed: 01/29/2023]
Abstract
Myelodysplastic syndromes (MDS) represent a heterogeneous group of myeloid neoplasms that are characterized by ineffective hematopoiesis, variable cytopenias, and a risk of progression to acute myeloid leukemia. Most patients with MDS are affected by anemia and anemia-related symptoms, which negatively impact their quality of life. While many patients with MDS have lower-risk disease and are managed by existing treatments, there currently is no clear standard of care for many patients. For patients with higher-risk disease, the treatment priority is changing the natural history of the disease by delaying disease progression to acute myeloid leukemia and improving overall survival. However, existing treatments for MDS are generally not curative and many patients experience relapse or resistance to first-line treatment. Thus, there remains an unmet need for new, more effective but tolerable strategies to manage MDS. Recent advances in molecular diagnostics have improved our understanding of the pathogenesis of MDS, and it is becoming clear that the diverse nature of genetic abnormalities that drive MDS demands a complex and personalized treatment approach. This review will discuss some of the challenges related to the current MDS treatment landscape, as well as new approaches currently in development.
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Affiliation(s)
- Uwe Platzbecker
- Department of Hematology, Cellular Therapy and Hemostaseology, Leipzig University Hospital, Leipzig, Germany.
- German MDS Study Group (D-MDS), Leipzig, Germany.
- The European Myelodysplastic Syndromes Cooperative Group (EMSCO), Leipzig, Germany.
| | - Anne Sophie Kubasch
- Department of Hematology, Cellular Therapy and Hemostaseology, Leipzig University Hospital, Leipzig, Germany
- German MDS Study Group (D-MDS), Leipzig, Germany
- The European Myelodysplastic Syndromes Cooperative Group (EMSCO), Leipzig, Germany
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20
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Acharya S, Liu JF, Tatevossian RG, Chiang J, Qaddoumi I, Gajjar A, Walker D, Harreld JH, Merchant TE, Ellison DW. Risk stratification in pediatric low-grade glioma and glioneuronal tumor treated with radiation therapy: an integrated clinicopathologic and molecular analysis. Neuro Oncol 2021; 22:1203-1213. [PMID: 32052049 DOI: 10.1093/neuonc/noaa031] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND Management of unresectable pediatric low-grade glioma and glioneuronal tumor (LGG/LGGNT) is controversial. There are no validated prognostic features to guide use of radiation therapy (RT). Our study aimed to identify negative prognostic features in patients treated with RT using clinicopathologic and molecular data and validate these findings in an external dataset. METHODS Children with non-metastatic, biopsy-proven unresectable LGG/LGGNT treated with RT at a single institution between 1997 and 2017 were identified. Recursive partitioning analysis (RPA) was used to stratify patients into low- and high-risk prognostic groups based on overall survival (OS). CNS9702 data were used for validation. RESULTS One hundred and fifty patients met inclusion criteria. Median follow-up was 11.4 years. RPA yielded low- and high-risk groups with 10-year OS of 95.6% versus 76.4% (95% CI: 88.7%-98.4% vs 59.3%-87.1%, P = 0.003), respectively. These risk groups were validated using CNS9702 dataset (n = 48) (4-year OS: low-risk vs high-risk: 100% vs 64%, P < 0.001). High-risk tumors included diffuse astrocytoma or location within thalamus/midbrain. Low-risk tumors included pilocytic astrocytoma/ganglioglioma located outside of the thalamus/midbrain. In the subgroup with known BRAF status (n = 49), risk stratification remained prognostic independently of BRAF alteration (V600E or fusion). Within the high-risk group, delayed RT, defined as RT after at least one line of chemotherapy, was associated with a further decrement in overall survival (P = 0.021). CONCLUSION A high-risk subgroup of patients, defined by diffuse astrocytoma histology or midbrain/thalamus tumor location, have suboptimal long-term survival and might benefit from timely use of RT. These results require validation.
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Affiliation(s)
- Sahaja Acharya
- Department of Radiation Oncology, St Jude Children's Research Hospital, Memphis, Tennessee, USA
| | - Jo-Fen Liu
- Children's Brain Tumor Research Centre, University of Nottingham, Nottingham, UK
| | - Ruth G Tatevossian
- Department of Pathology, St Jude Children's Research Hospital, Memphis, Tennessee, USA
| | - Jason Chiang
- Department of Pathology, St Jude Children's Research Hospital, Memphis, Tennessee, USA
| | - Ibrahim Qaddoumi
- Division of Neuro-Oncology, St Jude Children's Research Hospital, Memphis, Tennessee, USA
| | - Amar Gajjar
- Division of Neuro-Oncology, St Jude Children's Research Hospital, Memphis, Tennessee, USA
| | - David Walker
- Children's Brain Tumor Research Centre, University of Nottingham, Nottingham, UK
| | - Julie H Harreld
- Department of Diagnostic Imaging, St Jude Children's Research Hospital, Memphis, Tennessee, USA
| | - Thomas E Merchant
- Department of Radiation Oncology, St Jude Children's Research Hospital, Memphis, Tennessee, USA
| | - David W Ellison
- Department of Pathology, St Jude Children's Research Hospital, Memphis, Tennessee, USA
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21
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Liapis K, Papadopoulos V, Vrachiolias G, Galanopoulos AG, Papoutselis M, Papageorgiou SG, Diamantopoulos PT, Pappa V, Viniou NA, Kourakli A, Τsokanas D, Vassilakopoulos TP, Hatzimichael E, Bouronikou E, Ximeri M, Pontikoglou C, Megalakaki A, Zikos P, Panayiotidis P, Dimou M, Karakatsanis S, Papaioannou M, Vardi A, Kontopidou F, Harchalakis N, Adamopoulos I, Symeonidis A, Kotsianidis I. Refinement of prognosis and the effect of azacitidine in intermediate-risk myelodysplastic syndromes. Blood Cancer J 2021; 11:30. [PMID: 33574231 PMCID: PMC7878783 DOI: 10.1038/s41408-021-00424-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2020] [Accepted: 01/20/2021] [Indexed: 11/09/2022] Open
Affiliation(s)
- Konstantinos Liapis
- Department of Hematology, Democritus University of Thrace Medical School, Alexandroupolis, Greece.
| | - Vasileios Papadopoulos
- Department of Hematology, Democritus University of Thrace Medical School, Alexandroupolis, Greece
| | - George Vrachiolias
- Department of Hematology, Democritus University of Thrace Medical School, Alexandroupolis, Greece
| | | | - Menelaos Papoutselis
- Department of Hematology, Democritus University of Thrace Medical School, Alexandroupolis, Greece
| | | | | | - Vassiliki Pappa
- Second Department of Internal Medicine, Attikon University General Hospital, Athens, Greece
| | - Nora-Athina Viniou
- First Department of Internal Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Alexandra Kourakli
- Greece Department of Internal Medicine, University Hospital of Patras, Rio, Greece
| | - Dimitris Τsokanas
- Department of Clinical Hematology, Georgios Gennimatas Hospital, Athens, Greece
| | - Theodoros P Vassilakopoulos
- Department of Hematology, Laikon General Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | | | - Eleni Bouronikou
- Department of Hematology, University Hospital of Larissa, Larissa, Greece
| | - Maria Ximeri
- Department of Hematology, University General Hospital of Heraklion, Voutes, Heraklion, Greece
| | - Charalambos Pontikoglou
- Department of Hematology, University General Hospital of Heraklion, Voutes, Heraklion, Greece
| | | | - Panagiotis Zikos
- Department of Hematology, Aghios Andreas General Hospital, Patras, Greece
| | - Panayiotis Panayiotidis
- First Propedeutic Department of Internal Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Maria Dimou
- First Propedeutic Department of Internal Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | | | - Maria Papaioannou
- Department of Hematology, AHEPA University Hospital, Thessaloniki, Greece
| | - Anna Vardi
- Department of Hematology and Stem cell Transplantation, Georgios Papanicolaou General Hospital, Thessaloniki, Greece
| | - Flora Kontopidou
- Second Department of Internal Medicine, National and Kapodistrian University of Athens, Hippokratio General Hospital, Athens, Greece
| | - Nikolaos Harchalakis
- Department of Hematology and Bone Marrow Transplantation Unit, Evangelismos Hospital, Athens, Greece
| | - Ioannis Adamopoulos
- Department of Hematology and Thalassemia, Kalamata General Hospital, Kalamata, Greece
| | - Argiris Symeonidis
- Greece Department of Internal Medicine, University Hospital of Patras, Rio, Greece
| | - Ioannis Kotsianidis
- Department of Hematology, Democritus University of Thrace Medical School, Alexandroupolis, Greece
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22
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Volpe VO, Komrokji RS. Treatment options for lower-risk myelodysplastic syndromes. Where are we now? Ther Adv Hematol 2021; 12:2040620720986641. [PMID: 33505645 PMCID: PMC7812395 DOI: 10.1177/2040620720986641] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2020] [Accepted: 11/12/2020] [Indexed: 12/11/2022] Open
Abstract
Myelodysplastic syndromes (MDS) are a spectrum of clonal stem-cell disorders characterized clinically by bone-marrow failure. Resultant cytopenias are responsible for significant mortality and decreased quality of life in patients with MDS. In patients with low-risk MDS (LR-MDS), anemia is the most common cytopenia and erythropoiesis-stimulating agents (ESA) are usually used as first-line therapy. Those patients who become refractory to ESA have a poor survival. Available treatment options such as lenalidomide, hypomethylating agents, and immunosuppressive therapy can provide some hematologic response among selected subsets of patients, however durable responses are limited, and these agents can carry significant adverse effects. Chronic transfusions help to alleviate symptoms of anemia but still carry risks associated with transfusion and iron overload. Luspatercept, recently approved for those LR-MDS with ring sideroblasts refractory to ESA, was found to have an improvement in transfusion independence with a well-tolerated safety profile. While anemia is the most common cytopenia, thrombocytopenia and neutropenia management is challenging and the co-occurrence of these cytopenias with anemia may dictate the choice of therapy. In this article, we review LR-MDS and discuss the optimal use of current treatment options and explore new therapeutic options on the horizon.
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Affiliation(s)
- Virginia O Volpe
- H. Lee Moffitt Cancer Center and Research Institute, 12902 Magnolia Drive, Tampa, FL 33612, USA
| | - Rami S Komrokji
- H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA
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23
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Current and emerging strategies for management of myelodysplastic syndromes. Blood Rev 2020; 48:100791. [PMID: 33423844 DOI: 10.1016/j.blre.2020.100791] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2020] [Revised: 11/27/2020] [Accepted: 12/23/2020] [Indexed: 12/21/2022]
Abstract
Myelodysplastic syndromes (MDS) are characterized by ineffective hematopoiesis with varying degrees of dysplasia and peripheral cytopenias. MDS are driven by structural chromosomal alterations and somatic mutations in neoplastic myeloid cells, which are supported by a tumorigenic and a proinflammatory marrow microenvironment. Current treatment strategies for lower-risk MDS focus on improving quality of life and cytopenias, while prolonging survival and delaying disease progression is the focus for higher-risk MDS. Several promising drugs are in the horizon, including the hypoxia-inducible factor stabilizer roxadustat, telomerase inhibitor imetelstat, oral hypomethylating agents (CC-486), TP53 modulators (APR-246 and ALRN-6924), and the anti-CD47 antibody magrolimab. Targeted therapies approved for acute myeloid leukemia treatment, such as isocitrate dehdyrogenase inhibitors and venetoclax, are also being studied for use in MDS. In this review, we provide a brief overview of pathogenesis and current treatment strategies in MDS followed by a discussion of newer agents that are under clinical investigation.
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24
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Kubasch AS, Platzbecker U. Patient stratification in myelodysplastic syndromes: how a puzzle may become a map. HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2020; 2020:418-425. [PMID: 33275703 PMCID: PMC7727505 DOI: 10.1182/hematology.2020000126] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/13/2023]
Abstract
Heterogeneity is the disease-defining epithet of myelodysplastic syndromes (MDS), a clonal disorder of hematopoietic stem and progenitor cells. During the last decade, significant progress has been made to better understand the diversity of clinical, molecular, cellular, and immunological factors that are bound to the prognosis and outcomes of patients with MDS. Despite the rapid generation of all of this biological information, how to implement it has fallen short. Redefining clinical tools to use this new information remains a challenge. The holistic integration of novel, high-impact individual risk parameters such as patient-reported outcomes or mutational and immunological data into conventional risk stratification systems may further refine patient subgroups, improve predictive power for survival, and provide a next-generation classification and prognosis system for patients with MDS. Dichotomic treatment strategies in patients with MDS according to their patient and disease profiles highlight the importance of precise risk stratification, which may be complemented by the definition of granular cohorts of patients with myeloid neoplasms and a druggable target (ie, IDH1/2 mutations) across conventional blast thresholds.
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Affiliation(s)
- Anne Sophie Kubasch
- Department of Hematology, Cellular Therapy and Hemostaseology, Leipzig University Hospital, Leipzig, Germany; German MDS Study Group (D-MDS), Leipzig, Germany; and European Myelodysplastic Syndromes Cooperative Group (EMSCO), Leipzig, Germany
| | - Uwe Platzbecker
- Department of Hematology, Cellular Therapy and Hemostaseology, Leipzig University Hospital, Leipzig, Germany; German MDS Study Group (D-MDS), Leipzig, Germany; and European Myelodysplastic Syndromes Cooperative Group (EMSCO), Leipzig, Germany
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25
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A simple score derived from bone marrow immunophenotyping is important for prognostic evaluation in myelodysplastic syndromes. Sci Rep 2020; 10:20281. [PMID: 33219285 PMCID: PMC7679401 DOI: 10.1038/s41598-020-77158-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2020] [Accepted: 11/04/2020] [Indexed: 11/08/2022] Open
Abstract
Immunophenotyping of bone marrow (BM) precursors has been used as an ancillary diagnostic tool in myelodysplastic syndromes (MDS), but there is no general agreement about which variables are the most relevant for prognosis. We developed a parsimonious prognostic model based on BM cell populations well-defined by phenotype. We analyzed 95 consecutive patients with primary MDS diagnosed at our Institution between 2005 and 2012 where BM immunophenotyping had been performed at diagnosis. Median follow-up: 42 months (4-199). Median age: 67 years (33-79). According to IPSS-R, 71 cases were low or intermediate risk. Flow variables significant in the univariate Cox analysis: "%monocytes/TNCs", "% CD16+ monocytes/TNCs", "total alterations in monocytes", "% myeloid CD34+ cells", "number of abnormal expressions in myeloblasts" and "% of B-cell progenitors". In the multivariate model remained independent: "% myeloid CD34+ cells", B-cell progenitors" and "% CD16+ monocytes/TNCs". These variables were categorized by the extreme quartile risk ratio strategy in order to build the score: % myeloid CD34+ cells" (≥ 2.0% = 1 point), B-cell progenitors" (< 0.05% 1 point) and "CD16+ monocytes/TNCs" (≥ 1.0% 1 point). This score could separate patients with a different survival. There was a weak correlation between the score and IPSS-R. Both had independent prognostic values and so, the flow score adds value for the prognostic evaluation in MDS.
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26
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Garcia‐Manero G, Chien KS, Montalban‐Bravo G. Myelodysplastic syndromes: 2021 update on diagnosis, risk stratification and management. Am J Hematol 2020; 95:1399-1420. [PMID: 32744763 DOI: 10.1002/ajh.25950] [Citation(s) in RCA: 109] [Impact Index Per Article: 27.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2020] [Revised: 07/30/2020] [Accepted: 07/30/2020] [Indexed: 12/12/2022]
Abstract
DISEASE OVERVIEW The myelodysplastic syndromes (MDS) are a very heterogeneous group of myeloid disorders characterized by peripheral blood cytopenias and increased risk of transformation to acute myelogenous leukemia (AML). Myelodysplastic syndromes occur more frequently in older males and in individuals with prior exposure to cytotoxic therapy. DIAGNOSIS Diagnosis of MDS is based on morphological evidence of dysplasia upon visual examination of a bone marrow aspirate and biopsy. Information obtained from additional studies such as karyotype, flow cytometry and molecular genetics is usually complementary and may help refine diagnosis. RISK-STRATIFICATION Prognosis of patients with MDS can be calculated using a number of scoring systems. In general, all these scoring systems include analysis of peripheral cytopenias, percentage of blasts in the bone marrow and cytogenetic characteristics. The most commonly accepted system is the Revised International Prognostic Scoring System (IPSS-R). Somatic mutations can help define prognosis and therapy. RISK-ADAPTED THERAPY Therapy is selected based on risk, transfusion needs, percent of bone marrow blasts, cytogenetic and mutational profiles, comorbidities, potential for allogeneic stem cell transplantation (alloSCT) and prior exposure to hypomethylating agents (HMA). Goals of therapy are different in lower-risk patients than in higher-risk individuals and in those with HMA failure. In lower-risk MDS, the goal is to decrease transfusion needs and transformation to higher risk disease or AML, as well as to improve survival. In higher-risk disease, the goal is to prolong survival. In 2020, we witnessed an explosion of new agents and investigational approaches. Current available therapies include growth factor support, lenalidomide, HMAs, intensive chemotherapy and alloSCT. Novel therapeutics approved in 2020 are luspatercept and the oral HMA ASTX727. At the present time, there are no approved interventions for patients with progressive or refractory disease particularly after HMA-based therapy. Options include participation in a clinical trial, cytarabine-based therapy or alloSCT.
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Affiliation(s)
- Guillermo Garcia‐Manero
- Section of MDS, Department of Leukemia University of Texas MD Anderson Cancer Center Houston Texas USA
| | - Kelly S. Chien
- Section of MDS, Department of Leukemia University of Texas MD Anderson Cancer Center Houston Texas USA
| | - Guillermo Montalban‐Bravo
- Section of MDS, Department of Leukemia University of Texas MD Anderson Cancer Center Houston Texas USA
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Bewersdorf JP, Zeidan AM. Following in the footsteps of acute myeloid leukemia: are we witnessing the start of a therapeutic revolution for higher-risk myelodysplastic syndromes? Leuk Lymphoma 2020; 61:2295-2312. [PMID: 32421403 DOI: 10.1080/10428194.2020.1761968] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
For most patients with higher-risk myelodysplastic syndromes (HR-MDS) the hypomethylating agents (HMA) azacitidine and decitabine remain the mainstay of therapy. However, the prognosis mostly remains poor and aside from allogeneic hematopoietic stem cell transplantation no curative treatment options exist. Unlike acute myeloid leukemia, which has seen a dramatic expansion of available therapies recently, no new agents have been approved for MDS in the United States since 2006. However, various novel HMAs, HMA in combination with venetoclax, immune checkpoint inhibitors, and targeted therapies for genetically defined patient subgroups such as APR-246 or IDH inhibitors, have shown promising results in early stages of clinical testing. Furthermore, the wider availability of genetic testing is going to allow for a more individualized treatment of MDS patients. Herein, we review the current treatment approach for HR-MDS and discuss recent therapeutic advances and the implications of genetic testing on management of HR-MDS.
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Affiliation(s)
- Jan Philipp Bewersdorf
- Department of Internal Medicine, Section of Hematology, Yale University School of Medicine, New Haven, CT, USA
| | - Amer M Zeidan
- Department of Internal Medicine, Section of Hematology, Yale University School of Medicine, New Haven, CT, USA
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Davidoff AJ, Hu X, Bewersdorf JP, Wang R, Podoltsev NA, Huntington SF, Gore SD, Ma X, Zeidan AM. Hypomethylating agent (HMA) therapy use and survival in older adults with Refractory Anemia with Excess Blasts (RAEB) in the United States (USA): a large propensity score-matched population-based study †. Leuk Lymphoma 2020; 61:1178-1187. [PMID: 31878809 PMCID: PMC7735409 DOI: 10.1080/10428194.2019.1703970] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2019] [Revised: 11/16/2019] [Accepted: 12/06/2019] [Indexed: 12/13/2022]
Abstract
Hypomethylating agents (HMA) showed overall survival (OS) benefits in patients with higher-risk myelodysplastic syndromes (HR-MDS) in clinical trials. We conducted a retrospective cohort study of Surveillance, Epidemiology, and End Results (SEER)-Medicare data of patients ≥66 years diagnosed with refractory anemia with excess blasts (RAEB), a proxy for HR-MDS, in 01/2001-04/2004 (pre-period) or 01/2006-12/2011 (post-period). Association between post-period diagnosis and OS was examined using propensity scores (PS)-matched samples. Among 1876 RAEB patients, median OS was 9 months and 30.8% received HMAs (3.6% in pre-period; 43.0% in post-period) with no association between post-period diagnosis and OS. In the top PS quartile, post-period diagnosis was associated with a 74% lower risk of death (Hazard ratio [HR] = 0.26, 95%-CI: 0.10-0.69, p = 0.007), while outcomes were worse in the lowest PS quartile (HR = 2.80, 95%-CI: 1.06-7.36, p = 0.037). HMA lead to a 3-month OS benefit for patients most likely to receive HMA but not for unselected RAEB cohort.
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Affiliation(s)
- Amy J. Davidoff
- Cancer Outcomes, Public Policy, and Effectiveness Research (COPPER) Center, Yale University, New Haven, CT
- Department of Chronic Disease Epidemiology, School of Public Health, Yale University, New Haven, CT
| | - Xin Hu
- Cancer Outcomes, Public Policy, and Effectiveness Research (COPPER) Center, Yale University, New Haven, CT
| | | | - Rong Wang
- Cancer Outcomes, Public Policy, and Effectiveness Research (COPPER) Center, Yale University, New Haven, CT
- Department of Health Policy and Management, School of Public Health, Yale University, New Haven, CT
| | - Nikolai A. Podoltsev
- Cancer Outcomes, Public Policy, and Effectiveness Research (COPPER) Center, Yale University, New Haven, CT
- Department of Internal Medicine, School of Medicine, Yale University, New Haven, CT
| | - Scott F. Huntington
- Cancer Outcomes, Public Policy, and Effectiveness Research (COPPER) Center, Yale University, New Haven, CT
- Department of Internal Medicine, School of Medicine, Yale University, New Haven, CT
| | - Steven D. Gore
- Cancer Outcomes, Public Policy, and Effectiveness Research (COPPER) Center, Yale University, New Haven, CT
- Department of Internal Medicine, School of Medicine, Yale University, New Haven, CT
| | - Xiaomei Ma
- Cancer Outcomes, Public Policy, and Effectiveness Research (COPPER) Center, Yale University, New Haven, CT
- Department of Health Policy and Management, School of Public Health, Yale University, New Haven, CT
| | - Amer M. Zeidan
- Cancer Outcomes, Public Policy, and Effectiveness Research (COPPER) Center, Yale University, New Haven, CT
- Department of Internal Medicine, School of Medicine, Yale University, New Haven, CT
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Canaani J. Emerging Therapies for the Myelodysplastic Syndromes. Clin Hematol Int 2020; 2:13-17. [PMID: 34595438 PMCID: PMC8432342 DOI: 10.2991/chi.d.191202.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2019] [Accepted: 11/27/2019] [Indexed: 01/11/2023] Open
Abstract
Despite considerable advances in our understanding of the molecular and epigenetic underpinnings of the myelodysplastic syndromes (MDS), this diverse group of myeloid neoplasms remains a significant clinical challenge. Considerable barriers to timely development of effective therapy include the diverse molecular landscape encountered in MDS patients, the difficulty in translating specific molecular aberration into a clinically meaningful animal model, as well as challenges in patient recruitment into clinical trials. These speak to the need to discover efficacious novel therapeutic targets which would in turn translate into improved patient outcomes in terms of both survival and quality of life. In this review, we outline recently published data pertaining to therapeutic advances in TGF-β pathway inhibition, STAT3, Hedgehog signaling, and additional therapeutic venues being actively explored in MDS.
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Affiliation(s)
- Jonathan Canaani
- Hematology Division, Chaim Sheba Medical Center, Tel Aviv University, Tel Hashomer, Israel
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Garcia-Manero G. Improving Prognostic Tools for Patients With Myelodysplastic Syndromes. Mayo Clin Proc 2018; 93:1340-1342. [PMID: 30286827 DOI: 10.1016/j.mayocp.2018.08.025] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2018] [Accepted: 08/27/2018] [Indexed: 10/28/2022]
Affiliation(s)
- Guillermo Garcia-Manero
- Section of MDS, Department of Leukemia, University of Texas MD Anderson Cancer Center, Houston, TX.
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