1
|
Yang Y, Hu Q, Yang C, Chen M, Han B. High- vs regular-dose recombinant human thrombopoietin plus cyclosporine A in patients with newly diagnosed non-severe aplastic anemia: a retrospective cohort study. Hematology 2024; 29:2298523. [PMID: 38156735 DOI: 10.1080/16078454.2023.2298523] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2023] [Accepted: 12/18/2023] [Indexed: 01/03/2024] Open
Abstract
BACKGROUND Cyclosporine A (CsA) and regular doses of recombinant human thrombopoietin (rhTPO) can accelerate platelet recovery in patients with non-severe aplastic anemia (NSAA). However, it is unclear whether CsA plus rhTPO at a higher dose can further increase the efficacy. METHODS Data from patients with newly diagnosed NSAA, who had been treated with CsA in combination with different doses of rhTPO between February 2021 and August 2021 at Peking Union Medical College Hospital, were reviewed. All the enrolled patients had been treated with CsA at 3-5 mg/(kg/d), and patients were further classified into high-dose (with rhTPO 30000U qd × 14 days for 2 months) group or regular-dose (with rhTPO 15000U qd × 7days for 3 months) group. The treatment response and therapy-related adverse events were compared. RESULTS 36 patients including 16 (44.4%) in the high-dose and 20 (55.6%) in the regular-dose group were enrolled. The baseline characteristics were compatible between the two groups. The platelet counts were significantly higher at 1/3/6 months in the high-dose group (p = 0.028, 0.0063 and p = 0.040, respectively). The high-dose group had a significantly shorter time to platelet transfusion independence ([1 (0.5-6) months vs 2.5 (1-12) months, p = 0.040]). There was no significant difference in overall response and complete response rate between the two groups at 1/3/6/12 months (p > 0.05). Treatment-related morbidities were similar between the two groups (p > 0.05). CONCLUSIONS Adding a higher dose of rhTPO can further accelerate platelet recovery and platelet transfusion independence in patients with newly diagnosed NSAA.
Collapse
Affiliation(s)
- Yuan Yang
- Department of Hematology, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, People's Republic of China
- Department of Hematology, Lymphoma Research Center, Third Hospital, Peking University, Beijing, People's Republic of China
| | - Qinglin Hu
- Department of Hematology, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, People's Republic of China
| | - Chen Yang
- Department of Hematology, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, People's Republic of China
| | - Miao Chen
- Department of Hematology, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, People's Republic of China
| | - Bing Han
- Department of Hematology, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, People's Republic of China
| |
Collapse
|
2
|
Karel D, Valburg C, Woddor N, Nava VE, Aggarwal A. Myelodysplastic Neoplasms (MDS): The Current and Future Treatment Landscape. Curr Oncol 2024; 31:1971-1993. [PMID: 38668051 PMCID: PMC11049094 DOI: 10.3390/curroncol31040148] [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: 02/09/2024] [Revised: 03/16/2024] [Accepted: 03/30/2024] [Indexed: 04/28/2024] Open
Abstract
Myelodysplastic neoplasms (MDS) are a heterogenous clonal disorder of hemopoietic stem cells characterized by cytomorphologic dysplasia, ineffective hematopoiesis, peripheral cytopenias and risk of progression to acute myeloid leukemia (AML). Our understanding of this disease has continued to evolve over the last century. More recently, prognostication and treatment have been determined by cytogenetic and molecular data. Specific genetic abnormalities, such as deletion of the long arm of chromosome 5 (del(5q)), TP53 inactivation and SF3B1 mutation, are increasingly associated with disease phenotype and outcome, as reflected in the recently updated fifth edition of the World Health Organization Classification of Hematolymphoid Tumors (WHO5) and the International Consensus Classification 2022 (ICC 2022) classification systems. Treatment of lower-risk MDS is primarily symptom directed to ameliorate cytopenias. Higher-risk disease warrants disease-directed therapy at diagnosis; however, the only possible cure is an allogenic bone marrow transplant. Novel treatments aimed at rational molecular and cellular pathway targets have yielded a number of candidate drugs over recent years; however few new approvals have been granted. With ongoing research, we hope to increasingly offer our MDS patients tailored therapeutic approaches, ultimately decreasing morbidity and mortality.
Collapse
Affiliation(s)
- Daniel Karel
- Department of Hematology/Medical Oncology, The George Washington University, Washington, DC 20037, USA; (C.V.); (A.A.)
| | - Claire Valburg
- Department of Hematology/Medical Oncology, The George Washington University, Washington, DC 20037, USA; (C.V.); (A.A.)
| | - Navitha Woddor
- Department of Pathology, The George Washington University, Washington, DC 20037, USA; (N.W.); (V.E.N.)
| | - Victor E. Nava
- Department of Pathology, The George Washington University, Washington, DC 20037, USA; (N.W.); (V.E.N.)
- Department of Pathology, Washington DC VA Medical Center, Washington, DC 20422, USA
| | - Anita Aggarwal
- Department of Hematology/Medical Oncology, The George Washington University, Washington, DC 20037, USA; (C.V.); (A.A.)
- Department of Hematology/Medical Oncology, Washington DC VA Medical Center, Washington, DC 20422, USA
| |
Collapse
|
3
|
Foy P, Friedman KD, Michaelis LC. How I diagnose and treat thrombocytopenia in geriatric patients. Blood 2024; 143:214-223. [PMID: 37956435 DOI: 10.1182/blood.2022017634] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2022] [Revised: 07/31/2023] [Accepted: 08/16/2023] [Indexed: 11/15/2023] Open
Abstract
ABSTRACT Thrombocytopenia in older individuals is a common but diagnostically challenging condition that has variable clinical impact to those who are affected. Diagnostic approach requires evaluation of the preexisting clinical conditions, detailed review of medications, and assessment for disorders that warrant urgent treatment. In this article, we describe a systematic approach to diagnosis of thrombocytopenia and present a schematic review for management strategies. Three clinical scenarios are presented that are relevant for their prevalence and management challenges in an older adult population. The first scenario addresses primary immune thrombocytopenia (ITP) and reviews different treatment options. The second one addresses complications of thrombocytopenia in management of the myelodysplastic syndrome. The last one reviews diagnostic challenges of drug-induced ITP.
Collapse
Affiliation(s)
- Patrick Foy
- Department of Medicine, Division of Hematology-Oncology, Medical College of Wisconsin, Milwaukee, WI
| | | | - Laura C Michaelis
- Department of Medicine, Division of Hematology-Oncology, Medical College of Wisconsin, Milwaukee, WI
| |
Collapse
|
4
|
Oliva EN, Riva M, Niscola P, Santini V, Breccia M, Giai V, Poloni A, Patriarca A, Crisà E, Capodanno I, Salutari P, Reda G, Cascavilla N, Ferrero D, Guarini A, Tripepi G, Iannì G, Russo E, Castelli A, Fattizzo B, Beltrami G, Bocchia M, Molteni A, Fenaux P, Germing U, Ricco A, Palumbo GA, Impera S, Di Renzo N, Rivellini F, Buccisano F, Stamatoullas-Bastard A, Liberati AM, Candoni A, Delfino IM, Arcadi MT, Cufari P, Rizzo L, Bova I, D'Errigo MG, Zini G, Latagliata R. Eltrombopag for Low-Risk Myelodysplastic Syndromes With Thrombocytopenia: Interim Results of a Phase II, Randomized, Placebo-Controlled Clinical Trial (EQOL-MDS). J Clin Oncol 2023; 41:4486-4496. [PMID: 37294914 PMCID: PMC10552995 DOI: 10.1200/jco.22.02699] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2022] [Revised: 03/16/2023] [Accepted: 05/01/2023] [Indexed: 06/11/2023] Open
Abstract
PURPOSE In myelodysplastic syndromes (MDS), severe thrombocytopenia is associated with poor prognosis. This multicenter trial presents the second-part long-term efficacy and safety results of eltrombopag in patients with low-risk MDS and severe thrombocytopenia. METHODS In this single-blind, randomized, placebo-controlled, phase-II trial of adult patients with International Prognostic Scoring System low- or intermediate-1-risk MDS, patients with a stable platelet (PLT) count (<30 × 103/mm3) received eltrombopag or placebo until disease progression. Primary end points were duration of PLT response (PLT-R; calculated from the time of PLT-R to date of loss of PLT-R, defined as bleeding/PLT count <30 × 103/mm3 or last date in observation) and long-term safety and tolerability. Secondary end points included incidence and severity of bleeding, PLT transfusions, quality of life, leukemia-free survival, progression-free survival, overall survival and pharmacokinetics. RESULTS From 2011 to 2021, of 325 patients screened, 169 patients were randomly assigned oral eltrombopag (N = 112) or placebo (N = 57) at a starting dose of 50 mg once daily to maximum of 300 mg. PLT-R, with 25-week follow-up (IQR, 14-68) occurred in 47/111 (42.3%) eltrombopag patients versus 6/54 (11.1%) in placebo (odds ratio, 5.9; 95% CI, 2.3 to 14.9; P < .001). In eltrombopag patients, 12/47 (25.5%) lost the PLT-R, with cumulative thrombocytopenia relapse-free survival at 60 months of 63.6% (95% CI, 46.0 to 81.2). Clinically significant bleeding (WHO bleeding score ≥ 2) occurred less frequently in the eltrombopag arm than in the placebo group (incidence rate ratio, 0.54; 95% CI, 0.38 to 0.75; P = .0002). Although no difference in the frequency of grade 1-2 adverse events (AEs) was observed, a higher proportion of eltrombopag patients experienced grade 3-4 AEs (χ2 = 9.5, P = .002). AML evolution and/or disease progression occurred in 17% (for both) of eltrombopag and placebo patients with no difference in survival times. CONCLUSION Eltrombopag was effective and relatively safe in low-risk MDS with severe thrombocytopenia. This trial is registered with ClinicalTrials.gov identifier: NCT02912208 and EU Clinical Trials Register: EudraCT No. 2010-022890-33.
Collapse
Affiliation(s)
- Esther Natalie Oliva
- U.O.C. Ematologia, Grande Ospedale Metropolitano Bianchi Melacrino Morelli, Reggio di Calabria, Italy
| | - Marta Riva
- Dipartimento di Ematologia, Ospedale Niguarda Ca' Granda, Milano, Italy
| | | | - Valeria Santini
- U.O. di Ematologia, Azienda Ospedaliera Universitaria Careggi, Firenze, Italy
| | - Massimo Breccia
- Dipartimento di Ematologia Policlinico Umberto I, Università La Sapienza, Roma, Italy
| | - Valentina Giai
- S.C. a Direzione Universitaria di Ematologia A.O., SS. Antonio e Biagio e Cesare Arrigo Alessandria, Alessandria, Italy
| | - Antonella Poloni
- Clinica di Ematologia Azienda Ospedaliera Universitaria—Ospedali Riuniti di Ancona, Ancona, Italy
| | | | - Elena Crisà
- Candiolo Cancer Institute, FPO-IRCCS, Candiolo, Turin, Italy
| | - Isabella Capodanno
- U.O. di Ematologia, A.U.S.L.-IRCCS di Reggio Emilia, Reggio Emilia, Italy
| | - Prassede Salutari
- Dipartimento Oncologico-Ematologico, Ospedale Civile Spirito Santo, Pescara, Italy
| | - Gianluigi Reda
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Nicola Cascavilla
- U.O. Ematologia Ospedale Casa Sollievo della Sofferenza, San Giovanni Rotondo, Italy
| | - Dario Ferrero
- Dipartimento Biotecnologie Molecolari, Ematologia Universitaria A.O.U. Citta' della Salute e della Scienza di Torino, Turin, Italy
| | - Attilio Guarini
- U.O. Ematologia I.R.C.C.S. Istituto Tumori “Giovanni Paolo II”, Bari, Italy
| | - Giovanni Tripepi
- IFC-CNR Institute of Clinical Physiology, Reggio Calabria, Italy
| | | | - Emilio Russo
- Department of Pharmacology, University of Germaneto Catanzaro, Catanzaro, Italy
| | | | - Bruno Fattizzo
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
- Dipartimento di Oncologia ed Emato-Oncologia, Università degli Studi di Milano, Milan, Italy
| | - Germana Beltrami
- U.O. Ematologia e terapie cellulari, IRCCS Azienda Ospedaliera Universitaria San Martino, Genova, Italy
| | - Monica Bocchia
- UOC Ematologia, Università di Siena, Azienda Ospedaliera Universitaria Senese, Siena, Italy
| | | | - Pierre Fenaux
- Groupe Francais desmyélodysplasies (GFM), Paris, France
| | - Ulrich Germing
- Department of Hematology, Oncology, and Clinical Immunology, Heinrich-Heine-University Düsseldorf, Düsseldorf, Germany
| | - Alessandra Ricco
- U.O. Ematologia con Trapianto, Azienda Ospedale Policlinicodi Bari, Bari, Italy
| | - Giuseppe A. Palumbo
- Dipartimento di Scienze Mediche Chirurgiche e Tecnologie Avanzate “G.F. Ingrassia”, University of Catania, Catania, Italy
| | - Stefana Impera
- U.O. C. Ematologia, A. O.ad Alta Specializzazione Ospedale Garibaldi Nesima, Catania, Italy
| | | | - Flavia Rivellini
- Divisione Ematologia, P.O. A. Tortora di Pagani-ASL Salerno, Pagani, Italy
| | - Francesco Buccisano
- Divisione di Biopatologia e Diagnostica per Immagini, Policlinico Universitario Tor Vergata, Rome, Italy
| | | | - Anna Marina Liberati
- S.C. Oncoematologia, Università degli Studi di Perugia A.O. Santa Maria, Terni, Italy
| | - Anna Candoni
- Divisione Ematologia, P.O. Santa Maria della Misericordia, A.S.U.F.C di Udine, Udine, Italy
| | - Ilaria Maria Delfino
- U.O.C. Ematologia, Grande Ospedale Metropolitano Bianchi Melacrino Morelli, Reggio di Calabria, Italy
| | - Maria Teresa Arcadi
- U.O. Farmacia Grande Ospedale Metropolitano Bianchi Melacrino Morelli, Reggio di Calabria, Italy
| | - Patrizia Cufari
- U.O.C. Ematologia, Grande Ospedale Metropolitano Bianchi Melacrino Morelli, Reggio di Calabria, Italy
| | - Lorenzo Rizzo
- Dipartimento di Ematologia, Ospedale Niguarda Ca' Granda, Milan, Italy
| | - Irene Bova
- U.O.S. di Genetica Medica Grande Ospedale Metropolitano Bianchi Melacrino Morelli, Reggio di Calabria, Italy
| | - Maria Grazia D'Errigo
- U.O.S. di Genetica Medica Grande Ospedale Metropolitano Bianchi Melacrino Morelli, Reggio di Calabria, Italy
| | - Gina Zini
- Fondazione Policlinico, Universitario A. Gemelli IRCCS, Rome, Italy
- Università Cattolica del Sacro Cuore, Rome, Italy
| | | |
Collapse
|
5
|
Kulasekararaj AG, Trikha R. Eltrombopag in Lower-Risk Myelodysplastic Syndrome: Revival of Its Use in Thrombocytopenia. J Clin Oncol 2023; 41:4465-4468. [PMID: 37428990 DOI: 10.1200/jco.23.01141] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2023] [Revised: 06/04/2023] [Accepted: 06/12/2023] [Indexed: 07/12/2023] Open
Affiliation(s)
- Austin G Kulasekararaj
- The Department of Haematological Medicine, King's College Hospital NHS, London, United Kingdom
- National Institute for Health and Care Research and Wellcome King's Research Facility, London, United Kingdom
- King's College London, London, United Kingdom
| | - Roochi Trikha
- The Department of Haematological Medicine, King's College Hospital NHS, London, United Kingdom
| |
Collapse
|
6
|
Badar T, Madanat YF, Zeidan AM. Updates on risk stratification and management of lower-risk myelodysplastic syndromes/neoplasms. Future Oncol 2023; 19:1877-1889. [PMID: 37750305 DOI: 10.2217/fon-2023-0454] [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: 09/27/2023] Open
Abstract
The majority of lower-risk myelodysplastic syndromes/neoplasms patients present with anemia. Historically, these patients were treated with erythropoiesis-stimulating agents (ESA), with modest responses. A subset of these patients with del(5q) may do better with lenalidomide. Recently, in randomized trials, luspatercept has shown better responses compared with ESAs in treatment-naive patients and imetelstat in patients refractory to ESAs. Other evaluated novel compounds (fostamatinib, H3B-880, roxadustat, pyruvate kinase receptor activator) have not yet shown meaningful efficacy. More needs to be done to improve outcomes; in pursuance of this, participation in clinical trials evaluating novel therapies should be encouraged. While lower-risk myelodysplastic syndromes/neoplasms tend to have an indolent course, a subset of them has a dismal prognosis. Improving prognostication and serial monitoring will help in identifying high-risk patients for appropriate management.
Collapse
Affiliation(s)
- Talha Badar
- Division of Hematology & Oncology, Department of Medicine, Mayo Clinic, Jacksonville, FL 32224, USA
| | - Yazan F Madanat
- Division of Hematology & Medical Oncology, Department of Internal Medicine, UT Southwestern Medical Center, Dallas, TX 75390, USA
- Leukemia Program, Harold C. Simmons Comprehensive Cancer Center, UT Southwestern Medical Center, Dallas, TX 75390, USA
| | - Amer M Zeidan
- Section of Hematology, Department of Internal Medicine, Yale School of Medicine & Yale Cancer Center, New Haven, CT 06510, USA
| |
Collapse
|
7
|
Frumm SM, Shimony S, Stone RM, DeAngelo DJ, Bewersdorf JP, Zeidan AM, Stahl M. Why do we not have more drugs approved for MDS? A critical viewpoint on novel drug development in MDS. Blood Rev 2023; 60:101056. [PMID: 36805300 DOI: 10.1016/j.blre.2023.101056] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2022] [Revised: 01/15/2023] [Accepted: 02/09/2023] [Indexed: 02/16/2023]
Abstract
Approval of new agents to treat higher risk (HR) myelodysplastic syndrome (MDS) has stalled since the approval of DNA methyltransferase inhibitors (DNMTi). In addition, the options for patients with lower risk (LR) MDS who have high transfusion needs and do not harbor ring sideroblasts or 5q- syndrome are limited. Here, we review the current treatment landscape in MDS and identify areas of unmet need, such as treatment after failure of erythropoiesis-stimulating agents or DNMTis, TP53-mutated disease, and MDS with potentially targetable mutations. We discuss how our understanding of MDS pathogenesis can inform therapy development, including treating HR-MDS similarly to AML and pursuing therapies to address splicing factor mutations and dysregulated inflammation. We then bring a critical lens to current methodology of MDS studies and propose solutions to improve the efficiency and yield of these clinical trials, including using the most meaningful response metrics and expanding enrollment.
Collapse
Affiliation(s)
- Stacey M Frumm
- Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Shai Shimony
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA; Rabin Medical Center and Faculty of Medicine, Tel Aviv University, Israel
| | - Richard M Stone
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Daniel J DeAngelo
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Jan Phillipp Bewersdorf
- Department of Medicine, Leukemia Service, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Amer M Zeidan
- Section of Hematology, Department of Internal Medicine, Yale School of Medicine, and Yale Cancer Center, Yale University, New Haven, CT, USA
| | - Maximilian Stahl
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA.
| |
Collapse
|
8
|
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.
Collapse
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
| |
Collapse
|
9
|
Mittelman M, Platzbecker U, Grosicki S, Lawniczek T, Zhu Z, Selleslag D. Long-Term Safety and Efficacy of Eltrombopag for Advanced Myelodysplastic Syndromes or Acute Myeloid Leukemia and Severe Thrombocytopenia: Results of the ASPIRE Extension Study. Acta Haematol 2023; 146:373-378. [PMID: 37231838 PMCID: PMC10614231 DOI: 10.1159/000531146] [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: 10/25/2022] [Accepted: 05/09/2023] [Indexed: 05/27/2023]
Abstract
ASPIRE, a three-part, international, phase 2 trial (ClinicalTrials.gov identifier: NCT01440374), investigated eltrombopag efficacy and safety in patients with advanced myelodysplastic syndrome or acute myeloid leukemia and grade 4 thrombocytopenia (<25 × 109 platelets/L). Approximately 30-65% of patients in this open-label extension phase experienced clinically relevant thrombocytopenic events; no conclusions could be made regarding long-term efficacy (non-randomized design, no placebo control), and survival rates may simply reflect advanced disease. Long-term safety was consistent with the double-blind phase and contrasted with earlier SUPPORT study findings in higher-risk patients, suggesting that eltrombopag may have a role in treating thrombocytopenia in patients with low-/intermediate-risk myelodysplastic syndrome.
Collapse
Affiliation(s)
- Moshe Mittelman
- The Department of Hematology, Tel Aviv Sourasky Medical Center, Tel Aviv University, Tel Aviv, Israel
| | - Uwe Platzbecker
- Medical Clinic and Polyclinic I, Hematology and Cellular Therapy, University Hospital Leipzig, Leipzig, Germany
| | - Sebastian Grosicki
- Department of Hematology and Cancer Prevention, Medical University of Silesia, Katowice, Poland
| | | | - Zewen Zhu
- Novartis Pharmaceuticals Corporation, East Hanover, NJ, USA
| | - Dominik Selleslag
- Department of Hematology, AZ Sint-Jan Brugge-Oostende AV, Bruges, Belgium
| |
Collapse
|
10
|
Stempel JM, Xie Z, Bewersdorf JP, Stahl M, Zeidan AM. Evolution of Therapeutic Benefit Measurement Criteria in Myelodysplastic Syndromes/Neoplasms. Cancer J 2023; 29:203-211. [PMID: 37195777 DOI: 10.1097/ppo.0000000000000666] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/18/2023]
Abstract
ABSTRACT Myelodysplastic syndromes/neoplasms (MDS) are heterogeneous, clonal myeloid neoplasms characterized by ineffective hematopoiesis, progressive cytopenias, and an increased risk of progression to acute myeloid leukemia. The diversity in disease severity, morphology, and genetic landscape challenges not only novel drug development but also therapeutic response assessment. The MDS International Working Group (IWG) response criteria were first published in the year 2000 focusing on measures of blast burden reduction and hematologic recovery. Despite revision of the IWG criteria in 2006, correlation between IWG-defined responses and patient-focused outcomes, including long-term benefits, remains limited and has potentially contributed to failures of several phase III clinical trials. Several IWG 2006 criteria also lacked clear definitions leading to problems in practical applications and interobserver and intraobserver consistency of response reporting. Although the 2018 revision addressed lower-risk MDS, the most recent update in 2023 redefined responses for higher-risk MDS and has set out to provide clear definitions to enhance consistency while focusing on clinically meaningful outcomes and patient-centered responses. In this review, we analyze the evolution of the MDS response criteria, limitations, and areas of improvement.
Collapse
Affiliation(s)
- Jessica M Stempel
- From the Department of Internal Medicine, Hematology Section, Yale School of Medicine, New Haven, CT
| | - Zhuoer Xie
- Department of Hematology, H. Lee Moffitt Cancer Center, Tampa, FL
| | - Jan Philipp Bewersdorf
- Department of Medicine, Leukemia Service, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Maximilian Stahl
- Department of Medical Oncology, Dana-Farber Cancer Institute and Harvard Medical School, Harvard University, Boston, MA
| | - Amer M Zeidan
- From the Department of Internal Medicine, Hematology Section, Yale School of Medicine, New Haven, CT
| |
Collapse
|
11
|
Randall MP, DeZern AE. The Management of Low-Risk Myelodysplastic Syndromes-Current Standards and Recent Advances. Cancer J 2023; 29:152-159. [PMID: 37195771 DOI: 10.1097/ppo.0000000000000655] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/18/2023]
Abstract
ABSTRACT The myelodysplastic syndromes (MDSs) are a heterogeneous group of hematologic neoplasms with varied natural histories and prognoses. Specific to this review, treatment of low-risk MDS most often focuses on improving quality of life by correcting cytopenias, as opposed to urgent disease modification to avoid acute myeloid leukemia. These treatments include transfusion support with iron chelation when necessary, growth factors including novel maturation agents such as luspatercept, lenalidomide for del(5q) disease, and, increasingly, low-dose hypomethylating agents. Recent advances in the understanding of the genetic lesions that drive MDS have prompted a reassessment of how low-risk disease is defined and helped to identify a subset of low-risk MDS patients who may benefit from a more aggressive treatment paradigm, including hematopoietic stem cell transplantation.
Collapse
Affiliation(s)
- Michael P Randall
- From the Division of Hematology and Oncology, Department of Medicine, University of California San Francisco, San Francisco, CA
| | - Amy E DeZern
- Division of Hematologic Malignancies, The Johns Hopkins University School of Medicine, Baltimore, MD
| |
Collapse
|
12
|
Riva M, Bosi A, Rizzo L, Mazzon F, Ferrari S, Lussana F, Borin L, Castelli A, Cairoli R, Barcellini W, Molteni A, Fattizzo B. Danazol Treatment for Thrombocytopenia in Myelodysplastic Syndromes: Can an “Old-fashioned” Drug be Effective? Hemasphere 2023; 7:e867. [PMID: 36999006 PMCID: PMC10047600 DOI: 10.1097/hs9.0000000000000867] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2022] [Accepted: 02/17/2023] [Indexed: 03/30/2023] Open
Affiliation(s)
- Marta Riva
- Department of Haematology, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Alessandro Bosi
- Haematology Unit, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy
- Department of Oncology and Haemato-oncology, University of Milan, Italy
| | - Lorenzo Rizzo
- Department of Haematology, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Federico Mazzon
- Department of Haematology, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
- Department of Oncology and Haemato-oncology, University of Milan, Italy
| | - Silvia Ferrari
- Hematology and Bone Marrow Transplant Unit, ASST Papa Giovanni XXIII, Bergamo, Italy
| | - Federico Lussana
- Hematology and Bone Marrow Transplant Unit, ASST Papa Giovanni XXIII, Bergamo, Italy
| | - Lorenza Borin
- Department of Hematology, San Gerardo Hospital, Monza, Italy
| | | | - Roberto Cairoli
- Department of Haematology, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Wilma Barcellini
- Haematology Unit, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy
| | | | - Bruno Fattizzo
- Haematology Unit, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy
- Department of Oncology and Haemato-oncology, University of Milan, Italy
| |
Collapse
|
13
|
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.
Collapse
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.
| |
Collapse
|
14
|
Volpe VO, Garcia-Manero G, Komrokji RS. SOHO State of the Art Updates and Next Questions: Treatment of Lower Risk Myelodysplastic Syndromes. CLINICAL LYMPHOMA, MYELOMA & LEUKEMIA 2023; 23:168-177. [PMID: 36682988 DOI: 10.1016/j.clml.2023.01.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/01/2022] [Revised: 01/04/2023] [Accepted: 01/05/2023] [Indexed: 01/15/2023]
Abstract
MDS is a clonal stem cell neoplasm with a spectrum from lower risk disease to short term life threatening higher risk disease. The disease risk is dictated by clinical and molecular features. Majority of MDS patients including lower risk disease unfortunately succumb from disease related complications namely cytopenia. While cytopenias may be mild early upon diagnosis and can be surveilled, ultimately treatment is required. Anemia is the hall mark of disease and most common indication to treat in lower risk MDS. Erythroid stimulating agents are used in the first line setting. Treatment can be a personalized approach as in select patient such as patients with del(5q) and those with ringed sideroblasts, lenalidomide, and luspatercept can be extremely effective respectively at improving cytopenias. Younger patients and hypoplastic MDS have also shown and improved response to immunosuppressive therapy. Hypomethylating agents can be option for patients with higher risk features or thrombocytopenia/neutropenia. Refractory cytopenias still poses frustration as options are limited and there is need to add more treatments to our armamentarium.
Collapse
Affiliation(s)
- Virginia O Volpe
- Department of Medical Oncology, Dana Farber Cancer Institute, Boston, MA
| | | | - Rami S Komrokji
- Department of Malignant Hematology, H. Lee Moffitt Cancer Center, Tampa, FL.
| |
Collapse
|
15
|
Crickx E, Mahévas M, Michel M, Godeau B. Older Adults and Immune Thrombocytopenia: Considerations for the Clinician. Clin Interv Aging 2023; 18:115-130. [PMID: 36726813 PMCID: PMC9885884 DOI: 10.2147/cia.s369574] [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: 10/26/2022] [Accepted: 01/10/2023] [Indexed: 01/28/2023] Open
Abstract
Many epidemiological studies have shown that the incidence of immune thrombocytopenia (ITP) increases after age 60 years and peaks in patients over age 80 years. Therefore, ITP is a concern for physicians taking care of older patients, especially regarding its diagnosis and management. The diagnostic work-up should exclude other causes of thrombocytopenia and secondary ITP, including myelodysplastic syndrome and drug-induced ITP. The treatment decision is influenced by an increased risk of bleeding, infectious diseases and thrombosis in this population and should take into account comorbidities and concomitant medications such as anticoagulant drugs. First-line treatment is based on short corticosteroids courses and intravenous immunoglobulin, which should be reserved for patients with more severe bleeding complications, with their higher risk of toxic effects as compared with younger patients. Second-line treatment should be tailored to the patient's history, comorbidities and preferences. Preferred second-line treatments are thrombopoietin receptor agonists for most groups and guidelines given their good efficacy/tolerance ratio, but the thrombotic risk is increased in older people. Other second-line options that can be good alternatives depending on the clinical context include rituximab, dapsone, fostamatinib or immunosuppressive drugs. Splenectomy is less often performed but remains an option for fit patients with chronic refractory disease. Emerging treatments such as Syk or Bruton tyrosine kinase inhibitors and FcRn antagonists are becoming available for ITP and may modify the treatment algorithm in the near future. The aim of this review is to describe the particularities of the diagnosis and treatment of ITP in older people, including the response and tolerance to the currently available drugs. We also discuss some situations related to co-morbidities that can frequently lead to adapt the management strategy in older patients.
Collapse
Affiliation(s)
- Etienne Crickx
- Service de Médecine Interne, Centre national de référence des cytopénies auto-immunes de l’adulte, Hôpital Henri Mondor, Fédération Hospitalo-Universitaire TRUE InnovaTive theRapy for immUne disordErs, Assistance Publique Hôpitaux de Paris (AP-HP), Université Paris Est Créteil, Créteil, France,Université de Paris, Imagine Institute, Laboratory of Immunogenetics of Pediatric Autoimmune Diseases, Paris, F-75015, France
| | - Matthieu Mahévas
- Service de Médecine Interne, Centre national de référence des cytopénies auto-immunes de l’adulte, Hôpital Henri Mondor, Fédération Hospitalo-Universitaire TRUE InnovaTive theRapy for immUne disordErs, Assistance Publique Hôpitaux de Paris (AP-HP), Université Paris Est Créteil, Créteil, France,Institut Necker Enfants Malades (INEM), INSERM U1151/CNRS UMS 8253, ATIP-Avenir Team AI2B, Université de Paris, Université Paris-Est-Créteil, Paris, France,INSERM U955, équipe 2, Université Paris-Est Créteil (UPEC), Créteil, France
| | - Marc Michel
- Service de Médecine Interne, Centre national de référence des cytopénies auto-immunes de l’adulte, Hôpital Henri Mondor, Fédération Hospitalo-Universitaire TRUE InnovaTive theRapy for immUne disordErs, Assistance Publique Hôpitaux de Paris (AP-HP), Université Paris Est Créteil, Créteil, France
| | - Bertrand Godeau
- Service de Médecine Interne, Centre national de référence des cytopénies auto-immunes de l’adulte, Hôpital Henri Mondor, Fédération Hospitalo-Universitaire TRUE InnovaTive theRapy for immUne disordErs, Assistance Publique Hôpitaux de Paris (AP-HP), Université Paris Est Créteil, Créteil, France,Correspondence: Bertrand Godeau, Service de Médecine Interne, Hôpital Henri Mondor, Assistance Publique Hôpitaux de Paris (AP-HP), 51 avenue du maréchal de Lattre de Tassigny, Créteil, 94000, France, Tel +331 49 81 29 05, Fax +331 49 81 29 02, Email
| |
Collapse
|
16
|
Gonzalez-Lugo JD, Kambhampati S, Yacoub A, Donnellan WB, Berdeja J, Bhagat P, Fehn K, Remy C, Jasra S, Kazemi M, Pradhan K, Kim M, Mantzaris I, Sica RA, Shah N, Goldfinger M, Kornblum N, Gritsman K, Braunschweig I, Steidl U, Will B, Shastri A, Verma A. Lenalidomide and Eltrombopag for Treatment of Low- or Intermediate-Risk Myelodysplastic Syndrome: Result of a Phase II Clinical Trial. Clin Cancer Res 2023; 29:60-66. [PMID: 36255372 DOI: 10.1158/1078-0432.ccr-22-1457] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2022] [Revised: 07/15/2022] [Accepted: 10/14/2022] [Indexed: 02/06/2023]
Abstract
PURPOSE Thrombocytopenia is a serious complication of myelodysplastic syndromes (MDS) associated with an increased bleeding risk and worse prognosis. Eltrombopag (ELT), a thrombopoietin receptor agonist, can increase platelet counts and reverse anti-megakaryopoietic effects of lenalidomide (LEN) in preclinical studies. We hypothesized ELT would reduce the incidence of thrombocytopenia in MDS. PATIENTS AND METHODS We conducted a Phase II multicenter trial of ELT and LEN in adult patients with low- or intermediate-1-risk MDS with symptomatic or transfusion-dependent anemia or thrombocytopenia (NCT01772420). Thrombocytopenic patients were started on ELT and subsequently treated with LEN after platelets were increased. Patients without thrombocytopenia were started on LEN monotherapy and treated with ELT if they became thrombocytopenic. RESULTS Fifty-two patients were enrolled; mean age was 71 years (range 34-93). Overall response rate (ORR) in the intention-to-treat population was 35% (18/52). ELT monotherapy led to ORR of 33.3% (7/21), 29% achieving hematologic improvement (HI)-Platelets, and 24% bilineage responses. LEN monotherapy had 38% ORR (6/16) with all responders achieving HI-Erythroid. Fifteen patients received both ELT and LEN with ORR of 33.3%, 20% achieved HI-Erythroid, and 20% HI-Platelets with 13% bilineage responses. Median duration of response was 40 weeks for ELT (range 8-ongoing), 41 weeks (25-ongoing) for LEN, and 88 weeks (8.3-ongoing) for ELT/LEN. Non-hematologic grade 3-4 treatment-related adverse events were infrequent. Among patients on ELT, 2 had major bleeding events, 1 had a reversible increase in peripheral blasts, and 1 developed marrow fibrosis after 6 years on ELT. CONCLUSIONS ELT and LEN are well tolerated and effective in achieving hematologic improvement in patients with low-/intermediate-risk MDS.
Collapse
Affiliation(s)
- Jesus D Gonzalez-Lugo
- Division of Hemato-Oncology, Department of Oncology, Montefiore Einstein Cancer Center, Blood Cancer Institute, Bronx, New York
| | - Suman Kambhampati
- Sarah Cannon Transplant and Cellular Therapy Program, Kansas City, Kansas
| | | | | | - Jesus Berdeja
- Sarah Cannon Research Institute, Nashville, Tennessee
| | - Prafulla Bhagat
- Division of Hemato-Oncology, Department of Oncology, Montefiore Einstein Cancer Center, Blood Cancer Institute, Bronx, New York
| | - Karen Fehn
- Division of Hemato-Oncology, Department of Oncology, Montefiore Einstein Cancer Center, Blood Cancer Institute, Bronx, New York
| | - Cassady Remy
- Division of Hemato-Oncology, Department of Oncology, Montefiore Einstein Cancer Center, Blood Cancer Institute, Bronx, New York
| | - Sakshi Jasra
- University of Vermont Cancer Center, Burlington, Vermont
| | | | - Kith Pradhan
- Division of Hemato-Oncology, Department of Oncology, Montefiore Einstein Cancer Center, Blood Cancer Institute, Bronx, New York
| | - Mimi Kim
- Department of Epidemiology & Population Health, Albert Einstein College of Medicine, Bronx, New York
| | - Ioannis Mantzaris
- Division of Hemato-Oncology, Department of Oncology, Montefiore Einstein Cancer Center, Blood Cancer Institute, Bronx, New York
| | - R Alejandro Sica
- Division of Hemato-Oncology, Department of Oncology, Montefiore Einstein Cancer Center, Blood Cancer Institute, Bronx, New York
| | - Nishi Shah
- Division of Hemato-Oncology, Department of Oncology, Montefiore Einstein Cancer Center, Blood Cancer Institute, Bronx, New York
| | - Mendel Goldfinger
- Division of Hemato-Oncology, Department of Oncology, Montefiore Einstein Cancer Center, Blood Cancer Institute, Bronx, New York
| | - Noah Kornblum
- Division of Hemato-Oncology, Department of Oncology, Montefiore Einstein Cancer Center, Blood Cancer Institute, Bronx, New York
| | - Kira Gritsman
- Division of Hemato-Oncology, Department of Oncology, Montefiore Einstein Cancer Center, Blood Cancer Institute, Bronx, New York
| | - Ira Braunschweig
- Division of Hemato-Oncology, Department of Oncology, Montefiore Einstein Cancer Center, Blood Cancer Institute, Bronx, New York
| | - Ulrich Steidl
- Division of Hemato-Oncology, Department of Oncology, Montefiore Einstein Cancer Center, Blood Cancer Institute, Bronx, New York.,Department of Cell Biology, Albert Einstein College of Medicine, Bronx, New York
| | - Britta Will
- Division of Hemato-Oncology, Department of Oncology, Montefiore Einstein Cancer Center, Blood Cancer Institute, Bronx, New York.,Department of Cell Biology, Albert Einstein College of Medicine, Bronx, New York
| | - Aditi Shastri
- Division of Hemato-Oncology, Department of Oncology, Montefiore Einstein Cancer Center, Blood Cancer Institute, Bronx, New York
| | - Amit Verma
- Division of Hemato-Oncology, Department of Oncology, Montefiore Einstein Cancer Center, Blood Cancer Institute, Bronx, New York
| |
Collapse
|
17
|
Madanat YF, Xie Z, Zeidan AM. Advances in myelodysplastic syndromes: promising novel agents and combination strategies. Expert Rev Hematol 2023; 16:51-63. [PMID: 36620919 DOI: 10.1080/17474086.2023.2166923] [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: 01/10/2023]
Abstract
INTRODUCTION Myelodysplastic syndromes (MDS) are heterogeneous group of clonal hematopoietic stem cell neoplasms that have limited approved treatment options. Multiple novel agents are currently being tested in a clinical trial setting. From a therapeutic perspective, MDS is generally divided into lower-risk and higher-risk disease. In this review, we summarize some of the most prominent novel agents currently in development. AREAS COVERED This review focuses on select clinical trials in both lower- and higher-risk MDS, elucidating the mechanisms of action and rationale for drug combinations and summarizing early safety and efficacy data using novel agents in MDS. EXPERT OPINION Advances in understanding the innate immune system, telomere biology, as well as genomic drivers of the disease have led to the development of multiple novel agents that are currently in late stages of clinical development in MDS. Imetelstat is being tested in lower-risk disease and the phase III clinical trial recently completed accrual. Magrolimab, sabatolimab, and venetoclax in addition to novel oral hypomethylating agents (HMA) are being investigated in higher-risk MDS. These advances will hopefully bring better treatment options to patients and lead to a shift in the treatment paradigm. Post HMA therapy remains an area of dire unmet need.
Collapse
Affiliation(s)
- Yazan F Madanat
- Simmons Comprehensive Cancer Center, Division of Hematology/Oncology, Department of Internal Medicine, UT Southwestern Medical Center, Dallas, Texas, USA
| | - Zhuoer Xie
- Department of Malignant Hematology, H. Lee Moffitt Cancer Center, Tampa, Florida, USA
| | - Amer M Zeidan
- Section of Hematology, Department of Internal Medicine, Yale Cancer Center, New Haven, Connecticut, USA
| |
Collapse
|
18
|
How I Manage Transplant Ineligible Patients with Myelodysplastic Neoplasms. Clin Hematol Int 2022; 5:8-20. [PMID: 36574201 PMCID: PMC10063738 DOI: 10.1007/s44228-022-00024-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2022] [Accepted: 11/14/2022] [Indexed: 12/28/2022] Open
Abstract
AbstractMyelodysplastic neoplasms, formerly known as myelodysplastic syndromes (MDS), represent a group of clonal disorders characterized by a high degree of clinical and molecular heterogeneity, and an invariable tendency to progress to acute myeloid leukemia. MDS typically present in the elderly with cytopenias of different degrees and bone marrow dysplasia, the hallmarks of the disease. Allogeneic hematopoietic stem cell transplant is the sole curative approach to date. Nonetheless, given the disease’s demographics, only a minority of patients can benefit from this procedure. Currently used prognostic schemes such as the Revised International Prognostic Scoring System (R-IPSS), and most recently the molecular IPSS (IPSS-M), guide clinical management by dividing MDS into two big categories: lower- and higher-risk cases, based on a cut-off score of 3.5. The main clinical problem of the lower-risk group is represented by the management of cytopenias, whereas the prevention of secondary leukemia progression is the goal for the latter. Herein, we discuss the non-transplant treatment of MDS, focusing on current practice and available therapeutic options, while also presenting new investigational agents potentially entering the MDS therapeutic arsenal in the near future.
Collapse
|
19
|
Abstract
Myelodysplastic syndromes (MDS) are a family of myeloid cancers with diverse genotypes and phenotypes characterized by ineffective haematopoiesis and risk of transformation to acute myeloid leukaemia (AML). Some epidemiological data indicate that MDS incidence is increasing in resource-rich regions but this is controversial. Most MDS cases are caused by randomly acquired somatic mutations. In some patients, the phenotype and/or genotype of MDS overlaps with that of bone marrow failure disorders such as aplastic anaemia, paroxysmal nocturnal haemoglobinuria (PNH) and AML. Prognostic systems, such as the revised International Prognostic Scoring System (IPSS-R), provide reasonably accurate predictions of survival at the population level. Therapeutic goals in individuals with lower-risk MDS include improving quality of life and minimizing erythrocyte and platelet transfusions. Therapeutic goals in people with higher-risk MDS include decreasing the risk of AML transformation and prolonging survival. Haematopoietic cell transplantation (HCT) can cure MDS, yet fewer than 10% of affected individuals receive this treatment. However, how, when and in which patients with HCT for MDS should be performed remains controversial, with some studies suggesting HCT is preferred in some individuals with higher-risk MDS. Advances in the understanding of MDS biology offer the prospect of new therapeutic approaches.
Collapse
|
20
|
Sternberg A, Boucher R, Coulthard HC, Raghavan M, Culligan D, Jackson A, Cargo C, Dennis M, Metzner M, O'Sullivan J, Moore R, Bowen D, Vyas P. Phase Ib study of eltrombopag and azacitidine in patients with high-risk myelodysplastic syndromes and related disorders (the ELASTIC study). Br J Haematol 2022; 199:222-229. [PMID: 35918828 DOI: 10.1111/bjh.18389] [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: 05/03/2022] [Revised: 07/13/2022] [Accepted: 07/18/2022] [Indexed: 11/29/2022]
Abstract
Treating adverse risk myelodysplastic syndromes with azacitidine exacerbates thrombocytopenia. We report a study of eltrombopag in combination with azacitidine using a 3 + 3 cohort design. Patients with baseline platelets of <150 × 109 /l received eltrombopag ranging from 25 to 300 mg. An 8-day pre-phase of eltrombopag was followed by two cycles of combined therapy. Amongst 31 patients, there were no dose-limiting toxicities. The maximum tolerated dose (MTD) was 300 mg. Transient increases in bone marrow blasts at day 8 were common but no patient had protocol-defined progression following eltrombopag monotherapy. Marrow response rates after three and six treatment cycles were 32% and 29% respectively. In all, 70% of patients treated below and 36% treated at the MTD achieved a modified International Working Group 2006 platelet response at the end of cycle two. Of the platelet transfusion independent patients at baseline, 67% treated at the MTD became transfusion dependent during the first two cycles of treatment. Apart from lack of disease progression, our findings concur with a previously reported Phase III study (A StUdy of eltromboPag in myelodysPlastic SyndrOmes Receiving azaciTidine [SUPPORT]). We conclude that eltrombopag/azacitidine is safe in terms of conventional measures defined by adverse-event reporting. However, in light of SUPPORT and our own descriptive findings regarding efficacy, further combination studies in high-risk disease should be considered with caution.
Collapse
Affiliation(s)
| | - Rebecca Boucher
- Cancer Research UK Clinical Trials Unit, University of Birmingham, Birmingham, UK
| | | | - Manoj Raghavan
- Centre for Clinical Haematology, Queen Elizabeth Hospital, Birmingham, UK
| | - Dominic Culligan
- Department of Haematology, Aberdeen Royal Infirmary, Foresterhill, Aberdeen, UK
| | - Aimee Jackson
- Cancer Research UK Clinical Trials Unit, University of Birmingham, Birmingham, UK
| | - Catherine Cargo
- Department of Haematology, Leeds Teaching Hospitals, Leeds, UK
| | - Mike Dennis
- Department of Haematology, The Christie Hospital, Manchester, UK
| | - Marlen Metzner
- Weatherall Institute of Molecular Medicine, John Radcliffe Hospital, Oxford, UK
| | - Jennifer O'Sullivan
- Weatherall Institute of Molecular Medicine, John Radcliffe Hospital, Oxford, UK
| | - Rachel Moore
- Weatherall Institute of Molecular Medicine, John Radcliffe Hospital, Oxford, UK
| | - David Bowen
- Department of Haematology, Leeds Teaching Hospitals, Leeds, UK
| | - Paresh Vyas
- Weatherall Institute of Molecular Medicine, John Radcliffe Hospital, Oxford, UK
| |
Collapse
|
21
|
Moyo TK, Mendler JH, Itzykson R, Kishtagari A, Solary E, Seegmiller AC, Gerds AT, Ayers GD, Dezern AE, Nazha A, Valent P, van de Loosdrecht AA, Onida F, Pleyer L, Cirici BX, Tibes R, Geissler K, Komrokji RS, Zhang J, Germing U, Steensma DP, Wiseman DH, Pfeilstöecker M, Elena C, Cross NCP, Kiladjian JJ, Luebbert M, Mesa RA, Montalban-Bravo G, Sanz GF, Platzbecker U, Patnaik MM, Padron E, Santini V, Fenaux P, Savona MR. The ABNL-MARRO 001 study: a phase 1–2 study of randomly allocated active myeloid target compound combinations in MDS/MPN overlap syndromes. BMC Cancer 2022; 22:1013. [PMID: 36153475 PMCID: PMC9509596 DOI: 10.1186/s12885-022-10073-w] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2022] [Accepted: 09/09/2022] [Indexed: 11/10/2022] Open
Abstract
Background Myelodysplastic/myeloproliferative neoplasms (MDS/MPN) comprise several rare hematologic malignancies with shared concomitant dysplastic and proliferative clinicopathologic features of bone marrow failure and propensity of acute leukemic transformation, and have significant impact on patient quality of life. The only approved disease-modifying therapies for any of the MDS/MPN are DNA methyltransferase inhibitors (DNMTi) for patients with dysplastic CMML, and still, outcomes are generally poor, making this an important area of unmet clinical need. Due to both the rarity and the heterogeneous nature of MDS/MPN, they have been challenging to study in dedicated prospective studies. Thus, refining first-line treatment strategies has been difficult, and optimal salvage treatments following DNMTi failure have also not been rigorously studied. ABNL-MARRO (A Basket study of Novel therapy for untreated MDS/MPN and Relapsed/Refractory Overlap Syndromes) is an international cooperation that leverages the expertise of the MDS/MPN International Working Group (IWG) and provides the framework for collaborative studies to advance treatment of MDS/MPN and to explore clinical and pathologic markers of disease severity, prognosis, and treatment response. Methods ABNL MARRO 001 (AM-001) is an open label, randomly allocated phase 1/2 study that will test novel treatment combinations in MDS/MPNs, beginning with the novel targeted agent itacitinib, a selective JAK1 inhibitor, combined with ASTX727, a fixed dose oral combination of the DNMTi decitabine and the cytidine deaminase inhibitor cedazuridine to improve decitabine bioavailability. Discussion Beyond the primary objectives of the study to evaluate the safety and efficacy of novel treatment combinations in MDS/MPN, the study will (i) Establish the ABNL MARRO infrastructure for future prospective studies, (ii) Forge innovative scientific research that will improve our understanding of pathogenetic mechanisms of disease, and (iii) Inform the clinical application of diagnostic criteria, risk stratification and prognostication tools, as well as response assessments in this heterogeneous patient population. Trial registration This trial was registered with ClinicalTrials.gov on August 19, 2019 (Registration No. NCT04061421).
Collapse
|
22
|
Prospective validation of a biomarker-driven response prediction model to romiplostim in lower-risk myelodysplastic neoplasms - results of the EUROPE trial by EMSCO. Leukemia 2022; 36:2519-2527. [PMID: 36071100 PMCID: PMC9522582 DOI: 10.1038/s41375-022-01669-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2022] [Revised: 06/18/2022] [Accepted: 07/25/2022] [Indexed: 11/10/2022]
Abstract
The EUROPE phase 2 trial investigated the predictive value of biomarkers on the clinical efficacy of single agent romiplostim (ROM) treatment in patients with lower-risk myelodysplastic neoplasms (LR-MDS) and thrombocytopenia within the ‘European Myelodysplastic Neoplasms Cooperative Group‘ (EMSCO) network. A total of 77 patients with LR-MDS and a median platelet count of 25/nl were included, all patients received ROM at a starting dose of 750 μg by SC injection weekly. Thirty-two patients (42%) achieved a hematologic improvement of platelets (HI-P) with a median duration of 340 days. Neutrophil (HI-N) and erythroid (HI-E) responses were observed in three (4%) and seven (9%) patients, respectively. We could not confirm previous reports that HI-P correlated with baseline endogenous thrombopoietin levels and platelet transfusion history, but SRSF2 mutation status and hemoglobin levels at baseline were significantly linked to HI-P. Sequential analysis of variant allelic frequency of mutations like SRSF2 did not reveal an impact of ROM on clonal evolution in both responders and non-responders. In summary, our study confirms the safety and efficacy of ROM in LR-MDS patients and may allow to better define subgroups of patients with a high likelihood of response.
Collapse
|
23
|
Effect of thrombopoietin receptor agonist on health-related quality of life and platelet transfusion burden for patients with myelodysplastic syndromes: a systematic review and meta-analysis. Ann Hematol 2022; 101:2219-2229. [PMID: 35976414 DOI: 10.1007/s00277-022-04950-4] [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: 11/21/2021] [Accepted: 07/27/2022] [Indexed: 11/01/2022]
Abstract
Thrombocytopenia is a common and unsolved problem in myelodysplastic syndrome (MDS) patients; we aimed to summarize the evidence of TPO-RA treatment for heath-related quality of life (HRQoL) and platelet transfusion burden of MDS patients. We searched Pubmed, Web of Science, EMBASE, and CENTRAL for randomized clinical trials (RCTs) comparing TPO-RA to placebo in MDS published until July 31, 2021. A random-effect model was used. Eight RCTs with 908 patients were identified. Only three RCTs involving eltrombopag reported HRQoL, and all three studies treated HRQoL as a secondary outcome. In these three RCTs, the HRQoL instruments used in each study were different. However, this outcome cannot be meta-analyzed because some studies did not provide complete data. Subsequent clinical trials should pay more attention to this. Compared to placebo, TPO-RA did not affect platelet transfusion incidence 0.83 (95% CI 0.60-1.15). There was no evidence for subgroup differences in the analyses of different types of TPO-RA, different additional agent, and different types of MDS risk groups. However, platelet transfusion units (RR = 0.68, 95% CI 0.53 to 0.84) were significantly decreased. The RR of patients who did not require platelet transfusion for 56 or more consecutive days was not different between groups (RR = 0.98, 95% CI 0.41 to 2.34). TPO-RA may decrease platelet transfusion units in MDS patients with thrombocytopenia. But the significance of this finding should be interpreted with caution, because too few studies were meta-analyzed.
Collapse
|
24
|
Toprak SK. Past, present and future in low-risk myelodysplastic syndrome. Front Med (Lausanne) 2022; 9:967900. [PMID: 35911422 PMCID: PMC9334722 DOI: 10.3389/fmed.2022.967900] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2022] [Accepted: 06/28/2022] [Indexed: 11/13/2022] Open
Abstract
Myelodysplastic syndromes (MDS) is a heterogeneous group of disorders characterized by increased risk of acute myeloid leukemia transformation and cytopenia. The prognosis of MDS patients can be evaluated with various scoring systems, the most commonly used are IPSS (International Prognostic Scoring System), revised-IPSS, and WPSS (WHO classification-based prognostic scoring system). MDS treatment is decided according to the risk classification. The goal of treatment in low-risk MDS is to improve cytopenia, reduce transfusion needs, improve quality of life, prolong overall survival, and maybe reduce the risk of progression to leukemia. In the near future, combining both genomics-based, ex vivo functional based and molecular stratification analysis will lead the way to a personalized and targeted approach.
Collapse
|
25
|
EHA Guidelines on Management of Antithrombotic Treatments in Thrombocytopenic Patients With Cancer. Hemasphere 2022; 6:e750. [PMID: 35924068 PMCID: PMC9281983 DOI: 10.1097/hs9.0000000000000750] [Citation(s) in RCA: 22] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2022] [Accepted: 06/01/2022] [Indexed: 01/19/2023] Open
Abstract
In cancer patients, thrombocytopenia can result from bone marrow infiltration or from anticancer medications and represents an important limitation for the use of antithrombotic treatments, including anticoagulant, antiplatelet, and fibrinolytic agents. These drugs are often required for prevention or treatment of cancer-associated thrombosis or for cardioembolic prevention in atrial fibrillation in an increasingly older cancer population. Data indicate that cancer remains an independent risk factor for thrombosis even in case of thrombocytopenia, since mild-to-moderate thrombocytopenia does not protect against arterial or venous thrombosis. In addition, cancer patients are at increased risk of antithrombotic drug-associated bleeding, further complicated by thrombocytopenia and acquired hemostatic defects. Furthermore, some anticancer treatments are associated with increased thrombotic risk and may generate interactions affecting the effectiveness or safety of antithrombotic drugs. In this complex scenario, the European Hematology Association in collaboration with the European Society of Cardiology has produced this scientific document to provide a clinical practice guideline to help clinicians in the management of patients with cancer and thrombocytopenia. The Guidelines focus on adult patients with active cancer and a clear indication for anticoagulation, single or dual antiplatelet therapy, their combination, or reperfusion therapy, who have concurrent thrombocytopenia because of either malignancy or anticancer medications. The level of evidence and the strength of the recommendations were discussed according to a Delphi procedure and graded according to the Oxford Centre for Evidence-Based Medicine.
Collapse
|
26
|
Chandhok NS, Sekeres MA. What constitutes meaningful improvement in myelodysplastic syndromes? Leuk Lymphoma 2022; 63:2528-2535. [DOI: 10.1080/10428194.2022.2084732] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Affiliation(s)
- Namrata S. Chandhok
- Division of Hematology, Sylvester Comprehensive Cancer Center, University of Miami, Miami, FL, USA
| | - Mikkael A. Sekeres
- Division of Hematology, Sylvester Comprehensive Cancer Center, University of Miami, Miami, FL, USA
| |
Collapse
|
27
|
Bazinet A, Bravo GM. New Approaches to Myelodysplastic Syndrome Treatment. Curr Treat Options Oncol 2022; 23:668-687. [PMID: 35320468 DOI: 10.1007/s11864-022-00965-1] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/13/2022] [Indexed: 12/19/2022]
Abstract
OPINION STATEMENT The treatment of myelodysplastic syndromes (MDS) begins with risk stratification using a validated tool such as the International Prognostic Scoring System (IPSS) or its revised version (IPSS-R). This divides patients into lower- and higher- risk categories. Although treatment objectives in lower-risk MDS (LR-MDS) have traditionally been directed at improving cytopenias (usually anemia) as well as quality of life, recent data supports a potential role for early intervention in delaying transfusion dependency. In addition, careful individualized risk stratification incorporating clinical, cytogenetic, and mutational data might help identify patients at higher-than-expected risk for progression. Given the need for supportive care with red blood cell (RBC) transfusions leading to iron overload, iron chelation should be considered for patients with heavy transfusion requirements at risk for end-organ complications. For patients with LR-MDS and isolated anemia, no high-risk features, and endogenous erythropoietin (EPO) levels below 500 U/L, erythropoiesis-stimulating agents (ESAs) can be attempted to improve anemia. Some LR-MDS patient subgroups may also benefit from specific therapies including luspatercept (MDS with ring sideroblasts), lenalidomide (MDS with deletion 5q), or immunosuppressive therapy (hypocellular MDS). LR-MDS patients failing the above options, or those with multiple cytopenias and/or higher-risk features, can be considered for oral low-dose hypomethylating agent (HMA) therapy. Alternatively, these patients may be enrolled on a clinical trial with promising agents targeting the transforming-growth factor beta (TGF-β) pathway, the hypoxia-inducible factor (HIF) pathway, telomerase activity, inflammatory signaling, or the splicing machinery. In higher-risk MDS (HR-MDS), therapy seeks to modify the natural history of the disease and prolong survival. Eligible patients should be considered for curative allogeneic hematopoietic stem cell transplantation (aHSCT). Despite promising novel combinations, the HMAs azacitidine (AZA) or decitabine (DAC) are still the standard of care for these patients, with intensive chemotherapy-based approaches being a potential option in a small subset of patients. Individuals who fail to respond or progress after HMA experience dismal outcomes and represent a major unmet clinical need. Such patients should be treated as part of a clinical trial if possible. Experimental agents to consider include venetoclax, myeloid cell leukemia 1 (MCL-1) inhibitors, eprenetapopt, CPX-351, immunotherapies (directed towards CD47, TIM3, or CD70), interleukin-1 receptor-associated kinase 4 (IRAK4) inhibitors, pevonedistat, seclidemstat, and eltanexor. In this review, we extensively discuss the current landscape of experimental therapies for both LR- and HR-MDS.
Collapse
Affiliation(s)
- Alexandre Bazinet
- Department of Leukemia, University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd., Box 428, Houston, TX, 77030, USA
| | - Guillermo Montalban Bravo
- Department of Leukemia, University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd., Box 428, Houston, TX, 77030, USA.
| |
Collapse
|
28
|
Gupta A, Kapoor A, Choudhary A, Kumar S, Mishra B. Romiplostim – A narrative drug review. CANCER RESEARCH, STATISTICS, AND TREATMENT 2022. [DOI: 10.4103/crst.crst_17_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
|
29
|
Yang Y, Tang Z, Ji J, Yang C, Chen M, Han B. Recombinant Human Thrombopoietin Accelerates the Recovery of Platelet in Patients With Lower-Risk Myelodysplastic Syndrome: A Proof-of-Concept Study. Front Oncol 2021; 11:721764. [PMID: 34778037 PMCID: PMC8581467 DOI: 10.3389/fonc.2021.721764] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2021] [Accepted: 10/07/2021] [Indexed: 11/13/2022] Open
Abstract
Aim The effect of recombinant human thrombopoietin (rhTPO) is largely unknown in lower-risk myelodysplastic syndrome (LR-MDS). This study aimed at investigating the safety and efficacy of rhTPO in patients with LR-MDS. Methods LR-MDS patients receiving stanozolol (2 mg, t.i.d.) and supportive care alone (non-rhTPO) or additional rhTPO were enrolled in this study prospectively. rhTPO was given at 15,000 U (q.d.) for 7 days/month for at least 3 months. Patients stopped rhTPO if the platelet count was higher than 50 × 109/L or had no effects after 3 months of treatment. The overall response (OR), complete response (CR), platelet response, side effects, clone evolution, and clinical outcome were evaluated. Result Thirty-five patients were enrolled: 20 (57.1%) patients in the rhTPO group and 15 (42.9%) patients in the non-rhTPO group. The demographic and baseline characteristics were balanced between the two groups. Platelet response was higher at 1 and 2 months as compared with that in the non-rhTPO group (p = 0.006 and p = 0.001, respectively). Meanwhile, the rhTPO group had a shorter time to achieve a platelet transfusion-free state compared with the non-rhTPO group (p = 0.034). Hematologic response was higher at 1 and 2 months compared with that in the non-rhTPO group (p = 0.006 and p = 0.001, respectively). There was no significant difference in the overall response or complete response at 1, 2, 3, 6, and 12 months between the two groups. One patient in the rhTPO group evolved into higher-risk MDS at 9 months. No significant difference in disease progression, infection, gastrointestinal disorders, or drug-related liver/renal injuries was found between the two groups (p > 0.05). Conclusion Adding short-term rhTPO can accelerate the early platelet response and decrease platelet transfusion, with no obvious side effects. Clinical Trial Registration https://clinicaltrials.gov/ct2/show/NCT04324060?cond=NCT04324060&draw=2, identifier NCT04324060
Collapse
Affiliation(s)
- Yuan Yang
- Department of Hematology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Zengwei Tang
- Department of Hepatobiliary and Pancreatic Surgery, The First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Jiang Ji
- Department of Hematology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Chen Yang
- Department of Hematology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Miao Chen
- Department of Hematology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Bing Han
- Department of Hematology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| |
Collapse
|
30
|
Morales LF, Miyara SJ, Guevara S, Metz CN, Shoaib M, Watt S, Zafeiropoulos S, McCann-Molmenti A, Hayashida K, Takegawa R, Shinozaki K, Choudhary RC, Brindley EC, Nishikimi M, Kressel AM, Alsalmay YM, Mazzotta EA, Cho YM, Aranalde GI, Grande DA, Zanos S, Becker LB, Molmenti EP. Sequential Use of Romiplostim after Eltrombopag for Refractory Thrombocytopenia in Hydrocarbon-Induced Myelodysplasia. Int J Angiol 2021. [DOI: 10.1055/s-0041-1726366] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
Abstract
AbstractWe describe the clinical course of a 65-year-old male patient who suffered from hydrocarbon-induced myelodysplasia and was successfully treated with the thrombopoietin receptor agonist (TPO-RA), romiplostim. Myelodysplastic syndromes (MDS) are characterized by ineffective hematopoiesis, cytopenias, and increased risk of leukemic transformation. Here, we present a clinical vignette of MDS-associated thrombocytopenia refractory to first-line drugs as well as the TPO-RA, eltrombopag. To date, romiplostim is an U.S. Food and Drug Administration (FDA)-approved drug for idiopathic thrombocytopenic purpura and thrombocytopenia secondary to liver disease. Of note, currently the FDA advises against its use in MDS based on previous long-term safety concerns. Since the therapeutic options for thrombocytopenia in MDS patients are sparse, repurposing and reassessing romiplostim in this setting have been the focus of recent studies. At the time of writing, no published double-blind randomized clinical trials have conducted a head-to-head comparison between romiplostim and eltrombopag in thrombocytopenic MDS patients. To the best of our knowledge, for a thrombocytopenic patient in the setting of MDS, this is the first documented report of refractory clinical response after a 2-year use of eltrombopag in which replacement of treatment with romiplostim resulted in sustained physiological counts of thrombocytes within four weeks.
Collapse
Affiliation(s)
- Luis F. Morales
- Department of Surgery, North Shore University Hospital, Manhasset, New York
| | - Santiago J. Miyara
- Elmezzi Graduate School of Molecular Medicine, Manhasset, New York
- Feinstein Institutes for Medical Research, Manhasset, New York
| | - Sara Guevara
- Department of Surgery, North Shore University Hospital, Manhasset, New York
| | - Christine N. Metz
- Elmezzi Graduate School of Molecular Medicine, Manhasset, New York
- Feinstein Institutes for Medical Research, Manhasset, New York
| | - Muhammad Shoaib
- Feinstein Institutes for Medical Research, Manhasset, New York
- Department of Emergency Medicine, North Shore University Hospital, Manhasset, New York
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, New York
| | - Stacey Watt
- Jacobs School of Medicine and Biomedical Sciences, Buffalo, University at Buffalo, Buffalo, New York
| | - Stefanos Zafeiropoulos
- Elmezzi Graduate School of Molecular Medicine, Manhasset, New York
- Feinstein Institutes for Medical Research, Manhasset, New York
| | | | - Kei Hayashida
- Feinstein Institutes for Medical Research, Manhasset, New York
- Department of Emergency Medicine, North Shore University Hospital, Manhasset, New York
| | - Ryosuke Takegawa
- Feinstein Institutes for Medical Research, Manhasset, New York
- Department of Emergency Medicine, North Shore University Hospital, Manhasset, New York
| | - Koichiro Shinozaki
- Feinstein Institutes for Medical Research, Manhasset, New York
- Department of Emergency Medicine, North Shore University Hospital, Manhasset, New York
| | - Rishabh C. Choudhary
- Feinstein Institutes for Medical Research, Manhasset, New York
- Department of Emergency Medicine, North Shore University Hospital, Manhasset, New York
| | - Elena C. Brindley
- Feinstein Institutes for Medical Research, Manhasset, New York
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, New York
| | - Mitsuaki Nishikimi
- Feinstein Institutes for Medical Research, Manhasset, New York
- Department of Emergency Medicine, North Shore University Hospital, Manhasset, New York
| | - Adam M. Kressel
- Department of Surgery, North Shore University Hospital, Manhasset, New York
- Feinstein Institutes for Medical Research, Manhasset, New York
| | - Yaser M. Alsalmay
- Department of Surgery, North Shore University Hospital, Manhasset, New York
| | - Elvio A. Mazzotta
- Department of Anesthesiology, The Wexner Medical Center, The Ohio State University, Columbus, Ohio
| | - Young Min Cho
- Department of Surgery, North Shore University Hospital, Manhasset, New York
- Feinstein Institutes for Medical Research, Manhasset, New York
| | | | - Daniel A. Grande
- Elmezzi Graduate School of Molecular Medicine, Manhasset, New York
- Feinstein Institutes for Medical Research, Manhasset, New York
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, New York
| | - Stavros Zanos
- Elmezzi Graduate School of Molecular Medicine, Manhasset, New York
- Feinstein Institutes for Medical Research, Manhasset, New York
| | - Lance B. Becker
- Department of Surgery, North Shore University Hospital, Manhasset, New York
- Elmezzi Graduate School of Molecular Medicine, Manhasset, New York
- Feinstein Institutes for Medical Research, Manhasset, New York
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, New York
| | - Ernesto P. Molmenti
- Department of Surgery, North Shore University Hospital, Manhasset, New York
- Feinstein Institutes for Medical Research, Manhasset, New York
- Department of Emergency Medicine, North Shore University Hospital, Manhasset, New York
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, New York
| |
Collapse
|
31
|
Karantanos T, DeZern AE. Biology and clinical management of hypoplastic MDS: MDS as a bone marrow failure syndrome. Best Pract Res Clin Haematol 2021; 34:101280. [PMID: 34404534 DOI: 10.1016/j.beha.2021.101280] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2021] [Revised: 06/01/2021] [Accepted: 06/09/2021] [Indexed: 01/01/2023]
Abstract
Hypoplastic MDS is a subset of MDS characterized by marrow hypocellularity diagnosed in 10-15% of MDS patients. The pathogenesis of this disease shares features of aplastic anemia with activation of the effector T cells against hematopoietic stem and progenitor cells and high-risk MDS with acquisition of somatic mutations that provide survival and growth advantage of these cells in the inflammatory bone marrow microenvironment. Clonal evolution in hypoplastic MDS may be associated with accumulation of DNA damage and progression to AML while clonal hematopoiesis in aplastic anemia is strongly related to immune escape of the hematopoietic cells. Distinction of hypoplastic MDS from other acquired and inherited bone marrow failure syndromes is frequently challenging but it is critical for the appropriate clinical management of the patients. Treatment with immunosuppression is an important component of the clinical approach to patients with hypoplastic MDS while hypomethylating agents and early allogeneic bone marrow transplantation are also considerations in some patients. In this review, we summarize the current literature on the biology of hypoplastic MDS, the differences between this disease and other bone marrow failure syndromes, and the treatment algorithm for patients with this subtype of MDS.
Collapse
Affiliation(s)
- Theodoros Karantanos
- Department of Oncology, Sidney Kimmel Cancer Center at Johns Hopkins, Baltimore, MD, USA
| | - Amy E DeZern
- Department of Oncology, Sidney Kimmel Cancer Center at Johns Hopkins, Baltimore, MD, USA.
| |
Collapse
|
32
|
Kapoor S, Champion G, Olnes MJ. Thrombopoietin receptor agonists for marrow failure: A concise clinical review. Best Pract Res Clin Haematol 2021; 34:101274. [PMID: 34404526 DOI: 10.1016/j.beha.2021.101274] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2021] [Revised: 05/20/2021] [Accepted: 05/22/2021] [Indexed: 11/29/2022]
Abstract
Bone marrow failure is characterized by a disruption of hematopoietic stem cell (HSC) homeostasis and function, which causes decreased blood counts. Germline and somatic mutations within HSCs and immune dysregulation contribute to the pathogenesis of marrow failure. Allogeneic HSC transplant is a potentially curative therapy for marrow failure, although not all patients are candidates for this procedure. Immune suppressive therapy (IST) is an effective treatment for patients with aplastic anemia (AA) and select patients with myelodysplastic syndromes, but some patients fail to respond or relapse after IST. Over the past decade, the oral thrombopoietin receptor agonist eltrombopag has become a therapeutic option for AA in combination with frontline IST, and as a single agent for relapsed and refractory patients after IST. In this review, we highlight current knowledge of thrombopoietin receptor agonist mechanisms of action, and clinical indications and toxicities in patients with marrow failure, including the risk of clonal evolution.
Collapse
Affiliation(s)
- Sargam Kapoor
- Hematology and Medical Oncology, Alaska Native Tribal Health Consortium, 3900 Ambassador Dr, Anchorage, AK, 99508, USA
| | - Grace Champion
- University of Washington School of Medicine, 1959 NE Pacific St, Seattle, WA, 98195, USA
| | - Matthew J Olnes
- Hematology and Medical Oncology, Alaska Native Tribal Health Consortium, 3900 Ambassador Dr, Anchorage, AK, 99508, USA; University of Washington School of Medicine, 1959 NE Pacific St, Seattle, WA, 98195, USA; WWAMI School of Medical Education, University of Alaska Anchorage, 3211 Providence Drive, Anchorage, AK, 99508, USA.
| |
Collapse
|
33
|
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.
Collapse
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.
| |
Collapse
|
34
|
Killick SB, Ingram W, Culligan D, Enright H, Kell J, Payne EM, Krishnamurthy P, Kulasekararaj A, Raghavan M, Stanworth SJ, Green S, Mufti G, Quek L, Cargo C, Jones GL, Mills J, Sternberg A, Wiseman DH, Bowen D. British Society for Haematology guidelines for the management of adult myelodysplastic syndromes. Br J Haematol 2021; 194:267-281. [PMID: 34180045 DOI: 10.1111/bjh.17612] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Affiliation(s)
- Sally B Killick
- University Hospitals Dorset NHS Foundation Trust, The Royal Bournemouth Hospital, Bournemouth, UK
| | | | | | - Helen Enright
- Tallaght University Hospital, Dublin, Trinity College Medical School, Tallaght, UK
| | | | | | | | | | - Manoj Raghavan
- University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Simon J Stanworth
- Oxford University, Oxford University Hospitals NHS Trust & NHS Blood and Transplant, Oxford, UK
| | - Simone Green
- Hull and East Yorkshire Hospitals NHS Trust, Hull, UK
| | - Ghulam Mufti
- Kings College Hospital NHS Foundation Trust, London, UK
| | - Lynn Quek
- Kings College Hospital NHS Foundation Trust, London, UK
| | - Catherine Cargo
- St.James's Institute of Oncology, Leeds Teaching Hospitals, Leeds, UK
| | - Gail L Jones
- Newcastle Hospitals NHS Foundation Trust, Newcastle Upon Tyne, UK
| | - Juliet Mills
- Worcestershire Acute Hospitals NHS Trust and Birmingham NHS Foundation Trust, Worcester, UK
| | - Alex Sternberg
- Great Western Hospitals NHS Foundation Trust, Swindon, UK
| | | | - David Bowen
- St.James's Institute of Oncology, Leeds Teaching Hospitals, Leeds, UK
| |
Collapse
|
35
|
Myelodysplastic Syndromes in the Postgenomic Era and Future Perspectives for Precision Medicine. Cancers (Basel) 2021; 13:cancers13133296. [PMID: 34209457 PMCID: PMC8267785 DOI: 10.3390/cancers13133296] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2021] [Revised: 06/18/2021] [Accepted: 06/21/2021] [Indexed: 12/19/2022] Open
Abstract
Simple Summary With demographic ageing, improved cancer survivorship and increased diagnostic sensitivity, incident cases of patients with Myelodysplastic Syndromes (MDS) are continuously rising, leading to a relevant impact on health care resources. Disease heterogeneity and various comorbidities are challenges for the management of the generally elderly patients. Therefore, experienced physicians and multidisciplinary teams should be involved in the establishment of the correct diagnosis, risk-assessment and personalized treatment plan. Next-generation sequencing allows for early detection of clonal hematopoiesis and monitoring of clonal evolution, but also poses new challenges for its appropriate use. At present, allogeneic hematopoietic stem cell transplantation remains the only curative treatment option for a minority of fit MDS patients. All others receive palliative treatment and will eventually progress, having an unmet need for novel therapies. Targeting compounds are in prospect for precision medicine, however, abrogation of clonal evolution to acute myeloid leukemia remains actually out of reach. Abstract Myelodysplastic syndromes (MDS) represent a heterogeneous group of clonal disorders caused by sequential accumulation of somatic driver mutations in hematopoietic stem and progenitor cells (HSPCs). MDS is characterized by ineffective hematopoiesis with cytopenia, dysplasia, inflammation, and a variable risk of transformation into secondary acute myeloid leukemia. The advent of next-generation sequencing has revolutionized our understanding of the genetic basis of the disease. Nevertheless, the biology of clonal evolution remains poorly understood, and the stochastic genetic drift with sequential accumulation of genetic hits in HSPCs is individual, highly dynamic and hardly predictable. These continuously moving genetic targets pose substantial challenges for the implementation of precision medicine, which aims to maximize efficacy with minimal toxicity of treatments. In the current postgenomic era, allogeneic hematopoietic stem cell transplantation remains the only curative option for younger and fit MDS patients. For all unfit patients, regeneration of HSPCs stays out of reach and all available therapies remain palliative, which will eventually lead to refractoriness and progression. In this review, we summarize the recent advances in our understanding of MDS pathophysiology and its impact on diagnosis, risk-assessment and disease monitoring. Moreover, we present ongoing clinical trials with targeting compounds and highlight future perspectives for precision medicine.
Collapse
|
36
|
Mittelman M, Oster HS. Thrombocytopenia in myelodysplastic syndromes: time to lift the embargo on thrombomimetics? Br J Haematol 2021; 194:231-233. [PMID: 34151421 DOI: 10.1111/bjh.17538] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Affiliation(s)
- Moshe Mittelman
- The Department of Hematology, Tel Aviv Sourasky Medical Center, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Howard S Oster
- The Department of Internal Medicine, Tel Aviv Sourasky Medical Center, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| |
Collapse
|
37
|
Comont T, Meunier M, Cherait A, Santana C, Cluzeau T, Slama B, Laribi K, Giraud JT, Dimicoli S, Berceanu A, Le Clech L, Cony-Makhoul P, Gruson B, Torregrosa J, Sanhes L, Jachiet V, Azerad MA, Al Jijakli A, Gyan E, Gaudin C, Broner J, Guerveno C, Guillaume T, Ades PL, Beyne-Rauzy O, Fenaux P. Eltrombopag for myelodysplastic syndromes or chronic myelomonocytic leukaemia with no excess blasts and thrombocytopenia: a French multicentre retrospective real-life study. Br J Haematol 2021; 194:336-343. [PMID: 34151423 DOI: 10.1111/bjh.17539] [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: 02/02/2021] [Accepted: 03/30/2021] [Indexed: 12/15/2022]
Abstract
Despite a moderate prevalence in low-risk myelodysplastic syndromes (MDS) and chronic myelomonocytic leukaemia (CMML), thrombocytopenia remains a risk of severe bleeding and therapeutic options are still limited. There are only a few studies with eltrombopag (ELT), a thrombopoietin receptor agonist, in those patients. In this retrospective multicentre study, ELT was used in 50 patients with MDS and 11 with CMML, with no excess of marrow blasts and platelet counts of <50 × 109 /l in a 'real-life' situation. Platelet response occurred in 47 (77%) patients. The median (range) duration of response was 8 (0-69) months. None of the eight still responders who discontinued ELT had relapsed, at a median (range) of 16 (6-23) months after ELT discontinuation. Although 36% of the patients were anti-coagulated or anti-aggregated only 10% of patients had Grade ≥3 bleeding events. Thrombotic events were observed in six (10%) patients, who all but one had a medical history of arterial or venous thrombosis. Progression to acute myeloid leukaemia occurred in four (7%) patients. In this first 'real-life' study, ELT was effective and generally well tolerated in patients with MDS/CMML without excess blasts.
Collapse
Affiliation(s)
- Thibault Comont
- Service de Médecine Interne, IUCT Oncopole, Centre Hospitalier Universitaire de Toulouse, Toulouse, France
| | - Mathieu Meunier
- CHU Grenoble Alpes, Université Grenoble Alpes, Institute for Advanced Biosciences, INSERM U1209, CNRS, UMR 5309, Grenoble, France
| | - Amina Cherait
- Service d'Hématologie Sénior, Hôpital Saint-Louis, Assistance Publique Hôpitaux de Paris (APHP), Université de Paris, Paris, France
| | | | - Thomas Cluzeau
- Service d'Hématologie Clinique, CHU de Nice, Nice, France
| | - Bohrane Slama
- Service d'onco-hématologie, Centre Hospitalier Général d'Avignon, Avignon, France
| | - Kamel Laribi
- Service d'Hématologie, Centre Hospitalier Le Mans, Le Mans, France
| | - Jean-Thomas Giraud
- Service de Médecine Interne, Centre Hospitalier de Tarbes, Tarbes, France
| | - Sophie Dimicoli
- Service d'Hématologie, Centre Hospitalier Universitaire de Bordeaux, Bordeaux, France
| | - Ana Berceanu
- Service d'Hématologie, Centre Hospitalier Universitaire de Besançon, Besançon, France
| | - Lenaïg Le Clech
- Service d'Hématologie, Centre Hospitalier de Quimper, Quimper, France
| | | | - Berangere Gruson
- Service d'Hématologie, Centre Hospitalier Universitaire d'Amiens, Amiens, France
| | - Jose Torregrosa
- Service d'Hématologie et Thérapie Cellulaire, Centre Hospitalier Universitaire de Poitiers, Poitiers, France
| | - Laurence Sanhes
- Service d'Hématologie, Centre Hospitalier de Perpignan, Perpignan, France
| | - Vincent Jachiet
- Service de Médecine Interne, Hôpital Saint-Antoine, AP-HP, Paris, France
| | - Marie-Agnes Azerad
- Service d'Hématologie, Centre Hospitalier Universitaire de Liège, Liège, Belgique
| | - Ahmad Al Jijakli
- Service d'Hématologie, Centre Hospitalier d'Argenteuil, Argenteuil, France
| | - Emmanuel Gyan
- Service d'Hématologie et Thérapie Cellulaire, Centre Hospitalier Universitaire de Tours, Tours, France
| | - Clement Gaudin
- Service de Médecine Interne-Oncogériatrie, Hôpital Purpan, Centre Hospitalier Universitaire de Toulouse, Toulouse, France
| | - Jonathan Broner
- Service de Médecine Interne, Centre Hospitalier Universitaire de Nîmes, Nîmes, France
| | - Claire Guerveno
- Service de Médecine Interne, Centre Hospitalier d'Albi, Albi, France
| | - Thierry Guillaume
- Service d'Hématologie, Centre Hospitalier Universitaire de Nantes, Nantes, France
| | - Pr Lionel Ades
- Service d'Hématologie Sénior, Hôpital Saint-Louis, Assistance Publique Hôpitaux de Paris (APHP), Université de Paris, Paris, France
| | - Odile Beyne-Rauzy
- Service de Médecine Interne, IUCT Oncopole, Centre Hospitalier Universitaire de Toulouse, Toulouse, France
| | - Pierre Fenaux
- Service d'Hématologie Sénior, Hôpital Saint-Louis, Assistance Publique Hôpitaux de Paris (APHP), Université de Paris, Paris, France
| | | |
Collapse
|
38
|
Bussel JB, Soff G, Balduzzi A, Cooper N, Lawrence T, Semple JW. A Review of Romiplostim Mechanism of Action and Clinical Applicability. Drug Des Devel Ther 2021; 15:2243-2268. [PMID: 34079225 PMCID: PMC8165097 DOI: 10.2147/dddt.s299591] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2020] [Accepted: 05/06/2021] [Indexed: 12/17/2022] Open
Abstract
Thrombocytopenia results from a variety of conditions, including radiation, chemotherapy, autoimmune disease, bone marrow disorders, pathologic conditions associated with surgical procedures, hematopoietic stem cell transplant (HSCT), and hematologic disorders associated with severe aplastic anemia. Immune thrombocytopenia (ITP) is caused by immune reactions that accelerate destruction and reduce production of platelets. Thrombopoietin (TPO) is a critical component of platelet production pathways, and TPO receptor agonists (TPO-RAs) are important for the management of ITP by increasing platelet production and reducing the need for other treatments. Romiplostim is a TPO-RA approved for use in patients with ITP in the United States, European Union, Australia, and several countries in Africa and Asia, as well as for use in patients with refractory aplastic anemia in Japan and Korea. Romiplostim binds to and activates the TPO receptor on megakaryocyte precursors, thus promoting cell proliferation and viability, resulting in increased platelet production. Through this mechanism, romiplostim reduces the need for other treatments and decreases bleeding events in patients with thrombocytopenia. In addition to its efficacy in ITP, studies have shown that romiplostim is effective in improving platelet counts in various settings, thereby highlighting the versatility of romiplostim. The efficacy of romiplostim in such disorders is currently under investigation. Here, we review the structure, mechanism, pharmacokinetics, and pharmacodynamics of romiplostim. We also summarize the clinical evidence supporting its use in ITP and other disorders that involve thrombocytopenia, including chemotherapy-induced thrombocytopenia, aplastic anemia, acute radiation syndrome, perisurgical thrombocytopenia, post-HSCT thrombocytopenia, and liver disease.
Collapse
Affiliation(s)
- James B Bussel
- Department of Pediatrics, Division of Hematology, Weill Cornell Medicine, New York, NY, USA
| | - Gerald Soff
- Department of Medicine, Hematology Service, Memorial Sloan-Kettering Cancer Center, New York, NY, USA
| | - Adriana Balduzzi
- Clinica Pediatrica Università degli Studi di Milano Bicocca, Ospedale San Gerardo, Monza, Italy
| | | | | | - John W Semple
- Division of Hematology and Transfusion Medicine, Lund University, Lund, Sweden
- Department of Pharmacology, University of Toronto, Toronto, ON, Canada
| |
Collapse
|
39
|
Pasvolsky O, Shargian L, Rozovski U, Wolach O, Ram R, Shapira MY, Avni B, Stepensky P, Israeli M, Vidal-Fisher L, Shpilberg O, Raanani P, Yeshurun M. Eltrombopag for enhancement of platelet engraftment in patients undergoing allogeneic cord blood transplantation. Leuk Lymphoma 2021; 62:2747-2754. [PMID: 34013829 DOI: 10.1080/10428194.2021.1929957] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Platelet recovery after allogeneic umbilical cord blood (UCB) transplantation is delayed compared to other graft sources. We conducted a multicenter phase 2a study to explore whether eltrombopag, a thrombopoietin-receptor agonist, would enhance platelet recovery after UCB transplantation. Between 02/2013 and 07/2016, 12 (10 adults, 2 children) individuals (median age 50; range 6-74 years) with hematological malignancies in complete remission were enrolled. Eltrombopag was given for a median of 76 (range 15-175) days and was safe even at doses of 300 mg/day. Median time to neutrophil engraftment was 23 (range 16-40) days. Median time to platelets >20,000/µl and >50,000/µl was 55 (range 25-199) and 66 (range 31-230) days, respectively. A historical cohort comparison did not reveal an advantage for eltrombopag. In conclusion, in the present study eltrombopag seems safe. Based on our limited data, it seems unlikely that eltrombopag could enhance platelet engraftment after UCB transplantation.
Collapse
Affiliation(s)
- Oren Pasvolsky
- Institute of Hematology, Davidoff Cancer Center, Rabin Medical Center, Petah-Tikva, Israel.,Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Liat Shargian
- Institute of Hematology, Davidoff Cancer Center, Rabin Medical Center, Petah-Tikva, Israel.,Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Uri Rozovski
- Institute of Hematology, Davidoff Cancer Center, Rabin Medical Center, Petah-Tikva, Israel.,Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Ofir Wolach
- Institute of Hematology, Davidoff Cancer Center, Rabin Medical Center, Petah-Tikva, Israel.,Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Ron Ram
- Bone Marrow Transplantation Unit, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| | | | - Batia Avni
- Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel.,Department of Bone Marrow Transplantation, Hadassah Medical Center, Jerusalem, Israel
| | - Polina Stepensky
- Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel.,Department of Bone Marrow Transplantation, Hadassah Medical Center, Jerusalem, Israel
| | | | | | - Ofer Shpilberg
- Assuta Medical Center, Tel Aviv, Israel.,Ariel University, Tel Aviv, Israel
| | - Pia Raanani
- Institute of Hematology, Davidoff Cancer Center, Rabin Medical Center, Petah-Tikva, Israel.,Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Moshe Yeshurun
- Institute of Hematology, Davidoff Cancer Center, Rabin Medical Center, Petah-Tikva, Israel.,Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| |
Collapse
|
40
|
Nachtkamp K, Stark J, Kündgen A, Schroeder T, Strupp C, Strapatsas J, Schuler E, Kaivers J, Giagounidis A, Rautenberg C, Aul C, Runde V, Haas R, Kobbe G, Gattermann N, Germing U. Eligibility for clinical trials is unsatisfactory for patients with myelodysplastic syndromes, even at a tertiary referral center. Leuk Res 2021; 108:106611. [PMID: 33990002 DOI: 10.1016/j.leukres.2021.106611] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2021] [Revised: 04/30/2021] [Accepted: 05/04/2021] [Indexed: 12/01/2022]
Abstract
Participation in clinical trials may allow patients with MDS to gain access to therapies not otherwise available. However, access is limited by strict inclusion and exclusion criteria, reflecting academic or regulatory questions addressed by the respective studies. We performed a simulation in order to estimate the average proportion of MDS patients eligible for participation in a clinical trial. The simulation drew upon 1809 patients in the Düsseldorf MDS Registry whose clinical data allowed eligibility screening for a wide range of clinical trials. This cohort was assumed to be alive and available for study participation. The simulation also posited that all MDS trials (n = 47) conducted in our center between 1987 and 2016 were open for recruitment. In addition, study activities in the year 2016 were analyzed to determine the proportion of patients eligible for at least one of the 9 MDS trials open at that time. On average, each clinical trial was suitable for about 18 % of patients in the simulation cohort. Conversely, 34 % of the patients were eligible for at least one of the 9 clinical studies in 2016. Inclusion/exclusion criteria of studies initiated by the pharmaceutical industry excluded more than twice the fraction of patients compared with investigator initiated trials (potential inclusion of 10 % vs. 21 %, respectively). Karyotype (average exclusion rate 58 %), comorbidities (40 %), and prior therapies (55 %) were the main reasons for exclusion. We suggest that in- and exclusion criteria should be less restrictive, in order to meet the needs of the real-life population of elderly MDS patients.
Collapse
Affiliation(s)
- Kathrin Nachtkamp
- Department of Hematology, Oncology and Clinical Immunology, Heinrich-Heine-University, Moorenstr. 5, 40225 Düsseldorf, Germany.
| | - Josefine Stark
- Department of Hematology, Oncology and Clinical Immunology, Heinrich-Heine-University, Moorenstr. 5, 40225 Düsseldorf, Germany
| | - Andrea Kündgen
- Department of Hematology, Oncology and Clinical Immunology, Heinrich-Heine-University, Moorenstr. 5, 40225 Düsseldorf, Germany
| | - Thomas Schroeder
- Department of Hematology, Oncology and Clinical Immunology, Heinrich-Heine-University, Moorenstr. 5, 40225 Düsseldorf, Germany
| | - Corinna Strupp
- Department of Oncology, Rheinland Klinikum Dormagen, Dr.-Geldmacher-Straße 20, 41540 Dormagen, Germany
| | - Judith Strapatsas
- Department of Hematology, Oncology and Clinical Immunology, Heinrich-Heine-University, Moorenstr. 5, 40225 Düsseldorf, Germany
| | - Esther Schuler
- Department of Hematology, Oncology and Clinical Immunology, Heinrich-Heine-University, Moorenstr. 5, 40225 Düsseldorf, Germany
| | - Jennifer Kaivers
- Department of Hematology, Oncology and Clinical Immunology, Heinrich-Heine-University, Moorenstr. 5, 40225 Düsseldorf, Germany
| | - Aristoteles Giagounidis
- Department of Oncology and Hematology, VKKD Marienhospital Duesseldorf, Rochusstr. 2, 40479 Düsseldorf, Germany
| | - Christina Rautenberg
- Department of Hematology, Oncology and Clinical Immunology, Heinrich-Heine-University, Moorenstr. 5, 40225 Düsseldorf, Germany
| | - Carlo Aul
- Department of Oncology and Hematology, VKKD Marienhospital Duesseldorf, Rochusstr. 2, 40479 Düsseldorf, Germany
| | - Volker Runde
- Department of Hematology and Oncology, Katholisches Karl-Leisner-Klinikum, Voßheider Str. 214, 47574 Goch, Germany
| | - Rainer Haas
- Department of Hematology, Oncology and Clinical Immunology, Heinrich-Heine-University, Moorenstr. 5, 40225 Düsseldorf, Germany
| | - Guido Kobbe
- Department of Hematology, Oncology and Clinical Immunology, Heinrich-Heine-University, Moorenstr. 5, 40225 Düsseldorf, Germany
| | - Norbert Gattermann
- Department of Hematology, Oncology and Clinical Immunology, Heinrich-Heine-University, Moorenstr. 5, 40225 Düsseldorf, Germany
| | - Ulrich Germing
- Department of Hematology, Oncology and Clinical Immunology, Heinrich-Heine-University, Moorenstr. 5, 40225 Düsseldorf, Germany
| |
Collapse
|
41
|
Jachiet V, Moulis G, Hadjadj J, Seguier J, Laribi K, Schleinitz N, Vey N, Sacre K, Godeau B, Beyne-Rauzy O, Bouvet R, Broner J, Brun N, Comont T, Gaudin C, Lambotte O, Le Clech L, Peterlin P, Roy-Peaud F, Salvado C, Versini M, Isnard F, Kahn JE, Gobert D, Adès L, Fenaux P, Fain O, Mekinian A. Clinical spectrum, outcome and management of immune thrombocytopenia associated with myelodysplastic syndromes and chronic myelomonocytic leukemia. Haematologica 2021; 106:1414-1422. [PMID: 33626866 PMCID: PMC8094121 DOI: 10.3324/haematol.2020.272559] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2020] [Accepted: 11/23/2020] [Indexed: 12/15/2022] Open
Abstract
Myelodysplastic syndromes (MDS) and chronic myelomonocytic leukemia (CMML) are associated with systemic inflammatory or autoimmune diseases in 10-20 % of cases. Among them, immune thrombocytopenia (ITP) has been reported but large studies assessing this association are missing. Whether such patients have a particular phenotype and require particular management is unclear. This study analyzes the clinical spectrum, outcome and therapeutic management of patients with ITP associated with MDS or CMML, in comparison (i) to patients with primary ITP without MDS/CMML and (ii) to patients with MDS/CMML without ITP. Forty-one MDS/CMML-associated ITP patients were included, with chronic ITP in 26 (63%) patients, low-risk myelodysplasia in 30 (73%) patients and CMML in 24 (59%) patients. An associated autoimmune disease was noted in 10 (24%) patients. In comparison to primary ITP patients, MDS/CMML-associated ITP patients had a higher occurrence of severe bleeding despite similar platelet counts at diagnosis. First-line treatment consisted of glucocorticoids (98%) and intravenous immunoglobulin (IVIg) (56%). Response achievement with IVIg was more frequent in primary ITP than in MDS/CMML-associated ITP patients. Response rates to second-line therapies were not statistically different between primary ITP and MDS/CMMLassociated ITP patients. Ten percent (n=4) of patients with MDS/CMML-associated ITP had multirefractory ITP versus none in primary ITP controls. After a median follow-up of 60 months, there was no difference in overall survival between MDS/CMML-associated ITP and primary ITP patients. Leukemia-free-survival was significantly better in MDS/CMMLassociated ITP patients than in MDS/CMML without ITP MDS/CMML-associated ITP have a particular outcome with more severe bleeding and multirefractory profile than primary ITP, similar response profile to primary ITP therapy except for IVIg, and less progression toward acute myeloid leukemia than MDS/CMML without ITP.
Collapse
MESH Headings
- Humans
- Leukemia, Myeloid, Acute
- Leukemia, Myelomonocytic, Chronic/complications
- Leukemia, Myelomonocytic, Chronic/diagnosis
- Leukemia, Myelomonocytic, Chronic/therapy
- Myelodysplastic Syndromes/complications
- Myelodysplastic Syndromes/diagnosis
- Myelodysplastic Syndromes/therapy
- Purpura, Thrombocytopenic, Idiopathic/diagnosis
- Purpura, Thrombocytopenic, Idiopathic/etiology
- Purpura, Thrombocytopenic, Idiopathic/therapy
- Thrombocytopenia
Collapse
Affiliation(s)
- Vincent Jachiet
- Sorbonne Université, AP-HP, Hôpital Saint-Antoine, Service de Médecine Interne and Inflammation-Immunopathology-Biotherapy Department (DMU 3iD), F-75012, Paris
| | - Guillaume Moulis
- Service de médecine interne, CHU de Toulouse, France; CIC 1436, CHU de Toulouse, France; UMR 1027 Inserm-Université de Toulouse
| | - Jérome Hadjadj
- Imagine Institute, laboratory of Immunogenetics of Pediatric Autoimmune Diseases, INSERM UMR 1163, Université de Paris, F-75015, Paris ; Department of Internal Medicine, National Referral Center for Rare Systemic Autoimmune Diseases, Assistance Publique Hôpitaux de Paris-Centre (APHP-CUP), Université de Paris, F-75014
| | - Julie Seguier
- Département de médecine interne, Hôpital de la Timone, AP-HM, Aix Marseille Université, Marseille
| | - Kamel Laribi
- Department of Hematology, Centre hospitalier Le Mans, Le Mans
| | - Nicolas Schleinitz
- Département de médecine interne, Hôpital de la Timone, AP-HM, Aix Marseille Université, Marseille
| | - Norbert Vey
- Haematology Department, Institut Paoli-Calmettes, Aix-Marseille Université, Marseille
| | - Karim Sacre
- Departement de Médecine Interne, Hôpital Bichat, APHP, Université de Paris, INSERM U1149, Paris
| | - Bertrand Godeau
- Hôpitaux de Paris, Hôpital Henri Mondor, Médecine Interne, Centre de Référence des Cytopénies Autoimmunes de L'Adulte, Université Paris-Est Créteil, F-94010, Créteil
| | - Odile Beyne-Rauzy
- Department of internal medicine, Toulouse University Hospital, Institut universitaire du cancer de Toulouse, and University of Toulouse, F-31059, Toulouse
| | - Romain Bouvet
- Médecine interne et maladies systémiques, CHU Dijon Bourgogne, 21000 Dijon
| | - Jonathan Broner
- Internal Médicine Department, Nîmes University Hospital, University of Montpellier, Nîmes
| | - Natacha Brun
- Service de Médecine Interne, Centre Hospitalier de Rodez, Rodez
| | - Thibault Comont
- Department of internal medicine, Toulouse University Hospital, Institut universitaire du cancer de Toulouse, and University of Toulouse, F-31059, Toulouse
| | - Clément Gaudin
- Department of oncogeriatric medicine, University Hospital Purpan, Toulouse
| | - Olivier Lambotte
- Hôpitaux de Paris, Hôpital Bicêtre, Médecine Interne et Immunologie Clinique, F-94275, Le Kremlin-Bicêtre, France; INSERM U1184, Immunology of Viral Infections and Autoimmune Diseases, F-94276, Le Kremlin-Bicêtre, France; Université Paris Sud, UMR 1184, F-94276, Le Kremlin-Bicêtre, France; CEA, DSV/iMETI, IDMIT, F-92265, Fontenay-aux-Roses
| | - Lenaïg Le Clech
- Department of Internal Medicine, Infectious Diseases and Haematology, Cornouaille Hospital Quimper
| | | | - Frédérique Roy-Peaud
- Service de médecine interne, maladies infectieuses et tropicales, CHU de Poitiers, Poitiers
| | | | | | - Françoise Isnard
- Department of Clinical Hematology, Saint-Antoine Hospital, AP-HP, Paris
| | | | - Delphine Gobert
- Sorbonne Université, AP-HP, Hôpital Saint-Antoine, Service de Médecine Interne and Inflammation-Immunopathology-Biotherapy Department (DMU 3iD), F-75012, Paris
| | - Lionel Adès
- Hopital Saint-Louis (APHP) and Paris University and INSERM U944, Paris
| | - Pierre Fenaux
- Hopital Saint-Louis (APHP) and Paris University and INSERM U944, Paris
| | - Olivier Fain
- Sorbonne Université, AP-HP, Hôpital Saint-Antoine, Service de Médecine Interne and Inflammation-Immunopathology-Biotherapy Department (DMU 3iD), F-75012, Paris
| | - Arsène Mekinian
- Sorbonne Université, AP-HP, Hôpital Saint-Antoine, Service de Médecine Interne and Inflammation-Immunopathology-Biotherapy Department (DMU 3iD), F-75012, Paris.
| |
Collapse
|
42
|
Leader A, Hofstetter L, Spectre G. Challenges and Advances in Managing Thrombocytopenic Cancer Patients. J Clin Med 2021; 10:1169. [PMID: 33799591 PMCID: PMC8000983 DOI: 10.3390/jcm10061169] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2021] [Revised: 03/02/2021] [Accepted: 03/08/2021] [Indexed: 12/16/2022] Open
Abstract
Cancer patients have varying incidence, depth and duration of thrombocytopenia. The mainstay of managing severe chemotherapy-induced thrombocytopenia (CIT) in cancer is the use of platelet transfusions. While prophylactic platelet transfusions reduce the bleeding rate, multiple unmet needs remain, such as high residual rates of bleeding, and anticancer treatment dose reductions/delays. Accordingly, the following promising results in other settings, antifibrinolytic drugs have been evaluated for prevention and treatment of bleeding in patients with hematological malignancies and solid tumors. In addition, Thrombopoeitin receptor agonists have been studied for two major implications in cancer: treatment of severe thrombocytopenia associated with myelodysplastic syndrome and acute myeloid leukemia; primary and secondary prevention of CIT in solid tumors in order to maintain dose density and intensity of anti-cancer treatment. Furthermore, thrombocytopenic cancer patients are often prescribed antithrombotic medication for indications arising prior or post cancer diagnosis. Balancing the bleeding and thrombotic risks in such patients represents a unique clinical challenge. This review focuses upon non-transfusion-based approaches to managing thrombocytopenia and the associated bleeding risk in cancer, and also addresses the management of antithrombotic therapy in thrombocytopenic cancer patients.
Collapse
Affiliation(s)
- Avi Leader
- Institute of Hematology, Davidoff Cancer Center, Rabin Medical Center, Petah Tikva 4941492, Israel; (L.H.); (G.S.)
- Sackler School of Medicine, Tel Aviv University, Tel Aviv 6997801, Israel
- Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, 6229 ER Maastricht, The Netherlands
| | - Liron Hofstetter
- Institute of Hematology, Davidoff Cancer Center, Rabin Medical Center, Petah Tikva 4941492, Israel; (L.H.); (G.S.)
- Sackler School of Medicine, Tel Aviv University, Tel Aviv 6997801, Israel
| | - Galia Spectre
- Institute of Hematology, Davidoff Cancer Center, Rabin Medical Center, Petah Tikva 4941492, Israel; (L.H.); (G.S.)
- Sackler School of Medicine, Tel Aviv University, Tel Aviv 6997801, Israel
| |
Collapse
|
43
|
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.
Collapse
|
44
|
Chanias I, Wilk CM, Benz R, Daskalakis M, Stüssi G, Schmidt A, Bacher U, Bonadies N. Survey on Recommended Health Care for Adult Patients with Myelodysplastic Syndromes Identifies Areas for Improvement. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2020; 17:ijerph17249562. [PMID: 33371225 PMCID: PMC7766925 DOI: 10.3390/ijerph17249562] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 10/17/2020] [Revised: 12/12/2020] [Accepted: 12/14/2020] [Indexed: 12/29/2022]
Abstract
The impact on health care of patients with myelodysplastic syndromes (MDS) is continuously rising. To investigate the perception of hemato-oncologists concerning the recommended MDS patient care in Switzerland, we conducted a web-based survey on diagnosis, risk-stratification and treatment. 43/309 physicians (13.9%) replied to 135 questions that were based on current guidelines between 3/2017 and 2/2018. Only questions with feedback-rates >50% were further analysed and ratios >90% defined “high agreement”, 70–90% “agreement”, 30–70% “insufficient agreement” and <30% “disagreement”. For diagnosis, we found insufficient agreement on using flow-cytometry, classifying MDS precursor conditions, performing treatment response assessment after hypomethylating agents (HMA) and evaluating patients with suspected germ-line predisposition. For risk-stratification, we identified agreement on using IPSS-R but insufficient agreement for IPSS and patient-based assessments. For treatment, we observed disagreement on performing primary infectious prophylaxis in neutropenia but agreement on using only darbepoetin alfa in anaemic, lower-risk MDS patients. For thrombopoietin receptor agonists, insufficient agreement was found for the indication, preferred agent and triggering platelet count. Insufficient agreement was also found for immunosuppressive treatment in hypoplastic MDS and HMA dose adjustments. In conclusion, we identified areas for improvement in MDS patient care, in need of further clinical trials, information, and guiding documents.
Collapse
Affiliation(s)
- Ioannis Chanias
- Department of Hematology and Central Hematology Laboratory, Inselspital, Bern University Hospital, University of Bern, 3010 Bern, Switzerland; (I.C.); (M.D.); (U.B.)
| | - C. Matthias Wilk
- Department of Medical Oncology and Hematology, University Hospital Zurich and University of Zurich, 3010 Bern, Switzerland;
| | - Rudolf Benz
- Department of Hematology and Oncology, Cantonal Hospital Muensterlingen, 8596 Muensterlingen, Switzerland;
| | - Michael Daskalakis
- Department of Hematology and Central Hematology Laboratory, Inselspital, Bern University Hospital, University of Bern, 3010 Bern, Switzerland; (I.C.); (M.D.); (U.B.)
| | - Georg Stüssi
- Clinic of Hematology, Oncology Institute of Southern Switzerland, 6500 Bellinzona, Switzerland;
| | - Adrian Schmidt
- Clinic for Medical Oncology and Hematology, City Hospital Waid and Triemli, 8063 Zurich, Switzerland;
| | - Ulrike Bacher
- Department of Hematology and Central Hematology Laboratory, Inselspital, Bern University Hospital, University of Bern, 3010 Bern, Switzerland; (I.C.); (M.D.); (U.B.)
| | - Nicolas Bonadies
- Department of Hematology and Central Hematology Laboratory, Inselspital, Bern University Hospital, University of Bern, 3010 Bern, Switzerland; (I.C.); (M.D.); (U.B.)
- Department for BioMedical Research (DBMR), University of Bern, 3010 Bern, Switzerland
- Correspondence: ; Tel.: +41-(0)31-632-45-71
| | | |
Collapse
|
45
|
Carraway HE, Saygin C. Therapy for lower-risk MDS. HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2020; 2020:426-433. [PMID: 33275714 PMCID: PMC7727572 DOI: 10.1182/hematology.2020000127] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/09/2023]
Abstract
Lower-risk myelodysplastic syndromes (MDS) are characterized by the presence of dysplasia, low bone marrow blast percentage, low number and depth of cytopenia(s), and relatively good-risk karyotpic and molecular abnormalities. A score of ≤3.5 on the Revised International Prognostic Scoring System classifies patients as lower-risk MDS. Information from a mutational profile of the MDS at time of diagnosis (and over serial time points) can be reassuring for predicted behavior of lower-risk MDS compared with one expected to progress more rapidly (higher-risk MDS). Supportive care continues to be the crux of treatment, although the options to reduce transfusion needs have improved in 2020. Erythropoiesis stimulating agents, lenalidomide, and luspatercept address the most frequent (and symptomatic) cytopenia (anemia) and are started only when patients are transfusion dependent. Patients can derive long-term benefits (years) from these approaches but will often progress to higher-risk MDS. Interestingly, some patients with lower-risk MDS can present with an isolated thrombocytopenia for which thrombopoietin receptor analogs such as romiplostim and eltrombopag are options (as long as blast counts are low). The presence of pancytopenia and or intensifying and unremitting clinical symptoms are often treated with hypomethylating agents or (anti-thymocyte globulin if hypocellular MDS is of concern). Targeted therapies are emerging for small subsets of MDS patients with specific somatic mutations (ie, TP53, IDH1/2, FLT3), although currently, there are no approved, mutation-directed medications to treat MDS.
Collapse
Affiliation(s)
- Hetty E. Carraway
- Leukemia Program, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH; and
| | - Caner Saygin
- Wexner Medical Center, The Ohio State University, Cleveland, OH
| |
Collapse
|
46
|
Vicente A, Patel BA, Gutierrez-Rodrigues F, Groarke E, Giudice V, Lotter J, Feng X, Kajigaya S, Weinstein B, Barranta E, Olnes MJ, Parikh AR, Albitar M, Wu CO, Shalhoub R, Calvo KR, Townsley DM, Scheinberg P, Dunbar CE, Young NS, Winkler T. Eltrombopag monotherapy can improve hematopoiesis in patients with low to intermediate risk-1 myelodysplastic syndrome. Haematologica 2020; 105:2785-2794. [PMID: 33256377 PMCID: PMC7716353 DOI: 10.3324/haematol.2020.249995] [Citation(s) in RCA: 35] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Myelodysplastic syndromes (MDS) are a group of clonal myeloid disorders characterized by low blood counts and a propensity to develop acute myeloid leukemia. The management of lowerrisk (LR) MDS with persistent cytopenias remains suboptimal. Eltrombopag, a thrombopoietin-receptor agonist, can improve platelet counts in LR-MDS and trilineage hematopoiesis in aplastic anemia. We conducted a phase II dose modification study to investigate the safety and efficacy of eltrombopag in LR-MDS. The eltrombopag dose was escalated from 50 mg/day to a maximum of 150 mg/day over a period of 16 weeks. The primary efficacy endpoint was hematologic response at 16-20 weeks. Eleven of 25 (44%) patients responded; five and six patients had uni- or bi-lineage hematologic responses, respectively. The predictors of response were presence of a paroxysmal nocturnal hemoglobinuria clone, marrow hypocellularity, thrombocytopenia, and elevated plasma thrombopoietin levels at study entry. The safety profile was consistent with that found in previous eltrombopag studies in aplastic anemia; no patients discontinued the drug due to adverse events. Three patients developed reversible grade 3 liver toxicity and one patient had increased reticulin fibrosis. Ten patients discontinued eltrombopag after achieving a robust response (median time 16 months); four of them reinitiated eltrombopag because of declining blood counts, and all attained a second robust response. Six patients had disease progression not associated with expansion of mutated clones and no patient progressed to develop acute myeloid leukemia on study. In conclusion, eltrombopag was well-tolerated and effective in restoring hematopoiesis in some patients with low or intermediate-1 risk MDS. This study was registered at clinicaltrials.gov as #NCT00932156.
Collapse
Affiliation(s)
| | | | | | | | | | | | | | | | | | | | | | | | | | - Colin O Wu
- Office of Biostatistics Research, National Institutes of Health
| | - Ruba Shalhoub
- Office of Biostatistics Research, National Institutes of Health
| | | | | | | | | | | | | |
Collapse
|
47
|
Makris M. Thrombopoietin receptor agonists for the treatment of inherited thrombocytopenia. Haematologica 2020; 105:536-538. [PMID: 32115414 DOI: 10.3324/haematol.2019.241786] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Affiliation(s)
- Michael Makris
- Department of Infection, Immunity and Cardiovascular disease, University of Sheffield .,Sheffield Haemophilia and Thrombosis Centre, Royal Hallamshire Hospital, Sheffield, UK
| |
Collapse
|
48
|
Bowen D, Karakantza M. Thrombocytopenia and platelet transfusion in myelodysplastic syndromes. Transfusion 2020; 60:2164-2167. [DOI: 10.1111/trf.16093] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2020] [Accepted: 09/09/2020] [Indexed: 11/28/2022]
Affiliation(s)
- David Bowen
- Consultant Haematologist, Haematology Department Leeds Teaching Hospitals Leeds UK
| | - Marina Karakantza
- Consultant Haematologist, Transfusion Medicine Leeds Teaching Hospitals Leeds UK
| |
Collapse
|
49
|
Abdelmoumen K, Fabre M, Ducastelle-Lepretre S, Favier R, Ballerini P, Bordet JC, Dargaud Y. Eltrombopag for the Treatment of Severe Inherited Thrombocytopenia. Acta Haematol 2020; 144:308-313. [PMID: 32987389 DOI: 10.1159/000509922] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2020] [Accepted: 07/06/2020] [Indexed: 12/12/2022]
Abstract
Inherited thrombocytopenias correspond to a group of hereditary disorders characterized by a reduced platelet count, platelet dysfunction, and a family history of thrombocytopenia. It is commonly associated with mucocutaneous bleeding. Thrombocytopenia results from mutations in genes involved in megakaryocyte differentiation, platelet formation, and clearance. Here we report on a patient presenting with severe syndromic inherited thrombocytopenia manifesting as spontaneous mucocutaneous bleeds, requiring frequent platelet transfusions. Thrombocytopenia was explained by the presence of 4 mutations in 3 hematopoietic transcription factor genes: FLI1, RUNX1, and ETV6. The patient was successfully treated with high-dose eltrombopag at 150 mg/day, an orally available non-peptide thrombopoietin receptor agonist. Since the start of treatment 23 months ago, the manifestations of bleeding have resolved, and no platelet transfusions or corticosteroids have been required. The patient has no clinical or laboratory evidence of myeloid malignancy so far.
Collapse
Affiliation(s)
- Karim Abdelmoumen
- Unite d'Hemostase Clinique, Hopital Cardiologique Louis Pradel, Lyon, France
| | - Marc Fabre
- Service de Medecine Interne, Centre Hospitalier Pierre Oudot, Bourgoin-Jallieu, France
| | | | - Remi Favier
- Assistance Publique Hôpitaux de Paris, Service d'Hématologie Biologique, CRPP, Hôpital Armand Trousseau, Paris, France
| | - Paola Ballerini
- Assistance Publique Hôpitaux de Paris, Service d'Hématologie Biologique, CRPP, Hôpital Armand Trousseau, Paris, France
| | - Jean Claude Bordet
- Laboratoire d'Hemostase, Groupement Hospitalier Est, CHU de Lyon, Lyon, France
| | - Yesim Dargaud
- Unite d'Hemostase Clinique, Hopital Cardiologique Louis Pradel, Lyon, France,
- Laboratoire d'Hemostase, Groupement Hospitalier Est, CHU de Lyon, Lyon, France,
| |
Collapse
|
50
|
Mina A, Platanias LC. Increasing megakaryopoiesis without promoting the malignant clone in myeloid malignancies. Leuk Lymphoma 2020; 61:2289-2291. [PMID: 32779514 DOI: 10.1080/10428194.2020.1802453] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Affiliation(s)
- Alain Mina
- Robert H. Lurie Comprehensive Cancer Center, Northwestern University, Chicago, IL, USA.,Department of Medicine, Division of Hematology-Oncology, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Leonidas C Platanias
- Robert H. Lurie Comprehensive Cancer Center, Northwestern University, Chicago, IL, USA.,Department of Medicine, Division of Hematology-Oncology, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA.,Department of Medicine, Jesse Brown Veterans Affairs Medical Center, Chicago, IL, USA
| |
Collapse
|