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Meyran D, Arfeuille C, Chevret S, Neven Q, Caye-Eude A, Lainey E, Petit A, Rialland F, Michel G, Plantaz D, Jubert C, Theron A, Gandemer V, Ouachée-Chardin M, Paillard C, Bruno B, Buchbinder N, Pochon C, Calvo C, Fahd M, Baruchel A, Cavé H, Dalle JH, Strullu M. A predictive classifier of poor prognosis in transplanted patients with juvenile myelomonocytic leukemia: a study on behalf of the Société Francophone de Greffe de Moelle et de Thérapie Cellulaire. Haematologica 2024; 109:2908-2919. [PMID: 38385260 PMCID: PMC11367243 DOI: 10.3324/haematol.2023.284103] [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: 08/17/2023] [Accepted: 02/13/2024] [Indexed: 02/23/2024] Open
Abstract
Juvenile myelomonocytic leukemia (JMML) is an aggressive pediatric myeloproliferative neoplasm requiring hematopoietic stem cell transplantation (HSCT) in most cases. We retrospectively analyzed 119 JMML patients who underwent first allogeneic HSCT between 2002 and 2021. The majority (97%) carried a RAS-pathway mutation, and 62% exhibited karyotypic alterations or additional mutations in SETBP1, ASXL1, JAK3 and/or the RAS pathway. Relapse was the primary cause of death, with a 5-year cumulative incidence of 24.6% (95% CI: 17.1-32.9). Toxic deaths occurred in 12 patients, resulting in treatment-related mortality (TRM) of 9.0% (95% CI: 4.6-15.3). The 5-year overall (OS) and event-free survival were 73.6% (95% CI: 65.7-82.4) and 66.4% (95% CI: 58.2-75.8), respectively. Four independent adverse prognostic factors for OS were identified: age at diagnosis >2 years, time from diagnosis to HSCT ≥6 months, monocyte count at diagnosis >7.2x109/L, and the presence of additional genetic alterations. Based on these factors, we proposed a predictive classifier. Patients with 3 or more predictors (21% of the cohort) had a 5-year OS of 34.2%, whereas those with none (7%) had a 5-year OS of 100%. Our study demonstrates improved transplant outcomes compared to prior published data, which can be attributed to the synergistic impacts of a low TRM and a reduced, yet still substantial, relapse incidence. By integrating genetic information with clinical and hematologic features, we have devised a predictive classifier. This classifier effectively identifies a subgroup of patients who are at a heightened risk of unfavorable post-transplant outcomes who would benefit from novel therapeutic agents and post-transplant strategies.
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Affiliation(s)
- Déborah Meyran
- Service d'Hémato-Immunologie pédiatrique, Hôpital Robert Debré, GHU AP-HP Nord - Université Paris Cité, Paris, France; Children's Cancer Centre, Royal Children's Hospital, Parkville, Victoria, Australia; Sir Peter MacCallum Dept of Oncology, University of Melbourne, Melbourne, 3010 Australia
| | - Chloé Arfeuille
- Service de de Génétique Moléculaire, Hôpital Robert Debré, GHU AP-HP Nord - Université Paris Cité, Paris, France; INSERM UMR_S1131, Institut Universitaire d'Hématologie, Université Paris Cité, Paris-Cité, Paris
| | - Sylvie Chevret
- Service de biostatistique et information médicale, Hôpital Saint Louis, GHU AP-HP Nord - Université Paris Cité, Paris
| | - Quentin Neven
- Service d'Hémato-Immunologie pédiatrique, Hôpital Robert Debré, GHU AP-HP Nord - Université Paris Cité, Paris
| | - Aurélie Caye-Eude
- Service de de Génétique Moléculaire, Hôpital Robert Debré, GHU AP-HP Nord - Université Paris Cité, Paris
| | - Elodie Lainey
- INSERM UMR_S1131, Institut Universitaire d'Hématologie, Université Paris Cité, Paris-Cité, Paris, France; Service d'Hématologie Biologique, Hôpital Robert Debré, GHU AP-HP Nord - Université Paris Cité, Paris
| | - Arnaud Petit
- Service d'Hémato-Immunologie pédiatrique, Hôpital Armand Trousseau, Université Paris Sorbonne, Paris
| | - Fanny Rialland
- Service d'Onco-Hématologie pédiatrique, CHU de Nantes, Nantes
| | - Gérard Michel
- Service d'Hématologie pédiatrique, Assistance Publique des Hôpitaux de Marseille AP-HM, Marseille
| | | | - Charlotte Jubert
- CHU Bordeaux, Service d'hématologie oncologie pédiatrique, F-33000 Bordeaux
| | - Alexandre Theron
- Department of Pediatric Oncology and Hematology, CHU Montpellier, France; IRMB, University of Montpellier, INSERM, Montpellier
| | | | | | | | | | | | - Cécile Pochon
- Service d'Onco-Hématologie pédiatrique, Hôpital d'Enfants de Brabois, Vandoeuvre lès Nancy
| | - Charlotte Calvo
- Service d'Hémato-Immunologie pédiatrique, Hôpital Robert Debré, GHU AP-HP Nord - Université Paris Cité, Paris
| | - Mony Fahd
- Service d'Hémato-Immunologie pédiatrique, Hôpital Robert Debré, GHU AP-HP Nord - Université Paris Cité, Paris
| | - André Baruchel
- Service d'Hémato-Immunologie pédiatrique, Hôpital Robert Debré, GHU AP-HP Nord - Université Paris Cité, Paris, France; Unité Inserm U976, Université Paris Cité, Paris-Cité, Paris
| | - Hélène Cavé
- Service de de Génétique Moléculaire, Hôpital Robert Debré, GHU AP-HP Nord - Université Paris Cité, Paris, France; INSERM UMR_S1131, Institut Universitaire d'Hématologie, Université Paris Cité, Paris-Cité, Paris
| | - Jean-Hugues Dalle
- Service d'Hémato-Immunologie pédiatrique, Hôpital Robert Debré, GHU AP-HP Nord - Université Paris Cité, Paris, France; Unité Inserm U976, Université Paris Cité, Paris-Cité, Paris
| | - Marion Strullu
- Service d'Hémato-Immunologie pédiatrique, Hôpital Robert Debré, GHU AP-HP Nord - Université Paris Cité, Paris, France; INSERM UMR_S1131, Institut Universitaire d'Hématologie, Université Paris Cité, Paris-Cité, Paris.
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Gaál Z. Targeted Epigenetic Interventions in Cancer with an Emphasis on Pediatric Malignancies. Biomolecules 2022; 13:61. [PMID: 36671446 PMCID: PMC9855367 DOI: 10.3390/biom13010061] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2022] [Revised: 12/16/2022] [Accepted: 12/23/2022] [Indexed: 12/29/2022] Open
Abstract
Over the past two decades, novel hallmarks of cancer have been described, including the altered epigenetic landscape of malignant diseases. In addition to the methylation and hyd-roxymethylation of DNA, numerous novel forms of histone modifications and nucleosome remodeling have been discovered, giving rise to a wide variety of targeted therapeutic interventions. DNA hypomethylating drugs, histone deacetylase inhibitors and agents targeting histone methylation machinery are of distinguished clinical significance. The major focus of this review is placed on targeted epigenetic interventions in the most common pediatric malignancies, including acute leukemias, brain and kidney tumors, neuroblastoma and soft tissue sarcomas. Upcoming novel challenges include specificity and potential undesirable side effects. Different epigenetic patterns of pediatric and adult cancers should be noted. Biological significance of epigenetic alterations highly depends on the tissue microenvironment and widespread interactions. An individualized treatment approach requires detailed genetic, epigenetic and metabolomic evaluation of cancer. Advances in molecular technologies and clinical translation may contribute to the development of novel pediatric anticancer treatment strategies, aiming for improved survival and better patient quality of life.
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Affiliation(s)
- Zsuzsanna Gaál
- Department of Pediatric Hematology-Oncology, Institute of Pediatrics, University of Debrecen, 4032 Debrecen, Hungary
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Juvenile Myelomonocytic Leukemia in a Child: A Case Report of Palliative Chemotherapy and Literature Review Applied to Limited Resources Centers. Case Rep Hematol 2022; 2022:1185140. [DOI: 10.1155/2022/1185140] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2022] [Revised: 11/02/2022] [Accepted: 11/03/2022] [Indexed: 11/17/2022] Open
Abstract
Juvenile myelomonocytic leukemia (JMML) is a rare hematopoietic malignancy in children, with an incidence of 1.2 per million children per year. At this moment, we present a case report and a brief literature review of JMML in a child, primarily focused on its applicability in low-middle income countries. A 3.5-year-old male was referred to our tertiary center due to pallor, enlarging abdomen and neck mass, recurrent fever, and chronic diarrhea. Initial laboratory workup showed hemoglobin of 6.4 g/dl, white blood cell of 315.62 × 103/μL, and platelet of 17 × 103/μL. Blood smears showed 10% suspected blasts, 17% myelocytes, and 17% metamyelocytes with thrombocytopenic crisis. The HbF level was 5.8%. BCR-ABL gene tested negative. The patient was diagnosed with juvenile myelomonocytic leukemia. Considering that HSCT could not be done in our center and lack other financial possibilities to seek treatment abroad, the family agreed to do the palliative treatment. The patient was treated with oral 6-mercaptopurine and subcutaneous cytarabine. Four weeks after receiving 6-mercaptopurine, the white blood cell count decreased to 10.6 × 103/μL and the spleen size was half of the original size. The patient continued chemotherapy until week 15, chemotherapy was stopped, but 16 weeks after the diagnosis of JMML, he developed severe thrombocytopenia, endophthalmitis, and sepsis and passed away. As a conclusion, in JMML cases in developing countries without HSCT, palliative chemotherapy is acceptable, and palliative care is an important aspect.
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Genomic and Epigenomic Landscape of Juvenile Myelomonocytic Leukemia. Cancers (Basel) 2022; 14:cancers14051335. [PMID: 35267643 PMCID: PMC8909150 DOI: 10.3390/cancers14051335] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2022] [Revised: 02/25/2022] [Accepted: 03/02/2022] [Indexed: 02/04/2023] Open
Abstract
Simple Summary Juvenile myelomonocytic leukemia (JMML) is a rare pediatric myelodysplastic/myeloproliferative neoplasm characterized by the constitutive activation of the RAS pathway. In spite of the recent progresses in the molecular characterization of JMML, this disease is still a clinical challenge due to its heterogeneity, difficult diagnosis, poor prognosis, and the lack of curative treatment options other than hematopoietic stem cell transplantation (HSCT). In this review, we will provide a detailed overview of the genetic and epigenetic alterations occurring in JMML, and discuss their clinical relevance in terms of disease prognosis and risk of relapse after HSCT. We will also present the most recent advances on novel preclinical and clinical therapeutic approaches directed against JMML molecular targets. Finally, we will outline future research perspectives to further explore the oncogenic mechanism driving JMML leukemogenesis and progression, with special attention to the application of single-cell next-generation sequencing technologies. Abstract Juvenile myelomonocytic leukemia (JMML) is a rare myelodysplastic/myeloproliferative neoplasm of early childhood. Most of JMML patients experience an aggressive clinical course of the disease and require hematopoietic stem cell transplantation, which is currently the only curative treatment. JMML is characterized by RAS signaling hyperactivation, which is mainly driven by mutations in one of five genes of the RAS pathway, including PTPN11, KRAS, NRAS, NF1, and CBL. These driving mutations define different disease subtypes with specific clinico-biological features. Secondary mutations affecting other genes inside and outside the RAS pathway contribute to JMML pathogenesis and are associated with a poorer prognosis. In addition to these genetic alterations, JMML commonly presents aberrant epigenetic profiles that strongly correlate with the clinical outcome of the patients. This observation led to the recent publication of an international JMML stratification consensus, which defines three JMML clinical groups based on DNA methylation status. Although the characterization of the genomic and epigenomic landscapes in JMML has significantly contributed to better understand the molecular mechanisms driving the disease, our knowledge on JMML origin, cell identity, and intratumor and interpatient heterogeneity is still scarce. The application of new single-cell sequencing technologies will be critical to address these questions in the future.
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Takebayashi A, Yamamoto M, Igarashi K, Muramatsu H, Kawasaki Y. Azacitidine as a bridge to transplantation in juvenile myelomonocytic leukemia. Pediatr Int 2022; 64:e14929. [PMID: 35119175 DOI: 10.1111/ped.14929] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/26/2020] [Revised: 06/13/2021] [Accepted: 07/16/2021] [Indexed: 11/26/2022]
Affiliation(s)
- Akira Takebayashi
- Department of Pediatrics, Sapporo Medical University School of Medicine, Sapporo, Japan
| | - Masaki Yamamoto
- Department of Pediatrics, Sapporo Medical University School of Medicine, Sapporo, Japan
| | - Keita Igarashi
- Department of Pediatrics, Sapporo Medical University School of Medicine, Sapporo, Japan
| | - Hideki Muramatsu
- Department of Pediatrics, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Yukihiko Kawasaki
- Department of Pediatrics, Sapporo Medical University School of Medicine, Sapporo, Japan
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Response to upfront azacitidine in juvenile myelomonocytic leukemia in the AZA-JMML-001 trial. Blood Adv 2021; 5:2901-2908. [PMID: 34297046 DOI: 10.1182/bloodadvances.2020004144] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2020] [Accepted: 04/25/2021] [Indexed: 11/20/2022] Open
Abstract
Allogeneic hematopoietic stem cell transplantation (HSCT) is the only curative therapy for most children with juvenile myelomonocytic leukemia (JMML). Novel therapies controlling the disorder prior to HSCT are needed. We conducted a phase 2, multicenter, open-label study to evaluate the safety and antileukemic activity of azacitidine monotherapy prior to HSCT in newly diagnosed JMML patients. Eighteen patients enrolled from September 2015 to November 2017 were treated with azacitidine (75 mg/m2) administered IV once daily on days 1 to 7 of a 28-day cycle. The primary end point was the number of patients with clinical complete remission (cCR) or clinical partial remission (cPR) after 3 cycles of therapy. Pharmacokinetics, genome-wide DNA-methylation levels, and variant allele frequencies of leukemia-specific index mutations were also analyzed. Sixteen patients completed 3 cycles and 5 patients completed 6 cycles. After 3 cycles, 11 patients (61%) were in cPR and 7 (39%) had progressive disease. Six of 16 patients (38%) who needed platelet transfusions were transfusion-free after 3 cycles. All 7 patients with intermediate- or low-methylation signatures in genome-wide DNA-methylation studies achieved cPR. Seventeen patients received HSCT; 14 (82%) were leukemia-free at a median follow-up of 23.8 months (range, 7.0-39.3 months) after HSCT. Azacitidine was well tolerated and plasma concentration--time profiles were similar to observed profiles in adults. In conclusion, azacitidine monotherapy is a suitable option for children with newly diagnosed JMML. Although long-term safety and efficacy remain to be fully elucidated in this population, these data demonstrate that azacitidine provides valuable clinical benefit to JMML patients prior to HSCT. This trial was registered at www.clinicaltrials.gov as #NCT02447666.
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McCullough KB, Kuhn AK, Patnaik MM. Treatment advances for pediatric and adult onset neoplasms with monocytosis. Curr Hematol Malig Rep 2021; 16:256-266. [PMID: 33728588 DOI: 10.1007/s11899-021-00622-8] [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: 03/03/2021] [Indexed: 10/21/2022]
Abstract
PURPOSE OF REVIEW For decades, the management of chronic myelomonocytic leukemia (CMML) or juvenile myelomonocytic leukemia (JMML) has been largely inextricable from myelodysplastic syndromes (MDS), myeloproliferative neoplasms, and acute myeloid leukemia. Hallmarks of these diseases have been the emergence of unique genomic signatures and discouraging responses to available therapies. Here, we will critically examine the current options for management and review the rapidly developing opportunities based on advances in CMML and JMML disease biology. RECENT FINDINGS Few clinical trials have exclusively been done in CMML, and in JMML, the rarity of the disease limits wide scale participation. Recent case series in JMML suggest that hypomethylating agents (HMAs) are a viable option for bridging to curative intent with allogeneic hematopoietic stem cell transplant or as posttransplant maintenance. Emerging evidence has demonstrated targeting the RAS-pathway via MEK inhibition may also be considered. In CMML, treatment with HMAs is largely derived from data inclusive of MDS patients, including a small number of patients with dysplastic CMML variants. Based on CMML disease biology, additional therapeutic targets being investigated include inhibitors of splicing, CD123/dendritic cell axis, inherent GM-CSF progenitor cell hypersensitivity, and targeting the JAK/STAT pathway. Current evidence is also expanding for oral HMAs. The management of CMML and JMML is rapidly evolving and clinicians must be aware of the genetic landscape and expanding treatment options to ensure these rare populations are afforded therapeutic interventions best suited to their needs.
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Affiliation(s)
- Kristen B McCullough
- Department of Pharmacy Services, Mayo Clinic, 200 1st Street SW, Rochester, MN, 55905, USA.
| | - Alexis K Kuhn
- Department of Pharmacy Services, Mayo Clinic, 200 1st Street SW, Rochester, MN, 55905, USA
| | - Mrinal M Patnaik
- Division of Hematology, Department of Medicine, Mayo Clinic, Rochester, MN, USA
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Gupta AK, Meena JP, Chopra A, Tanwar P, Seth R. Juvenile myelomonocytic leukemia-A comprehensive review and recent advances in management. AMERICAN JOURNAL OF BLOOD RESEARCH 2021; 11:1-21. [PMID: 33796386 PMCID: PMC8010610] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 09/25/2020] [Accepted: 01/24/2021] [Indexed: 06/12/2023]
Abstract
Juvenile myelomonocytic leukemia (JMML) is a rare pediatric myelodysplastic/myeloproliferative neoplasm overlap disease. JMML is associated with mutations in the RAS pathway genes resulting in the myeloid progenitors being sensitive to granulocyte monocyte colony-stimulating factor (GM-CSF). Karyotype abnormalities and additional epigenetic alterations can also be found in JMML. Neurofibromatosis and Noonan's syndrome have a predisposition for JMML. In a few patients, the RAS genes (NRAS, KRAS, and PTPN11) are mutated at the germline and this usually results in a transient myeloproliferative disorder with a good prognosis. JMML with somatic RAS mutation behaves aggressively. JMML presents with cytopenias and leukemic infiltration into organs. The laboratory findings include hyperleukocytosis, monocytosis, increased hemoglobin-F levels, and circulating myeloid precursors. The blast cells in the peripheral blood/bone-marrow aspirate are less than 20% and the absence of the BCR-ABL translocation helps to differentiate from chronic myeloid leukemia. JMML should be differentiated from immunodeficiencies, viral infections, intrauterine infections, hemophagolymphohistiocytosis, other myeloproliferative disorders, and leukemias. Chemotherapy is employed as a bridge to HSCT, except in few with less aggressive disease, in which chemotherapy alone can result in long term remission. Azacitidine has shown promise as a single agent to stabilize the disease. The prognosis of JMML is poor with about 50% of patients surviving after an allogeneic hematopoietic stem cell transplant (HSCT). Allogeneic HSCT is the only known cure for JMML to date. Myeloablative conditioning is most commonly used with graft versus host disease (GVHD) prophylaxis tailored to the aggressiveness of the disease. Relapses are common even after HSCT and a second HSCT can salvage a third of these patients. Novel options in the treatment of JMML e.g., hypomethylating agents, MEK inhibitors, JAK inhibitors, tyrosine kinase inhibitors, etc. are being explored.
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Affiliation(s)
- Aditya Kumar Gupta
- Division of Pediatric Oncology, Department of Pediatrics, All India Institute of Medical SciencesNew Delhi 110029, India
| | - Jagdish Prasad Meena
- Division of Pediatric Oncology, Department of Pediatrics, All India Institute of Medical SciencesNew Delhi 110029, India
| | - Anita Chopra
- Laboratory Oncology Unit, Dr. B. R. A. Institute Rotary Cancer Hospital, All India Institute of Medical SciencesNew Delhi 110029, India
| | - Pranay Tanwar
- Laboratory Oncology Unit, Dr. B. R. A. Institute Rotary Cancer Hospital, All India Institute of Medical SciencesNew Delhi 110029, India
| | - Rachna Seth
- Division of Pediatric Oncology, Department of Pediatrics, All India Institute of Medical SciencesNew Delhi 110029, India
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