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Jerez J, Santiago M. Unraveling germline predisposition in hematological neoplasms: Navigating complexity in the genomic era. Blood Rev 2024; 64:101143. [PMID: 37989620 DOI: 10.1016/j.blre.2023.101143] [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: 08/29/2023] [Revised: 10/14/2023] [Accepted: 11/14/2023] [Indexed: 11/23/2023]
Abstract
Genomic advancements have yielded pivotal insights into hematological neoplasms, particularly concerning germline predisposition mutations. Following the WHO 2016 revisions, dedicated segments were proposed to address these aspects. Current WHO 2022, ICC 2022, and ELN 2022 classifications recognize their significance, introducing more mutations and prompting integration into clinical practice. Approximately 5-10% of hematological neoplasm patients show germline predisposition gene mutations, rising with risk factors such as personal cancer history and familial antecedents, even in older adults. Nevertheless, technical challenges persist. Optimal DNA samples are skin fibroblast-extracted, although not universally applicable. Alternatives such as hair follicle use are explored. Moreover, the scrutiny of germline genomics mandates judicious test selection to ensure precise and accurate interpretation. Given the significant influence of genetic counseling on patient care and post-assessment procedures, there arises a demand for dedicated centers offering specialized services.
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Affiliation(s)
- Joaquín Jerez
- Hematology Department, Fundación Arturo López Pérez, Chile; Resident of Hematology, Universidad de los Andes, Chile.
| | - Marta Santiago
- Hematology Department, Hospital La Fe, 46026, Valencia, Spain; Hematology Research Group, Instituto de Investigación Sanitaria La Fe, 46026, Valencia, Spain.
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2
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Gurnari C, Robin M, Godley LA, Drozd-Sokołowska J, Włodarski MW, Raj K, Onida F, Worel N, Ciceri F, Carbacioglu S, Kenyon M, Aljurf M, Bonfim C, Makishima H, Niemeyer C, Fenaux P, Zebisch A, Hamad N, Chalandon Y, Hellström-Lindberg E, Voso MT, Mecucci C, Duarte FB, Sebert M, Sicre de Fontbrune F, Soulier J, Shimamura A, Lindsley RC, Maciejewski JP, Calado RT, Yakoub-Agha I, McLornan DP. Germline predisposition traits in allogeneic hematopoietic stem-cell transplantation for myelodysplastic syndromes: a survey-based study and position paper on behalf of the Chronic Malignancies Working Party of the EBMT. Lancet Haematol 2023; 10:e994-e1005. [PMID: 37898151 DOI: 10.1016/s2352-3026(23)00265-x] [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: 05/24/2023] [Revised: 08/15/2023] [Accepted: 08/18/2023] [Indexed: 10/30/2023]
Abstract
The recent application of whole exome or whole genome sequencing unveiled a plethora of germline variants predisposing to myeloid disorders, particularly myelodysplastic neoplasms. The presence of such variants in patients with myelodysplastic syndromes has important clinical repercussions for haematopoietic stem-cell transplantation, from donor selection and conditioning regimen to graft-versus-host disease prophylaxis and genetic counselling for relatives. No international guidelines exist to harmonise management approaches to this particular clinical scenario. Moreover, the application of germline testing, and how this informs clinical decisions, differs according to the expertise of individual clinical practices and according to different countries, health-care systems, and legislations. Leveraging the global span of the European Society for Blood and Marrow Transplantation (EBMT) network, we took a snapshot of the current European situation on these matters by disseminating an electronic survey to EBMT centres experienced in myelodysplastic syndromes transplantation. An international group of haematologists, transplantation physicians, paediatricians, nurses, and experts in molecular biology and constitutional genetics with experience in myelodysplastic syndromes contributed to this Position Paper. The panel met during multiple online meetings to discuss the results of the EBMT survey and to establish suggested harmonised guidelines for such clinical situations, which are presented here.
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Affiliation(s)
- Carmelo Gurnari
- Department of Biomedicine and Prevention, University of Rome Tor Vergata, Rome, Italy; Department of Translational Hematology and Oncology Research, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Marie Robin
- Department of Hematology and Bone Marrow Transplantation, Hôpital Saint-Louis, AP-HP, University Paris, Paris, France
| | - Lucy A Godley
- Section of Hematology and Oncology, Departments of Medicine and Human Genetics, The University of Chicago, Chicago, IL, USA
| | - Joanna Drozd-Sokołowska
- Department of Hematology, Transplantation and Internal Medicine, Medical University of Warsaw, Warsaw, Poland
| | - Marcin W Włodarski
- Department of Hematology, St Jude Children's Research Hospital, Memphis, TN, USA
| | - Kavita Raj
- University College London NHS Foundation Trust, London, UK
| | - Francesco Onida
- Hematology Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Nina Worel
- Department of Transfusion Medicine and Cell Therapy, Medical University of Vienna, Vienna, Austria
| | | | - Selim Carbacioglu
- Department of Paediatric Oncology, Haematology and Stem Cell Transplantation, University Children's Hospital Regensburg, Regensburg, Germany
| | - Michelle Kenyon
- Department of Haematological Medicine, King's College Hospital NHS Foundation Trust, London, UK
| | - Mahmoud Aljurf
- Division of Hematology, Stem Cell Transplantation and Cellular Therapy, Oncology Center, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
| | - Carmem Bonfim
- Pediatric Blood and Marrow Transplantation Division and Pele Pequeno Principe Research Institute, Hospital Pequeno Principe, Curitiba, Brazil
| | - Hideki Makishima
- Department of Pathology and Tumor Biology, Kyoto University, Kyoto, Japan
| | - Charlotte Niemeyer
- Department of Pediatrics and Adolescent Medicine, Division of Pediatric Hematology and Oncology, Medical Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Pierre Fenaux
- Department of Hematology and Bone Marrow Transplantation, Hôpital Saint-Louis, AP-HP, University Paris, Paris, France; INSERM U944, CNRS UMR7212, Paris, France; Saint-Louis Hospital, Hematology Laboratory, AP-HP, Paris, France
| | - Armin Zebisch
- Division of Hematology and Otto Loewi Research Center for Vascular Biology, Immunology and Inflammation, Division of Pharmacology, Medical University of Graz, Graz, Austria
| | - Nada Hamad
- Department of Hematology, St Vincent's Hospital Sydney, NSW, Australia
| | - Yves Chalandon
- Division of Hematology, Bone Marrow Transplant Unit, University Hospital of Geneva and Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | - Eva Hellström-Lindberg
- Center for Hematology and Regenerative Medicine, Department of Medicine Huddinge, Karolinska Institutet and Department of Hematology, Karolinska University Hospital, Stockholm, Sweden
| | - Maria Teresa Voso
- Department of Biomedicine and Prevention, University of Rome Tor Vergata, Rome, Italy
| | - Cristina Mecucci
- Institute of Hematology and Center for Hemato-Oncology Research, University and Hospital of Perugia, Perugia, Italy
| | | | - Marie Sebert
- Department of Hematology and Bone Marrow Transplantation, Hôpital Saint-Louis, AP-HP, University Paris, Paris, France; INSERM U944, CNRS UMR7212, Paris, France; Saint-Louis Hospital, Hematology Laboratory, AP-HP, Paris, France
| | - Flore Sicre de Fontbrune
- Department of Hematology and Bone Marrow Transplantation, Hôpital Saint Louis, AP-HP, Université Paris Cité, Centre National de Reference des Aplasies Médullaires Acquises et Constitutionnelles, Paris, France
| | - Jean Soulier
- INSERM U944, CNRS UMR7212, Paris, France; Saint-Louis Hospital, Hematology Laboratory, AP-HP, Paris, France
| | - Akiko Shimamura
- Dana-Farber/Boston Children's Cancer and Blood Disorders Center, Boston, MA, USA
| | | | - Jarosław P Maciejewski
- Department of Translational Hematology and Oncology Research, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Rodrigo T Calado
- Department of Medical Imaging, Hematology, and Oncology, Ribeirão Preto Medical School, University of São Paulo, Brazil
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3
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Zoller J, Trajanova D, Feurstein S. Germline and somatic drivers in inherited hematologic malignancies. Front Oncol 2023; 13:1205855. [PMID: 37904876 PMCID: PMC10613526 DOI: 10.3389/fonc.2023.1205855] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2023] [Accepted: 09/15/2023] [Indexed: 11/01/2023] Open
Abstract
Inherited hematologic malignancies are linked to a heterogenous group of genes, knowledge of which is rapidly expanding using panel-based next-generation sequencing (NGS) or whole-exome/whole-genome sequencing. Importantly, the penetrance for these syndromes is incomplete, and disease development, progression or transformation has critical clinical implications. With the earlier detection of healthy carriers and sequential monitoring of these patients, clonal hematopoiesis and somatic driver variants become significant factors in determining disease transformation/progression and timing of (preemptive) hematopoietic stem cell transplant in these patients. In this review, we shed light on the detection of probable germline predisposition alleles based on diagnostic/prognostic 'somatic' NGS panels. A multi-tier approach including variant allele frequency, bi-allelic inactivation, persistence of a variant upon clinical remission and mutational burden can indicate variants with high pre-test probability. We also discuss the shared underlying biology and frequency of germline and somatic variants affecting the same gene, specifically focusing on variants in DDX41, ETV6, GATA2 and RUNX1. Germline variants in these genes are associated with a (specific) pattern or over-/underrepresentation of somatic molecular or cytogenetic alterations that may help identify the underlying germline syndrome and predict the course of disease in these individuals. This review is based on the current knowledge about somatic drivers in these four syndromes by integrating data from all published patients, thereby providing clinicians with valuable and concise information.
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Affiliation(s)
| | | | - Simone Feurstein
- Department of Internal Medicine, Section of Hematology, Oncology & Rheumatology, University Hospital Heidelberg, Heidelberg, Germany
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Rajput RV, Arnold DE. GATA2 Deficiency: Predisposition to Myeloid Malignancy and Hematopoietic Cell Transplantation. Curr Hematol Malig Rep 2023:10.1007/s11899-023-00695-7. [PMID: 37247092 DOI: 10.1007/s11899-023-00695-7] [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: 04/04/2023] [Indexed: 05/30/2023]
Abstract
PURPOSE OF REVIEW GATA2 deficiency is a haploinsufficiency syndrome associated with a wide spectrum of disease, including severe monocytopenia and B and NK lymphopenia, predisposition to myeloid malignancies, human papillomavirus infections, and infections with opportunistic organisms, particularly nontuberculous mycobacteria, herpes virus, and certain fungi. GATA2 mutations have variable penetrance and expressivity with imperfect genotype-phenotype correlations. However, approximately 75% of patients will develop a myeloid neoplasm at some point. Allogeneic hematopoietic cell transplantation (HCT) is the only currently available curative therapy. Here, we review the clinical manifestations of GATA2 deficiency, characterization of the hematologic abnormalities and progression to myeloid malignancy, and current HCT practices and outcomes. RECENT FINDINGS Cytogenetic abnormalities are common with high rates of trisomy 8, monosomy 7, and unbalanced translocation der(1;7) and may suggest an underlying GATA2 deficiency in patients presenting with myelodysplastic syndrome (MDS). Mutations in ASXL1 and STAG2 are the most frequently encountered somatic mutations and are associated with lower survival probability. A recent report of 59 patients with GATA2 deficiency who underwent allogenic HCT with myeloablative, busulfan-based conditioning and post-transplant cyclophosphamide reported excellent overall and event-free survival of 85% and 82% with reversal of disease phenotype and low rates of graft versus host disease. Allogeneic HCT with myeloablative conditioning results in disease correction and should be considered for patients with a history of recurrent, disfiguring and/or severe infections, organ dysfunction, MDS with cytogenetic abnormalities, high-risk somatic mutations or transfusion dependence, or myeloid progression. Improved genotype/phenotype correlations are needed to allow for greater predictive capabilities.
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Affiliation(s)
- Roma V Rajput
- Hematology Branch, National Hematology, Lung, and Blood Institute, National Institute of Health, Bethesda, USA
| | - Danielle E Arnold
- Immune Deficiency-Cellular Therapy Program, Center for Cancer Research, National Cancer Institute, Building 10-CRC, Room 1-5130, Bethesda, MD, 20892, USA.
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Santiago M, Liquori A, Such E, Zúñiga Á, Cervera J. The Clinical Spectrum, Diagnosis, and Management of GATA2 Deficiency. Cancers (Basel) 2023; 15:cancers15051590. [PMID: 36900380 PMCID: PMC10000430 DOI: 10.3390/cancers15051590] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2023] [Revised: 03/02/2023] [Accepted: 03/02/2023] [Indexed: 03/08/2023] Open
Abstract
Hereditary myeloid malignancy syndromes (HMMSs) are rare but are becoming increasingly significant in clinical practice. One of the most well-known syndromes within this group is GATA2 deficiency. The GATA2 gene encodes a zinc finger transcription factor essential for normal hematopoiesis. Insufficient expression and function of this gene as a result of germinal mutations underlie distinct clinical presentations, including childhood myelodysplastic syndrome and acute myeloid leukemia, in which the acquisition of additional molecular somatic abnormalities can lead to variable outcomes. The only curative treatment for this syndrome is allogeneic hematopoietic stem cell transplantation, which should be performed before irreversible organ damage happens. In this review, we will examine the structural characteristics of the GATA2 gene, its physiological and pathological functions, how GATA2 genetic mutations contribute to myeloid neoplasms, and other potential clinical manifestations. Finally, we will provide an overview of current therapeutic options, including recent transplantation strategies.
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Affiliation(s)
- Marta Santiago
- Hematology Department, Hospital La Fe, 46026 Valencia, Spain; (M.S.); (E.S.); (J.C.)
- Hematology Research Group, Instituto de Investigación Sanitaria La Fe, 46026 Valencia, Spain
| | - Alessandro Liquori
- Hematology Research Group, Instituto de Investigación Sanitaria La Fe, 46026 Valencia, Spain
- Centro de Investigación Biomédica en Red de Cáncer (CIBERONC), 28029 Madrid, Spain
- Correspondence:
| | - Esperanza Such
- Hematology Department, Hospital La Fe, 46026 Valencia, Spain; (M.S.); (E.S.); (J.C.)
- Hematology Research Group, Instituto de Investigación Sanitaria La Fe, 46026 Valencia, Spain
- Centro de Investigación Biomédica en Red de Cáncer (CIBERONC), 28029 Madrid, Spain
| | - Ángel Zúñiga
- Genetics Unit, Hospital La Fe, 46026 Valencia, Spain;
| | - José Cervera
- Hematology Department, Hospital La Fe, 46026 Valencia, Spain; (M.S.); (E.S.); (J.C.)
- Hematology Research Group, Instituto de Investigación Sanitaria La Fe, 46026 Valencia, Spain
- Centro de Investigación Biomédica en Red de Cáncer (CIBERONC), 28029 Madrid, Spain
- Genetics Unit, Hospital La Fe, 46026 Valencia, Spain;
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Bierman-Chow S, Holland SM, Hsu AP, Palmer C, Lynch J, Mina Y, Joo (Sophie) Cho H. Clinical, Imaging, and Laboratory Findings in Patients With GATA2 Deficiency Presenting With Early-Onset Ischemic Stroke. Neurology 2023; 100:338-341. [PMID: 36357187 PMCID: PMC9969925 DOI: 10.1212/wnl.0000000000201569] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2022] [Accepted: 09/28/2022] [Indexed: 11/12/2022] Open
Abstract
OBJECTIVE The purpose of this study was to characterize the clinical, laboratory, and imaging findings of 10 patients with GATA2 deficiency who presented with early-onset ischemic stroke. METHODS A retrospective chart review was conducted on a 127-patient cohort enrolled in the Natural History Study of GATA2 Deficiency and Related Disorders protocol at NIH between 2013 and 2021. All patients had a genetically confirmed GATA2 deficiency. Patients were included if they had evidence of an ischemic stroke through clinical evaluation and neuroimaging. Stroke diagnosis was confirmed through brain magnetic resonance imaging and/or CT. RESULTS Ten patients between the ages of 15 and 38 years (4 males and 6 females) were identified with at least one ischemic stroke while 6 patients experienced recurrent strokes (7.9% overall, 10/127). Stroke etiology varied and included small vessel (n = 4), large vessel (n = 1), cardioembolic (n = 1), and undetermined (n = 4). Nine patients had lupus anticoagulant, and 2 patients had a history of recurrent deep vein thrombosis. DISCUSSION We describe the clinical, laboratory, and imaging findings of 10 patients with GATA2 deficiency younger than 40 years who suffered one or more ischemic strokes , suggesting a link between GATA2 deficiency and stroke. This report emphasizes the need for further research to understand this unique vulnerability within this patient population.
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Affiliation(s)
- Shaia Bierman-Chow
- From the National Institute of Neurological Disorders and Stroke (S.B.-C., J.L., Y.M., H.J.(S.)C.), National Institutes of Health, Bethesda, MD; National Institute of Allergy and Infectious Diseases (S.M.H., A.P.H.), National Institutes of Health, Bethesda, MD; National Institutes of Health Bethesda (C.P.), Maryland; and Sackler Faculty of Medicine (Y.M.), Tel Aviv University, Israel.
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Coiteux V, Fenwarth L, Duployez N, Ainaoui M, Borel C, Polomeni A, Yakoub-Agha I, Chalandon Y. [Management of genetic predisposition to hematologic malignancies in patients undergoing allogeneic hematopoietic cell transplantation (HCT): Guidelines from the SFGM-TC]. Bull Cancer 2023; 110:S13-S29. [PMID: 36307324 DOI: 10.1016/j.bulcan.2022.09.002] [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: 06/29/2022] [Revised: 09/04/2022] [Accepted: 09/05/2022] [Indexed: 11/06/2022]
Abstract
The advent of new technologies has made it possible to identify genetic predispositions to myelodysplastic syndromes (MDS) and acute leukemias (AL) more frequently. The most frequent and best characterized at present are mutations in CEBPA, RUNX1, GATA2, ETV6 and DDX41 and, either in the presence of one of these mutations with a high allelic frequency, or in the case of a personal or family history suggestive of blood abnormalities such as non-immune thrombocytopenia, it is recommended to look for the possibility of a hereditary hematological malignancy (HHM). Indeed, early recognition of these HHMs allows better adaptation of the management of patients and their relatives, as allogeneic hematopoietic stem cell transplantation (HSCT) is very often proposed for these pathologies. According to current data, with the exception of the GATA2 mutation, the constitutional or somatic nature of the mutations does not seem to influence the prognosis of hematological diseases. Therefore, the indication for an allograft will be determined according to the usual criteria. However, when searching for a family donor, it is important to ensure that there is no hereditary disease in the donor. In order to guarantee the possibility of performing the HSC allograft within a short period of time, it may be necessary to initiate a parallel procedure to find an unrelated donor. Given the limited information on the modalities of HSC transplantation in this setting, it is important to assess the benefit/risk of the disease and the procedure to decide on the type of conditioning (myeloablative or reduced intensity). In view of the limited experience with the risk of secondary cancers in the medium and long-term, it may be appropriate to recommend reduced intensity conditioning, as in the case of better characterized syndromic hematological diseases such as Fanconi anemia or telomere diseases. In summary, it seems important to evoke HHM more frequently, particularly in the presence of a family history, certain mutations or persistent blood abnormalities, in order to discuss the specific modalities of HSC allografting, particularly with regard to the search for a donor and the evaluation of certain modalities of the procedure, such as conditioning. It should be noted that the discovery of HHM, especially if the indication of an allogeneic HSC transplant is retained, will raise ethical and psychological considerations not only for the patient, but also for his family. A multidisciplinary approach involving molecular biologists, geneticists, hematologists and psychologists is essential.
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Affiliation(s)
- Valérie Coiteux
- Hôpital Huriez, CHU de Lille, service de maladies du sang, 1, place de Verdun, 59037 Lille cedex, France.
| | - Laurène Fenwarth
- Université de Lille, CHU de Lille, CNRS, UMR9020-U1277-CANTHER-Cancer Heterogeneity Plasticity and Resistance to Therapies, Inserm, 59000 Lille, France
| | - Nicolas Duployez
- Université de Lille, CHU de Lille, CNRS, UMR9020-U1277-CANTHER-Cancer Heterogeneity Plasticity and Resistance to Therapies, Inserm, 59000 Lille, France
| | - Malika Ainaoui
- Hôpital Huriez, hôpital Fontan, CHU de Lille, service de maladies du sang, service de psychiatrie de liaison, 1, place de Verdun, 59037 Lille cedex, France
| | - Cécile Borel
- CHU de Toulouse, institut universitaire du cancer de Toulouse Oncopole, service d'hématologie, 1, avenue Irène-Joliot-Curie, 31059 Toulouse, France
| | - Alice Polomeni
- AP-HP, hôpital Saint-Antoine, service d'hématologie clinique et thérapie cellulaire, 184, rue du faubourg Saint-Antoine, 75012 Paris, France
| | | | - Yves Chalandon
- Université de Genève, hôpitaux universitaires de Genève, faculté de médecine, service d'hématologie, 4, rue Gabrielle-Perret-Gentil, 1211 Genève, Suisse.
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Deng J, McReynolds LJ. Inherited bone marrow failure syndromes: a review of current practices and potential future research directions. Curr Opin Pediatr 2023; 35:75-83. [PMID: 36354296 PMCID: PMC9812861 DOI: 10.1097/mop.0000000000001196] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
PURPOSE OF REVIEW Recent advances in diagnosis and treatment of inherited bone marrow failure syndromes (IBMFS) have significantly improved disease understanding and patient outcomes. Still, IBMFS present clinical challenges that require further progress. This review aims to provide an overview of the current state of diagnosis and treatment modalities of the major IBMFS seen in paediatrics and present areas of prioritization for future research. RECENT FINDINGS Haematopoietic cell transplantation (HCT) for IBMFS has greatly improved in recent years, shifting the research and clinical focus towards cancer predispositions and adverse effects of treatment. Each year, additional novel genes and pathogenic variants are described, and genotype-phenotype mapping becomes more sophisticated. Moreover, novel therapeutics exploring disease-specific mechanisms show promise to complement HCT and treat patients who cannot undergo current treatment options. SUMMARY Research on IBMFS should have short-term and long-term goals. Immediate challenges include solidifying diagnostic and treatment guidelines, cancer detection and treatment, and continued optimization of HCT. Long-term goals should emphasize genotype-phenotype mapping, genetic screening tools and gene-targeted therapy.
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Affiliation(s)
- Joseph Deng
- Clinical Genetics Branch, Division of Cancer Epidemiology and Genetics, National Cancer Institute, Bethesda, MD, USA
| | - Lisa J. McReynolds
- Clinical Genetics Branch, Division of Cancer Epidemiology and Genetics, National Cancer Institute, Bethesda, MD, USA
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DeFilipp Z, Ciurea SO, Cutler C, Robin M, Warlick ED, Nakamura R, Brunner AM, Dholaria B, Walker AR, Kröger N, Bejanyan N, Atallah E, Tamari R, Solh MM, Percival ME, de Lima M, Scott B, Oran B, Garcia-Manero G, Hamadani M, Carpenter P, DeZern AE. Hematopoietic Cell Transplantation in the Management of Myelodysplastic Syndrome: An Evidence-Based Review from the American Society for Transplantation and Cellular Therapy Committee on Practice Guidelines. Transplant Cell Ther 2023; 29:71-81. [PMID: 36436780 DOI: 10.1016/j.jtct.2022.11.014] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2022] [Accepted: 11/18/2022] [Indexed: 11/26/2022]
Abstract
The sole curative therapy for myelodysplastic syndrome (MDS) is allogeneic hematopoietic cell transplantation (HCT). Here this therapeutic modality is reviewed and critically evaluated in the context of the evidence. Specific criteria were used for searching the published literature and for grading the quality and strength of the evidence and the strength of the recommendations. A panel of MDS experts comprising transplantation and nontransplantation physicians developed consensus treatment recommendations. This review summarizes the standard MDS indications for HCT and addresses areas of controversy. Recent prospective trials have confirmed that allogeneic HCT confers survival benefits in patients with advanced or high-risk MDS compared with nontransplantation approaches, and the use of HCT is increasing in older patients with good performance status. However, patients with high-risk cytogenetic or molecular mutations remain at high risk for relapse. It is unknown whether administration of novel therapies before or after transplantation may decrease the risk of disease relapse in selected populations. Ongoing and future studies will investigate revised approaches to disease risk stratification, patient selection, and post-transplantation approaches to optimize allogeneic HCT outcomes for patients with MDS.
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Affiliation(s)
- Zachariah DeFilipp
- Hematopoieitic Cell Transplant and Cell Therapy Program, Massachusetts General Hospital, Boston, Massachusetts.
| | - Stefan O Ciurea
- Hematopoietic Stem Cell Transplantation and Cellular Therapy Program, Division of Hematology/Oncology, Department of Medicine, University of California Irvine, Orange, California
| | - Corey Cutler
- Division of Stem Cell Transplantation and Cellular Therapy, Dana Farber Cancer Institute, Boston, Massachusetts
| | - Marie Robin
- Service d'Hématologie-Greffe, Hôpital Saint-Louis, APHP, Université de Paris-Cité, Paris, France
| | - Erica D Warlick
- Division of Hematology, Oncology, and Transplantation, University of Minnesota, Minneapolis, Minnesota
| | - Ryotaro Nakamura
- Department of Hematology & Hematopoietic Cell Transplantation, City of Hope, Duarte, California
| | - Andrew M Brunner
- Center for Leukemia, Massachusetts General Hospital, Boston, Massachusetts
| | - Bhagirathbhai Dholaria
- Division of Hematology and Oncology, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Alison R Walker
- Department of Malignant Hematology, Moffitt Cancer Center, Tampa, Florida
| | - Nicolaus Kröger
- University Hospital Eppendorf, Bone Marrow Transplant Centre, Hamburg, Germany
| | - Nelli Bejanyan
- Department of Blood & Marrow Transplant and Cellular Immunotherapy, Moffitt Cancer Center, Tampa, Florida
| | - Ehab Atallah
- Division of Hematology and Oncology, Medical College of Wisconsin, Cancer Center-Froedtert Hospital, Milwaukee, Wisconsin
| | - Roni Tamari
- Adult Bone Marrow Transplant Service, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Melhem M Solh
- Blood and Marrow Transplant Program at Northside Hospital, Atlanta, Georgia
| | - Mary-Elizabeth Percival
- Fred Hutchinson Cancer Research Center, Clinical Research Division and University of Washington, Seattle, Washington
| | - Marcos de Lima
- The Ohio State University James Comprehensive Cancer Center, Columbus, Ohio
| | - Bart Scott
- Fred Hutchinson Cancer Research Center, Clinical Research Division and University of Washington, Seattle, Washington
| | - Betul Oran
- Department of Stem Cell Transplantation and Cellular Therapy, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | | | - Mehdi Hamadani
- Blood and Marrow Transplant and Cellular Therapy Program, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Paul Carpenter
- Fred Hutchinson Cancer Research Center, Clinical Research Division and University of Washington, Seattle, Washington
| | - Amy E DeZern
- Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University, Baltimore, Maryland
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10
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Kotmayer L, Romero‐Moya D, Marin‐Bejar O, Kozyra E, Català A, Bigas A, Wlodarski MW, Bödör C, Giorgetti A. GATA2 deficiency and MDS/AML: Experimental strategies for disease modelling and future therapeutic prospects. Br J Haematol 2022; 199:482-495. [PMID: 35753998 PMCID: PMC9796058 DOI: 10.1111/bjh.18330] [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: 04/07/2022] [Revised: 06/10/2022] [Accepted: 06/11/2022] [Indexed: 12/30/2022]
Abstract
The importance of predisposition to leukaemia in clinical practice is being increasingly recognized. This is emphasized by the establishment of a novel WHO disease category in 2016 called "myeloid neoplasms with germline predisposition". A major syndrome within this group is GATA2 deficiency, a heterogeneous immunodeficiency syndrome with a very high lifetime risk to develop myelodysplastic syndrome (MDS) and acute myeloid leukaemia (AML). GATA2 deficiency has been identified as the most common hereditary cause of MDS in adolescents with monosomy 7. Allogenic haematopoietic stem cell transplantation is the only curative option; however, chances of survival decrease with progression of immunodeficiency and MDS evolution. Penetrance and expressivity within families carrying GATA2 mutations is often variable, suggesting that co-operating extrinsic events are required to trigger the disease. Predictive tools are lacking, and intrafamilial heterogeneity is poorly understood; hence there is a clear unmet medical need. On behalf of the ERAPerMed GATA2 HuMo consortium, in this review we describe the genetic, clinical, and biological aspects of familial GATA2-related MDS, highlighting the importance of developing robust disease preclinical models to improve early detection and clinical decision-making of GATA2 carriers.
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Affiliation(s)
- Lili Kotmayer
- HCEMM‐SE Molecular Oncohematology Research Group, 1st Department of Pathology and Experimental Cancer ResearchSemmelweis UniversityBudapestHungary
| | - Damia Romero‐Moya
- Regenerative Medicine ProgramInstitut d'Investigació Biomèdica de Bellvitge (IDIBELL)BarcelonaSpain
| | - Oskar Marin‐Bejar
- Regenerative Medicine ProgramInstitut d'Investigació Biomèdica de Bellvitge (IDIBELL)BarcelonaSpain
| | - Emilia Kozyra
- Division of Pediatric Hematology and Oncology, Department of Pediatrics and Adolescent Medicine, Medical Center, Faculty of MedicineUniversity of FreiburgFreiburgGermany,Faculty of BiologyUniversity of FreiburgFreiburgGermany
| | - Albert Català
- Department of Hematology and OncologyInstitut de Recerca Sant Joan de DéuHospital Sant Joan de DeuBarcelonaSpain,Biomedical Network Research Centre on Rare DiseasesInstituto de Salud Carlos IIIMadridSpain
| | - Anna Bigas
- Cancer Research ProgramInstitut Hospital del Mar d'Investigacions Mèdiques, CIBERONC, Hospital del MarBarcelonaSpain,Josep Carreras Research Institute (IJC), BadalonaBarcelonaSpain
| | - Marcin W. Wlodarski
- Division of Pediatric Hematology and Oncology, Department of Pediatrics and Adolescent Medicine, Medical Center, Faculty of MedicineUniversity of FreiburgFreiburgGermany,Department of HematologySt. Jude Children's Research HospitalMemphisTennesseeUSA
| | - Csaba Bödör
- HCEMM‐SE Molecular Oncohematology Research Group, 1st Department of Pathology and Experimental Cancer ResearchSemmelweis UniversityBudapestHungary
| | - Alessandra Giorgetti
- Regenerative Medicine ProgramInstitut d'Investigació Biomèdica de Bellvitge (IDIBELL)BarcelonaSpain,Fondazione Pisana Per la Scienza ONLUS (FPS)San Giuliano TermeItaly,Department of Pathology and Experimental Therapeutics, Faculty of Medicine and Health SciencesBarcelona UniversityBarcelonaSpain
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11
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Toya T, Harada H, Harada Y, Doki N. Adult-onset hereditary myeloid malignancy and allogeneic stem cell transplantation. Front Oncol 2022; 12:997530. [PMID: 36185231 PMCID: PMC9524153 DOI: 10.3389/fonc.2022.997530] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2022] [Accepted: 08/31/2022] [Indexed: 11/13/2022] Open
Abstract
Hereditary myeloid malignancies, especially in adults or elderly persons, had been considered quite rare before the next-generation sequencing era; however, increased usage of clinical sequencing has revealed much higher prevalence of inherited myeloid malignancies. DDX41 and various pathogenic germline mutations have newly been recognized as the cause of adult-onset familial leukemia and myeloid malignancies. Although germline predisposition to myeloid neoplasms had been categorized as a provisional entity in the World Health Organization classification of hematopoietic neoplasms in 2016, methodology for the identification of hereditary myeloid malignancies has not been fully established yet. In addition, many unresolved problems, such as epidemiology, the exact pathogenic mechanisms, and ideal treatment strategy, including indications of allogeneic hematopoietic stem cell transplantation, still remain. Related donor selection for stem cell transplant is a particularly sensitive issue due to the possibility of germline mutation of the candidate relatives and the risk of donor cell leukemia after transplantation. Here, we reviewed the current evidence regarding epidemiology, diagnosis, mechanisms of progression, and transplantation strategy for hereditary myeloid malignancies.
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Affiliation(s)
- Takashi Toya
- Hematology Division, Tokyo Metropolitan Cancer and Infectious Diseases Center, Komagome Hospital, Tokyo, Japan
| | - Hironori Harada
- Hematology Division, Tokyo Metropolitan Cancer and Infectious Diseases Center, Komagome Hospital, Tokyo, Japan
- Laboratory of Oncology, School of Life Sciences, Tokyo University of Pharmacy & Life Sciences, Tokyo, Japan
- *Correspondence: Hironori Harada,
| | - Yuka Harada
- Clinical Research Support Center, Tokyo Metropolitan Cancer and Infectious Diseases Center, Komagome Hospital, Tokyo, Japan
| | - Noriko Doki
- Hematology Division, Tokyo Metropolitan Cancer and Infectious Diseases Center, Komagome Hospital, Tokyo, Japan
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12
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Perrard N, Pokeerbux MR, Quesnel B, Duployez N, Fenwarth L, Preudhomme C, Lefèvre G, Baillet C, Launay D, Terriou L. [GATA2 gene mutations: 3 cases]. Rev Med Interne 2022; 43:677-682. [PMID: 36041908 DOI: 10.1016/j.revmed.2022.08.007] [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: 05/23/2022] [Revised: 08/15/2022] [Accepted: 08/21/2022] [Indexed: 11/18/2022]
Abstract
INTRODUCTION Heterozygous germline mutations of GATA2 gene (guanine-adenine-thymine-adenine binding protein 2) are hereditary mutations that can be pathogenic, sometimes occurring sporadically, responsible for a florid clinical-biological picture, sometimes serious and quickly leading to the death. CASE REPORTS We reported two women and one man with germline mutations in the GATA2 gene. The first patient, aged 19, initially presented with monocytopenia and chronic lymphedema of the four limbs, suggestive of Emberger syndrome. The second patient, 28-years-old, presented with a disseminated atypical mycobacterium (Mycobacterium kansasii) infection, raising suspicion of an immune deficiency such as MonoMAC syndrome (deficiency syndrome of dendritic cells, monocytes, B lymphocytes and NK cells). The last patient, 30-years-old, presented with pancytopenia, leading to the diagnosis of a family form of myelodysplastic syndromes and acute myeloid leukemia characterized by a mutation of the GATA2 gene. CONCLUSIONS Each case illustrates a typical clinical presentation of GATA2 deficiency, although the evolution of these syndromes ultimately reveals a complex, heterogeneous and intricate picture of hematological, dermatological, infectious, pulmonary, ENT or oncological symptoms. Mutations in the GATA2 gene remain a diagnostic and therapeutic challenge for the internist, and require multidisciplinary management given the florid picture that can be of interest to all specialties. The clinical spectrum of these GATA2 mutations as well as the latest management recommendations from the recent litterature and the "GATA2 club" are described in this article.
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Affiliation(s)
- N Perrard
- U1286 - INFINITE - Institute for translational research in inflammation, university Lille, 59000 Lille, France; Inserm, 59000 Lille, France; Département de médecine interne et immunologie clinique, CHU Lille, 59000 Lille, France; Centre de référence des maladies autoimmunes et autoinflammatoires rares (CERAINO), 59000 Lille, France.
| | - M R Pokeerbux
- Service de médecine, clinique Sainte-Clotilde, 97400 Saint-Denis, Réunion
| | - B Quesnel
- Service des maladies du sang, CHU de Lille, Lille, France; U1277 - CANTHER - Cancer Heterogeneity Plasticity and Resistance to Therapies, University Lille, 59000 Lille, France
| | - N Duployez
- U1277 - CANTHER - Cancer Heterogeneity Plasticity and Resistance to Therapies, University Lille, 59000 Lille, France; Laboratoire d'hématologie, CHU Lille, 59000 Lille, France
| | - L Fenwarth
- U1277 - CANTHER - Cancer Heterogeneity Plasticity and Resistance to Therapies, University Lille, 59000 Lille, France; Laboratoire d'hématologie, CHU Lille, 59000 Lille, France
| | - C Preudhomme
- U1277 - CANTHER - Cancer Heterogeneity Plasticity and Resistance to Therapies, University Lille, 59000 Lille, France; Laboratoire d'hématologie, CHU Lille, 59000 Lille, France
| | - G Lefèvre
- U1286 - INFINITE - Institute for translational research in inflammation, university Lille, 59000 Lille, France; Inserm, 59000 Lille, France; Département de médecine interne et immunologie clinique, CHU Lille, 59000 Lille, France; Centre de référence des maladies autoimmunes et autoinflammatoires rares (CERAINO), 59000 Lille, France; Pôle de biologie-pathologie-génétique - institut d'immunologie, CHU de Lille, Lille, France
| | - C Baillet
- Médecine nucléaire et imagerie fonctionnelle, CHU de Lille, Lille, France
| | - D Launay
- U1286 - INFINITE - Institute for translational research in inflammation, university Lille, 59000 Lille, France; Inserm, 59000 Lille, France; Département de médecine interne et immunologie clinique, CHU Lille, 59000 Lille, France; Centre de référence des maladies autoimmunes et autoinflammatoires rares (CERAINO), 59000 Lille, France
| | - L Terriou
- U1286 - INFINITE - Institute for translational research in inflammation, university Lille, 59000 Lille, France; Inserm, 59000 Lille, France; Département de médecine interne et immunologie clinique, CHU Lille, 59000 Lille, France; Centre de référence des maladies autoimmunes et autoinflammatoires rares (CERAINO), 59000 Lille, France
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13
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Heropolitańska-Pliszka E, Piątosa B, Szmydki-Baran A, Kuczborska K, Miarka-Walczyk K, Pastorczak A, Młynarski W, Sędek Ł, Szczepański T, Ussowicz M. Case report: Successful allogeneic stem cell transplantation in a child with novel GATA2 defect associated B-cell acute lymphoblastic leukemia. Front Immunol 2022; 13:928529. [PMID: 35983050 PMCID: PMC9378963 DOI: 10.3389/fimmu.2022.928529] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2022] [Accepted: 07/12/2022] [Indexed: 11/13/2022] Open
Abstract
GATA-binding protein 2 (GATA2) is a transcription factor responsible for the regulation of blood cell proliferation, differentiation, and maintenance in hematopoietic stem cells. Here, we describe successful bone marrow transplantation in a carrier of a novel GATA2 pathogenic variant who was diagnosed with immunodeficiency a few years after completion of B-cell precursor acute lymphoblastic leukemia (BCP-ALL) treatment. At the age of 4 years, the patient was diagnosed with and treated for BCP-ALL. Antileukemic therapy was complicated by pulmonary cryptococcosis. Two years after completion of the maintenance therapy, the child was consulted by an immunologist because of recurrent respiratory tract infections and an episode of sepsis. Flow cytometry revealed deep monocytopenia, lymphopenia, absence of B lymphocytes, considerably reduced NK cells, poor thymic T lymphocyte production, minor defects in T cell maturation, and absence of TCRγδ+ T cells. The presence of the likely pathogenic, heterozygous missense variant within exon 5 of GATA2 (NM_032638.5: c.1047T>G, Cys349Trp) was identified in the proband and confirmed in the father of the patient, who underwent allogeneic hematopoietic stem cell transplantation (HSCT) from a matched unrelated donor due to myelodysplastic syndrome with excess blasts at the age of 22 years. An allogeneic hematopoietic stem cell transplantation with a reduced toxicity conditioning protocol was performed using a matched sibling donor. Pre-transplant conditioning included fludarabine (5 × 30 mg/m2), treosulfan (3 × 14 g/m2), and thiotepa (10 mg/kg). Complete donor chimerism was achieved on post-transplant day 17. During the 12 months of the posttransplant observation period, she remained free from symptoms of acute or chronic graft-versus-host disease, and immunosuppressive treatment was therefore stopped. This is the second reported case of BCP-ALL in a patient with GATA2 deficiency, and the first successfully treated with a reduced-toxicity conditioning HSCT protocol. The co-occurrence of lymphoid malignancies and primary immunodeficiencies points to the role of genetic counseling and family screening for possible cancer predisposition syndromes prior to the selection of related HSCT donors.
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Affiliation(s)
| | - Barbara Piątosa
- Histocompatibility Laboratory, Children’s Memorial Health Institute, Warsaw, Poland
| | - Anna Szmydki-Baran
- Department of Oncology, Pediatric Hematology, Transplantology, and Pediatrics, Children’s Hospital, Medical University of Warsaw, Warsaw, Poland
| | - Karolina Kuczborska
- Department of Pediatrics, Nutrition and Metabolic Disorders, Children’s Memorial Health Institute, Warsaw, Poland
| | | | - Agata Pastorczak
- Department of Pediatrics, Hematology and Oncology, Medical University of Lodz, Lodz, Poland
| | - Wojciech Młynarski
- Department of Pediatrics, Hematology and Oncology, Medical University of Lodz, Lodz, Poland
| | - Łukasz Sędek
- Department of Microbiology and Immunology, Zabrze, Medical University of Silesia, Katowice, Poland
| | - Tomasz Szczepański
- Department of Pediatric Hematology and Oncology, Zabrze, Medical University of Silesia, Katowice, Poland
| | - Marek Ussowicz
- Department and Clinic of Pediatric Oncology, Haematology and Bone Marrow Transplantation, Wroclaw Medical University, Wroclaw, Poland
- *Correspondence: Marek Ussowicz,
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14
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Spadea M, Quarello P, Saglio F, Pedace L, Fagioli F. GATA2-related myeloid neoplasms in pediatrics: where do we stand? Pediatr Hematol Oncol 2022; 39:365-369. [PMID: 34668827 DOI: 10.1080/08880018.2021.1987600] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Affiliation(s)
- Manuela Spadea
- Pediatric Oncohematology, Stem Cell Transplantation and Cell Therapy Division, A.O.U. Città della Salute e della Scienza-Regina Margherita Children's Hospital, Turin, Italy
| | - Paola Quarello
- Pediatric Oncohematology, Stem Cell Transplantation and Cell Therapy Division, A.O.U. Città della Salute e della Scienza-Regina Margherita Children's Hospital, Turin, Italy
| | - Francesco Saglio
- Pediatric Oncohematology, Stem Cell Transplantation and Cell Therapy Division, A.O.U. Città della Salute e della Scienza-Regina Margherita Children's Hospital, Turin, Italy
| | - Lucia Pedace
- Department of Pediatric Hematology/Oncology and Cellular and Gene Therapy, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Franca Fagioli
- Pediatric Oncohematology, Stem Cell Transplantation and Cell Therapy Division, A.O.U. Città della Salute e della Scienza-Regina Margherita Children's Hospital, Turin, Italy
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15
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Roloff GW, Drazer MW, Godley LA. Inherited Susceptibility to Hematopoietic Malignancies in the Era of Precision Oncology. JCO Precis Oncol 2022; 5:107-122. [PMID: 34994594 DOI: 10.1200/po.20.00387] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023] Open
Abstract
As germline predisposition to hematopoietic malignancies has gained increased recognition and attention in the field of oncology, it is important for clinicians to use a systematic framework for the identification, management, and surveillance of patients with hereditary hematopoietic malignancies (HHMs). In this article, we discuss strategies for identifying individuals who warrant diagnostic evaluation and describe considerations pertaining to molecular testing. Although a paucity of prospective data is available to guide clinical monitoring of individuals harboring pathogenic variants, we provide recommendations for clinical surveillance based on consensus opinion and highlight current advances regarding the risk of progression to overt malignancy in HHM variant carriers. We also discuss the prognosis of HHMs and considerations surrounding the utility of allogeneic stem-cell transplantation in these individuals. We close with an overview of contemporary issues at the intersection of HHMs and precision oncology.
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Affiliation(s)
- Gregory W Roloff
- Department of Medicine, Loyola University Medical Center, Maywood, IL
| | - Michael W Drazer
- Section of Hematology/Oncology, Department of Medicine and the Department of Human Genetics, the University of Chicago, Chicago, IL
| | - Lucy A Godley
- Section of Hematology/Oncology, Department of Medicine and the Department of Human Genetics, the University of Chicago, Chicago, IL
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16
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Avagyan S, Shimamura A. Lessons From Pediatric MDS: Approaches to Germline Predisposition to Hematologic Malignancies. Front Oncol 2022; 12:813149. [PMID: 35356204 PMCID: PMC8959480 DOI: 10.3389/fonc.2022.813149] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2021] [Accepted: 01/26/2022] [Indexed: 12/13/2022] Open
Abstract
Pediatric myelodysplastic syndromes (MDS) often raise concern for an underlying germline predisposition to hematologic malignancies, referred to as germline predisposition herein. With the availability of genetic testing, it is now clear that syndromic features may be lacking in patients with germline predisposition. Many genetic lesions underlying germline predisposition may also be mutated somatically in de novo MDS and leukemias, making it critical to distinguish their germline origin. The verification of a suspected germline predisposition informs therapeutic considerations, guides monitoring pre- and post-treatment, and allows for family counseling. Presentation of MDS due to germline predisposition is not limited to children and spans a wide age range. In fact, the risk of MDS may increase with age in many germline predisposition conditions and can present in adults who lack classical stigmata in their childhood. Furthermore, germline predisposition associated with DDX41 mutations presents with older adult-onset MDS. Although a higher proportion of pediatric patients with MDS will have a germline predisposition, the greater number of MDS diagnoses in adult patients may result in a larger overall number of those with an underlying germline predisposition. In this review, we present a framework for the evaluation of germline predisposition to MDS across all ages. We discuss characteristics of personal and family history, clinical exam and laboratory findings, and integration of genetic sequencing results to assist in the diagnostic evaluation. We address the implications of a diagnosis of germline predisposition for the individual, for their care after MDS therapy, and for family members. Studies on MDS with germline predisposition have provided unique insights into the pathogenesis of hematologic malignancies and mechanisms of somatic genetic rescue vs. disease progression. Increasing recognition in adult patients will inform medical management and may provide potential opportunities for the prevention or interception of malignancy.
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Affiliation(s)
- Serine Avagyan
- Dana-Farber/Boston Children's Hospital Cancer and Blood Disorders Center, Harvard Medical School, Boston, MA, United States
| | - Akiko Shimamura
- Dana-Farber/Boston Children's Hospital Cancer and Blood Disorders Center, Harvard Medical School, Boston, MA, United States
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17
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Tawana K, Brown AL, Churpek JE. Integrating germline variant assessment into routine clinical practice for myelodysplastic syndrome and acute myeloid leukaemia: current strategies and challenges. Br J Haematol 2021; 196:1293-1310. [PMID: 34658019 DOI: 10.1111/bjh.17855] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2021] [Revised: 08/24/2021] [Accepted: 09/12/2021] [Indexed: 12/28/2022]
Abstract
Over the last decade, the field of hereditary haematological malignancy syndromes (HHMSs) has gained increasing recognition among clinicians and scientists worldwide. Germline mutations now account for almost 10% of adult and paediatric myelodysplasia/acute myeloid leukaemia (MDS/AML). As our ability to diagnose HHMSs has improved, we are now faced with the challenges of integrating these advances into routine clinical practice for patients with MDS/AML and how to optimise management and surveillance of patients and asymptomatic carriers. Discoveries of novel syndromes combined with clinical, genetic and epigenetic profiling of tumour samples, have highlighted unique patterns of disease evolution across HHMSs. Despite these advances, causative lesions are detected in less than half of familial cases and evidence-based guidelines are often lacking, suggesting there is much still to learn. Future research efforts are needed to sustain current momentum within the field, led not only by advancing genetic technology but essential collaboration between clinical and academic communities.
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Affiliation(s)
- Kiran Tawana
- Department of Haematology, Addenbrooke's Hospital, Cambridge, UK
| | - Anna L Brown
- Department of Genetics and Molecular Pathology, SA Pathology, Adelaide, SA, Australia.,Centre for Cancer Biology, SA Pathology, University of South Australia, Adelaide, SA, Australia.,Adelaide Medical School, University of Adelaide, Adelaide, SA, Australia
| | - Jane E Churpek
- Division of Hematology, Medical Oncology, and Palliative Care, Department of Medicine, School of Medicine and Public Health, The University of Wisconsin, Madison, WI, USA
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18
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Connelly JA, Savani BN. Finding the best haematopoietic stem cell transplant regimen for GATA2 haploinsufficiency: how close are we? Br J Haematol 2021; 196:13-14. [PMID: 34580866 DOI: 10.1111/bjh.17859] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2021] [Revised: 09/11/2021] [Accepted: 09/12/2021] [Indexed: 11/26/2022]
Affiliation(s)
- James A Connelly
- Department of Pediatrics, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Bipin N Savani
- Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
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19
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Takai J, Shimada T, Nakamura T, Engel JD, Moriguchi T. Gata2 heterozygous mutant mice exhibit reduced inflammatory responses and impaired bacterial clearance. iScience 2021; 24:102836. [PMID: 34471858 PMCID: PMC8390858 DOI: 10.1016/j.isci.2021.102836] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2020] [Revised: 05/17/2021] [Accepted: 07/08/2021] [Indexed: 01/18/2023] Open
Abstract
Infectious diseases continually pose global medical challenges. The transcription factor GATA2 establishes gene networks and defines cellular identity in hematopoietic stem/progenitor cells and in progeny committed to specific lineages. GATA2-haploinsufficient patients exhibit a spectrum of immunodeficiencies associated with bacterial, viral, and fungal infections. Despite accumulating clinical knowledge of the consequences of GATA2 haploinsufficiency in humans, it is unclear how GATA2 haploinsufficiency compromises host anti-infectious defenses. To address this issue, we examined Gata2-heterozygous mutant (G2 Het) mice as a model for human GATA2 haploinsufficiency. In vivo inflammation imaging and cytokine multiplex analysis demonstrated that G2 Het mice had attenuated inflammatory responses with reduced levels of inflammatory cytokines, particularly IFN-γ, IL-12p40, and IL-17A, during lipopolysaccharide-induced acute inflammation. Consequently, bacterial clearance was significantly impaired in G2 Het mice after cecal ligation and puncture-induced polymicrobial peritonitis. These results provide direct molecular insights into GATA2-directed host defenses and the pathogenic mechanisms underlying observed immunodeficiencies in GATA2-haploinsufficient patients.
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Affiliation(s)
- Jun Takai
- Division of Medical Biochemistry, Tohoku Medical and Pharmaceutical University, 1-15-1 Fukumuro, Miyagino-ku, Sendai 983-8536, Japan
| | - Takashi Shimada
- Division of Medical Biochemistry, Tohoku Medical and Pharmaceutical University, 1-15-1 Fukumuro, Miyagino-ku, Sendai 983-8536, Japan
| | - Tadaho Nakamura
- Division of Pharmacology, Faculty of Medicine, Tohoku Medical and Pharmaceutical University, 1-15-1 Fukumuro, Miyagino-ku, Sendai 983-8536, Japan
| | - James Douglas Engel
- Cell and Developmental Biology, University of Michigan Medical School, Ann Arbor, MI 48109, USA
| | - Takashi Moriguchi
- Division of Medical Biochemistry, Tohoku Medical and Pharmaceutical University, 1-15-1 Fukumuro, Miyagino-ku, Sendai 983-8536, Japan
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20
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Fabozzi F, Strocchio L, Mastronuzzi A, Merli P. GATA2 and marrow failure. Best Pract Res Clin Haematol 2021; 34:101278. [PMID: 34404529 DOI: 10.1016/j.beha.2021.101278] [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: 05/14/2021] [Revised: 05/28/2021] [Accepted: 05/31/2021] [Indexed: 02/08/2023]
Abstract
GATA2 gene encodes a zinc finger transcription factor crucial for normal hematopoiesis. Its haploinsufficiency, caused by a great variety of heterozygous loss-of-function mutations, underlies one of the most common causes of inherited bone marrow failure, recognized as GATA2 deficiency. Its phenotype is characterized by a broad spectrum of clinical presentations, including: haematological malignancies; immunodeficiency leading to invasive viral, mycobacterial and fungal infections; recurrent warts; lymphedema; pulmonary alveolar proteinosis; deafness; and miscarriage. The onset of symptoms ranges from early childhood to late adulthood, more frequently between adolescence and early adulthood. The only curative treatment is allogenic hematopoietic stem cell transplantation (HSCT), that can restore the function of both hematopoietic and immune system and prevent lung deterioration. Currently, there are no consensus guidelines about the management of patients affected by GATA2 deficiency, especially with regard to the optimal time to proceed to HSCT.
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Affiliation(s)
- Francesco Fabozzi
- Department of Hematology/Oncology, Cell and Gene Therapy, IRCCS Bambino Gesù Children's Hospital, 00165, Rome, Italy.
| | - Luisa Strocchio
- Department of Hematology/Oncology, Cell and Gene Therapy, IRCCS Bambino Gesù Children's Hospital, 00165, Rome, Italy.
| | - Angela Mastronuzzi
- Department of Hematology/Oncology, Cell and Gene Therapy, IRCCS Bambino Gesù Children's Hospital, 00165, Rome, Italy.
| | - Pietro Merli
- Department of Hematology/Oncology, Cell and Gene Therapy, IRCCS Bambino Gesù Children's Hospital, 00165, Rome, Italy.
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21
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Bortnick R, Wlodarski M, de Haas V, De Moerloose B, Dworzak M, Hasle H, Masetti R, Starý J, Turkiewicz D, Ussowicz M, Kozyra E, Albert M, Bader P, Bordon V, Cario G, Beier R, Schulte J, Bresters D, Müller I, Pichler H, Sedlacek P, Sauer MG, Zecca M, Göhring G, Yoshimi A, Noellke P, Erlacher M, Locatelli F, Niemeyer CM, Strahm B. Hematopoietic stem cell transplantation in children and adolescents with GATA2-related myelodysplastic syndrome. Bone Marrow Transplant 2021; 56:2732-2741. [PMID: 34244664 PMCID: PMC8563415 DOI: 10.1038/s41409-021-01374-y] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2021] [Revised: 05/20/2021] [Accepted: 06/01/2021] [Indexed: 01/08/2023]
Abstract
GATA2 deficiency is a heterogeneous multi-system disorder characterized by a high risk of developing myelodysplastic syndrome (MDS) and myeloid leukemia. We analyzed the outcome of 65 patients reported to the registry of the European Working Group (EWOG) of MDS in childhood carrying a germline GATA2 mutation (GATA2mut) who had undergone hematopoietic stem cell transplantation (HSCT). At 5 years the probability of overall survival and disease-free survival (DFS) was 75% and 70%, respectively. Non-relapse mortality and relapse equally contributed to treatment failure. There was no evidence of increased incidence of graft-versus-host-disease or excessive rates of infections or organ toxicities. Advanced disease and monosomy 7 (-7) were associated with worse outcome. Patients with refractory cytopenia of childhood (RCC) and normal karyotype showed an excellent outcome (DFS 90%) compared to RCC and -7 (DFS 67%). Comparing outcome of GATA2mut with GATA2wt patients, there was no difference in DFS in patients with RCC and normal karyotype. The same was true for patients with -7 across morphological subtypes. We demonstrate that HSCT outcome is independent of GATA2 germline mutations in pediatric MDS suggesting the application of standard MDS algorithms and protocols. Our data support considering HSCT early in the course of GATA2 deficiency in young individuals.
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Affiliation(s)
- Rachel Bortnick
- Department of Pediatrics and Adolescent Medicine, Division of Pediatric Hematology and Oncology, Medical Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany.,Department of Pediatrics, University Hospital Salzburg, Paracelsus Medical University, Salzburg, Austria
| | - Marcin Wlodarski
- Department of Pediatrics and Adolescent Medicine, Division of Pediatric Hematology and Oncology, Medical Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany.,Department of Hematology, St. Jude Children's Research Hospital, Memphis, TN, USA
| | - Valerie de Haas
- Princess Maxima Center, Diagnostic Laboratory/DCOG Laboratory, Utrecht, The Netherlands
| | - Barbara De Moerloose
- Department of Pediatric Hematology-Oncology and Stem Cell Transplantation, Ghent University Hospital, Ghent, Belgium
| | - Michael Dworzak
- Department of Pediatrics, St. Anna Children's Hospital, Medical University of Vienna, Vienna, Austria
| | - Henrik Hasle
- Department of Pediatrics, Aarhus University Hospital Skejby, Aarhus, Denmark
| | - Riccardo Masetti
- Department of Pediatric Oncology and Hematology, University of Bologna, Bologna, Italy
| | - Jan Starý
- Department of Pediatric Hematology and Oncology, Charles University and University Hospital Motol, Prague, Czech Republic
| | - Dominik Turkiewicz
- Department of Pediatric Oncology/Hematology, Skåne University Hospital, Lund, Sweden
| | - Marek Ussowicz
- Department of Bone Marrow Transplantation, Oncology and Hematology, Wroclaw Medical University, Wroclaw, Poland
| | - Emilia Kozyra
- Department of Pediatrics and Adolescent Medicine, Division of Pediatric Hematology and Oncology, Medical Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Michael Albert
- Department of Pediatrics, Dr. von Hauner Children's Hospital, University Hospital, LMU, Munich, Germany
| | - Peter Bader
- Department for Children and Adolescents, Division for Stem Cell Transplantation and Immunology, University Hospital Frankfurt, Frankfurt am Main, Frankfurt, Germany
| | - Victoria Bordon
- Department of Pediatric Hematology-Oncology and Stem Cell Transplantation, Ghent University Hospital, Ghent, Belgium
| | - Gunnar Cario
- Department of Pediatrics, Christian-Albrechts-University Kiel and University Medical Center Schleswig-Holstein, Kiel, Germany
| | - Rita Beier
- Department of Pediatrics and Adolescent Medicine, Division of Pediatric Hematology and Oncology, University Hospital of Essen, Essen, Germany
| | - Johannes Schulte
- Department of Pediatric Oncology, Hematology and Stem Cell Transplantation, Charité University Medicine Berlin, Berlin, Germany
| | - Dorine Bresters
- Princess Máxima Center for Pediatric Oncology, Utrecht, The Netherlands
| | - Ingo Müller
- Department of Pediatric Hematology and Oncology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Herbert Pichler
- Department of Pediatrics, St. Anna Children's Hospital, Medical University of Vienna, Vienna, Austria
| | - Petr Sedlacek
- Department of Pediatric Hematology and Oncology, Charles University and University Hospital Motol, Prague, Czech Republic
| | - Martin G Sauer
- Pediatric Hematology and Oncology, Hannover Medical School, Hannover, Germany
| | - Marco Zecca
- Pediatric Hematology/Oncology, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Gudrun Göhring
- Department of Human Genetics, Hannover Medical School, Hannover, Germany
| | - Ayami Yoshimi
- Department of Pediatrics and Adolescent Medicine, Division of Pediatric Hematology and Oncology, Medical Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Peter Noellke
- Department of Pediatrics and Adolescent Medicine, Division of Pediatric Hematology and Oncology, Medical Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Miriam Erlacher
- Department of Pediatrics and Adolescent Medicine, Division of Pediatric Hematology and Oncology, Medical Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany.,German Cancer Consortium (DKTK), Heidelberg and Freiburg, Freiburg, Germany
| | - Franco Locatelli
- Department of Pediatric Hematology and Oncology, IRCCS Ospedale Pediatrico Bambino Gesù, Sapienza, University of Rome, Rome, Italy
| | - Charlotte M Niemeyer
- Department of Pediatrics and Adolescent Medicine, Division of Pediatric Hematology and Oncology, Medical Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany.,German Cancer Consortium (DKTK), Heidelberg and Freiburg, Freiburg, Germany
| | - Brigitte Strahm
- Department of Pediatrics and Adolescent Medicine, Division of Pediatric Hematology and Oncology, Medical Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany.
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22
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Human GATA2 mutations and hematologic disease: how many paths to pathogenesis? Blood Adv 2021; 4:4584-4592. [PMID: 32960960 DOI: 10.1182/bloodadvances.2020002953] [Citation(s) in RCA: 37] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2020] [Accepted: 08/21/2020] [Indexed: 01/19/2023] Open
Abstract
The surge of human genetic information, enabled by increasingly facile and economically feasible genomic technologies, has accelerated discoveries on the relationship of germline genetic variation to hematologic diseases. For example, germline variation in GATA2, encoding a vital transcriptional regulator of multilineage hematopoiesis, creates a predisposition to bone marrow failure and acute myeloid leukemia termed GATA2 deficiency syndrome. More than 300 GATA2 variants representing missense, truncating, and noncoding enhancer mutations have been documented. Although these variants can diminish GATA2 expression and/or function, the functional ramifications of many variants are unknown. Studies using genetic rescue and knockin mouse systems have established that GATA2 mutations differentially affect molecular processes in distinct target genes and within a single target cell. Considering that target genes for a transcription factor can differ in sensitivity to altered levels of the factor, and transcriptional mechanisms are often cell type specific, the context-dependent consequences of GATA2 mutations in experimental systems portend the complex phenotypes and interindividual variation of GATA2 deficiency syndrome. This review documents GATA2 human genetics and the state of efforts to traverse from physiological insights to pathogenic mechanisms.
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23
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Bonfim C. Special pre- and posttransplant considerations in inherited bone marrow failure and hematopoietic malignancy predisposition syndromes. HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2020; 2020:107-114. [PMID: 33275667 PMCID: PMC7727534 DOI: 10.1182/hematology.2020000095] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/04/2023]
Abstract
Advances in the diagnosis and treatment of inherited bone marrow failure syndromes (IBMFS) have provided insight into the complexity of these diseases. The diseases are heterogeneous and characterized by developmental abnormalities, progressive marrow failure, and predisposition to cancer. A correct diagnosis allows for appropriate treatment, genetic counseling, and cancer surveillance. The common IBMFSs are Fanconi anemia, dyskeratosis congenita, and Diamond-Blackfan anemia. Hematopoietic cell transplantation (HCT) offers curative treatment of the hematologic complications of IBMFS. Because of the systemic nature of these diseases, transplant strategies are modified to decrease immediate and late toxicities. HCT from HLA-matched related or unrelated donors offers excellent survival for young patients in aplasia. Challenges include the treatment of adults with marrow aplasia, presentation with myeloid malignancy regardless of age, and early detection or treatment of cancer. In this article, I will describe our approach and evaluation of patients transplanted with IBMFS and review most frequent complications before and after transplant.
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Affiliation(s)
- Carmem Bonfim
- Division of Bone Marrow Transplantation, General Hospital of the Federal University of Parana, Curitiba, Brazil
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24
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Bruzzese A, Leardini D, Masetti R, Strocchio L, Girardi K, Algeri M, Del Baldo G, Locatelli F, Mastronuzzi A. GATA2 Related Conditions and Predisposition to Pediatric Myelodysplastic Syndromes. Cancers (Basel) 2020; 12:cancers12102962. [PMID: 33066218 PMCID: PMC7602110 DOI: 10.3390/cancers12102962] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2020] [Revised: 10/08/2020] [Accepted: 10/10/2020] [Indexed: 02/06/2023] Open
Abstract
Simple Summary GATA2 deficiency is considered one of the most common cancer predisposition syndromes determining myelodysplastic syndrome in children. Little is known of this recently described syndrome, often resulting in a misdiagnosis and unclear management. In this review, we describe GATA2 deficiency clinical presentation in order to focus on phenotypes that, in patients with myelodysplastic syndrome, may be suggestive of GATA2 deficiency. Moreover, due to the lack of clear guidelines, we performed an overview on literature data regarding management of GATA2-related myelodysplastic syndrome, in order to understand the best choice of treatment for these patients. Abstract Myelodysplastic syndromes (MDS) are hematopoietic disorders rare in childhood, often occurring in patients with inherited bone marrow failure syndromes or germinal predisposition syndromes. Among the latter, one of the most frequent involves the gene GATA binding protein 2 (GATA2), coding for a transcriptional regulator of hematopoiesis. The genetic lesion as well as the clinical phenotype are extremely variable; many patients present hematological malignancies, especially MDS with the possibility to evolve into acute myeloid leukemia. Variable immune dysfunction, especially resulting in B- and NK-cell lymphopenia, lead to severe infections, including generalized warts and mycobacterial infection. Defects of alveolar macrophages lead to pulmonary alveolar proteinosis through inadequate clearance of surfactant proteins. Currently, there are no clear guidelines for the monitoring and treatment of patients with GATA2 mutations. In patients with MDS, the only curative treatment is allogeneic hematopoietic stem cell transplantation (HSCT) that restores normal hematopoiesis preventing the progression to acute myeloid leukemia and clears long-standing infections. However, to date, the donor type, conditioning regimen, and the optimal time to proceed to HSCT, as well as the level of chimerism needed to reverse the phenotype, remain unclear highlighting the need for consensus guidelines.
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Affiliation(s)
- Antonella Bruzzese
- Department of Hematology/Oncology, Cell and Gene Therapy, IRCCS Bambino Gesù Children’s Hospital, 00165 Rome, Italy; (L.S.); (K.G.); (M.A.); (G.D.B.); (F.L.); (A.M.)
- Correspondence: or
| | - Davide Leardini
- Pediatric Hematology/Oncology, Sant’Orsola Malpighi Hospital, University of Bologna, 40138 Bologna, Italy; (D.L.); (R.M.)
| | - Riccardo Masetti
- Pediatric Hematology/Oncology, Sant’Orsola Malpighi Hospital, University of Bologna, 40138 Bologna, Italy; (D.L.); (R.M.)
| | - Luisa Strocchio
- Department of Hematology/Oncology, Cell and Gene Therapy, IRCCS Bambino Gesù Children’s Hospital, 00165 Rome, Italy; (L.S.); (K.G.); (M.A.); (G.D.B.); (F.L.); (A.M.)
| | - Katia Girardi
- Department of Hematology/Oncology, Cell and Gene Therapy, IRCCS Bambino Gesù Children’s Hospital, 00165 Rome, Italy; (L.S.); (K.G.); (M.A.); (G.D.B.); (F.L.); (A.M.)
| | - Mattia Algeri
- Department of Hematology/Oncology, Cell and Gene Therapy, IRCCS Bambino Gesù Children’s Hospital, 00165 Rome, Italy; (L.S.); (K.G.); (M.A.); (G.D.B.); (F.L.); (A.M.)
| | - Giada Del Baldo
- Department of Hematology/Oncology, Cell and Gene Therapy, IRCCS Bambino Gesù Children’s Hospital, 00165 Rome, Italy; (L.S.); (K.G.); (M.A.); (G.D.B.); (F.L.); (A.M.)
| | - Franco Locatelli
- Department of Hematology/Oncology, Cell and Gene Therapy, IRCCS Bambino Gesù Children’s Hospital, 00165 Rome, Italy; (L.S.); (K.G.); (M.A.); (G.D.B.); (F.L.); (A.M.)
- Department of Maternal Infantile and Urological Sciences, Sapienza University of Rome, 00161 Rome, Italy
| | - Angela Mastronuzzi
- Department of Hematology/Oncology, Cell and Gene Therapy, IRCCS Bambino Gesù Children’s Hospital, 00165 Rome, Italy; (L.S.); (K.G.); (M.A.); (G.D.B.); (F.L.); (A.M.)
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