1
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Elli EM, Di Veroli A, Bartoletti D, Iurlo A, Carmosino I, Benevolo G, Abruzzese E, Bonifacio M, Bergamaschi M, Polverelli N, Caramella M, Cilloni D, Tiribelli M, Pugliese N, Caocci G, Crisà E, Porrini R, Markovic U, Renso R, Auteri G, Cattaneo D, Trawinska MM, Scaffidi L, Biale L, Bucelli C, Breccia M, Gambacorti-Passerini C, Palumbo GA, Latagliata R, Palandri F. Deferasirox in the management of iron overload in patients with myelofibrosis treated with ruxolitinib: The multicentre retrospective RUX-IOL study. Br J Haematol 2022; 197:190-200. [PMID: 35137397 DOI: 10.1111/bjh.18057] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2021] [Accepted: 01/10/2022] [Indexed: 12/11/2022]
Abstract
Deferasirox (DFX) is used for the management of iron overload (IOL) in many haematological malignancies including myelofibrosis (MF). The 'RUX-IOL' study retrospectively collected 69 MF patients treated with ruxolitinib (RUX) and DFX for IOL to assess: safety, efficacy in term of iron chelation response (ICR) and erythroid response (ER), and impact on overall survival of the combination therapy. The RUX-DFX therapy was administered for a median time of 12.4 months (interquartile range 3.1-71.2). During treatment, 36 (52.2%) and 34 (49.3%) patients required RUX and DFX dose reductions, while eight (11.6%) and nine (13.1%) patients discontinued due to RUX- or DFX-related adverse events; no unexpected toxicity was reported. ICR and ER were achieved by 33 (47.8%) and 32 patients (46.4%) respectively. Thirteen (18.9%) patients became transfusion-independent. Median time to ICR and ER was 6.2 and 2 months respectively. Patients achieving an ER were more likely to obtain an ICR also (p = 0.04). In multivariable analysis, the absence of leukocytosis at baseline (p = 0.02) and achievement of an ICR at any time (p = 0.02) predicted improved survival. In many MF patients, the RUX-DFX combination provided ICR and ER responses that correlated with improved outcome in the absence of unexpected toxicities. This strategy deserves further clinical investigation.
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Affiliation(s)
- Elena Maria Elli
- Hematology Division and Bone Marrow Unit, Ospedale San Gerardo, Monza, Italy
| | | | - Daniela Bartoletti
- IRCCS Azienda Ospedaliero-Universitaria di Bologna, Istituto di Ematologia 'Seràgnoli', Bologna, Italy.,Dipartimento di Medicina Specialistica, Diagnostica e Sperimentale, Università di Bologna, Bologna, Italy
| | - Alessandra Iurlo
- Hematology Division, Foundation IRCCS Cà Granda - Ospedale Maggiore Policlinico, Milan, Italy
| | - Ida Carmosino
- Hematology, Department of Translational and Precision Medicine, Policlinico Umberto I, Sapienza University, Rome, Italy
| | - Giulia Benevolo
- Division of Haematology, Città della Salute e della Scienza Hospital, Turin, Italy
| | | | | | - Micaela Bergamaschi
- Medicina Interna PO ponente, Ospedale Santa Corona Pietra Ligure, Savona, Italy
| | - Nicola Polverelli
- Unit of Blood Diseases and Stem Cell Transplantation, ASST Spedali Civili di Brescia, Brescia, Italy
| | - Marianna Caramella
- Division of Haematology, ASST Grande Ospedale Metropolitano, Niguarda, Milan, Italy
| | - Daniela Cilloni
- Haematology Division, Department of Clinical and Biological Sciences, Ospedale San Luigi di Orbassano, University of Turin, Orbassano, Italy
| | - Mario Tiribelli
- Division of Haematology and BMT, Department of Medical Area and Azienda Ospedaliero-Universitaria Friuli Centrale, Udine, Italy
| | - Novella Pugliese
- Department of Clinical Medicine and Surgery, Haematology Section, University of Naples 'Federico II', Naples, Italy
| | - Giovanni Caocci
- Ematologia, Ospedale Businco, Università degli studi di Cagliari, Cagliari, Italy
| | - Elena Crisà
- Division of Haematology, Department of Translational Medicine, Università del Piemonte Orientale and Azienda Ospedaliero-Universitaria Maggiore della Carità, Novara, Italy
| | | | - Uros Markovic
- Hematology Division, AOU Policlinico 'G. Rodolico' - San Marco, Catania, Italy
| | - Rossella Renso
- Hematology Division and Bone Marrow Unit, Ospedale San Gerardo, Monza, Italy
| | - Giuseppe Auteri
- IRCCS Azienda Ospedaliero-Universitaria di Bologna, Istituto di Ematologia 'Seràgnoli', Bologna, Italy.,Dipartimento di Medicina Specialistica, Diagnostica e Sperimentale, Università di Bologna, Bologna, Italy
| | - Daniele Cattaneo
- Hematology Division, Foundation IRCCS Cà Granda - Ospedale Maggiore Policlinico, Milan, Italy
| | | | - Luigi Scaffidi
- Department of Medicine, Section of Haematology, University of Verona, Verona, Italy
| | - Lucia Biale
- Banca del Sangue, Servizio di Immunoematologia, Città della Salute e della Scienza Hospital, Turin, Italy
| | - Cristina Bucelli
- Hematology Division, Foundation IRCCS Cà Granda - Ospedale Maggiore Policlinico, Milan, Italy
| | - Massimo Breccia
- Hematology, Department of Translational and Precision Medicine, Policlinico Umberto I, Sapienza University, Rome, Italy
| | | | - Giuseppe Alberto Palumbo
- Department of Scienze Mediche, Chirurgiche e Tecnologie Avanzate 'G.F. Ingrassia', University of Catania, Catania, Italy
| | | | - Francesca Palandri
- IRCCS Azienda Ospedaliero-Universitaria di Bologna, Istituto di Ematologia 'Seràgnoli', Bologna, Italy
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2
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Brissot E, Troadec M, Loréal O, Brissot P. Iron and platelets: A subtle, under-recognized relationship. Am J Hematol 2021; 96:1008-1016. [PMID: 33844865 DOI: 10.1002/ajh.26189] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2021] [Revised: 03/16/2021] [Accepted: 04/08/2021] [Indexed: 12/16/2022]
Abstract
The role of iron in the formation and functioning of erythrocytes, and to a lesser degree of white blood cells, is well established, but the relationship between iron and platelets is less documented. Physiologically, iron plays an important role in hematopoiesis, including thrombopoiesis; iron levels direct, together with genetic factors, the lineage commitment of megakaryocytic/erythroid progenitors toward either megakaryocyte or erythroid progenitors. Megakaryocytic iron contributes to cellular machinery, especially energy production in platelet mitochondria. Thrombocytosis, possibly favoring vascular thrombosis, is a classical feature observed with abnormally low total body iron stores (mainly due to blood losses or decreased duodenal iron intake), but thrombocytopenia can also occur in severe iron deficiency anemia. Iron sequestration, as seen in inflammatory conditions, can be associated with early thrombocytopenia due to platelet consumption and followed by reactive replenishment of the platelet pool with possibility of thrombocytosis. Iron overload of genetic origin (hemochromatosis), despite expected mitochondrial damage related to ferroptosis, has not been reported to cause thrombocytopenia (except in case of high degree of hepatic fibrosis), and iron-related alteration of platelet function is still a matter of debate. In acquired iron overload (of transfusional and/or dyserythropoiesis origin), quantitative or qualitative platelet changes are difficult to attribute to iron alone due to the interference of the underlying hematological conditions; likewise, hematological improvement, including increased blood platelet counts, observed under iron oral chelation is likely to reflect mechanisms other than the sole beneficial impact of iron depletion.
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Affiliation(s)
- Eolia Brissot
- Service d'Hématologie Clinique et de Thérapie Cellulaire, Hôpital Saint Antoine APHP Paris France
- Sorbonne Universités, UPMC Univ. Paris 06, Centre de recherche Saint‐Antoine, UMR‐S938 Paris France
| | - Marie‐Bérengère Troadec
- Univ Brest, Inserm, EFS, UMR 1078, GGB Brest France
- Service de génétique, laboratoire de génétique chromosomique CHRU Brest Brest France
| | - Olivier Loréal
- Inserm, University of Rennes1, UMR 1241, Inrae, NuMeCan Institute Rennes France
| | - Pierre Brissot
- Inserm, University of Rennes1, UMR 1241, Inrae, NuMeCan Institute Rennes France
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3
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Genome-wide transcriptomics leads to the identification of deregulated genes after deferasirox therapy in low-risk MDS patients. THE PHARMACOGENOMICS JOURNAL 2020; 20:664-671. [DOI: 10.1038/s41397-020-0154-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/12/2019] [Revised: 01/21/2020] [Accepted: 01/23/2020] [Indexed: 12/16/2022]
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4
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Brissot E, Bernard DG, Loréal O, Brissot P, Troadec MB. Too much iron: A masked foe for leukemias. Blood Rev 2020; 39:100617. [DOI: 10.1016/j.blre.2019.100617] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2019] [Revised: 08/20/2019] [Accepted: 08/30/2019] [Indexed: 02/07/2023]
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5
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Leitch HA, Gattermann N. Hematologic improvement with iron chelation therapy in myelodysplastic syndromes: Clinical data, potential mechanisms, and outstanding questions. Crit Rev Oncol Hematol 2019; 141:54-72. [DOI: 10.1016/j.critrevonc.2019.06.002] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2018] [Revised: 11/25/2018] [Accepted: 06/03/2019] [Indexed: 12/25/2022] Open
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Tataranni T, Mazzoccoli C, Agriesti F, De Luca L, Laurenzana I, Simeon V, Ruggieri V, Pacelli C, Della Sala G, Musto P, Capitanio N, Piccoli C. Deferasirox drives ROS-mediated differentiation and induces interferon-stimulated gene expression in human healthy haematopoietic stem/progenitor cells and in leukemia cells. Stem Cell Res Ther 2019; 10:171. [PMID: 31196186 PMCID: PMC6567456 DOI: 10.1186/s13287-019-1293-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2019] [Revised: 05/15/2019] [Accepted: 05/31/2019] [Indexed: 12/11/2022] Open
Abstract
Background Administration of the iron chelator deferasirox (DFX) in transfusion-dependent patients occasionally results in haematopoiesis recovery by a mechanism remaining elusive. This study aimed to investigate at a molecular level a general mechanism underlying DFX beneficial effects on haematopoiesis, both in healthy and pathological conditions. Methods Human healthy haematopoietic stem/progenitor cells (HS/PCs) and three leukemia cell lines were treated with DFX. N-Acetyl cysteine (NAC) and fludarabine were added as antioxidant and STAT1 inhibitor, respectively. In vitro colony-forming assays were assessed both in healthy and in leukemia cells. Intracellular and mitochondrial reactive oxygen species (ROS) as well as mitochondrial content were assessed by cytofluorimetric and confocal microscopy analysis; mtDNA was assessed by qRT-PCR. Differentiation markers were monitored by cytofluorimetric analysis. Gene expression analysis (GEA) was performed on healthy HS/PCs, and differently expressed genes were validated in healthy and leukemia cells by qRT-PCR. STAT1 expression and phosphorylation were assessed by Western blotting. Data were compared by an unpaired Student t test or one-way ANOVA. Results DFX, at clinically relevant concentrations, increased the clonogenic capacity of healthy human CD34+ HS/PCs to form erythroid colonies. Extension of this analysis to human-derived leukemia cell lines Kasumi-1, K562 and HL60 confirmed DFX capacity to upregulate the expression of specific markers of haematopoietic commitment. Notably, the abovementioned DFX-induced effects are all prevented by the antioxidant NAC and accompanied with overproduction of mitochondria-generated reactive oxygen species (ROS) and increase of mitochondrial content and mtDNA copy number. GEA unveiled upregulation of genes linked to interferon (IFN) signalling and tracked back to hyper-phosphorylation of STAT1. Treatment of leukemic cell lines with NAC prevented the DFX-mediated phosphorylation of STAT1 as well as the expression of the IFN-stimulated genes. However, STAT1 inhibition by fludarabine was not sufficient to affect differentiation processes in leukemic cell lines. Conclusions These findings suggest a significant involvement of redox signalling as a major regulator of multiple DFX-orchestrated events promoting differentiation in healthy and tumour cells. The understanding of molecular mechanisms underlying the haematological response by DFX would enable to predict patient’s ability to respond to the drug, to extend treatment to other patients or to anticipate the treatment, regardless of the iron overload. Electronic supplementary material The online version of this article (10.1186/s13287-019-1293-y) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Tiziana Tataranni
- Laboratory of Pre-Clinical and Translational Research, IRCCS-CROB, Referral Cancer Center of Basilicata, Rionero in Vulture, PZ, Italy
| | - Carmela Mazzoccoli
- Laboratory of Pre-Clinical and Translational Research, IRCCS-CROB, Referral Cancer Center of Basilicata, Rionero in Vulture, PZ, Italy
| | - Francesca Agriesti
- Laboratory of Pre-Clinical and Translational Research, IRCCS-CROB, Referral Cancer Center of Basilicata, Rionero in Vulture, PZ, Italy
| | - Luciana De Luca
- Laboratory of Pre-Clinical and Translational Research, IRCCS-CROB, Referral Cancer Center of Basilicata, Rionero in Vulture, PZ, Italy
| | - Ilaria Laurenzana
- Laboratory of Pre-Clinical and Translational Research, IRCCS-CROB, Referral Cancer Center of Basilicata, Rionero in Vulture, PZ, Italy
| | - Vittorio Simeon
- Department of Public, Clinical and Preventive Medicine, Medical Statistics Unit, University of Campania Luigi Vanvitelli, Caserta, Italy
| | - Vitalba Ruggieri
- Laboratory of Pre-Clinical and Translational Research, IRCCS-CROB, Referral Cancer Center of Basilicata, Rionero in Vulture, PZ, Italy
| | - Consiglia Pacelli
- Department of Clinical and Experimental Medicine, University of Foggia, Foggia, Italy
| | - Gerardo Della Sala
- Laboratory of Pre-Clinical and Translational Research, IRCCS-CROB, Referral Cancer Center of Basilicata, Rionero in Vulture, PZ, Italy
| | - Pellegrino Musto
- Hematology Department of Basilicata, IRCCS-CROB Referral Cancer Center of Basilicata, Rionero in Vulture, Italy
| | - Nazzareno Capitanio
- Department of Clinical and Experimental Medicine, University of Foggia, Foggia, Italy
| | - Claudia Piccoli
- Laboratory of Pre-Clinical and Translational Research, IRCCS-CROB, Referral Cancer Center of Basilicata, Rionero in Vulture, PZ, Italy. .,Department of Clinical and Experimental Medicine, University of Foggia, Foggia, Italy.
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7
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Leitch HA, Buckstein R, Zhu N, Nevill TJ, Yee KWL, Leber B, Keating MM, St Hilaire E, Kumar R, Delage R, Geddes M, Storring JM, Shamy A, Elemary M, Wells RA. Iron overload in myelodysplastic syndromes: Evidence based guidelines from the Canadian consortium on MDS. Leuk Res 2018; 74:21-41. [PMID: 30286330 DOI: 10.1016/j.leukres.2018.09.005] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2018] [Revised: 08/08/2018] [Accepted: 09/15/2018] [Indexed: 01/19/2023]
Abstract
In 2008 the first evidence-based Canadian consensus guideline addressing the diagnosis, monitoring and management of transfusional iron overload in patients with myelodysplastic syndromes (MDS) was published. The Canadian Consortium on MDS, comprised of hematologists from across Canada with a clinical and academic interest in MDS, reconvened to update these guidelines. A literature search was updated in 2017; topics reviewed include mechanisms of iron overload induced cellular damage, evidence for clinical endpoints impacted by iron overload including organ dysfunction, infections, marrow failure, overall survival, acute myeloid leukemia progression, and endpoints around hematopoietic stem-cell transplant. Evidence for an impact of iron reduction on the same endpoints is discussed, guidelines are updated, and areas identified where evidence is suboptimal. The guidelines address common questions around the diagnosis, workup and management of iron overload in clinical practice, and take the approach of who, when, why and how to treat iron overload in MDS. Practical recommendations for treatment and monitoring are made. Evidence levels and grading of recommendations are provided for all clinical endpoints examined.
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Affiliation(s)
- Heather A Leitch
- Hematology, St. Paul's Hospital and the University of British Columbia, Vancouver, BC, Canada.
| | - Rena Buckstein
- Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Nancy Zhu
- Hematology/Oncology, University of Alberta, Edmonton, Alberta, Canada
| | - Thomas J Nevill
- Leukemia/BMT Program of British Columbia, Division of Hematology, Vancouver, BC, Canada
| | - Karen W L Yee
- Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada
| | - Brian Leber
- McMaster University, Hamilton, Ontario, Canada
| | | | - Eve St Hilaire
- Centre d'Oncologie, Dr-Leon-Richard, Moncton, New Brunswick, Canada
| | - Rajat Kumar
- Hematology/Oncology, CancerCare Manitoba, Winnipeg, Manitoba, Canada
| | - Robert Delage
- Hematology Department, Centre Hospitalier Universitaire, Laval University, Quebec, QC, Canada
| | - Michelle Geddes
- Department of Medicine/Hematology, Foothills Medical Centre, Calgary, Alberta, Canada
| | | | - April Shamy
- Sir Mortimer B Davis Hospital, McGill University, Montreal, Quebec, Canada
| | - Mohamed Elemary
- Saskatoon Cancer Center, University of Saskatchewan, Saskatoon, Saskatchewan, Canada
| | - Richard A Wells
- Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
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8
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Parvu AV, Bojan A, Urian L, Torok T, Zsoldos IA, Iancu M. Ferritin level changes and erythroid improvement in a group of adult polytransfused patients treated with Deferasirox. ACTA ACUST UNITED AC 2018; 91:288-292. [PMID: 30093806 PMCID: PMC6082613 DOI: 10.15386/cjmed-942] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2017] [Accepted: 12/05/2017] [Indexed: 11/23/2022]
Abstract
Background and aims Chelating agents therapy is recommended for polytransfused patients that have evidence of iron overload (an elevated serum ferritin or received over 20 units of red blood cell transfusions). Deferasirox showed efficacy and safety in maintaining or reducing body iron. Iron chelation therapy was associated with hematopoiesis improvement in transfusion-dependent patients.Our objectives were to analyze differences in ferritin level in adult polytransfused patients treated with Deferasirox, to estimate the erythroid improvement and variation of the number of red blood cell transfusion after introducing Deferasirox, to evaluate the side effects of the treatment. Methods Retrospective study including all the adult polytransfused patients treated with Deferasirox in Hematology Departments of three county hospitals in the North-West of Romania. Results We included 40 polytransfused patients treated with Deferasirox in standard doses. There was a significant reduction in serum ferritine from baseline for all the patients (Friedman test, χ2(2)=26.82, p<0.001). Safety profile of Deferasirox was good (three digestive side effects). RBCT were administered before (mean 2.43±1.09 units/month) and after starting Deferasirox (mean 1.40±0.97 units/month), the difference is statistically significant (Student Test, t(39)=6.98, p<0.001). Conclusions Deferasirox proves to be an effective iron chelator, the serum level of ferritine decreased for all the patients during the treatment and 22.5 % of the patients developed an erythroid improvement. Safety and compliance were good.
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Affiliation(s)
- Andrada Viorica Parvu
- Hematology Department, Iuliu Hatieganu University of Medicine and Pharmacy, Cluj-Napoca, Romania
| | - Anca Bojan
- Hematology Department, Iuliu Hatieganu University of Medicine and Pharmacy, Cluj-Napoca, Romania
| | - Laura Urian
- Hematology Department, Iuliu Hatieganu University of Medicine and Pharmacy, Cluj-Napoca, Romania
| | - Tunde Torok
- Hematology Department, Iuliu Hatieganu University of Medicine and Pharmacy, Cluj-Napoca, Romania
| | - Iulia Andrea Zsoldos
- Hematology Department, Iuliu Hatieganu University of Medicine and Pharmacy, Cluj-Napoca, Romania
| | - Mihaela Iancu
- Medical Informatics and Biostatistics Department, Iuliu Hatieganu University of Medicine and Pharmacy, Cluj-Napoca, Romania
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9
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Rose C, Lenoir C, Gyan E, Hacini M, Amé S, Corront B, Beyne-Rauzy O, Adiko D, Loppinet E, Ali-Ammar N, Laribi K, Wattel E, Dreyfus F, Roué CS, Cheze S. Prospective evaluation of the effect of deferasirox on hematologic response in transfusion-dependent patients with low-risk MDS and iron overload. Eur J Haematol 2018; 101:165-173. [PMID: 29719933 DOI: 10.1111/ejh.13088] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/19/2018] [Indexed: 12/26/2022]
Abstract
OBJECTIVES To assess the reduction of transfusions rate in transfusion-dependent patients with low-risk myelodysplastic syndrome (MDS) with iron overload treated with deferasirox. METHODS Prospective observational study. Primary endpoint was reduction in transfusion requirements (RTR) at 3 months, (assessed on 8-week period). Secondary endpoints were hematologic improvement according to International Working Group (IWG) 2006 criteria at 3, 6, and 12 months. RESULTS Fifty-seven patients were evaluable. After 3 months of chelation, no effect was seen on transfusion requirement (5.9 packed red blood cells (PRBC) vs 5.8 before chelation). According to the Kaplan-Meier analysis, the probability of RTR at 3, 6, and 12 months was assessed as 3.5%, 9.1%, and 18.7%, respectively. Median duration of RTR was 182 days. However, during the 12-month follow-up after deferasirox initiation, 17 patients (31.5%) achieved minor erythroid response [HI-E] according to IWG criteria, 10 of whom having achieved Hb improvement at month 12. CONCLUSION After 3 months of treatment, deferasirox had no impact on transfusion requirement in regularly transfused patients with low-risk MDS. However, deferasirox could induce 31% of erythroid response during the 12-month follow-up period thus suggesting that iron chelation therapy with deferasirox may induce an effect on hematopoiesis in a subset of patients with MDS and iron overload.
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Affiliation(s)
- Christian Rose
- Hospital Saint Vincent de Paul, Catholic University of Lille, Lille, France
| | | | - Emmanuel Gyan
- Hospital Bretonneau, University of Tours, Tours, France
| | | | - Shanti Amé
- Hospital Hautepierre, University of Strasbourg, Strasbourg, France
| | | | | | | | | | | | | | - Eric Wattel
- Hospital Lyon-Sud, University of Lyon, Pierre-Bénite, France
| | | | | | - Stephane Cheze
- Hospital Côte de Nacre, University of Caen, Caen, France
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10
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Iron toxicity - Its effect on the bone marrow. Blood Rev 2018; 32:473-479. [PMID: 29699840 DOI: 10.1016/j.blre.2018.04.004] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2017] [Revised: 03/22/2018] [Accepted: 04/12/2018] [Indexed: 12/21/2022]
Abstract
Excess iron can be extremely toxic for the body and may cause organ damage in the absence of iron chelation therapy. Preclinical studies on the role of free iron on bone marrow function have shown that iron toxicity leads to the accumulation of reactive oxygen species, affects the expression of genes coding for proteins that regulate hematopoiesis, and disrupts hematopoiesis. These effects could be partially attenuated by iron-chelation treatment with deferasirox, suggesting iron toxicity may have a negative impact on the hematopoietic microenvironment. Iron toxicity is of concern in transfusion-dependent patients. Importantly, iron chelation with deferasirox can cause the loss of transfusion dependency and may induce hematological responses, although the mechanisms through which deferasirox exerts this action are currently unknown. This review will focus on the possible mechanisms of toxicity of free iron at the bone marrow level and in the bone marrow microenvironment.
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11
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Pilo F, Angelucci E. A storm in the niche: Iron, oxidative stress and haemopoiesis. Blood Rev 2017; 32:29-35. [PMID: 28847531 DOI: 10.1016/j.blre.2017.08.005] [Citation(s) in RCA: 38] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2017] [Revised: 08/05/2017] [Accepted: 08/11/2017] [Indexed: 12/18/2022]
Abstract
Iron, although essential, is harmful in high amounts. Oxidative stress as a result of excess reactive oxygen species (ROS) and a prooxidative/antioxidative imbalance between ROS production and elimination, play a key role in cellular damage. There is evidence to support the role of ROS in the pathogenesis of a range of diseases including the myelodysplastic syndromes (MDS) and leukaemia. Oxidative stress seems to affect the self-renewal, proliferation and differentiation of haematopoietic stem cells and impair cell growth. Three aspects of these defective haemopoietic mechanisms may be associated with the activities of ROS: clonal evolution, haematological improvement and recovery of haemopoiesis after haematopoietic stem cell transplantation (HSCT). This review aims to provide haematologists with an overview of results from in vitro and murine models and preliminary clinical evidence on the diagnostic, prognostic and therapeutic implications of the complex interactions between the haemopoietic niche, iron, oxidative stress and inadequate haemopoiesis.
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Affiliation(s)
- Federica Pilo
- Hematology and Transplant Center, Ospedale Oncologico di Riferimento Regionale "Armando Businco", Azienda Ospedaliera Brotzu, Cagliari, Italy..
| | - Emanuele Angelucci
- Hematology and Transplant Center, Ospedale Policlinico San Martino, Genova, Italy.
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12
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Musto P, Maurillo L, Simeon V, Poloni A, Finelli C, Balleari E, Ricco A, Rivellini F, Cortelezzi A, Tarantini G, Villani O, Mansueto G, Milella MR, Scapicchio D, Marziano G, Breccia M, Niscola P, Sanna A, Clissa C, Voso MT, Fenu S, Venditti A, Santini V, Angelucci E, Levis A. Iron-chelating therapy with deferasirox in transfusion-dependent, higher risk myelodysplastic syndromes: a retrospective, multicentre study. Br J Haematol 2017; 177:741-750. [PMID: 28419408 DOI: 10.1111/bjh.14621] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2016] [Accepted: 12/27/2016] [Indexed: 01/19/2023]
Abstract
Iron chelation is controversial in higher risk myelodysplastic syndromes (HR-MDS), outside the allogeneic transplant setting. We conducted a retrospective, multicentre study in 51 patients with transfusion-dependent, intermediate-to-very high risk MDS, according to the revised international prognostic scoring system, treated with the oral iron chelating agent deferasirox (DFX). Thirty-six patients (71%) received azacitidine concomitantly. DFX was given at a median dose of 1000 mg/day (range 375-2500 mg) for a median of 11 months (range 0·4-75). Eight patients (16%) showed grade 2-3 toxicities (renal or gastrointestinal), 4 of whom (8%) required drug interruption. Median ferritin levels decreased from 1709 μg/l at baseline to 1100 μg/l after 12 months of treatment (P = 0·02). Seventeen patients showed abnormal transaminase levels at baseline, which improved or normalized under DFX treatment in eight cases. One patient showed a remarkable haematological improvement. At a median follow up of 35·3 months, median overall survival was 37·5 months. The results of this first survey of DFX in HR-MDS are comparable, in terms of safety and efficacy, with those observed in lower-risk MDS. Though larger, prospective studies are required to demonstrate real clinical benefits, our data suggest that DFX is feasible and might be considered in a selected cohort of HR-MDS patients.
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Affiliation(s)
- Pellegrino Musto
- Scientific Direction, IRCCS-CROB, "Referral Cancer Centre of Basilicata", Rionero In Vulture (Pz), Italy
| | - Luca Maurillo
- Haematology, Department of Biomedicine and Prevention, "Tor Vergata" University, Rome, Italy
| | - Vittorio Simeon
- Laboratory of Pre-clinical and Translational Research, IRCCS-CROB, "Referral Cancer Centre of Basilicata", Rionero In Vulture (Pz), Italy
| | - Antonella Poloni
- Haematology Clinic, Department of Clinic and Molecular Sciences, "Università Politecnica delle Marche", Ancona, Italy
| | - Carlo Finelli
- "Seràgnoli Institute of Haematology", University School of Medicine, Bologna, Italy
| | - Enrico Balleari
- Department of Haematology and Oncology, IRCCS AOU San Martino - IST, Genova, Italy
| | - Alessandra Ricco
- Department of Emergency and Organ Transplantation, Haematology Section, University of Bari, Bari, Italy
| | | | - Agostino Cortelezzi
- Department of Oncology and Haemato-Oncology, University of Milan and Haematology Unit, "Fondazione IRCCS Ca' Granda, Ospedale Maggiore" Policlinico, Milan, Italy
| | | | - Oreste Villani
- Department of Onco-Haematology, IRCCS-CROB, "Referral Cancer Centre of Basilicata", Rionero in Vulture (Pz), Italy
| | - Giovanna Mansueto
- Department of Onco-Haematology, IRCCS-CROB, "Referral Cancer Centre of Basilicata", Rionero in Vulture (Pz), Italy
| | - Maria R Milella
- Pharmacy Unit, IRCCS-CROB, "Referral Cancer Centre of Basilicata", Rionero In Vulture (Pz), Italy
| | - Daniele Scapicchio
- Management Control Unit, IRCCS-CROB, "Referral Cancer Centre of Basilicata", Rionero In Vulture (Pz), Italy
| | - Gioacchino Marziano
- Scientific Direction, IRCCS-CROB, "Referral Cancer Centre of Basilicata", Rionero In Vulture (Pz), Italy
| | - Massimo Breccia
- Department of Cellular Biotechnologies and Haematology, "La Sapienza" University, Rome, Italy
| | | | - Alessandro Sanna
- Haematology, University of Florence, AOU Careggi, Florence, Italy
| | - Cristina Clissa
- Haematology and Haematopoietic Stem Cell Transplant Centre, AORMN, Pesaro, Italy
| | - Maria T Voso
- Haematology, Department of Biomedicine and Prevention, "Tor Vergata" University, Rome, Italy
| | - Susanna Fenu
- Haematology, "San Giovanni" Hospital, Rome, Italy
| | - Adriano Venditti
- Haematology, Department of Biomedicine and Prevention, "Tor Vergata" University, Rome, Italy
| | - Valeria Santini
- Haematology, University of Florence, AOU Careggi, Florence, Italy
| | - Emanuele Angelucci
- Department of Haematology and Oncology, IRCCS AOU San Martino - IST, Genova, Italy
| | - Alessandro Levis
- FISM, Fondazione Italiana Sindromi Mielodisplastiche, Alessandria, Italy
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13
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Hemorrhagic risk due to platelet dysfunction in myelodysplastic patients, correlations with anemia severity and iron overload. Blood Coagul Fibrinolysis 2015; 26:743-9. [DOI: 10.1097/mbc.0000000000000287] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
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14
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Vetro C, Rosso R, Palmucci S, Russello M, Colletta G, Romeo MA, Ximenes B, Romano A, Palumbo GA, Di Raimondo F. Erythrocytapheresis is a valid and safe therapeutic option in dysmetabolic iron overload syndrome. J Clin Apher 2015; 31:443-7. [PMID: 26411360 DOI: 10.1002/jca.21434] [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: 04/03/2015] [Accepted: 09/10/2015] [Indexed: 11/10/2022]
Abstract
Dysmetabolic iron overload syndrome is a rare event causing hepatic impairment with serious long-term side effects. Here, we describe a case of metabolic syndrome-related hepatic iron overload that showed a rapid, effective, and safe response to erythrocytapheresis. J. Clin. Apheresis 31:443-447, 2016. © 2015 Wiley Periodicals, Inc.
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Affiliation(s)
- Calogero Vetro
- Unit of Thalassemia, Division of Haematology, a.O. "Policlinico-Vittorio Emanuele", University of Catania, Catania, Italy.
| | - Rosamaria Rosso
- Unit of Thalassemia, Division of Haematology, a.O. "Policlinico-Vittorio Emanuele", University of Catania, Catania, Italy
| | - Stefano Palmucci
- Radiodiagnostic and Radiotherapy Unit, University Hospital "Policlinico-Vittorio Emanuele", Catania, Catania, Italy
| | | | - Grazia Colletta
- Unit of Thalassemia, Division of Haematology, a.O. "Policlinico-Vittorio Emanuele", University of Catania, Catania, Italy
| | - Maria Anna Romeo
- Unit of Thalassemia, Division of Haematology, a.O. "Policlinico-Vittorio Emanuele", University of Catania, Catania, Italy
| | - Benedetta Ximenes
- Unit of Thalassemia, Division of Haematology, a.O. "Policlinico-Vittorio Emanuele", University of Catania, Catania, Italy
| | - Alessandra Romano
- Unit of Thalassemia, Division of Haematology, a.O. "Policlinico-Vittorio Emanuele", University of Catania, Catania, Italy
| | - Giuseppe Alberto Palumbo
- Unit of Thalassemia, Division of Haematology, a.O. "Policlinico-Vittorio Emanuele", University of Catania, Catania, Italy
| | - Francesco Di Raimondo
- Unit of Thalassemia, Division of Haematology, a.O. "Policlinico-Vittorio Emanuele", University of Catania, Catania, Italy
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15
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Sanford D, Hsia CC. A case of transfusion independence in a patient with myelodysplastic syndrome using deferasirox, sustained for two years after stopping therapy. ACTA ACUST UNITED AC 2015; 22:e128-32. [PMID: 25908918 DOI: 10.3747/co.22.2100] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Patients with myelodysplastic syndrome (mds) experience clinical complications related to progressive marrow failure and have an increased risk of developing acute myeloid leukemia. Frequent red blood cell transfusion can lead to clinical iron overload and is associated with decreased survival in mds patients. Iron chelation therapy reduces markers of iron overload and prevents end-organ damage. Here, we present the case of a patient with low-risk mds with transfusional iron overload. He was treated for 2 years with an oral iron chelator, deferasirox, and after 12 months of treatment, he experienced a hemoglobin increase of more than 50 g/L, becoming transfusion-independent. He has remained transfusion-independent, with a normal hemoglobin level, for more than 2 years since stopping chelation therapy. Hematologic and erythroid responses have previously been reported in mds patients treated with iron chelation. The durability of our patient's response suggests that iron chelation might alter the natural history of mds in some patients.
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Affiliation(s)
- D Sanford
- Department of Medicine, Division of Hematology, London Health Sciences Centre, University of Western Ontario, London, ON
| | - C C Hsia
- Department of Medicine, Division of Hematology, London Health Sciences Centre, University of Western Ontario, London, ON
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16
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Durable Red Blood Cell Transfusion Independence in a Patient with an MDS/MPN Overlap Syndrome Following Discontinuation of Iron Chelation Therapy. Case Rep Hematol 2015; 2015:253294. [PMID: 25918650 PMCID: PMC4396885 DOI: 10.1155/2015/253294] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2014] [Revised: 01/11/2015] [Accepted: 03/06/2015] [Indexed: 01/14/2023] Open
Abstract
Background. Hematologic improvement (HI) occurs in some patients with acquired anemias and transfusional iron overload receiving iron chelation therapy (ICT) but there is little information on transfusion status after stopping chelation. Case Report. A patient with low IPSS risk RARS-T evolved to myelofibrosis developed a regular red blood cell (RBC) transfusion requirement. There was no response to a six-month course of study medication or to erythropoietin for three months. At 27 months of transfusion dependence, she started deferasirox and within 6 weeks became RBC transfusion independent, with the hemoglobin normalizing by 10 weeks of chelation. After 12 months of chelation, deferasirox was stopped; she remains RBC transfusion independent with a normal hemoglobin 17 months later. We report the patient's course in detail and review the literature on HI with chelation. Discussion. There are reports of transfusion independence with ICT, but that transfusion independence may be sustained long term after stopping chelation deserves emphasis. This observation suggests that reduction of iron overload may have a lasting favorable effect on bone marrow failure in at least some patients with acquired anemias.
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17
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Tataranni T, Agriesti F, Mazzoccoli C, Ruggieri V, Scrima R, Laurenzana I, D'Auria F, Falzetti F, Di Ianni M, Musto P, Capitanio N, Piccoli C. The iron chelator deferasirox affects redox signalling in haematopoietic stem/progenitor cells. Br J Haematol 2015; 170:236-46. [DOI: 10.1111/bjh.13381] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2014] [Accepted: 02/04/2015] [Indexed: 01/19/2023]
Affiliation(s)
- Tiziana Tataranni
- Laboratory of Pre-Clinical and Translational Research; IRCCS-CROB; Referral Cancer Centre of Basilicata; Rionero in Vulture (Pz) Italy
| | - Francesca Agriesti
- Laboratory of Pre-Clinical and Translational Research; IRCCS-CROB; Referral Cancer Centre of Basilicata; Rionero in Vulture (Pz) Italy
| | - Carmela Mazzoccoli
- Laboratory of Pre-Clinical and Translational Research; IRCCS-CROB; Referral Cancer Centre of Basilicata; Rionero in Vulture (Pz) Italy
| | - Vitalba Ruggieri
- Laboratory of Pre-Clinical and Translational Research; IRCCS-CROB; Referral Cancer Centre of Basilicata; Rionero in Vulture (Pz) Italy
| | - Rosella Scrima
- Department of Clinical and Experimental Medicine; University of Foggia; Foggia Italy
| | - Ilaria Laurenzana
- Laboratory of Pre-Clinical and Translational Research; IRCCS-CROB; Referral Cancer Centre of Basilicata; Rionero in Vulture (Pz) Italy
| | - Fiorella D'Auria
- Laboratory of Clinical Research and Advanced Diagnostics; IRCCS-CROB; Referral Cancer Centre of Basilicata; Rionero in Vulture (PZ) Italy
| | - Franca Falzetti
- Haematology and Clinical Immunology Section; University of Perugia; Perugia Italy
| | - Mauro Di Ianni
- Department of Internal Medicine and Public Health; University of L'Aquila; L'Aquila Italy
| | - Pellegrino Musto
- Scientific Direction; IRCCS-CROB; Referral Cancer Centre of Basilicata; Rionero in Vulture (PZ) Italy
| | - Nazzareno Capitanio
- Department of Clinical and Experimental Medicine; University of Foggia; Foggia Italy
| | - Claudia Piccoli
- Laboratory of Pre-Clinical and Translational Research; IRCCS-CROB; Referral Cancer Centre of Basilicata; Rionero in Vulture (Pz) Italy
- Department of Clinical and Experimental Medicine; University of Foggia; Foggia Italy
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18
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An increase in hemoglobin, platelets and white blood cells levels by iron chelation as single treatment in multitransfused patients with myelodysplastic syndromes: clinical evidences and possible biological mechanisms. Ann Hematol 2015; 94:771-7. [DOI: 10.1007/s00277-015-2341-z] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2014] [Accepted: 02/16/2015] [Indexed: 12/16/2022]
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19
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Merkel DG, Nagler A. Toward resolving the unsettled role of iron chelation therapy in myelodysplastic syndromes. Expert Rev Anticancer Ther 2014; 14:817-29. [PMID: 24641787 DOI: 10.1586/14737140.2014.896208] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Transfusion dependent low risk myelodysplastic syndromes (MDS) patients, eventually develop iron overload. Iron toxicity, via oxidative stress, can damage cellular components and impact organ function. In thalassemia major patients, iron chelation therapy lowered iron levels with recovery of cardiac and liver functions and significant improvement in survival. Several noncontrolled studies show inferior survival in MDS patients with iron overload, including an increase in transplant-related mortality and infection risk while iron chelation appears to improve survival in both lower risk MDS patients and in stem cell transplant settings. Collated data are presented on the pathophysiological impact of iron overload; measuring techniques and chelating agents' therapy positive impact on hematological status and overall survival are discussed. Although suggested by retrospective analyses, the lack of clear prospective data of the beneficial effects of iron chelation on morbidity and survival, the role of iron chelation therapy in MDS patients remains controversial.
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Affiliation(s)
- Drorit G Merkel
- Division of Hematology, Chaim Sheba Medical Center, Tel Aviv University, Tel-Hashomer, Israel
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