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Farmer I, Radia DH. Systemic Mastocytosis: State of the Art. Curr Hematol Malig Rep 2024; 19:197-207. [PMID: 39187708 DOI: 10.1007/s11899-024-00737-8] [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] [Accepted: 06/25/2024] [Indexed: 08/28/2024]
Abstract
PURPOSE OF REVIEW Since identification of Systemic mastocytosis (SM) as a distinct disease entity by the World Health Organisation (WHO), there has been a wealth of new research in therapeutic targeting of the pathogenic C-KIT D816V mutation. RECENT FINDINGS Avapritinib, the first licensed drug in SM capable of disease modification alongside the increasingly potent, oral and highly selective KIT tyrosine kinase inhibitors (TKIs) Bezuclastinib and now Elenestinib have enabled the prospect of long-term remissions. Studies have shown improved survival and symptomatic control in patients with SM. Of great triumph, this has been achieved in an outpatient setting with apparent tolerable and minimal toxicity. The importance of molecular profiling is being demonstrated in administering combination therapies for SM with an associated haematological neoplasm (AHN), allowing more personalised and streamlined treatment regimes. This review focuses on current management strategies of SM, focusing on state-of-the-art directed therapies, the evidence behind their use with presentation of two clinical cases to highlight key messages.
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Affiliation(s)
- Isabel Farmer
- Department of Haematology, Guy's and St Thomas' NHS Foundation Trust, London, SE1 7EH, UK.
| | - Deepti H Radia
- Department of Haematology, Guy's and St Thomas' NHS Foundation Trust, London, SE1 7EH, UK.
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2
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Ngo HX, Oh E, Li C, Yu J. Oncology Dose Selection in Subsequent Indications: What Can We Learn From FDA-approved Oncology Drugs? Clin Ther 2024:S0149-2918(24)00259-5. [PMID: 39304367 DOI: 10.1016/j.clinthera.2024.08.020] [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: 06/28/2024] [Revised: 08/08/2024] [Accepted: 08/22/2024] [Indexed: 09/22/2024]
Abstract
PURPOSE The modern oncology drug development landscape has shifted away from traditional cytotoxic chemotherapies. Following their initial approvals, many oncology drugs have been approved in subsequent indications either as monotherapy or in combination to benefit a broader patient population. To date, dose selection strategies for subsequent indications have not been systematically reviewed. This review examines how approved dosing regimens were selected in subsequent indications for FDA-approved oncology drugs. METHODS The Drugs@FDA database was used to identify FDA-approved new molecular entities (NMEs) between 2010 and 2023. NMEs with more than 1 approved indication were included in the analysis. In total, the dosing regimens for 67 novel oncology drugs that obtained FDA approvals for multiple indications were evaluated. FINDINGS Overall, in subsequent indications, 72% of NMEs used the same or clinically equivalent alternative dosing regimens to those approved in the initial indications. Amongst the 28% of NMEs that used different dosing regimens, safety/tolerability was the leading cause of a dosing regimen changes in both monotherapy and combination therapy settings. Other factors leading to changes in dosing regimens include differences in tumor biology, disease burden, pharmacokinetics, and overall benefit-risk profiles obtained from dose-finding studies. IMPLICATIONS Our analysis highlighted the importance of selecting a safe, tolerable, and yet efficacious dosing regimen for the initial indication as a suboptimal initially approved regimen could lead to dosing regimen changes in later indications. Preclinical and clinical data could be leveraged to understand the pharmacology, pharmacokinetic, and pharmacodynamic differences between indications and thus support dose selection in subsequent indications.
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Affiliation(s)
- Huy X Ngo
- Department of Clinical Pharmacology, Genentech, Inc., South San Francisco, California, USA
| | - Elise Oh
- Department of Clinical Pharmacology, Genentech, Inc., South San Francisco, California, USA
| | - Chunze Li
- Department of Clinical Pharmacology, Genentech, Inc., South San Francisco, California, USA
| | - Jiajie Yu
- Department of Clinical Pharmacology, Genentech, Inc., South San Francisco, California, USA.
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3
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Heiblig M, Gourguechon C, Guilpain P, Bulai-Livideanu C, Barete S, Chantran Y, Agopian J, Brenet F, Dubreuil P, Lespinasse J, Lemal R, Tournilhac O, Terriou L, Launay D, Bouillet L, Chatain C, Damaj G, Ballul T, Greco C, Polivka L, Frenzel L, Meni C, Bouktit H, Benabou D, Gaudy-Marqueste C, Gousseff M, Le Mouel E, Neel A, Ranta D, Jaussaud R, Molina TJ, Bruneau J, Villarese P, Lhermitte L, Maouche-Chrétien L, Temple M, Kosmider O, Javier RM, Pelletier F, Castelain F, Retornaz F, Cabrera Q, Zunic P, Gourin MP, Wierzbicka-Hainaut E, Viallard JF, Lavigne C, Hoarau C, Durieu I, Dimicoli-Salazar S, Torregrosa-Diaz JM, Wemeau M, Soria A, Arock M, Bodemer C, Lortholary O, Hermine O, Rossignol J. Comparison of prognostic scores according to WHO classification in 170 patients with advanced mastocytosis and C-finding treated with midostaurin. Am J Hematol 2024. [PMID: 39287048 DOI: 10.1002/ajh.27478] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2024] [Revised: 08/05/2024] [Accepted: 08/06/2024] [Indexed: 09/19/2024]
Abstract
Advanced systemic mastocytosis (AdvSM) encompasses heterogeneous mastocytosis subtypes and is associated with poor outcomes. Although midostaurin was the first tyrosine kinase inhibitor to be approved for AdvSM patients, long-lasting responses are limited. The mutation-Adjusted Risk Score (MARS), the International Prognostic Scoring System for mastocytosis (IPSM) and the Global Prognostic Score for Systemic Mastocytosis (GPSM) have been established to characterize the outcomes of patients with overall AdvSM. However, given the outcome's dependency on the AdvSM subtype, prognostic characterization within each subtype is critical. We aimed to study the predictive ability using Harrell's concordance index of prognostic scores according to the AdvSM subtype. We conducted a nationwide retrospective study using the French mastocytosis reference center's registry and included all midostaurin-treated patients with C finding. Overall, 170 patients were identified: 46 aggressive SM (ASM), 11 mast cell leukemia (MCL), and 113 SM with associated hematological neoplasm (SM-AHN). All risk scores improved their discriminative value for overall survival (OS) when combined with the AdvSM subtype. The best predictive value was for adjusted MARS (C-index = 0.689), followed by GPSM (C-index = 0.677) and IPSM (C-index = 0.618). In a multivariable analysis, MARS stratification and the AdvSM subtype were both prognostic for OS. Accordingly, five subgroups of patients with AdvSM and a different median OS were identified: 9.9 months for MCL, 24 months for intermediate/high-risk SM-AHN, 33 months for intermediate/high-risk ASM, 58 months for low-risk SM-AHN and was not reached for low-risk ASM (p < 0.001). The AdvSM subtype and the MARS are the most predictive of OS and should prompt specific management.
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Affiliation(s)
- Maël Heiblig
- Hematology Department, Centre Hospitalier Lyon Sud, Pierre-Bénite, France
| | | | - Philippe Guilpain
- CEREMAST, the Department of Internal Medicine-Multi-organ Diseases, Saint-Eloi University Hospital, Montpellier University, Montpellier, France
| | | | - Stéphane Barete
- Sorbonne Université, APHP, Unité Fonctionnelle de Dermatologie, Groupe Hospitalier Pitié-Salpêtrière-C. Foix, Paris, France
- French Reference Center for Mastocytosis (CEREMAST), Necker-Enfants Malades University Hospital, APHP, Paris, France
| | - Yannick Chantran
- Department of Biological Hematology, Pitié-Salpêtrière Hospital, DMU BioGem, AP-HP, Sorbonne University, Paris, France
- Department of Biological Immunology, Saint-Antoine Hospital, DMU BioGem, AP-HP, Sorbonne University, Paris, France
- Health Environmental Risk Assessment (HERA) Team, Centre of Research in Epidemiology and Statistics (CRESS), Inserm/INRAE, Faculty of Pharmacy, Université de Paris, Paris, France
| | - Julie Agopian
- Association Française pour les Initiatives de Recherche sur le Mastocyte et les Mastocytoses (AFIRMM), Paris, France
| | - Fabienne Brenet
- Centre de Recherche en Cancérologie de Marseille (CRCM) INSERM U1068, CNRS UMR7258, AMU U105, Département d'Onco-Hématologie-Immunologie, Institut Paoli-Calmettes, Marseille, France
| | - Patrice Dubreuil
- Centre de Recherche en Cancérologie de Marseille (CRCM) INSERM U1068, CNRS UMR7258, AMU U105, Département d'Onco-Hématologie-Immunologie, Institut Paoli-Calmettes, Marseille, France
| | | | - Richard Lemal
- Adult Clinical Hematology, Clermont-Ferrand University Hospital, INSERM CIC501, EA 7453-Université Clermont Auvergne, Clermont-Ferrand, France
| | - Olivier Tournilhac
- Adult Clinical Hematology, Clermont-Ferrand University Hospital, INSERM CIC501, EA 7453-Université Clermont Auvergne, Clermont-Ferrand, France
| | - Louis Terriou
- INSERM, CHU Lille, Department of Internal Medicine and Clinical Immunology, U1286 - INFINITE - Institute for Translational Research in Inflammation, University Lille, Lille, France
| | - David Launay
- INSERM, CHU Lille, Service de Médecine Interne et Immunologie Clinique, Centre de référence des maladies autoimmunes systémiques rares du Nord et Nord-Ouest de France (CeRAINO), U1286 - INFINITE - Institute for Translational Research in Inflammation, University Lille, Lille, France
| | - Laurence Bouillet
- Internal Medicine Department, Grenoble Alpes University Hospital, Univ. Grenoble Alpes, T-RAIG unit, CNRS, UMR 5525, VetAgro Sup, Grenoble INP, CHU Grenoble Alpes, TIMC, Grenoble, France
| | - Catharina Chatain
- Internal Medicine Department, Grenoble Alpes University Hospital, Univ. Grenoble Alpes, T-RAIG unit, CNRS, UMR 5525, VetAgro Sup, Grenoble INP, CHU Grenoble Alpes, TIMC, Grenoble, France
| | - Ghandi Damaj
- Haematology Institute, Normandy University School of Medicine, Caen, France
| | - Thomas Ballul
- French Reference Center for Mastocytosis (CEREMAST), Necker-Enfants Malades University Hospital, APHP, Paris, France
- Imagine Institute, INSERM U1163, Necker-Enfants Malades University Hospital, Paris University, Paris, France
| | - Celine Greco
- CEREMAST, the Department of Pain and Palliative Care Unit, Necker-Children's Hospital, AP-HP, Paris Centre University, Paris, France
| | - Laura Polivka
- Haematology Institute, Normandy University School of Medicine, Caen, France
- Department of Dermatology, Reference Center for Genodermatoses (MAGEC), Necker Hospital for Sick Children, Assistance Publique-Hôpitaux de Paris (AP-HP), Paris Cité University, Paris, France
- CEREMAST, the Department of Hematology, Necker-Children's Hospital, AP-HP, Paris Centre University, Paris, France
| | - Laurent Frenzel
- French Reference Center for Mastocytosis (CEREMAST), Necker-Enfants Malades University Hospital, APHP, Paris, France
- Imagine Institute, INSERM U1163, Necker-Enfants Malades University Hospital, Paris University, Paris, France
| | - Cécile Meni
- French Reference Center for Mastocytosis (CEREMAST), Necker-Enfants Malades University Hospital, APHP, Paris, France
| | - Hassiba Bouktit
- French Reference Center for Mastocytosis (CEREMAST), Necker-Enfants Malades University Hospital, APHP, Paris, France
| | - Dina Benabou
- French Reference Center for Mastocytosis (CEREMAST), Necker-Enfants Malades University Hospital, APHP, Paris, France
| | | | - Marie Gousseff
- Department of Internal Medicine, Bretagne Atlantique Hospital, Vannes, France
| | - Edwige Le Mouel
- Department of Internal Medicine and Clinical Immunology, Rennes University Hospital, Rennes, France
| | - Antoine Neel
- CEREMAST, the Department of Internal Medicine, Hôtel-Dieu University Hospital, Nantes, France
| | - Dana Ranta
- Department of Haematology, Nancy University Hospital, Nancy, France
| | - Roland Jaussaud
- Department of Internal Medicine and Clinical Immunology, Vandoeuvre-lès-Nancy, France
| | - Thierry Jo Molina
- Department of pathology, Necker-Children's Hospital, AP-HP, Paris Centre University, Paris, France
| | - Julie Bruneau
- Imagine Institute, INSERM U1163, Necker-Enfants Malades University Hospital, Paris University, Paris, France
- Department of pathology, Necker-Children's Hospital, AP-HP, Paris Centre University, Paris, France
| | - Patrick Villarese
- Laboratory of Onco-Hematology, Necker Children's Hospital, Assistance Publique-Hôpitaux de Paris (AP-HP), Paris, France
| | - Ludovic Lhermitte
- Laboratory of Onco-Hematology, Necker Children's Hospital, Assistance Publique-Hôpitaux de Paris (AP-HP), Paris, France
- CNRS, INSERM U1151, Institut Necker Enfants Malades (INEM), Université Paris Cité, Paris, France
| | - Leila Maouche-Chrétien
- Imagine Institute, INSERM U1163, Necker-Enfants Malades University Hospital, Paris University, Paris, France
| | - Marie Temple
- Hematology Laboratory, Assistance Publique-Hôpitaux de Paris, Cochin Hospital, Paris, France
- INSERM U1016, Université de Paris, Institut Cochin, Paris, France
| | - Olivier Kosmider
- Hematology Laboratory, Assistance Publique-Hôpitaux de Paris, Cochin Hospital, Paris, France
- INSERM U1016, Université de Paris, Institut Cochin, Paris, France
| | - Rose-Marie Javier
- Rheumatology Department, Competence Center for Rare Genetic Bone Disorders, University-Hospital of Strasbourg, Strasbourg, France
| | - Fabien Pelletier
- CEREMAST, the Department of Dermatology, Allergology Unit, University Hospital of Besançon, Besançon, France
| | - Florence Castelain
- Unité Transversale Allergologie, Dermatologie, CHU Besançon - Université de Franche-Comté, EFS, INSERM, UMR RIGHT, Besançon, France
| | - Frederique Retornaz
- Unité de soins et de recherche en médecine interne et maladies infectieuses, European Hospital, Marseille, France
| | - Quentin Cabrera
- Department of Haematology, Sud Reunion University Hospital, Saint Pierre, France
| | - Patricia Zunic
- Department of Haematology, Sud Reunion University Hospital, Saint Pierre, France
| | | | | | - Jean François Viallard
- Department of Internal Medicine, Hôpital Haut-Lévêque, Université de BORDEAUX, Pessac, France
| | - Christian Lavigne
- Department of Internal Medicine, Angers University Hospital, Angers, France
| | - Cyrille Hoarau
- The Service d'Immunologie Clinique et d'Allergologie, Centre Hospitalier Régional Universitaire, Tours, France
| | - Isabelle Durieu
- Internal Medicine Department, Centre Hospitalier Lyon Sud, Pierre-Bénite, France
- INSERM U1290, Université Lyon 1, Lyon, France
| | | | | | - Mathieu Wemeau
- Department of Haematology, Hospital Centre of Roubaix, Roubaix, France
| | - Angèle Soria
- Department of Dermatology and Allergy, Tenon Hospital, Sorbonne University, Paris, France
| | - Michel Arock
- Platform of Molecular Analysis for Mastocytosis and MCAD (CEREMAST), Department of Biological Hematology, Pitié-Salpêtrière Hospital, AP-HP, Paris Sorbonne University, Paris, France
| | - Christine Bodemer
- Department of Dermatology, Reference Center for Genodermatoses (MAGEC), Necker Hospital for Sick Children, Assistance Publique-Hôpitaux de Paris (AP-HP), Paris Cité University, Paris, France
- CEREMAST, the Department of Hematology, Necker-Children's Hospital, AP-HP, Paris Centre University, Paris, France
| | - Olivier Lortholary
- French Reference Center for Mastocytosis (CEREMAST), Necker-Enfants Malades University Hospital, APHP, Paris, France
| | - Olivier Hermine
- French Reference Center for Mastocytosis (CEREMAST), Necker-Enfants Malades University Hospital, APHP, Paris, France
- CEREMAST, the Department of Pain and Palliative Care Unit, Necker-Children's Hospital, AP-HP, Paris Centre University, Paris, France
| | - Julien Rossignol
- French Reference Center for Mastocytosis (CEREMAST), Necker-Enfants Malades University Hospital, APHP, Paris, France
- Imagine Institute, INSERM U1163, Necker-Enfants Malades University Hospital, Paris University, Paris, France
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Tremblay D, Wagner NE, Mascarenhas J. Management of Advanced Systemic Mastocytosis: Clinical Challenges. J Blood Med 2024; 15:421-433. [PMID: 39279879 PMCID: PMC11402342 DOI: 10.2147/jbm.s366367] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2024] [Accepted: 09/02/2024] [Indexed: 09/18/2024] Open
Abstract
Advanced systemic mastocytosis (AdvSM) is a rare hematologic malignancy with organ damage and compromised life expectancy arising from organ accumulation of neoplastic mast cells. Identification of the gain-of-function KITD816V in the majority of cases has accelerated pharmaceutical development culminating with the development of selective KIT inhibitors such as avapritinib. While the advent of these therapies has improved the quality and quantity of life in patients with AdvSM, current challenges remain in the management of this disease. In this review, we summarize the present and future therapeutics landscape of AdvSM, highlighting the development of novel KIT inhibitors including elenestinib and bezuclastinib. We also explore the continued role of additional treatment modalities including allogeneic stem cell transplantation before discussing unresolved clinical challenges in the management of AdvSM.
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Affiliation(s)
- Douglas Tremblay
- Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Nicole E Wagner
- Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - John Mascarenhas
- Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
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Kim DH, Jia F, Patel KP, Bose P, Wang SA, Bueso-Ramos C, Ok CY. Utility of KIT Mutations in Myeloid Neoplasms Without Documented Systemic Mastocytosis to Detect Hidden Mast Cells in Bone Marrow. CLINICAL LYMPHOMA, MYELOMA & LEUKEMIA 2024:S2152-2650(24)00266-0. [PMID: 39107203 DOI: 10.1016/j.clml.2024.07.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/07/2024] [Revised: 07/03/2024] [Accepted: 07/11/2024] [Indexed: 08/09/2024]
Abstract
BACKGROUND KIT p.D816 mutation is strongly associated with systemic mastocytosis (SM). Next-generation sequencing (NGS) is now routinely performed in almost all bone marrow sample and KIT mutations are detected from patients who are not known or suspected to have SM. Therefore, we wanted to assess if KIT mutations in this patient population are associated with unsuspected SM. METHODS We searched NGS result in our institution with positive result for KIT mutation from patients with known/suspected myeloid neoplasms. Patients with previously documented history of systemic mastocytosis were excluded. Bone marrow biopsies from patients with KIT mutation were assessed with immunohistochemical stains for CD117 and mast cell tryptase (MST). RESULTS Bone marrow biopsies were assessed with immunohistochemical stains for CD117 and mast cell tryptase (n = 49). Most patients had acute myeloid leukemia (AML, n = 38) or chronic myelomonocytic leukemia (CMML, n = 6). Immunohistochemical stains for CD117 and tryptase were performed in all 49 patients. A total of 4 patients (8.2%) showed mast cell nodules where spindled shaped mast cells were present, meeting the WHO criteria for SM. All four patients had KIT p.D816V mutation and had high mutant allelic frequency (∼ 50%) except one patient (1%). CONCLUSION We discovered approximately 8% of patients who had myeloid neoplasms with unexpected KIT mutations fulfilled the diagnostic criteria for systemic mastocytosis after additional immunohistochemical studies. Our data support that application of additional immunohistochemical studies is recommended to identify underrecognized SM when KIT mutations are found by molecular assays.
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Affiliation(s)
- Do Hwan Kim
- Department of Hematopathology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Fuli Jia
- Department of Hematopathology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Keyur P Patel
- Department of Hematopathology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Prithviraj Bose
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Sa A Wang
- Department of Hematopathology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Carlos Bueso-Ramos
- Department of Hematopathology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Chi Young Ok
- Department of Hematopathology, The University of Texas MD Anderson Cancer Center, Houston, TX.
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Chifotides HT, Bose P. SOHO State of the Art Update and Next Questions: Current and Emerging Therapies for Systemic Mastocytosis. CLINICAL LYMPHOMA, MYELOMA & LEUKEMIA 2024:S2152-2650(24)00239-8. [PMID: 39168723 DOI: 10.1016/j.clml.2024.06.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/26/2024] [Revised: 06/20/2024] [Accepted: 06/20/2024] [Indexed: 08/23/2024]
Abstract
Systemic mastocytosis (SM) is a heterogeneous myeloid neoplasm, characterized by clonal proliferation of mast cells (MCs) in ≥ 1 extracutaneous organs, including the bone marrow (BM) and gastrointestinal tract. Aberrant MC proliferation is driven by mutation KIT D816V in ≈90-95% of SM patients. Indolent SM (ISM) is the most common SM subtype with various symptoms that can be severe. Advanced SM (AdvSM) has markedly poor prognosis. The advent of KIT inhibitors, targeting mutant KIT and neoplastic MCs, led to a paradigm shift in SM management and markedly improved outcomes. Midostaurin inaugurated the era of KIT inhibitors and was approved for AdvSM in 2017. Avapritinib is the first highly potent and selective inhibitor of KIT D816V that was approved to treat AdvSM and symptomatic ISM (platelets ≥ 50 × 109/L), in the US, in 2021 and 2023, respectively. Pooled analysis of the EXPLORER and PATHFINDER studies, assessing avapritinib in AdvSM, demonstrated rapid and profound reductions (≥ 50%) in markers of MC burden, high response rates (71-75%), and prolonged survival. In the PIONEER study, avapritinib significantly and rapidly improved symptoms/quality of life, and reduced markers of MC burden in ISM patients. The investigational agents bezuclastinib and elenestinib are highly potent and selective inhibitors of KIT D816V with minimal blood-brain barrier penetration. Bezuclastinib reduced markers of MC burden by ≥ 50% in ≈50% of AdvSM patients and ≈90-100% of nonAdvSM patients and reduced symptoms (≥ 50%) in the APEX and SUMMIT studies, respectively. Elenestinib demonstrated dose-dependent efficacy in reducing MC burden markers and improved symptoms in ISM patients in the HARBOR study.
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Affiliation(s)
- Helen T Chifotides
- Department of Leukemia, University of Texas MD Anderson Cancer Center, Houston, TX
| | - Prithviraj Bose
- Department of Leukemia, University of Texas MD Anderson Cancer Center, Houston, TX.
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Lübke J, Christen D, Schwaab J, Kaiser A, Naumann N, Shoumariyeh K, Jentzsch M, Sockel K, Schaffrath J, Ayuk FA, Stelljes M, Hilgendorf I, Sala E, Kaivers J, Schönland S, Wittke C, Hertenstein B, Radsak M, Kaiser U, Brückl V, Kröger N, Brümmendorf TH, Hofmann WK, Klein S, Jost E, Reiter A, Panse J. Allogeneic Hematopoietic Cell Transplantation in Advanced Systemic Mastocytosis: A retrospective analysis of the DRST and GREM registries. Leukemia 2024; 38:810-821. [PMID: 38448757 PMCID: PMC10997505 DOI: 10.1038/s41375-024-02186-x] [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: 12/23/2023] [Accepted: 02/14/2024] [Indexed: 03/08/2024]
Abstract
We identified 71 patients with AdvSM (aggressive SM [ASM], SM with an associated hematologic neoplasm [SM-AHN, e.g., acute myeloid leukemia, SM-AML], mast cell leukemia [MCL]) in two national registries (DRST/GREM) who received an allogeneic hematopoietic cell transplantation (alloHCT) performed in Germany from 1999-2021. Median overall survival (OS) of ASM/SM-AHN (n = 30, 45%), SM-AML (n = 28, 39%) and MCL ± AHN (n = 13, 19%) was 9.0, 3.3 and 0.9 years (P = 0.007). Improved median OS was associated with response of SM (17/41, 41%; HR 0.4 [0.2-0.9], P = 0.035) and/or of AHN (26/43, 60%, HR 0.3 [0.1-0.7], P = 0.004) prior to alloHCT. Adverse predictors for OS included absence of KIT D816V (10/61, 16%, HR 2.9 [1.2-6.5], P < 0.001) and a complex karyotype (9/60, 15%, HR 4.2 [1.8-10.0], P = 0.016). HLA-match, conditioning type or transplantation at centers reporting above-average alloHCTs (≥7) had no impact on OS. Taking into account competing events at years 1, 3 and 5, relapse-related mortality and non-relapse mortality rate were 15%/23%, 20%/30% and 23%/35%, respectively. Irrespective of subtype, subsequent treatment response was achieved in 13/30 (43%) patients and was highest on midostaurin/avapritinib (7/9, 78%). We conclude that outcome of alloHCT in AdvSM is more affected by disease phenotype and treatment response prior to transplant than by transplant characteristics.
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Affiliation(s)
- Johannes Lübke
- Department of Hematology and Oncology, University Hospital Mannheim, Heidelberg University, Mannheim, Germany
| | - Deborah Christen
- Department of Oncology, Hematology, Hemostaseology and Stem Cell Transplantation, University Hospital RWTH Aachen, Aachen, Germany & Center for Integrated Oncology (CIO), Aachen, Bonn, Cologne, Düsseldorf (ABCD), Aachen, Germany
| | - Juliana Schwaab
- Department of Hematology and Oncology, University Hospital Mannheim, Heidelberg University, Mannheim, Germany
| | - Anne Kaiser
- Department of Oncology, Hematology, Hemostaseology and Stem Cell Transplantation, University Hospital RWTH Aachen, Aachen, Germany & Center for Integrated Oncology (CIO), Aachen, Bonn, Cologne, Düsseldorf (ABCD), Aachen, Germany
| | - Nicole Naumann
- Department of Hematology and Oncology, University Hospital Mannheim, Heidelberg University, Mannheim, Germany
| | - Khalid Shoumariyeh
- Department of Medicine I, Medical Center- University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany and German Cancer Consortium (DKTK), Partner Site Freiburg, Freiburg, Germany
| | - Madlen Jentzsch
- Clinic and Policlinic for Hematology and Cellular Therapy, University of Leipzig Medical Center, Leipzig, Germany
| | - Katja Sockel
- Medical Department I, University Hospital Carl Gustav Carus, TU Dresden, Dresden, Germany
| | - Judith Schaffrath
- Department of Internal Medicine IV, Hematology and Oncology, Martin Luther University Halle-Wittenberg, Halle (Saale), Germany
| | - Francis A Ayuk
- Department of Stem Cell Transplantation with Research Department Cell and Gene Therapy University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Matthias Stelljes
- Department of Medicine A/Hematology and Oncology, University of Muenster, Münster, Germany
| | - Inken Hilgendorf
- Universitätsklinikum Jena, Klinik für Innere Medizin II, Abteilung für Hämatologie und Internistische Onkologie, Jena, Germany
| | - Elisa Sala
- Department of Internal Medicine III, University Hospital Ulm, Ulm, Germany
| | - Jennifer Kaivers
- Department of Hematology and Stem Cell Transplantation, West German Cancer Center, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
| | - Stefan Schönland
- Department of Internal Medicine V, Division of Hematology/Oncology, Heidelberg University Hospital, Heidelberg, Germany
| | - Christoph Wittke
- Department of Medicine, Clinic III, Hematology, Oncology and Palliative Medicine, Rostock University Medical Center, Rostock, Germany
| | | | - Markus Radsak
- 3rd Department of Medicine, Johannes Gutenberg University Medical Center, Mainz, Germany
| | - Ulrich Kaiser
- Department of Internal Medicine III, University Hospital Regensburg, Regensburg, Germany
| | - Valeska Brückl
- Department of Internal Medicine 5, Hematology and Oncology, University Hospital Erlangen, Erlangen, Germany
| | - Nicolaus Kröger
- Department of Stem Cell Transplantation with Research Department Cell and Gene Therapy University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Tim H Brümmendorf
- Department of Oncology, Hematology, Hemostaseology and Stem Cell Transplantation, University Hospital RWTH Aachen, Aachen, Germany & Center for Integrated Oncology (CIO), Aachen, Bonn, Cologne, Düsseldorf (ABCD), Aachen, Germany
| | - Wolf-Karsten Hofmann
- Department of Hematology and Oncology, University Hospital Mannheim, Heidelberg University, Mannheim, Germany
| | - Stefan Klein
- Department of Hematology and Oncology, University Hospital Mannheim, Heidelberg University, Mannheim, Germany
| | - Edgar Jost
- Department of Oncology, Hematology, Hemostaseology and Stem Cell Transplantation, University Hospital RWTH Aachen, Aachen, Germany & Center for Integrated Oncology (CIO), Aachen, Bonn, Cologne, Düsseldorf (ABCD), Aachen, Germany
| | - Andreas Reiter
- Department of Hematology and Oncology, University Hospital Mannheim, Heidelberg University, Mannheim, Germany.
| | - Jens Panse
- Department of Oncology, Hematology, Hemostaseology and Stem Cell Transplantation, University Hospital RWTH Aachen, Aachen, Germany & Center for Integrated Oncology (CIO), Aachen, Bonn, Cologne, Düsseldorf (ABCD), Aachen, Germany
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8
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Pardanani A, Reichard K, Tefferi A. Advanced systemic mastocytosis-Revised classification, new drugs and how we treat. Br J Haematol 2024; 204:402-414. [PMID: 38054381 DOI: 10.1111/bjh.19245] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2023] [Revised: 11/19/2023] [Accepted: 11/24/2023] [Indexed: 12/07/2023]
Abstract
Mastocytosis constitutes the neoplastic proliferation of mast cells and is broadly classified into systemic mastocytosis (SM), cutaneous mastocytosis and mast cell sarcoma. SM is further partitioned into advanced (AdvSM) and non-advanced (SM-non-Adv) subcategories. AdvSM includes aggressive SM (ASM), SM with an associated haematological neoplasm (SM-AHN) and mast cell leukaemia (MCL). In 2022, two separate expert committees representing the 5th edition of the World Health Organization (WHO5) and the International Consensus (ICC) classification systems submitted revised classification criteria for SM, highlighted by the ICC-proposed incorporation of mast cell cytomorphology in the diagnostic criteria for MCL and myeloid-lineage restriction for the AHN component in SM-AHN. Recent developments in SM also include the introduction of KIT-targeting tyrosine kinase inhibitors (KITi), including midostaurin and avapritinib, both drugs have shown potent activity in reducing mast cell and mutant KIT burden and alleviating mast cell-associated organopathy and mediator symptoms; however, their overall impact on survival or superiority over pre-KITi era treatment options (e.g. cladribine) has not been studied in a controlled setting. In the current review, we provide a summary of recent changes in disease classification and an analysis of recent clinical trials and their impact on our current treatment approach in AdvSM.
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Affiliation(s)
| | - Kaaren Reichard
- Division of Hematopathology, Mayo Clinic, Rochester, Minnesota, USA
| | - Ayalew Tefferi
- Division of Hematology, Mayo Clinic, Rochester, Minnesota, USA
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9
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Veitch S, Radia DH. Recent Advances in the Therapeutic Management of Advanced Systemic Mastocytosis. Diagnostics (Basel) 2023; 14:80. [PMID: 38201389 PMCID: PMC10802166 DOI: 10.3390/diagnostics14010080] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2023] [Revised: 12/22/2023] [Accepted: 12/26/2023] [Indexed: 01/12/2024] Open
Abstract
Advanced systemic mastocytosis (AdvSM) is a rare haematological neoplasm characterised by the accumulation of neoplastic mast cells (MCs) in various organs, resulting in organ dysfunction and reduced life expectancy. The subtypes include aggressive SM (ASM), SM with an associated haematological neoplasm (SM-AHN) and mast cell leukaemia (MCL). The gain of function KIT D816V mutation is present in most cases. The availability of tyrosine kinase inhibitors (TKIs) has revolutionised the treatment landscape for patients with this life-limiting disease. Patients are now able to achieve molecular remission, improved quality of life and improved overall survival. This review focuses on the targeted therapies currently available in clinical practice and within the clinical trial setting for AdvSM. This review also highlights possible future therapeutic targets and discusses therapeutic strategies for this multimutated and clinically heterogeneous disease.
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Affiliation(s)
- Scott Veitch
- Department of Haematology, Guy’s and St Thomas’ NHS Foundation Trust, London SE1 7EH, UK
| | - Deepti H. Radia
- Department of Haematology, Guy’s and St Thomas’ NHS Foundation Trust, London SE1 7EH, UK
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10
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Costa A, Scalzulli E, Carmosino I, Capriata M, Ielo C, Masucci C, Passucci M, Martelli M, Breccia M. Systemic mastocytosis: 2023 update on diagnosis and management in adults. Expert Opin Emerg Drugs 2023; 28:153-165. [PMID: 37256917 DOI: 10.1080/14728214.2023.2221028] [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: 04/11/2023] [Revised: 05/27/2023] [Accepted: 05/30/2023] [Indexed: 06/02/2023]
Abstract
INTRODUCTION Systemic mastocytosis (SM) is a complex and heterogeneous disease, characterized by the clonal accumulation of mast cells in one or more organs. In 2022 both the World Health Organization (WHO) and the International Consensus Classification (ICC) modified the diagnostic and classification criteria of SM. Moreover, the identification of new clinical and molecular variables has improved prognostic tools and led to increasingly individualized therapeutic strategies. AREAS COVERED The aim of this review is to present the updates introduced by the International Consensus Classification in diagnostic criteria of SM. In addition, we report the latest data available from the most important clinical trials in patients both with non-advanced and advanced disease, including elenestinib and bezuclastinib. EXPERT OPINION Diagnosis and classification of SM has evolved over years. The most recent WHO and ICC classification improved SM diagnostic work-up, providing clinicians with a clear and simplified diagnostic scheme. New approved targeted therapies such as midostaurin and avapritinib modified the treatment paradigm in patients in advanced stage, and next-generation inhibitors actually investigated in clinical trials are expected in the next future.
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Affiliation(s)
- Alessandro Costa
- Hematology Unit, Businco Hospital, Department of Medical Sciences and Public Health, University of Cagliari, Cagliari, Italy
| | - Emilia Scalzulli
- Hematology, Department of Translational and Precision Medicine, Az. Policlinico Umberto I-Sapienza University, Rome, Italy
| | - Ida Carmosino
- Hematology, Department of Translational and Precision Medicine, Az. Policlinico Umberto I-Sapienza University, Rome, Italy
| | - Marcello Capriata
- Hematology, Department of Translational and Precision Medicine, Az. Policlinico Umberto I-Sapienza University, Rome, Italy
| | - Claudia Ielo
- Hematology, Department of Translational and Precision Medicine, Az. Policlinico Umberto I-Sapienza University, Rome, Italy
| | - Chiara Masucci
- Hematology, Department of Translational and Precision Medicine, Az. Policlinico Umberto I-Sapienza University, Rome, Italy
| | - Mauro Passucci
- Hematology, Department of Translational and Precision Medicine, Az. Policlinico Umberto I-Sapienza University, Rome, Italy
| | - Maurizio Martelli
- Hematology, Department of Translational and Precision Medicine, Az. Policlinico Umberto I-Sapienza University, Rome, Italy
| | - Massimo Breccia
- Hematology, Department of Translational and Precision Medicine, Az. Policlinico Umberto I-Sapienza University, Rome, Italy
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11
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Tashi T, Deininger MW. Management of Advanced Systemic Mastocytosis and Associated Myeloid Neoplasms. Immunol Allergy Clin North Am 2023; 43:723-741. [PMID: 37758409 DOI: 10.1016/j.iac.2023.04.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/03/2023]
Abstract
Advanced systemic mastocytosis (AdvSM) is a heterogeneous group of disorders characterized by neoplastic mast cell-related organ damage and frequently associated with a myeloid neoplasm. The 3 clinical entities that comprise AdvSM are aggressive SM (ASM), SM-associated hematologic neoplasm, and mast cell leukemia. A gain-of-function KIT D816 V mutation is the primary oncogenic driver found in about 90% of all patients with AdvSM. Midostaurin, an oral multikinase inhibitor with activity against KIT D816V, and avapritinib, an oral selective KIT D816V inhibitor are approved for AdvSM.
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Affiliation(s)
- Tsewang Tashi
- Division of Hematology and Hematologic Malignancies, Huntsman Cancer Institute, University of Utah, 2000, Circle of Hope, Salt Lake City, UT 84112, USA.
| | - Michael W Deininger
- Division of Hematology and Oncology, Medical College of Wisconsin, Versiti Blood Research Institute, 8727 West Watertown Plank Road, Milwaukee, WI 53226, USA
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12
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Abuhelwa Z, Beran A, Kahlon N, Sayeh W, Khokher W, Assaly R, Hamouda DM. Midostaurin in Advanced Systemic Mastocytosis: A Systematic Review and Meta-analysis. Am J Ther 2023; 30:e573-e575. [PMID: 35446286 DOI: 10.1097/mjt.0000000000001508] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
- Ziad Abuhelwa
- Department of Internal Medicine, University of Toledo, Toledo, OH
| | - Azizullah Beran
- Department of Internal Medicine, University of Toledo, Toledo, OH
| | - Navkirat Kahlon
- Division of Hematology and Oncology, Department of Internal Medicine, University of Toledo, Toledo, OH
| | - Wasef Sayeh
- Department of Internal Medicine, University of Toledo, Toledo, OH
| | - Waleed Khokher
- Department of Internal Medicine, University of Toledo, Toledo, OH
| | - Ragheb Assaly
- Department of Internal Medicine, University of Toledo, Toledo, OH
- Division of Pulmonology and Critical Care Medicine, Department of Internal Medicine, University of Toledo, Toledo, OH
| | - Danae M Hamouda
- Division of Hematology and Oncology, Department of Internal Medicine, University of Toledo, Toledo, OH
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13
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Hernandez CL, Lynch DM, Golash AJ, Marquis K, Besz KM, Oxnard G, Rotow J, DeAngelo DJ, Castells M. Anaphylaxis and systemic mastocytosis controlled with KIT inhibitors in a patient with metastatic lung adenocarcinoma. Ann Allergy Asthma Immunol 2023; 131:668-670. [PMID: 37597693 DOI: 10.1016/j.anai.2023.08.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2023] [Revised: 08/03/2023] [Accepted: 08/04/2023] [Indexed: 08/21/2023]
Affiliation(s)
- Camellia L Hernandez
- Department of Allergy and Clinical Immunology, Brigham and Women's Hospital, Boston, Massachusetts.
| | - Donna-Marie Lynch
- Department of Allergy and Clinical Immunology, Brigham and Women's Hospital, Boston, Massachusetts
| | - Abby Jane Golash
- Department of Allergy and Clinical Immunology, Brigham and Women's Hospital, Boston, Massachusetts
| | - Kathleen Marquis
- Department of Allergy and Clinical Immunology, Brigham and Women's Hospital, Boston, Massachusetts
| | - Kylie Marie Besz
- Department of Allergy and Clinical Immunology, Brigham and Women's Hospital, Boston, Massachusetts
| | - Geoffrey Oxnard
- Department of Medical Oncology, Boston Medical Center, Boston, Massachusetts
| | - Julia Rotow
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Daniel J DeAngelo
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Mariana Castells
- Department of Allergy and Clinical Immunology, Brigham and Women's Hospital, Boston, Massachusetts
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14
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Wilhelm T, Toledo MAS, Simons I, Stuth C, Mohta V, Mülfarth R, Nitsche M, Maschke-Neuß K, Schmitz S, Kaiser A, Panse J, Christen D, Arock M, Zenke M, Huber M. Capitalizing on paradoxical activation of the mitogen-activated protein kinase pathway for treatment of Imatinib-resistant mast cell leukemia. Hematol Oncol 2023; 41:520-534. [PMID: 36383121 DOI: 10.1002/hon.3100] [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: 08/08/2021] [Revised: 08/29/2022] [Accepted: 11/14/2022] [Indexed: 11/17/2022]
Abstract
Prevention of fatal side effects during cancer therapy of cancer patients with high-dosed pharmacological inhibitors is to date a major challenge. Moreover, the development of drug resistance poses severe problems for the treatment of patients with leukemia or solid tumors. Particularly drug-mediated dimerization of RAF kinases can be the cause of acquired resistance, also called "paradoxical activation." In the present work we re-analyzed the effects of different tyrosine kinase inhibitors (TKIs) on the proliferation, metabolic activity, and survival of the Imatinib-resistant, KIT V560G, D816V-expressing human mast cell (MC) leukemia (MCL) cell line HMC-1.2. We observed that low concentrations of the TKIs Nilotinib and Ponatinib resulted in enhanced proliferation, suggesting paradoxical activation of the MAPK pathway. Indeed, these TKIs caused BRAF-CRAF dimerization, resulting in ERK1/2 activation. The combination of Ponatinib with the MEK inhibitor Trametinib, at nanomolar concentrations, effectively suppressed HMC-1.2 proliferation, metabolic activity, and induced apoptotic cell death. Effectiveness of this drug combination was recapitulated in the human KIT D816V MC line ROSAKIT D816V and in KIT D816V hematopoietic progenitors obtained from patient-derived induced pluripotent stem cells (iPS cells) and systemic mastocytosis patient samples. In conclusion, mutated KIT-driven Imatinib resistance and possible TKI-induced paradoxical activation can be efficiently overcome by a low concentration Ponatinib and Trametinib co-treatment, potentially reducing the negative side effects associated with MCL therapy.
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Affiliation(s)
- Thomas Wilhelm
- Institute of Biochemistry and Molecular Immunology, Medical Faculty, RWTH Aachen University, Aachen, Germany
| | - Marcelo A S Toledo
- Department of Cell Biology, Institute for Biomedical Engineering, RWTH Aachen University Medical School, Aachen, Germany
- Helmholtz-Institute for Biomedical Engineering, RWTH Aachen University, Aachen, Germany
- Department of Hematology, Oncology, Hemostaseology and Stem Cell Transplantation, Faculty of Medicine, RWTH Aachen University Medical School, Aachen, Germany
- Center for Integrated Oncology Aachen Bonn Cologne Düsseldorf (CIO ABCD), Aachen, Germany
| | - Ilka Simons
- Institute of Biochemistry and Molecular Immunology, Medical Faculty, RWTH Aachen University, Aachen, Germany
| | - Christian Stuth
- Institute of Biochemistry and Molecular Immunology, Medical Faculty, RWTH Aachen University, Aachen, Germany
| | - Vrinda Mohta
- Institute of Biochemistry and Molecular Immunology, Medical Faculty, RWTH Aachen University, Aachen, Germany
| | - Ronja Mülfarth
- Institute of Biochemistry and Molecular Immunology, Medical Faculty, RWTH Aachen University, Aachen, Germany
| | - Marcus Nitsche
- Institute of Biochemistry and Molecular Immunology, Medical Faculty, RWTH Aachen University, Aachen, Germany
| | - Karin Maschke-Neuß
- Institute of Biochemistry and Molecular Immunology, Medical Faculty, RWTH Aachen University, Aachen, Germany
| | - Susanne Schmitz
- Department of Cell Biology, Institute for Biomedical Engineering, RWTH Aachen University Medical School, Aachen, Germany
- Helmholtz-Institute for Biomedical Engineering, RWTH Aachen University, Aachen, Germany
| | - Anne Kaiser
- Department of Hematology, Oncology, Hemostaseology and Stem Cell Transplantation, Faculty of Medicine, RWTH Aachen University Medical School, Aachen, Germany
- Center for Integrated Oncology Aachen Bonn Cologne Düsseldorf (CIO ABCD), Aachen, Germany
| | - Jens Panse
- Department of Hematology, Oncology, Hemostaseology and Stem Cell Transplantation, Faculty of Medicine, RWTH Aachen University Medical School, Aachen, Germany
- Center for Integrated Oncology Aachen Bonn Cologne Düsseldorf (CIO ABCD), Aachen, Germany
| | - Deborah Christen
- Department of Hematology, Oncology, Hemostaseology and Stem Cell Transplantation, Faculty of Medicine, RWTH Aachen University Medical School, Aachen, Germany
- Center for Integrated Oncology Aachen Bonn Cologne Düsseldorf (CIO ABCD), Aachen, Germany
| | - Michel Arock
- Department of Hematological Biology, Pitié-Salpêtrière Hospital, Pierre et Marie Curie University (UPMC), Paris, France
| | - Martin Zenke
- Department of Cell Biology, Institute for Biomedical Engineering, RWTH Aachen University Medical School, Aachen, Germany
- Helmholtz-Institute for Biomedical Engineering, RWTH Aachen University, Aachen, Germany
- Department of Hematology, Oncology, Hemostaseology and Stem Cell Transplantation, Faculty of Medicine, RWTH Aachen University Medical School, Aachen, Germany
- Center for Integrated Oncology Aachen Bonn Cologne Düsseldorf (CIO ABCD), Aachen, Germany
| | - Michael Huber
- Institute of Biochemistry and Molecular Immunology, Medical Faculty, RWTH Aachen University, Aachen, Germany
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15
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Aquino A, Bianchi N, Terrazzan A, Franzese O. Protein Kinase C at the Crossroad of Mutations, Cancer, Targeted Therapy and Immune Response. BIOLOGY 2023; 12:1047. [PMID: 37626933 PMCID: PMC10451643 DOI: 10.3390/biology12081047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/30/2023] [Revised: 07/18/2023] [Accepted: 07/21/2023] [Indexed: 08/27/2023]
Abstract
The frequent PKC dysregulations observed in many tumors have made these enzymes natural targets for anticancer applications. Nevertheless, this considerable interest in the development of PKC modulators has not led to the expected therapeutic benefits, likely due to the complex biological activities regulated by PKC isoenzymes, often playing ambiguous and protective functions, further driven by the occurrence of mutations. The structure, regulation and functions of PKCs have been extensively covered in other publications. Herein, we focused on PKC alterations mostly associated with complete functional loss. We also addressed the modest yet encouraging results obtained targeting PKC in selected malignancies and the more frequent negative clinical outcomes. The reported observations advocate the need for more selective molecules and a better understanding of the involved pathways. Furthermore, we underlined the most relevant immune mechanisms controlled by PKC isoforms potentially impacting the immune checkpoint inhibitor blockade-mediated immune recovery. We believe that a comprehensive examination of the molecular features of the tumor microenvironment might improve clinical outcomes by tailoring PKC modulation. This approach can be further supported by the identification of potential response biomarkers, which may indicate patients who may benefit from the manipulation of distinctive PKC isoforms.
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Affiliation(s)
- Angelo Aquino
- Department of Systems Medicine, University of Rome Tor Vergata, 00133 Rome, Italy;
| | - Nicoletta Bianchi
- Department of Translational Medicine, University of Ferrara, 44121 Ferrara, Italy; (N.B.); (A.T.)
| | - Anna Terrazzan
- Department of Translational Medicine, University of Ferrara, 44121 Ferrara, Italy; (N.B.); (A.T.)
- Laboratory for Advanced Therapy Technologies (LTTA), University of Ferrara, 44121 Ferrara, Italy
| | - Ornella Franzese
- Department of Systems Medicine, University of Rome Tor Vergata, 00133 Rome, Italy;
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16
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Fazio M, Vetro C, Markovic U, Duminuco A, Parisi M, Maugeri C, Mauro E, Parrinello NL, Stagno F, Villari L, Triolo AM, Stella S, Palumbo GA, Di Raimondo F, Romano A, Zanotti R. A case of high-risk AML in a patient with advanced systemic mastocytosis. Clin Case Rep 2023; 11:e7134. [PMID: 37469366 PMCID: PMC10352544 DOI: 10.1002/ccr3.7134] [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: 12/22/2022] [Revised: 03/01/2023] [Accepted: 03/13/2023] [Indexed: 07/21/2023] Open
Abstract
Aggressive SM + AML has limited therapeutic options. Even a strong combination of decitabine-venetoclax-midostaurin has a transient effect on AML and a mitigated effect on SM. Larger series are required to identify the best therapeutic strategy.
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Affiliation(s)
- Manlio Fazio
- Post Graduation School of HematologyUniversity of Catania, A.O.U. Policlinico “G.Rodolico‐San Marco”CataniaItaly
| | - Calogero Vetro
- Division of HematologyA.O.U. Policlinico “G.Rodolico‐San Marco”CataniaItaly
| | - Uroš Markovic
- Division of HematologyA.O.U. Policlinico “G.Rodolico‐San Marco”CataniaItaly
| | - Andrea Duminuco
- Post Graduation School of HematologyUniversity of Catania, A.O.U. Policlinico “G.Rodolico‐San Marco”CataniaItaly
| | - Marina Parisi
- Division of HematologyA.O.U. Policlinico “G.Rodolico‐San Marco”CataniaItaly
| | - Cinzia Maugeri
- Division of HematologyA.O.U. Policlinico “G.Rodolico‐San Marco”CataniaItaly
| | - Elisa Mauro
- Division of HematologyA.O.U. Policlinico “G.Rodolico‐San Marco”CataniaItaly
| | | | - Fabio Stagno
- Division of HematologyA.O.U. Policlinico “G.Rodolico‐San Marco”CataniaItaly
| | - Loredana Villari
- Department of PathologyA.O.U. Policlinico di CataniaCataniaItaly
| | - Anna Maria Triolo
- Division of HematologyA.O.U. Policlinico “G.Rodolico‐San Marco”CataniaItaly
| | - Stefania Stella
- Center of Experimental Oncology and HematologyA.O.U. Policlinico “G. Rodolico‐San Marco”CataniaItaly
| | - Giuseppe A. Palumbo
- Post Graduation School of HematologyUniversity of Catania, A.O.U. Policlinico “G.Rodolico‐San Marco”CataniaItaly
- Dipartimento di specialità Medico‐Chirurgiche, CHIRMED, sezione di EmatologiaUniversità degli Studi di CataniaCataniaItaly
- Dipartimento di Scienze Mediche, Chirurgiche e Tecnologie Avanzate “G.F. Ingrassia”University of CataniaCataniaItaly
| | - Francesco Di Raimondo
- Division of HematologyA.O.U. Policlinico “G.Rodolico‐San Marco”CataniaItaly
- Dipartimento di specialità Medico‐Chirurgiche, CHIRMED, sezione di EmatologiaUniversità degli Studi di CataniaCataniaItaly
| | - Alessandra Romano
- Dipartimento di specialità Medico‐Chirurgiche, CHIRMED, sezione di EmatologiaUniversità degli Studi di CataniaCataniaItaly
| | - Roberta Zanotti
- Department of Medicine, Hematology UnitAzienda Ospedaliera Universitaria Integrata di VeronaVeronaItaly
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17
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Pardanani A. Systemic mastocytosis in adults: 2023 update on diagnosis, risk stratification and management. Am J Hematol 2023; 98:1097-1116. [PMID: 37309222 DOI: 10.1002/ajh.26962] [Citation(s) in RCA: 12] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2023] [Revised: 04/29/2023] [Accepted: 05/02/2023] [Indexed: 06/14/2023]
Abstract
OVERVIEW Systemic mastocytosis (SM) results from clonal proliferation of mast cells (MC) in extracutaneous organs. DIAGNOSIS The major criterion is presence of multifocal MC clusters in the bone marrow and/or extracutaneous organs. Minor diagnostic criteria include elevated serum tryptase level, MC CD25/CD2/CD30 expression, and presence of activating KIT mutations. RISK STRATIFICATION Establishing SM subtype as per the International Consensus Classification/World Health Organization classification systems is an important first step. Patients either have indolent/smoldering SM (ISM/SSM) or advanced SM, including aggressive SM (ASM), SM with associated myeloid neoplasm (SM-AMN), and mast cell leukemia. Identification of poor-risk mutations (i.e., ASXL1, RUNX1, SRSF2, NRAS) further refines the risk stratification. Several risk models are available to help assign prognosis in SM patients. MANAGEMENT Treatment goals for ISM patients are primarily directed toward anaphylaxis prevention/symptom control/osteoporosis treatment. Patients with advanced SM frequently need MC cytoreductive therapy to reverse disease-related organ dysfunction. Tyrosine kinase inhibitors (TKI) (midostaurin, avapritinib) have changed the treatment landscape in SM. While deep biochemical, histological and molecular responses have been documented with avapritinib treatment, its efficacy as monotherapy against a multimutated AMN disease component in SM-AMN patients remains unclear. Cladribine continues to have a role for MC debulking, whereas interferon-α has a diminishing role in the TKI era. Treatment of SM-AMN primarily targets the AMN component, particularly if an aggressive disease such as acute leukemia is present. Allogeneic stem cell transplant has a role in such patients. Imatinib has a therapeutic role only in the rare patient with an imatinib-sensitive KIT mutation.
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Affiliation(s)
- Animesh Pardanani
- Division of Hematology, Department of Medicine, Mayo Clinic, Rochester, Minnesota, USA
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18
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Lübke J, Naumann N, Metzgeroth G, Kreil S, Brand T, Horny HP, Sotlar K, Cross NCP, Fabarius A, Valent P, Hofmann WK, Reiter A, Schwaab J. Response and resistance to cladribine in patients with advanced systemic mastocytosis: a registry-based analysis. Ann Hematol 2023:10.1007/s00277-023-05180-y. [PMID: 37012462 DOI: 10.1007/s00277-023-05180-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2022] [Accepted: 03/13/2023] [Indexed: 04/05/2023]
Abstract
We sought to evaluate the efficacy of the purine analogue cladribine in 79 patients with advanced systemic mastocytosis (AdvSM) using data from the 'German Registry on Disorders of Eosinophils and Mast Cells (GREM)'. The overall response rate according to modified Valent criteria (46 evaluable patients) for first- (1L) and second-line (2L) cladribine treatment was 41% (12/29) and 35% (6/17, P = 0.690), respectively, and the median overall survival (OS, all patients evaluable) was 1.9 years (n = 48) and 1.2 years (n = 31; P = 0.311). Univariate and multivariable analyses of baseline and on-treatment parameters identified diagnosis of mast cell leukemia (hazard ratio [HR] 3.5, 95% confidence interval [CI, 1.3-9.1], P = 0.012), eosinophilia ≥ 1.5 × 109/L (HR 2.9 [CI 1.4-6.2], P = 0.006) and < 3 cycles of cladribine (HR 0.4 [CI 0.2-0.8], P = 0.008) as independent adverse prognostic parameters for OS. There was no impact of other laboratory (anemia, thrombocytopenia, serum tryptase) or genetic markers (mutations in SRSF2, ASXL1 or RUNX1) on OS. In consequence, none of the recently established prognostic scoring systems (MARS, IPSM, MAPS or GPSM) was predictive for OS. Modified Valent criteria were superior to a single factor-based response assessment (HR 2.9 [CI 1.3-6.6], P = 0.026). In conclusion, cladribine is effective in 1L and 2L treatment of AdvSM. Mast cell leukemia, eosinophilia, application of < 3 cycles and a lack of response are adverse prognostic markers.
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Affiliation(s)
- Johannes Lübke
- Department of Hematology and Oncology, University Hospital Mannheim, Heidelberg University, Mannheim, Germany
| | - Nicole Naumann
- Department of Hematology and Oncology, University Hospital Mannheim, Heidelberg University, Mannheim, Germany
| | - Georgia Metzgeroth
- Department of Hematology and Oncology, University Hospital Mannheim, Heidelberg University, Mannheim, Germany
| | - Sebastian Kreil
- Department of Hematology and Oncology, University Hospital Mannheim, Heidelberg University, Mannheim, Germany
| | - Timo Brand
- Department of Hematology and Oncology, University Hospital Mannheim, Heidelberg University, Mannheim, Germany
| | - Hans-Peter Horny
- Department of Pathology, Ludwig-Maximilians-University, Munich, Germany
| | - Karl Sotlar
- Department of Pathology, Paracelsus Medical University of Salzburg, Salzburg, Austria
| | | | - Alice Fabarius
- Department of Hematology and Oncology, University Hospital Mannheim, Heidelberg University, Mannheim, Germany
| | - Peter Valent
- Department of Internal Medicine I, Division of Hematology & Hemostaseology, Medical University of Vienna, Vienna, Austria
- Ludwig Boltzmann Institute for Hematology and Oncology, Medical University of Vienna, Vienna, Austria
| | - Wolf-Karsten Hofmann
- Department of Hematology and Oncology, University Hospital Mannheim, Heidelberg University, Mannheim, Germany
| | - Andreas Reiter
- Department of Hematology and Oncology, University Hospital Mannheim, Heidelberg University, Mannheim, Germany.
| | - Juliana Schwaab
- Department of Hematology and Oncology, University Hospital Mannheim, Heidelberg University, Mannheim, Germany
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19
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Desai A, Reddy NK, Subbiah V. Top advances of the year: Precision oncology. Cancer 2023; 129:1634-1642. [PMID: 36946766 DOI: 10.1002/cncr.34743] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/23/2023]
Abstract
The advent of precision medicine has changed the landscape of oncologic biomarkers, drug discovery, drug development, and, more importantly, outcomes for patients with cancer. Precision oncology entails the genomic profiling of tumors to detect actionable aberrations. The advances in clinical next-generation sequencing from both tumor tissue and liquid biopsy and availability of targeted therapies has rapidly entered mainstream clinical practice. In this review, recent major developments in precision oncology that have affected outcomes for patients with cancer are discussed. Rapid clinical development was seen of targeted agents across various mutational profiles such as KRASG12C (which was considered "undruggable" for almost 4 decades), Exon 20 insertions, and RET mutations. Approaches to precision chemotherapy delivery by the introduction of antibody drug conjugates in the armamentarium against lung cancer has been appreciated.
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Affiliation(s)
- Aakash Desai
- Division of Medical Oncology, MayoClinic, Rochester, Minnesota, USA
| | - Neha K Reddy
- Department of Internal Medicine, The University of Texas at Austin Dell Medical School, Austin, Texas, USA
| | - Vivek Subbiah
- Division of Cancer Medicine, Department of Investigational Cancer Therapeutics, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
- Division of Pediatrics, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
- MD Anderson Cancer Network, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
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20
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Mancini M, Monaldi C, De Santis S, Papayannidis C, Rondoni M, Sartor C, Bruno S, Pagano L, Criscuolo M, Zanotti R, Bonifacio M, Tosi P, Arock M, Valent P, Cavo M, Soverini S. SETD2 non genomic loss of function in advanced systemic mastocytosis is mediated by an Aurora kinase A/MDM2 axis and can be therapeutically targeted. Biomark Res 2023; 11:29. [PMID: 36894973 PMCID: PMC9999558 DOI: 10.1186/s40364-023-00468-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2022] [Accepted: 02/22/2023] [Indexed: 03/11/2023] Open
Abstract
BACKGROUND The SETD2 tumor suppressor gene encodes a histone methyltransferase that safeguards transcription fidelity and genomic integrity via trimethylation of histone H3 lysine 36 (H3K36Me3). SETD2 loss of function has been observed in solid and hematologic malignancies. We have recently reported that most patients with advanced systemic mastocytosis (AdvSM) and some with indolent or smoldering SM display H3K36Me3 deficiency as a result of a reversible loss of SETD2 due to reduced protein stability. METHODS Experiments were conducted in SETD2-proficient (ROSAKIT D816V) and -deficient (HMC-1.2) cell lines and in primary cells from patients with various SM subtypes. A short interfering RNA approach was used to silence SETD2 (in ROSAKIT D816V cells), MDM2 and AURKA (in HMC-1.2 cells). Protein expression and post-translational modifications were assessed by WB and immunoblotting. Protein interactions were tested by using co-immunoprecipitation. Apoptotic cell death was evaluated by flow cytometry after annexin V and propidium iodide staining, respectively. Drug cytotoxicity in in vitro experiments was evaluated by clonogenic assays. RESULTS Here, we show that the proteasome inhibitors suppress cell growth and induce apoptosis in neoplastic mast cells by promoting SETD2/H3K36Me3 re-expression. Moreover, we found that Aurora kinase A and MDM2 are implicated in SETD2 loss of function in AdvSM. In line with this observation, direct or indirect targeting of Aurora kinase A with alisertib or volasertib induced reduction of clonogenic potential and apoptosis in human mast cell lines and primary neoplastic cells from patients with AdvSM. Efficacy of Aurora A or proteasome inhibitors was comparable to that of the KIT inhibitor avapritinib. Moreover, combination of alisertib (Aurora A inhibitor) or bortezomib (proteasome inhibitor) with avapritinib allowed to use lower doses of each drug to achieve comparable cytotoxic effects. CONCLUSIONS Our mechanistic insights into SETD2 non-genomic loss of function in AdvSM highlight the potential value of novel therapeutic targets and agents for the treatment of patients who fail or do not tolerate midostaurin or avapritinib.
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Affiliation(s)
- Manuela Mancini
- IRCCS Azienda Ospedaliero-Universitaria Di Bologna, Istituto Di Ematologia "Seràgnoli", Bologna, Italy.
| | - Cecilia Monaldi
- Dipartimento Di Medicina Specialistica, Diagnostica E Sperimentale, Università Di Bologna, Bologna, Italy
| | - Sara De Santis
- Dipartimento Di Medicina Specialistica, Diagnostica E Sperimentale, Università Di Bologna, Bologna, Italy
| | - Cristina Papayannidis
- IRCCS Azienda Ospedaliero-Universitaria Di Bologna, Istituto Di Ematologia "Seràgnoli", Bologna, Italy
| | | | - Chiara Sartor
- IRCCS Azienda Ospedaliero-Universitaria Di Bologna, Istituto Di Ematologia "Seràgnoli", Bologna, Italy
- Dipartimento Di Medicina Specialistica, Diagnostica E Sperimentale, Università Di Bologna, Bologna, Italy
| | - Samantha Bruno
- Dipartimento Di Medicina Specialistica, Diagnostica E Sperimentale, Università Di Bologna, Bologna, Italy
| | - Livio Pagano
- Divisione Di Ematologia Geriatrica Ed Emopatie Rare, Fondazione Policlinico Universitario Agostino Gemelli - IRCCS - Università Cattolica del Sacro Cuore, Roma, Italy
| | - Marianna Criscuolo
- Dipartimento Di Diagnostica Per Immagini, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Radioterapia Oncologica Ed Ematologia, Roma, Italy
| | - Roberta Zanotti
- Section of Hematology, Multidisciplinary Outpatients Clinics for Mastocytosis, Department of Medicine, University Hospital of Verona, Verona, Italy
| | - Massimiliano Bonifacio
- Section of Hematology, Multidisciplinary Outpatients Clinics for Mastocytosis, Department of Medicine, University Hospital of Verona, Verona, Italy
| | | | - Michel Arock
- Department of Hematological Biology, Pitié-Salpêtrière Hospital, Pierre Et Marie Curie University (UPMC), Paris, France
| | - Peter Valent
- Department of Internal Medicine I, Division of Hematology and Hemostaseology, Medical University of Vienna, Vienna, Austria
- Ludwig Boltzmann Institute of Hematology and Oncology, Medical University of Vienna, Vienna, Austria
| | - Michele Cavo
- IRCCS Azienda Ospedaliero-Universitaria Di Bologna, Istituto Di Ematologia "Seràgnoli", Bologna, Italy
- Dipartimento Di Medicina Specialistica, Diagnostica E Sperimentale, Università Di Bologna, Bologna, Italy
| | - Simona Soverini
- Dipartimento Di Medicina Specialistica, Diagnostica E Sperimentale, Università Di Bologna, Bologna, Italy
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21
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Decruyenaere P, Mazure D, Moors I, Van Dorpe J, Van der Linden M, Denys B, Hofmans M, Offner F. Systemic mastocytosis with myeloid sarcoma and B-CLL: molecular and clonal heterogeneity in a rare case of SM-AHN with review of literature. Acta Clin Belg 2023; 78:58-66. [PMID: 35098906 DOI: 10.1080/17843286.2022.2033919] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
BACKGROUND Systemic mastocytosis (SM) is a rare myeloproliferative disease that results from a clonal proliferation of abnormal mast cells in one or more extra-cutaneous organs. Systemic mastocytosis with an associated hematological neoplasm (SM-AHN) is the second most common subgroup and is diagnosed when WHO criteria for both SM and a hematological neoplasm of non-mast cell lineage are met. The SM-AHN category as currently proposed is highly heterogeneous in terms of pathogenesis, clinical presentation, and prognosis. CASE PRESENTATION We present the first reported case of SM-AHN associated with two hematological malignancies of different lineages, a monocytic myeloid sarcoma and a B-cell chronic lymphatic leukemia. Cytogenetic and molecular analyses revealed a distinct clonal origin of the two associated malignancies. The SM-myeloid sarcoma clone demonstrated an abnormal karyotype, trisomy 8 and del(13)(q12.3q14.3), as well as mutations in KITD816V, DNMT3A and RUNX1. The DNMT3A mutation could be detected years before disease onset, supporting its potential role as early driver of leukemogenesis. No genetic aberrations could be identified in the CLL clone, which is assumed to present coincidentally. CONCLUSIONS This report highlights the importance of full diagnostic work-up in SM patients in whom an associated hematological malignancy is suspected. Moreover, the importance of genetic analysis is highlighted, as it provides additional insights in the underlying clonal pathogenesis of different phenotypes, can aid in risk stratification, and may help identify potential therapy targets.
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Affiliation(s)
- Philippe Decruyenaere
- Department of Hematology, Ghent University Hospital, Ghent, Belgium.,OncoRNALab, Cancer Research Institute Ghent (Crig), Ghent University, Ghent, Belgium.,Department of Biomolecular Medicine, Ghent University, Ghent, Belgium
| | - Dominiek Mazure
- Department of Hematology, Ghent University Hospital, Ghent, Belgium
| | - Ine Moors
- Department of Hematology, Ghent University Hospital, Ghent, Belgium
| | - Jo Van Dorpe
- Department of Pathology, Ghent University Hospital, Ghent, Belgium
| | | | - Barbara Denys
- Department of Diagnostic Sciences, Ghent University Hospital, Ghent, Belgium
| | - Mattias Hofmans
- Department of Diagnostic Sciences, Ghent University Hospital, Ghent, Belgium
| | - Fritz Offner
- Department of Hematology, Ghent University Hospital, Ghent, Belgium
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22
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Gotlib J. Available and emerging therapies for bona fide advanced systemic mastocytosis and primary eosinophilic neoplasms. HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2022; 2022:34-46. [PMID: 36485158 PMCID: PMC9821059 DOI: 10.1182/hematology.2022000368] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
The historically poor prognosis of patients with advanced systemic mastocytosis (AdvSM) and primary eosinophilic neoplasms has shifted to increasingly favorable outcomes with the discovery of druggable targets. The multikinase/KIT inhibitor midostaurin and the highly selective KIT D816V inhibitor avapritinib can elicit marked improvements in measures of mast cell (MC) burden as well as reversion of MC-mediated organ damage (C-findings) and disease symptoms. With avapritinib, the achievement of molecular remission of KIT D816V and improved survival compared with historical therapy suggests a potential to affect disease natural history. BLU-263 and bezuclastinib are KIT D816V inhibitors currently being tested in trials of AdvSM. In the new World Health Organization and International Consensus Classifications, the category of "myeloid/lymphoid neoplasms with eosinophilia and tyrosine kinase (TK) gene fusions" is inclusive of rearrangements involving PDGFRA, PDGFRB, FGFR1, JAK2, FLT3, and ETV6::ABL1. While the successful outcomes with imatinib in FIP1L1::PDGFRA-positive cases and PDGFRB-rearranged neoplasms have become the "poster children" of these disorders, the responses of the other TK-driven neoplasms to small-molecule inhibitors are more variable. The selective FGFR inhibitor pemigatinib, approved in August 2022, is a promising therapy in aggressive FGFR1-driven diseases and highlights the role of such agents in bridging patients to allogeneic transplantation. This review summarizes the data for these approved and investigational agents and discusses open questions and future priorities regarding the management of these rare diseases.
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Affiliation(s)
- Jason Gotlib
- Division of Hematology, Stanford Cancer Institute/Stanford University School of Medicine, Stanford, CA
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23
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Avapritinib for advanced systemic mastocytosis. Blood 2022; 140:1667-1673. [PMID: 35877999 DOI: 10.1182/blood.2021014612] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2022] [Accepted: 07/16/2022] [Indexed: 11/20/2022] Open
Abstract
Avapritinib, a highly selective inhibitor of KIT D816V, was approved by the Food and Drug Administration in 2021 for treatment of advanced systemic mastocytosis (AdvSM) and by the European Medicines Agency in 2022 for AdvSM after prior systemic therapy. The phase 1 EXPLORER and phase 2 PATHFINDER trials demonstrated that avapritinib can elicit complete and durable clinical responses and molecular remission of KIT D816V. Key management challenges relate to the complex mutational landscape of AdvSM, often found with an associated hematologic neoplasm.
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24
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Velloso EDRP, Padulla GA, de Cerqueira AMM, de Sousa AM, Sandes AF, Traina F, Seguro FS, Nogueira FL, Pereira GDF, Boechat JL, Pagnano KBB, Marchi LL, Ensina LF, Giavina-Bianchi M, Aun MV, Agondi RC, Santos FPDS, Giavina-Bianchi P. Diagnosis and treatment of systemic mastocytosis in Brazil: Recommendations of a multidisciplinary expert panel. Hematol Transfus Cell Ther 2022; 44:582-594. [PMID: 35688791 PMCID: PMC9605912 DOI: 10.1016/j.htct.2022.04.006] [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: 12/10/2021] [Revised: 03/04/2022] [Accepted: 04/25/2022] [Indexed: 11/29/2022] Open
Abstract
INTRODUCTION Systemic Mastocytosis comprises a group of neoplastic diseases characterized by clonal expansion and infiltration of mast cells into several organs. The diagnosis and treatment of this disease may be challenging for non-specialists. OBJECTIVE Make suggestions or recommendations in Systemic Mastocytosis based in a panel of Brazilian specialists. METHOD AND RESULTS An online expert panel with 18 multidisciplinary specialists was convened to propose recommendations on the diagnosis and treatment of Systemic Mastocytosis in Brazil. Recommendations were based on discussions of topics and multiple-choice questions and were graded using the Oxford Centre for Evidence-Based Medicine 2011 Levels of Evidence Chart. CONCLUSION Twenty-two recommendations or suggestions were proposed based on a literature review and graded according to the findings.
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Affiliation(s)
- Elvira D Rodrigues Pereira Velloso
- Clinical Immunology and Allergy Division. Faculdade de Medicina da Universidade de São Paulo, São Paulo, SP, Brazil; Hospital Israelita Albert Einstein, São Paulo, SP, Brazil.
| | - Geórgia A Padulla
- Clinical Immunology and Allergy Division. Faculdade de Medicina da Universidade de São Paulo, São Paulo, SP, Brazil
| | | | - Adriana Martins de Sousa
- Instituto de Pediatria e Puericultura Martagão Gesteira da Universidade Federal do Rio de Janeiro (IPPMG UFRJ), Rio de Janeiro, RJ, Brazil
| | - Alex Freire Sandes
- Grupo Fleury, São Paulo, SP, Brazil; Universidade Federal de São Paulo (Unifesp), São Paulo, SP, Brazil
| | - Fabiola Traina
- Faculdade de Medicina de Ribeirão Preto, Universidade de São Paulo (FMRP USP), São Paulo, SP, Brazil
| | - Fernanda Salles Seguro
- Clinical Immunology and Allergy Division. Faculdade de Medicina da Universidade de São Paulo, São Paulo, SP, Brazil
| | - Frederico Lisboa Nogueira
- Hospital Luxemburgo, Instituto Mário Penna, Belo Horizonte, MG, Brazil; Grupo Oncoclínicas, Belo Horizonte, MG, Brazil
| | | | - José Laerte Boechat
- Faculdade de Medicina da Universidade Federal Fluminense (FM UFF), Niteroi, RJ, Brazil
| | | | - Luan Lima Marchi
- Clinical Immunology and Allergy Division. Faculdade de Medicina da Universidade de São Paulo, São Paulo, SP, Brazil
| | | | - Mara Giavina-Bianchi
- Clinical Immunology and Allergy Division. Faculdade de Medicina da Universidade de São Paulo, São Paulo, SP, Brazil
| | - Marcelo Vivolo Aun
- Clinical Immunology and Allergy Division. Faculdade de Medicina da Universidade de São Paulo, São Paulo, SP, Brazil; Faculdade Israelita de Ciências da Saúde Albert Einstein, São Paulo, SP, Brazil
| | - Rosana Câmara Agondi
- Clinical Immunology and Allergy Division. Faculdade de Medicina da Universidade de São Paulo, São Paulo, SP, Brazil
| | - Fabio Pires de Souza Santos
- Hospital Israelita Albert Einstein, São Paulo, SP, Brazil; A Beneficência Portuguesa de São Paulo, BP, São Paulo, SP, Brazil
| | - Pedro Giavina-Bianchi
- Clinical Immunology and Allergy Division. Faculdade de Medicina da Universidade de São Paulo, São Paulo, SP, Brazil
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25
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Crupi F, Sordi B, Vanderwert F, Gesullo F, Amorosi A, Mannelli F, Santi R. Histopathology and Molecular Genetics in Systemic Mastocytosis: Implications for Clinical Management. Int J Mol Sci 2022; 23:ijms23158772. [PMID: 35955907 PMCID: PMC9369381 DOI: 10.3390/ijms23158772] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2022] [Revised: 07/21/2022] [Accepted: 08/03/2022] [Indexed: 11/16/2022] Open
Abstract
The diagnosis of systemic mastocytosis (SM) is based on various clinical, dermatological, serological, and hematological findings but essentially relies on histological evidence of an abnormal increase in tissue-localized mast cells (MCs). The extra-cutaneous organ most frequently affected is the bone marrow (BM), and therefore, histological examination of trephine biopsy specimens of the iliac crest is mandatory on suspicion of SM. At microscopic examination, neoplastic MCs show aberrant morphology, usually with prominent spindling. Immunohistochemistry is a useful tool in the diagnosis of SM because mast cell (MC) infiltrates may be slight and scarce, in a mixed background of lymphohistiocytic cells, eosinophils, and plasma cells. Moreover, neoplastic MCs exhibit an aberrant phenotype. Recent evidence, largely derived from molecular genetics, has enhanced the diagnostic capability of SM, also providing the basis for adequate prognostic and therapeutic evaluation. The cases herein reported illustrate the variable clinical manifestations and disease course of SM, focusing on diagnostic and therapeutic challenges. In accordance with the World Health Organization (WHO) classification and the International Consensus Classification (ICC) systems, our findings emphasize the importance of an integrated diagnostic approach for SM, with proper application of diverse assessment methodologies in order to improve SM classification and treatment effectiveness.
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Affiliation(s)
- Francesca Crupi
- Centro Ricerca e Innovazione Malattie Mieloproliferative (CRIMM), AOU Careggi, 50134 Firenze, Italy
| | - Benedetta Sordi
- Centro Ricerca e Innovazione Malattie Mieloproliferative (CRIMM), AOU Careggi, 50134 Firenze, Italy
| | - Fiorenza Vanderwert
- Centro Ricerca e Innovazione Malattie Mieloproliferative (CRIMM), AOU Careggi, 50134 Firenze, Italy
| | - Francesca Gesullo
- Centro Ricerca e Innovazione Malattie Mieloproliferative (CRIMM), AOU Careggi, 50134 Firenze, Italy
| | - Andrea Amorosi
- Dipartimento di Scienze della Salute, Università Magna Grecia, 88100 Catanzaro, Italy
| | - Francesco Mannelli
- Centro Ricerca e Innovazione Malattie Mieloproliferative (CRIMM), AOU Careggi, 50134 Firenze, Italy
| | - Raffaella Santi
- Sezione di Anatomia Patologica, Dipartimento di Scienze della Salute, Università degli Studi di Firenze, 50121 Firenze, Italy
- Correspondence:
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26
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Gotlib J, Schwaab J, Shomali W, George TI, Radia DH, Castells M, Carter MC, Hartmann K, Álvarez-Twose I, Brockow K, Bonadonna P, Hermine O, Niedoszytko M, Hoermann G, Sperr WR, Elberink HO, Siebenhaar F, Butterfield JH, Ustun C, Zanotti R, Triggiani M, Schwartz LB, Lyons JJ, Orfao A, Sotlar K, Horny HP, Arock M, Metcalfe DD, Akin C, Lübke J, Valent P, Reiter A. Proposed European Competence Network on Mastocytosis-American Initiative in Mast Cell Diseases (ECNM-AIM) Response Criteria in Advanced Systemic Mastocytosis. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2022; 10:2025-2038.e1. [PMID: 35724948 DOI: 10.1016/j.jaip.2022.05.034] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/21/2022] [Revised: 05/23/2022] [Accepted: 05/25/2022] [Indexed: 12/18/2022]
Abstract
Advanced systemic mastocytosis (AdvSM) is characterized by the presence of KIT D816V and other somatic mutations (eg, in SRSF2, ASXL1, and RUNX1) in 95% and 60% to 70% of patients, respectively. The biological and clinical consequences of AdvSM include multilineage involvement (eg, associated hematologic neoplasm) in 60% to 80% of patients, variable infiltration and damage (C-findings) of predominantly bone marrow and visceral organs through affected mast cell (MC) and non-MC lineages, and elevated levels of serum tryptase. Recently, the treatment landscape has substantially changed with the introduction of the multikinase/KIT inhibitor midostaurin and the selective KIT D816V inhibitor avapritinib. In this review, we discuss the evolution of AdvSM response criteria that have been developed to better capture clinical benefit (eg, improved responses and progression-free and overall survival). We propose refined response criteria from European Competence Network on Mastocytosis and American Initiative in Mast Cell Diseases investigators that use a tiered approach to segregate the effects of histopathologic (eg, bone marrow MC burden, tryptase), molecular (eg, KIT D816V variant allele frequency), clinical (eg, C-findings), and symptom response on long-term outcomes. These response criteria require evaluation in future prospective clinical trials of selective KIT inhibitors and other novel agents.
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Affiliation(s)
- Jason Gotlib
- Stanford Cancer Institute/Stanford University School of Medicine, Stanford, Calif.
| | - Juliana Schwaab
- Department of Hematology and Oncology, University Hospital Mannheim, Heidelberg University, Mannheim, Germany
| | - William Shomali
- Stanford Cancer Institute/Stanford University School of Medicine, Stanford, Calif
| | - Tracy I George
- Department of Pathology, University of Utah, Salt Lake City, Utah
| | - Deepti H Radia
- Department of Clinical Haematology, Guys and St Thomas' NHS Hospitals, London, United Kingdom
| | - Mariana Castells
- Division of Allergy and Immunology, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Mass
| | - Melody C Carter
- Mast Cell Biology Section, Laboratory of Allergic Diseases, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Md
| | - Karin Hartmann
- Division of Allergy, Department of Dermatology, University Hospital Basel and University of Basel, Basel, Switzerland; Department of Biomedicine, University Hospital Basel and University of Basel, Switzerland
| | - Ivan Álvarez-Twose
- Instituto de Estudios de Mastocitosis de Castilla La Mancha and Centro de Investigación Biomédica en Red de Oncología (CIBERONC), Hospital Virgen del Valle, Toledo, Spain
| | - Knut Brockow
- Department of Dermatology and Allergy Biederstein, School of Medicine, Technical University of Munich, Munich, Germany
| | | | - Olivier Hermine
- Imagine Institute Université de Paris, Sorbonne, INSERM U1163, Centre National de Référence des Mastocytoses, Hôpital Necker, Assistance Publique Hôpitaux de Paris, Paris, France
| | - Marek Niedoszytko
- Department of Allergology, Medical University of Gdansk, Gdansk, Poland
| | - Gregor Hoermann
- MLL Munich Leukemia Laboratory, Munich, Germany; Ludwig Boltzmann Institute for Hematology and Oncology, Medical University of Vienna, Vienna, Austria
| | - Wolfgang R Sperr
- Ludwig Boltzmann Institute for Hematology and Oncology, Medical University of Vienna, Vienna, Austria; Department of Internal Medicine I, Division of Hematology and Hemostaseology, Medical University of Vienna, Vienna, Austria
| | - Hanneke Oude Elberink
- Department of Allergology, University Medical Center Groningen and GRIAC Research Institute, University of Groningen, Groningen, The Netherlands
| | - Frank Siebenhaar
- Institute of Allergology, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany; Department of Allergology and Immunology, Fraunhofer Institute for Translational Medicine and Pharmacology ITMP, Berlin, Germany
| | | | - Celalettin Ustun
- Department of Medicine, Division of Hematology, Oncology, and Cell Therapy, Coleman Foundation Blood and Marrow Transplant Center at Rush University Medical Center, Chicago, Ill
| | - Roberta Zanotti
- Section of Hematology, Multidisciplinary Outpatients Clinics for Mastocytosis, Department of Medicine, University Hospital of Verona, Verona, Italy
| | - Massimo Triggiani
- Division of Allergy and Clinical Immunology, University of Salerno, Salerno, Italy
| | - Lawrence B Schwartz
- Department of Internal Medicine, Division of Rheumatology, Allergy, and Immunology, Virginia Commonwealth University, Richmond, Va
| | - Jonathan J Lyons
- Translational Allergic Immunopathology Unit, Laboratory of Allergic Diseases, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Md
| | - Alberto Orfao
- Servicio Central de Citometria (NUCLEUS), Instituto de Biología Molecular y Celular del Cáncer (IBMCC) Instituto Biosanitario de Salamanca, CIBERONC and Department of Medicine, University of Salamanca, Salamanca, Spain; Utah
| | - Karl Sotlar
- Institute of Pathology, Paracelsus Medical University Salzburg, Salzburg, Austria
| | - Hans-Peter Horny
- Institute of Pathology, Ludwig-Maximilians-University, Munich, Germany
| | - Michel Arock
- Department of Hematological Biology, Pitié-Salpêtrière Hospital, Pierre et Marie Curie University, Paris, France
| | - Dean D Metcalfe
- Mast Cell Biology Section, Laboratory of Allergic Diseases, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Md
| | - Cem Akin
- Division of Allergy and Clinical Immunology, University of Michigan, Ann Arbor, Mich
| | - Johannes Lübke
- Department of Hematology and Oncology, University Hospital Mannheim, Heidelberg University, Mannheim, Germany
| | - Peter Valent
- Ludwig Boltzmann Institute for Hematology and Oncology, Medical University of Vienna, Vienna, Austria; Department of Internal Medicine I, Division of Hematology and Hemostaseology, Medical University of Vienna, Vienna, Austria
| | - Andreas Reiter
- Department of Hematology and Oncology, University Hospital Mannheim, Heidelberg University, Mannheim, Germany
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27
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Systemic Mastocytosis and Other Entities Involving Mast Cells: A Practical Review and Update. Cancers (Basel) 2022; 14:cancers14143474. [PMID: 35884535 PMCID: PMC9322501 DOI: 10.3390/cancers14143474] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2022] [Revised: 07/11/2022] [Accepted: 07/13/2022] [Indexed: 02/05/2023] Open
Abstract
Evidence in the recent literature suggests that the presentation spectrum of mast cell neoplasms is broad. In this article, we elaborate on recent data pertaining to minor diagnostic criteria of systemic mastocytosis (SM), including sensitive testing methods for detection of activating mutations in the KIT gene or its variants, and adjusted serum tryptase levels in cases with hereditary α-tryptasemia. We also summarize entities that require differential diagnosis, such as the recently reclassified SM subtype named bone marrow mastocytosis, mast cell leukemia (an SM subtype that can be acute or chronic); the rare morphological variant of all SM subtypes known as well-differentiated systemic mastocytosis; the extremely rare myelomastocytic leukemia and its differentiating features from mast cell leukemia; and mast cell activation syndrome. In addition, we provide a concise clinical update of the latest adjusted risk stratification model incorporating genomic data to define prognosis in SM and new treatments that were approved for advanced SM (midostaurin, avapritinib).
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Efficacy of avapritinib versus best available therapy in the treatment of advanced systemic mastocytosis. Leukemia 2022; 36:2108-2120. [PMID: 35790816 PMCID: PMC9343245 DOI: 10.1038/s41375-022-01615-z] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2022] [Revised: 05/05/2022] [Accepted: 05/25/2022] [Indexed: 12/18/2022]
Abstract
Advanced systemic mastocytosis (AdvSM) is a rare myeloid neoplasm associated with poor overall survival (OS). This study (NCT04695431) compared clinical outcomes between patients with AdvSM treated with avapritinib in the Phase 1 EXPLORER (NCT0256198) and Phase 2 PATHFINDER (NCT03580655) trials (N = 176) and patients treated with best available therapy (BAT; N = 141). A multi-center, observational, retrospective chart review study was conducted at six study sites (four European, two American) to collect data from patients with AdvSM who received BAT; these data were pooled with data from EXPLORER and PATHFINDER. Comparisons between outcomes of OS, duration of treatment (DOT), and maximum reduction in serum tryptase were conducted between the treatment cohorts, with adjustment for key covariates. The results indicated that the avapritinib cohort had significantly better survival (adjusted hazard ratio (HR) (95% confidence interval (CI)): 0.48 (0.29, 0.79); p = 0.004) and significantly longer DOT (HR: 0.36 (0.26, 0.51); p < 0.001) compared to the BAT cohort. Additionally, the mean difference in percentage maximum reduction in serum tryptase levels was 60.3% greater in the avapritinib cohort (95% CI: −72.8, −47.9; p < 0.001). With no randomized controlled trials comparing avapritinib to BAT, these data offer crucial insights into the improved efficacy of avapritinib for the treatment of AdvSM.
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Sciumè M, De Magistris C, Galli N, Ferretti E, Milesi G, De Roberto P, Fabris S, Grifoni FI. Target Therapies for Systemic Mastocytosis: An Update. Pharmaceuticals (Basel) 2022; 15:ph15060738. [PMID: 35745657 PMCID: PMC9229771 DOI: 10.3390/ph15060738] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2022] [Revised: 06/04/2022] [Accepted: 06/09/2022] [Indexed: 02/01/2023] Open
Abstract
Systemic mastocytosis (SM) results from a clonal proliferation of abnormal mast cells (MCs) in extra-cutaneous organs. It could be divided into indolent SM, smoldering SM, SM with an associated hematologic (non-MC lineage) neoplasm, aggressive SM, and mast cell leukemia. SM is generally associated with the presence of a gain-of-function somatic mutation in KIT at codon 816. Clinical features could be related to MC mediator release or to uncontrolled infiltration of MCs in different organs. Whereas indolent forms have a near-normal life expectancy, advanced diseases have a poor prognosis with short survival times. Indolent forms should be considered for symptom-directed therapy, while cytoreductive therapy represents the first-line treatment for advanced diseases. Since the emergence of tyrosine kinase inhibitors (TKIs), KIT inhibition has been an attractive approach. Initial reports showed that only the rare KITD816V negative cases were responsive to first-line TKI imatinib. The development of new TKIs with activity against the KITD816V mutation, such as midostaurin or avapritinib, has changed the management of this disease. This review aims to focus on the available clinical data of therapies for SM and provide insights into possible future therapeutic targets.
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Affiliation(s)
- Mariarita Sciumè
- Hematology Unit, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, 20122 Milan, Italy; (G.M.); (P.D.R.); (S.F.); (F.I.G.)
- Correspondence: ; Tel.: +39-02-5503-3466
| | - Claudio De Magistris
- Department of Oncology and Oncohaematology, Università degli Studi di Milano, 20122 Milan, Italy; (C.D.M.); (N.G.)
| | - Nicole Galli
- Department of Oncology and Oncohaematology, Università degli Studi di Milano, 20122 Milan, Italy; (C.D.M.); (N.G.)
| | - Eleonora Ferretti
- Direzione Scientifica, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, 20122 Milan, Italy;
| | - Giulia Milesi
- Hematology Unit, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, 20122 Milan, Italy; (G.M.); (P.D.R.); (S.F.); (F.I.G.)
| | - Pasquale De Roberto
- Hematology Unit, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, 20122 Milan, Italy; (G.M.); (P.D.R.); (S.F.); (F.I.G.)
| | - Sonia Fabris
- Hematology Unit, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, 20122 Milan, Italy; (G.M.); (P.D.R.); (S.F.); (F.I.G.)
| | - Federica Irene Grifoni
- Hematology Unit, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, 20122 Milan, Italy; (G.M.); (P.D.R.); (S.F.); (F.I.G.)
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Singh A, Al‐Kali A, Begna KH, Litzow MR, Larsen JT, Sher T, Abdelmagid MG, Farrukh F, Reichard KK, Gangat N, Pardanani A, Tefferi A. Midostaurin therapy for advanced systemic mastocytosis: Mayo Clinic experience in 33 consecutive cases. Am J Hematol 2022; 97:630-637. [PMID: 35156231 DOI: 10.1002/ajh.26498] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2022] [Revised: 02/07/2022] [Accepted: 02/10/2022] [Indexed: 12/13/2022]
Abstract
We retrospectively examined our experience with midostaurin therapy in 33 consecutive patients (median age 68 years; 58% females) with advanced systemic mastocytosis (adv-SM): aggressive SM (ASM; n = 17), SM associated with another hematologic neoplasm (SM-AHN; n = 14) and mast cell leukemia (MCL; n = 2). KITD816V mutation was detected in 84% of the patients and C findings in 91%. Eleven (33%) patients were previously treated with other cytoreductive drugs, including cladribine (n = 4) and imatinib (n = 3). Median time from diagnosis to initiation of midostaurin therapy was 2.2 months (range 0.3-41). Using modified valent criteria, overall response was 42% (53% ASM, 29% SM-AHN, 50% MCL; p = .22), all classified as being major. Responses included ≥50% reduction in bone marrow mast cells in 40% and normalization of serum tryptase in 29%, of evaluated cases. After a median follow-up of 14.6 months from initiation of midostaurin therapy, 7 (21%) deaths, 1 (3%) leukemic progression, and 18 (55%) treatment discontinuations were documented; median duration of midostaurin treatment was 7.9 months (range 0.5-123) and response duration 21.5 months (range 2.9-123). Most frequent side effect was gastrointestinal (51%) while grade 3/4 neutropenia or thrombocytopenia occurred in 12% of patients. Response to treatment was not predicted by KIT mutation (p = .67) or exposure to prior cytoreductive therapy (p = .44). Median survival was longer in midostaurin responders but not significantly (median 26.5 vs. 16 months; p = .15). Findings from the current study are broadly consistent with previously published clinical trial observations.
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Affiliation(s)
- Amritpal Singh
- Division of Hematology Mayo Clinic Rochester Minnesota USA
| | - Aref Al‐Kali
- Division of Hematology Mayo Clinic Rochester Minnesota USA
| | | | - Mark R. Litzow
- Division of Hematology Mayo Clinic Rochester Minnesota USA
| | | | - Taimur Sher
- Division of Hematology Mayo Clinic Jacksonville Florida USA
| | | | - Faiqa Farrukh
- Division of Hematology Mayo Clinic Rochester Minnesota USA
| | | | - Naseema Gangat
- Division of Hematology Mayo Clinic Rochester Minnesota USA
| | | | - Ayalew Tefferi
- Division of Hematology Mayo Clinic Rochester Minnesota USA
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Understanding human mast cells: lesson from therapies for allergic and non-allergic diseases. Nat Rev Immunol 2022; 22:294-308. [PMID: 34611316 DOI: 10.1038/s41577-021-00622-y] [Citation(s) in RCA: 80] [Impact Index Per Article: 40.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/19/2021] [Indexed: 02/07/2023]
Abstract
Mast cells have crucial roles in allergic and other inflammatory diseases. Preclinical approaches provide circumstantial evidence for mast cell involvement in many diseases, but these studies have major limitations - for example, there is still a lack of suitable mouse models for some mast cell-driven diseases such as urticaria. Some approaches for studying mast cells are invasive or can induce severe reactions, and very few mediators or receptors are specific for mast cells. Recently, several drugs that target human mast cells have been developed. These include monoclonal antibodies and small molecules that can specifically inhibit mast cell degranulation via key receptors (such as FcεRI), that block specific signal transduction pathways involved in mast cell activation (for example, BTK), that silence mast cells via inhibitory receptors (such as Siglec-8) or that reduce mast cell numbers and prevent their differentiation by acting on the mast/stem cell growth factor receptor KIT. In this Review, we discuss the existing and emerging therapies that target mast cells, and we consider how these treatments can help us to understand mast cell functions in disease.
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Pharm.D. MA, Hoermann G, Sotlar K, Hermine O, Sperr WR, Hartmann K, Brockow K, Akin C, Triggiani M, Broesby-Olsen S, Reiter A, Gotlib J, Horny HP, Orfao A, Metcalfe DD, Valent P. Clinical Impact and Proposed Application of Molecular Markers, Genetic Variants and Cytogenetic Analysis in Mast Cell Neoplasms: Status 2022. J Allergy Clin Immunol 2022; 149:1855-1865. [DOI: 10.1016/j.jaci.2022.04.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2022] [Revised: 03/28/2022] [Accepted: 04/08/2022] [Indexed: 10/18/2022]
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Farrukh F, Gangat N, Shah MV, Litzow MR, Elliott MA, Begna K, Hook CC, Tefferi A, Pardanani A. Midostaurin therapy for indolent and smoldering systemic mastocytosis: Retrospective review of Mayo Clinic experience. Am J Hematol 2022; 97:E138-E140. [PMID: 35015315 DOI: 10.1002/ajh.26464] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2021] [Revised: 01/05/2022] [Accepted: 01/09/2022] [Indexed: 11/10/2022]
Affiliation(s)
- Faiqa Farrukh
- Division of Hematology, Department of Internal Medicine Mayo Clinic Rochester Minnesota USA
| | - Naseema Gangat
- Division of Hematology, Department of Internal Medicine Mayo Clinic Rochester Minnesota USA
| | - Mithun V. Shah
- Division of Hematology, Department of Internal Medicine Mayo Clinic Rochester Minnesota USA
| | - Mark R. Litzow
- Division of Hematology, Department of Internal Medicine Mayo Clinic Rochester Minnesota USA
| | - Michelle A. Elliott
- Division of Hematology, Department of Internal Medicine Mayo Clinic Rochester Minnesota USA
| | - Kebede Begna
- Division of Hematology, Department of Internal Medicine Mayo Clinic Rochester Minnesota USA
| | - Christopher C. Hook
- Division of Hematology, Department of Internal Medicine Mayo Clinic Rochester Minnesota USA
| | - Ayalew Tefferi
- Division of Hematology, Department of Internal Medicine Mayo Clinic Rochester Minnesota USA
| | - Animesh Pardanani
- Division of Hematology, Department of Internal Medicine Mayo Clinic Rochester Minnesota USA
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Arnán Sangerman M, Fernández Moreno A, García Quintana A, García-Vidal C, Olave Rubio MT, Del Mar Tormo Díaz M, Vendranas M, Rodriguez Macias G. Practical tips for managing FLT3 mutated acute myeloid leukemia with midostaurin. Expert Rev Hematol 2022; 15:203-214. [PMID: 35332831 DOI: 10.1080/17474086.2022.2054801] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
INTRODUCTION FLT3 inhibitors have been recently introduced as novel treatment targets in patients with FLT3-mutated acute myeloid leukemia (AML). Midostaurin is an oral multikinase inhibitor that targets multiple receptor tyrosine kinases including FLT3 and has been approved for the treatment of AML with FLT3 mutations in patients candidates for intensive chemotherapy. This article presents an updated overall overview of the use of midostaurin in clinical practice. AREAS COVERED Tests and examinations to be performed before the use of midostaurin, antifungal and antimicrobial treatment, as well as antifungal and antimicrobial prophylaxis are discussed. Practical tips for the treatment of QTc interval prolongation and heart failure are also presented. EXPERT OPINION Midostaurin is the first agent showing significant survival benefit when combined with chemotherapy in FLT3-mutated AML patients. Optimal use of midostaurin should be a priority, being essential to know the interactions with other drugs like strong CYP3A4 inhibitors or inducers, which are particularly used in the concomitant treatment of AML patients and may increase toxicity or decrease therapeutic benefit. The active role of hematologists and nursing teams is crucial to ensure patient adherence to midostaurin treatment and to minimize adverse effects by administrating the optimal dose for each situation.
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Affiliation(s)
- Montserrat Arnán Sangerman
- Hematology Department, Institut Català d'Oncologia-Hospital Duran i Reynals, IDIBELL, L'Hospitalet de Llobregat, Barcelona, Spain
| | | | - Antonio García Quintana
- Cardiology Unit, Hospital Universitario de Gran Canaria Doctor Negrín, Las Palmas de Gran Canaria, Spain
| | | | | | - María Del Mar Tormo Díaz
- Hematology Department, Hospital Clínico Universitario de Valencia, Instituto de Investigación Sanitaria INCLIVA, Valencia, Spain
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Systemic Mastocytosis Treatment with Midostaurin: [18F]FDG PET/CT as a Potential Monitoring Tool for Therapy Outcome. Diagnostics (Basel) 2022; 12:diagnostics12030680. [PMID: 35328232 PMCID: PMC8947295 DOI: 10.3390/diagnostics12030680] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2022] [Revised: 03/05/2022] [Accepted: 03/08/2022] [Indexed: 02/05/2023] Open
Abstract
We report the case of a 68-year-old patient with diagnosed systemic mastocytosis and histopathologically confirmed manifestations in the stomach and intestinal tract who underwent 18F-Fluorodeoxyglucose ([18F]FDG) positron-emission tomography/computed tomography (PET/CT) pre- and post-6-month therapy with midostaurin, an established tyrosine kinase inhibitor. Post-therapeutic [18F]FDG PET/CT showed decreased multifocal tracer uptake in the known lesions in the gastrointestinal tract, which was consistent with relief of the patient’s symptoms and decrease in serum tryptase level. [18F]FDG PET/CT may thus be considered a potential method for monitoring the outcome of midostaurin therapy in systemic mastocytosis.
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Lübke J, Schwaab J, Naumann N, Horny HP, Weiß C, Metzgeroth G, Kreil S, Cross NCP, Sotlar K, Fabarius A, Hofmann WK, Valent P, Gotlib J, Jawhar M, Reiter A. Superior Efficacy of Midostaurin Over Cladribine in Advanced Systemic Mastocytosis: A Registry-Based Analysis. J Clin Oncol 2022; 40:1783-1794. [PMID: 35235417 DOI: 10.1200/jco.21.01849] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
PURPOSE On the basis of data from the German Registry on Disorders of Eosinophils and Mast Cells, we compared the efficacy of midostaurin and cladribine in patients with advanced systemic mastocytosis (AdvSM). PATIENTS AND METHODS Patients with AdvSM (n = 139) were treated with midostaurin only (n = 63, 45%), cladribine only (n = 23, 17%), or sequentially (midostaurin-cladribine, n = 30, 57%; cladribine-midostaurin, n = 23, 43%). Prognosis was assessed through the Mutation-Adjusted Risk Score (MARS). Besides the comparison of efficacy between midostaurin and cladribine on response (eg, organ dysfunction, bone marrow mast cell [MC] infiltration, and tryptase), overall survival (OS), and leukemia-free survival, we focused on the impact of treatment on involved non-MC lineages, for example, monocytes or eosinophils, and the KIT D816V expressed allele burden. RESULTS Midostaurin only was superior to cladribine only with effects from responses on MC and non-MC lineages conferring on a significantly improved OS (median 4.2 v 1.9 years, P = .033) and leukemia-free survival (2.7 v 1.3 years, P = .044) on the basis of a propensity score-weighted analysis of parameters included in MARS. Midostaurin compensated the inferior efficacy of cladribine in first- and second-line treatment. On midostaurin in any line, response of eosinophilia did not improve its baseline adverse prognostic impact, whereas response of monocytosis proved to be a positive on-treatment parameter. Multivariable analysis allowed to establish three risk categories (low/intermediate/high) through the combination of MARS and the reduction of the KIT D816V expressed allele burden of ≥ 25% at month 6 (median OS not reached v 3.0 years v 1.0 year; P < .001). CONCLUSION In this registry-based analysis, midostaurin revealed superior efficacy over cladribine in patients with AdvSM. In midostaurin-treated patients, the combination of baseline MARS and molecular response provided a compelling three-tier risk categorization (MARSv2.0) for OS.
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Affiliation(s)
- Johannes Lübke
- Department of Hematology and Oncology, University Hospital Mannheim, Heidelberg University, Mannheim, Germany
| | - Juliana Schwaab
- Department of Hematology and Oncology, University Hospital Mannheim, Heidelberg University, Mannheim, Germany
| | - Nicole Naumann
- Department of Hematology and Oncology, University Hospital Mannheim, Heidelberg University, Mannheim, Germany
| | - Hans-Peter Horny
- Department of Pathology, Ludwig-Maximilians-University, Munich, Germany
| | - Christel Weiß
- Department of Medical Statistics and Biomathematics, University Hospital Mannheim, Heidelberg University, Mannheim, Germany
| | - Georgia Metzgeroth
- Department of Hematology and Oncology, University Hospital Mannheim, Heidelberg University, Mannheim, Germany
| | - Sebastian Kreil
- Department of Hematology and Oncology, University Hospital Mannheim, Heidelberg University, Mannheim, Germany
| | - Nicholas C P Cross
- Wessex Regional Genetics Laboratory, Salisbury, United Kingdom.,University of Southampton, Southampton, United Kingdom
| | - Karl Sotlar
- Department of Pathology, Paracelsus Medical University of Salzburg, Salzburg, Austria
| | - Alice Fabarius
- Department of Hematology and Oncology, University Hospital Mannheim, Heidelberg University, Mannheim, Germany
| | - Wolf-Karsten Hofmann
- Department of Hematology and Oncology, University Hospital Mannheim, Heidelberg University, Mannheim, Germany
| | - Peter Valent
- Division of Hematology and Hemostaseology, Department of Internal Medicine I, Medical University of Vienna, Vienna, Austria.,Ludwig Boltzmann Institute for Hematology and Oncology, Medical University of Vienna, Vienna, Austria
| | - Jason Gotlib
- Hematology Division, Stanford University School of Medicine/Stanford Cancer Institute, Stanford, CA
| | - Mohamad Jawhar
- Department of Hematology and Oncology, University Hospital Mannheim, Heidelberg University, Mannheim, Germany
| | - Andreas Reiter
- Department of Hematology and Oncology, University Hospital Mannheim, Heidelberg University, Mannheim, Germany
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Pilkington H, Smith S, Roskell N, Iannazzo S. Indirect treatment comparisons of avapritinib versus midostaurin for patients with advanced systemic mastocytosis. Future Oncol 2022; 18:1583-1594. [PMID: 35114819 DOI: 10.2217/fon-2021-1509] [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] [Indexed: 11/21/2022] Open
Abstract
Objective: This research aimed to compare the relative efficacy of avapritinib versus midostaurin for patients with advanced systemic mastocytosis. Method: A systematic literature review was performed to identify relevant evidence. Unanchored matching-adjusted indirect comparisons were conducted for overall survival (OS), overall response rate (ORR) and complete remission (CR). Results: The systematic literature review identified the clinical trials EXPLORER and PATHFINDER (investigating avapritinib) and D2201 and A2213 (investigating midostaurin). The avapritinib versus midostaurin adjusted hazard ratio for OS was 0.44 (95% CI: 0.25-0.76), and the adjusted odds ratios for ORR and CR were 4.06 (95% CI: 3.09-5.33) and 9.56 (95% CI: 0.97-93.81), respectively. Conclusion: The results suggest that avapritinib improves survival and response (ORR and CR) compared with midostaurin.
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Affiliation(s)
| | - Sarah Smith
- BresMed Health Solutions, Manchester, M2 1DH, UK
| | - Neil Roskell
- BresMed Health Solutions, Manchester, M2 1DH, UK
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DeAngelo DJ, Radia DH, George TI, Robinson WA, Quiery AT, Drummond MW, Bose P, Hexner EO, Winton EF, Horny HP, Tugnait M, Schmidt-Kittler O, Evans EK, Lin HM, Mar BG, Verstovsek S, Deininger MW, Gotlib J. Safety and efficacy of avapritinib in advanced systemic mastocytosis: the phase 1 EXPLORER trial. Nat Med 2021; 27:2183-2191. [PMID: 34873347 PMCID: PMC8674134 DOI: 10.1038/s41591-021-01538-9] [Citation(s) in RCA: 73] [Impact Index Per Article: 24.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2021] [Accepted: 09/13/2021] [Indexed: 12/26/2022]
Abstract
Advanced systemic mastocytosis (AdvSM) is a rare hematologic neoplasm driven by the KIT D816V mutation and associated with poor survival. This phase 1 study (NCT02561988) evaluated avapritinib (BLU-285), a selective KIT D816V inhibitor, in patients with AdvSM. The primary endpoints were the maximum tolerated dose, recommended phase 2 dose and safety of avapritinib. Secondary endpoints included overall response rate and changes in measures of mast cell burden. Avapritinib was evaluated at doses of 30–400 mg once daily in 86 patients, 69 with centrally confirmed AdvSM. Maximum tolerated dose was not reached, and 200 mg and 300 mg daily were studied in dose-expansion cohorts. The most frequent adverse events observed were periorbital edema (69%), anemia (55%), diarrhea (45%), thrombocytopenia (44%) and nausea (44%). Intracranial bleeding occurred in 13% overall, but in only 1% of patients without severe thrombocytopenia (platelets <50 × 109/l). In 53 response-evaluable patients, the overall response rate was 75%. The complete remission rate was 36%. Avapritinib elicited ≥50% reductions in marrow mast cells and serum tryptase in 92% and 99% of patients, respectively. Avapritinib induced deep and durable responses, including molecular remission of KIT D816V in patients with AdvSM, and was well tolerated at the recommended phase 2 dose of 200 mg daily. In a phase 1 trial of patients with advanced systemic mastocytosis, avapritinib, a selective KIT inhibitor, was generally well tolerated, elicited durable clinical responses and led to reductions in mast cell disease burden.
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Affiliation(s)
- Daniel J DeAngelo
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA.
| | | | - Tracy I George
- ARUP Laboratories, University of Utah, Salt Lake City, UT, USA
| | | | | | | | - Prithviraj Bose
- The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Elizabeth O Hexner
- Abramson Cancer Center, University of Pennsylvania, Philadelphia, PA, USA
| | - Elliott F Winton
- Department of Hematology and Medical Oncology, Winship Cancer Institute of Emory University, Atlanta, GA, USA
| | - Hans-Peter Horny
- Institute of Pathology, Ludwig-Maximilians University, Munich, Germany
| | | | | | | | - Hui-Min Lin
- Blueprint Medicines Corporation, Cambridge, MA, USA
| | | | - Srdan Verstovsek
- The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Michael W Deininger
- Versiti Blood Research Institute and Division Hematology and Oncology, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Jason Gotlib
- Stanford University School of Medicine and Stanford Cancer Institute, Stanford, CA, USA
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Tefferi A, Kittur J, Farrukh F, Begna KH, Patnaik MM, Al-Kali A, Elliott MA, Reichard KK, Gangat N, Pardanani A. Cladribine therapy for advanced and indolent systemic mastocytosis: Mayo Clinic experience in 42 consecutive cases. Br J Haematol 2021; 196:975-983. [PMID: 34729775 DOI: 10.1111/bjh.17932] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2021] [Revised: 10/16/2021] [Accepted: 10/18/2021] [Indexed: 01/08/2023]
Abstract
We describe our single institution experience with cladribine therapy in 42 patients with systemic mastocytosis (SM): 22 advanced (adv-SM; median age 65 years, 68% males) and 20 indolent/smouldering SM (ISM/SSM; median age 56 years, 45% males); subcategories included eight aggressive, 13 associated with another haematological neoplasm, one mast cell leukaemia, 17 ISM and three SSM. Overall/major response rates were 77%/45% for adv-SM and 70%/60% for ISM/SSM, and median (range) duration of response 10 (4-75) and 46 (4-140) months respectively. A >50% reduction in bone marrow mast cell burden and serum tryptase level was documented in 63% and 67% of patients with adv-SM and 50% and 46% with ISM/SSM respectively. The presence of KIT proto-oncogene, receptor tyrosine kinase (KIT)D816V predicted response in adv-SM: 17 (90%) of 19 with and none of three without the mutation responded (P < 0·01). Treatment-emergent adverse events were mostly limited to transient cytopenias: Grade 3/4 neutropenia, thrombocytopenia, or lymphopenia occurred in 27%, 27% and 27% of patients with adv-SM, and 5%, 5% and 30% with ISM/SSM respectively. The present study provides practical information that might be considered when making treatment choices between cladribine and newer KIT-targeted therapies and identifies the absence of KITD816V as a potential marker of cladribine resistance in advanced SM; the latter observation needs confirmation in a larger study.
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Affiliation(s)
- Ayalew Tefferi
- Division of Hematology, Department of Internal Medicine, Mayo Clinic, Rochester, MN, USA
| | - Jaya Kittur
- Division of Hematology, Department of Internal Medicine, Mayo Clinic, Rochester, MN, USA
| | - Faiqa Farrukh
- Division of Hematology, Department of Internal Medicine, Mayo Clinic, Rochester, MN, USA
| | - Kebede H Begna
- Division of Hematology, Department of Internal Medicine, Mayo Clinic, Rochester, MN, USA
| | - Mrinal M Patnaik
- Division of Hematology, Department of Internal Medicine, Mayo Clinic, Rochester, MN, USA
| | - Aref Al-Kali
- Division of Hematology, Department of Internal Medicine, Mayo Clinic, Rochester, MN, USA
| | - Michelle A Elliott
- Division of Hematology, Department of Internal Medicine, Mayo Clinic, Rochester, MN, USA
| | - Kaaren K Reichard
- Division of Hematopathology, Department of Laboratory Medicine, Mayo Clinic, Rochester, MN, USA
| | - Naseema Gangat
- Division of Hematology, Department of Internal Medicine, Mayo Clinic, Rochester, MN, USA
| | - Animesh Pardanani
- Division of Hematology, Department of Internal Medicine, Mayo Clinic, Rochester, MN, USA
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Precision Medicine in Systemic Mastocytosis. Medicina (B Aires) 2021; 57:medicina57111135. [PMID: 34833353 PMCID: PMC8623914 DOI: 10.3390/medicina57111135] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2021] [Revised: 10/11/2021] [Accepted: 10/12/2021] [Indexed: 12/20/2022] Open
Abstract
Mastocytosis is a rare hematological neoplasm characterized by the proliferation of abnormal clonal mast cells (MCs) in different cutaneous and extracutaneous organs. Its diagnosis is based on well-defined major and minor criteria, including the pathognomonic dense infiltrate of MCs detected in bone marrow (BM), elevated serum tryptase level, abnormal MCs CD25 expression, and the identification of KIT D816V mutation. The World Health Organization (WHO) classification subdivides mastocytosis into a cutaneous form (CM) and five systemic variants (SM), namely indolent/smoldering (ISM/SSM) and advanced SM (AdvSM) including aggressive SM (ASM), SM associated to hematological neoplasms (SM-AHN), and mast cell leukemia (MCL). More than 80% of patients with SM carry a somatic point mutation of KIT at codon 816, which may be targeted by kinase inhibitors. The presence of additional somatic mutations detected by next generation sequencing analysis may impact prognosis and drive treatment strategy, which ranges from symptomatic drugs in indolent forms to kinase-inhibitors active on KIT. Allogeneic stem cell transplant (SCT) may be considered in selected SM cases. Here, we review the clinical, diagnostic, and therapeutic issues of SM, with special emphasis on the translational implications of SM genetics for a precision medicine approach in clinical practice.
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Activators and Inhibitors of Protein Kinase C (PKC): Their Applications in Clinical Trials. Pharmaceutics 2021; 13:pharmaceutics13111748. [PMID: 34834162 PMCID: PMC8621927 DOI: 10.3390/pharmaceutics13111748] [Citation(s) in RCA: 35] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2021] [Revised: 10/18/2021] [Accepted: 10/19/2021] [Indexed: 02/05/2023] Open
Abstract
Protein kinase C (PKC), a family of phospholipid-dependent serine/threonine kinase, is classed into three subfamilies based on their structural and activation characteristics: conventional or classic PKC isozymes (cPKCs; α, βI, βII, and γ), novel or non-classic PKC isozymes (nPKCs; δ, ε, η, and θ), and atypical PKC isozymes (aPKCs; ζ, ι, and λ). PKC inhibitors and activators are used to understand PKC-mediated intracellular signaling pathways and for the diagnosis and treatment of various PKC-associated diseases, such as cancers, neurological diseases, cardiovascular diseases, and infections. Many clinical trials of PKC inhibitors in cancers showed no significant clinical benefits, meaning that there is a limitation to design a cancer therapeutic strategy targeting PKC alone. This review will focus on the activators and inhibitors of PKC and their applications in clinical trials.
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Below S, Michaelis LC. Avapritinib in the Treatment of Systemic Mastocytosis: an Update. Curr Hematol Malig Rep 2021; 16:464-472. [PMID: 34580817 DOI: 10.1007/s11899-021-00650-4] [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] [Accepted: 06/15/2021] [Indexed: 01/08/2023]
Abstract
PURPOSE OF REVIEW Patients with systemic mastocytosis, a dangerous and rare myeloid neoplasm, have long had few therapies available to them and, historically, rarely achieved from significant disease control. However, research and translational developments over the last decade have led to promising new options for disease management. In this review, we briefly outline the history of treatment for systemic mastocytosis and subsequently focus on the clinical development and potential applications of avapritinib (previously known as BLU-285), a potent and selective oral inhibitor of the tyrosine kinase most commonly mutated in this condition. RECENT FINDINGS Phase I data and recent phase II data have demonstrated both safety and efficacy of this agent used as monotherapy, even in patients who have progressed on other targeted therapy. Studies to date have focused on patients with the most aggressive disease, but new trials in indolent mastocytosis are accruing currently. Over the next several years, one may anticipate finalized, peer-reviewed, and formally published data for this agent in both advanced systemic and indolent mastocytosis. Evidence from these early studies will also likely highlight where more research is needed.
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Affiliation(s)
- Samantha Below
- Department of Medicine, Medical College of Wisconsin, 9200 W. Wisconsin Ave, Milwaukee, WI, 53226, USA
| | - Laura C Michaelis
- Department of Medicine, Medical College of Wisconsin, 9200 W. Wisconsin Ave, Milwaukee, WI, 53226, USA.
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43
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El Hussein S, Hu S, Fang H, Garces S, Muzzafar T, Wang SA, Medeiros LJ, Bueso-Ramos C, Jelloul FZ. Well-differentiated systemic mastocytosis with associated myeloid sarcoma and myelodysplastic syndrome: Diagnostic challenges of an underrecognized entity. Leuk Lymphoma 2021; 63:235-238. [PMID: 34510998 DOI: 10.1080/10428194.2021.1978089] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Affiliation(s)
- Siba El Hussein
- Department of Pathology, The University of Rochester Medical Center, Rochester, NY, USA.,Department of Hematopathology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Shimin Hu
- Department of Hematopathology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Hong Fang
- Department of Hematopathology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Sofia Garces
- Department of Hematopathology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Tariq Muzzafar
- Department of Hematopathology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Sa A Wang
- Department of Hematopathology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - L Jeffrey Medeiros
- Department of Hematopathology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Carlos Bueso-Ramos
- Department of Hematopathology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Fatima Zahra Jelloul
- Department of Hematopathology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
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Abstract
INTRODUCTION Systemic mastocytosis (SM) is a rare myeloid neoplasm driven in ≈95% of cases by activating KIT mutations, usually D816V. SM can be indolent (ISM), smoldering (SSM) and advanced (AdvSM), the latter characterized by organ damage resulting from infiltrating neoplastic mast cells. The vast majority of cases are indolent, with near-normal life expectancy, although symptoms can be severe. AdvSM, comprising aggressive SM, SM with an associated hematologic neoplasm and mast cell leukemia, however, carries a poor prognosis. Avapritinib is a highly potent and selective inhibitor of mutant KIT. AREAS COVERED We provide an overview of SM, including the current therapeutic landscape, and discuss avapritinib in detail: its chemistry and discovery, pharmacodynamic and pharmacokinetic data, current approval status and safety and efficacy profiles in both advanced and non-advanced SM. EXPERT OPINION With a response rate of 75% amongst evaluable patients with AdvSM and marked reductions observed in measures of mast cell and disease burden, avapritinib stands out as a highly effective targeted therapy for this mutant KIT-driven disease. Cognitive impairment may occur, and intracranial hemorrhage has been reported, particularly in association with severe thrombocytopenia. Early results in patients with ISM/SSM are encouraging. Avapritinib is now approved in the US for AdvSM.
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Affiliation(s)
- Prithviraj Bose
- Department of Leukemia, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Srdan Verstovsek
- Department of Leukemia, University of Texas MD Anderson Cancer Center, Houston, TX, USA
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Systemic Mastocytosis: Molecular Landscape and Implications for Treatment. Mediterr J Hematol Infect Dis 2021; 13:e2021046. [PMID: 34276915 PMCID: PMC8265368 DOI: 10.4084/mjhid.2021.046] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2021] [Accepted: 06/11/2021] [Indexed: 12/04/2022] Open
Abstract
Over the past decade, we have witnessed significant advances in the molecular characterization of systemic mastocytosis (SM). This has provided important information for a better understanding of the pathogenesis of the disease but has also practically impacted the way we diagnose and manage it. Advances in molecular testing have run in parallel with advances in therapeutic targeting of constitutive active KIT, the major driver of the disease. Therefore, assessing the molecular landscape in each SM patient is essential for diagnosis, prognosis, treatment, and therapeutic efficacy monitoring. This is facilitated by the routine availability of novel technologies like digital PCR and NGS. This review aims to summarize the pathogenesis of the disease, discuss the value of molecular diagnostic testing and how it should be performed, and provide an overview of present and future therapeutic concepts based on fine molecular characterization of SM patients.
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Naumann N, Lübke J, Shomali W, Reiter L, Horny HP, Jawhar M, Dangelo V, Fabarius A, Metzgeroth G, Kreil S, Sotlar K, Oni C, Harrison C, Hofmann WK, Cross NCP, Valent P, Radia D, Gotlib J, Reiter A, Schwaab J. Clinical and histopathological features of myeloid neoplasms with concurrent Janus kinase 2 (JAK2) V617F and KIT proto-oncogene, receptor tyrosine kinase (KIT) D816V mutations. Br J Haematol 2021; 194:344-354. [PMID: 34060083 DOI: 10.1111/bjh.17567] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2021] [Revised: 04/22/2021] [Accepted: 04/29/2021] [Indexed: 01/23/2023]
Abstract
We report on 45 patients with myeloid neoplasms and concurrent Janus kinase 2 (JAK2) V617F and KIT proto-oncogene, receptor tyrosine kinase (KIT) D816V (JAK2pos . /KITpos . ) mutations, which are individually identified in >60% of patients with classical myeloproliferative neoplasms (MPN) and >90% of patients with systemic mastocytosis (SM) respectively. In SM, the concurrent presence of a clonal non-mast cell neoplasm [SM with associated haematological neoplasm (SM-AHN)] usually constitutes a distinct subtype associated with poor survival. All 45 patients presented with a heterogeneous combination of clinical/morphological features typical of the individual disorders (e.g. leuco-/erythro-/thrombocytosis and elevated lactate dehydrogenase for MPN; elevated serum tryptase and alkaline phosphatase for SM). Overlapping features identified in 70% of patients included splenomegaly, cytopenia(s), bone marrow fibrosis and additional somatic mutations. Molecular dissection revealed discordant development of variant allele frequency for both mutations and absence of concurrently positive single-cell derived colonies, indicating disease evolution in two independent clones rather than monoclonal disease in >60% of patients examined. Overall survival of JAK2pos . /KITpos . patients without additional somatic high-risk mutations [HRM, e.g. in serine and arginine-rich splicing factor 2 (SRSF2), additional sex combs like-1 (ASXL1) or Runt-related transcription factor 1 (RUNX1)] at 5 years was 77%, indicating that the mutual impact of JAK2 V617F and KIT D816V on prognosis is fundamentally different from the adverse impact of additional HRM in the individual disorders.
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Affiliation(s)
- Nicole Naumann
- Haematology and Oncology, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
| | - Johannes Lübke
- Haematology and Oncology, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
| | - William Shomali
- Division of Hematology, Stanford Cancer Institute/Stanford University School of Medicine, Stanford, CA, USA
| | - Lukas Reiter
- Haematology and Oncology, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
| | - Hans-Peter Horny
- Institute of Pathology, Ludwig-Maximilian-University, Munich, Germany
| | - Mohamad Jawhar
- Haematology and Oncology, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
| | - Vito Dangelo
- Haematology and Oncology, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
| | - Alice Fabarius
- Haematology and Oncology, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
| | - Georgia Metzgeroth
- Haematology and Oncology, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
| | - Sebastian Kreil
- Haematology and Oncology, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
| | - Karl Sotlar
- Institute of Pathology, University Hospital Salzburg, Paracelsus Medical University, Salzburg, Austria
| | - Claire Oni
- Department of Haematology, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Claire Harrison
- Department of Haematology, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Wolf-Karsten Hofmann
- Haematology and Oncology, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
| | - Nicholas C P Cross
- Wessex Regional Genetics Laboratory, Salisbury, UK.,School of Medicine, University of Southampton, Southampton, UK
| | - Peter Valent
- Department of Internal Medicine I, Division of Haematology and Ludwig Boltzmann Institute for Haematology and Oncology, Medical University of Vienna, Vienna, Austria
| | - Deepti Radia
- Department of Haematology, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Jason Gotlib
- Division of Hematology, Stanford Cancer Institute/Stanford University School of Medicine, Stanford, CA, USA
| | - Andreas Reiter
- Haematology and Oncology, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
| | - Juliana Schwaab
- Haematology and Oncology, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
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Clonal evolution and heterogeneity in advanced systemic mastocytosis revealed by single-cell DNA sequencing. Blood Adv 2021; 5:1733-1736. [PMID: 33734329 DOI: 10.1182/bloodadvances.2020003980] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2020] [Accepted: 02/01/2021] [Indexed: 11/20/2022] Open
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Klug LR, Corless CL, Heinrich MC. Inhibition of KIT Tyrosine Kinase Activity: Two Decades After the First Approval. J Clin Oncol 2021; 39:1674-1686. [PMID: 33797935 DOI: 10.1200/jco.20.03245] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Affiliation(s)
- Lillian R Klug
- Oregon Health & Science University, Knight Cancer Institute, Portland, OR.,Division of Hematology and Medical Oncology, Oregon Health & Science University, Portland, OR.,VA Portland Health Care System, Portland, OR
| | - Christopher L Corless
- Oregon Health & Science University, Knight Cancer Institute, Portland, OR.,Department of Pathology, Oregon Health & Science University, Portland, OR
| | - Michael C Heinrich
- Oregon Health & Science University, Knight Cancer Institute, Portland, OR.,Division of Hematology and Medical Oncology, Oregon Health & Science University, Portland, OR.,VA Portland Health Care System, Portland, OR
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49
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Pardanani A. Systemic mastocytosis in adults: 2021 Update on diagnosis, risk stratification and management. Am J Hematol 2021; 96:508-525. [PMID: 33524167 DOI: 10.1002/ajh.26118] [Citation(s) in RCA: 90] [Impact Index Per Article: 30.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2021] [Accepted: 01/08/2021] [Indexed: 12/16/2022]
Abstract
OVERVIEW Systemic mastocytosis (SM) results from a clonal proliferation of abnormal mast cells (MC) in extra-cutaneous organs. DIAGNOSIS The major criterion is presence of multifocal clusters of spindled MC in the bone marrow. Minor diagnostic criteria include elevated serum tryptase level, abnormal MC CD25 expression, and presence of KITD816V mutation. RISK STRATIFICATION Establishing SM subtype as per the World Health Organization classification system is an important first step. Broadly, patients either have indolent/smoldering SM (ISM/SSM) or advanced SM, the latter includes aggressive SM (ASM), SM with associated hematological neoplasm (SM-AHN), and mast cell leukemia (MCL). Identification of poor-risk mutations (ie, ASXL1, RUNX1, SRSF2, NRAS) further refines the risk stratification. Recently, clinical and hybrid clinical-molecular risk models have been developed to more accurately assign prognosis in SM patients. MANAGEMENT Treatment goals for ISM patients are primarily directed towards anaphylaxis prevention/symptom control/osteoporosis treatment. Patients with advanced SM frequently need MC cytoreductive therapy to ameliorate disease-related organ dysfunction. High response rates have been seen with small-molecule inhibitors that target mutant-KIT, including midostaurin (Food and Drug Administration approved) or avapritinib (investigational). Other options for MC cytoreduction include cladribine or interferon-α, although head-to-head comparisons are lacking. Treatment of SM-AHN primarily targets the AHN component, particularly if an aggressive disease such as acute myeloid leukemia is present. Allogeneic stem cell transplant can be considered in such patients, or in those with relapsed/refractory advanced SM. Imatinib has a limited therapeutic role in SM; effective cytoreduction is limited to those with imatinib-sensitive KIT mutations.
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Affiliation(s)
- Animesh Pardanani
- Division of Hematology, Department of Medicine Mayo Clinic Rochester Minnesota
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50
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Response Criteria in Advanced Systemic Mastocytosis: Evolution in the Era of KIT Inhibitors. Int J Mol Sci 2021; 22:ijms22062983. [PMID: 33804174 PMCID: PMC8001403 DOI: 10.3390/ijms22062983] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2021] [Revised: 03/11/2021] [Accepted: 03/12/2021] [Indexed: 12/12/2022] Open
Abstract
Systemic mastocytosis (SM) is a rare clonal hematologic neoplasm, driven, in almost all cases, by the activating KIT D816V mutation that leads to the growth and accumulation of neoplastic mast cells. While patients with advanced forms of SM have a poor prognosis, the introduction of KIT inhibitors (e.g., midostaurin, and avapritinib) has changed their outlook. Because of the heterogenous nature of advanced SM (advSM), successive iterations of response criteria have tried to capture different dimensions of the disease, including measures of mast cell burden (percentage of bone marrow mast cells and serum tryptase level), and mast cell-related organ damage (referred to as C findings). Historically, response criteria have been anchored to reversion of one or more organ damage finding(s) as a minimal criterion for response. This is a central principle of the Valent criteria, Mayo criteria, and International Working Group-Myeloproliferative Neoplasms Research and Treatment and European Competence Network on Mastocytosis (IWG-MRT-ECNM) consensus criteria. Irrespective of the response criteria, an ever-present challenge is how to apply response criteria in patients with SM and an associated hematologic neoplasm, where the presence of both diseases complicates assignment of organ damage and adjudication of response. In the context of trials with the selective KIT D816V inhibitor avapritinib, pure pathologic response (PPR) criteria, which rely solely on measures of mast cell burden and exclude consideration of organ damage findings, are being explored as more robust surrogate of overall survival. In addition, the finding that avapritinib can elicit complete molecular responses of KIT D816V allele burden, establishes a new benchmark for advSM and motivates the inclusion of definitions for molecular response in future criteria. Herein, we also outline how the concept of PPR can inform a proposal for new response criteria which use a tiered evaluation of pathologic, molecular, and clinical responses.
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