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Davidson MB, Kennedy JA, Capo-Chichi JM, Shi Y, Xu W, Cheung V, Arruda A, Bankar A, Richard-Carpentier G, Chan S, Maze D, Minden MD, Schimmer AD, Schuh AC, Sibai H, Yee K, Tierens A, Viswabandya A, Gupta V. Outcomes of intensive and nonintensive blast-reduction strategies in accelerated and blast-phase MPN. Blood Adv 2024; 8:1281-1294. [PMID: 38170760 PMCID: PMC10918486 DOI: 10.1182/bloodadvances.2023011735] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2023] [Revised: 11/28/2023] [Accepted: 12/13/2023] [Indexed: 01/05/2024] Open
Abstract
ABSTRACT Transformation of BCR::ABL1-negative myeloproliferative neoplasms (MPN) to an accelerated or blast phase is associated with poor outcomes. The efficacy of acute myeloid leukemia (AML)-type intensive and nonintensive hypomethylating agent-based regimens is not well studied. We therefore performed a retrospective analysis of patients with MPN-AP/BP (N = 138) treated with intensive (N = 81) and nonintensive (N = 57) blast-reduction strategies. We used clinically relatable response criteria developed at the Princess Margaret Cancer Centre. The overall best response, comprising complete remission (CR), complete remission with incomplete hematologic recovery (CRi), and reversion to chronic phase MPN (cMPN), in the intensive and nonintensive groups was 77% (62 of 81) and 39% (21 of 54), respectively. Similar overall best response rates were observed in patients receiving induction with daunorubicin combined with cytarabine arabinoside (daunorubicin + ara-C) (74% [23 of 31]) or FLAG-IDA/NOVE-HiDAC (78% [39 of 50], P = .78). However, patients receiving daunorubicin + ara-C more often required second inductions (29% [9 of 31] vs 4% [2 of 50], P = .002). Most responses in the entire cohort were reversions to cMPN (55 of 83 [66%]). CR and CRi comprised 30% (25 of 83) and 4% (3 of 83) of responses, respectively. Mutations in TP53 (overall response [OR] 8.2 [95% confidence interval [CI] 2.01, 37.1], P = .004) and RAS pathway (OR 5.1 [95%CI 1.2, 23.7], P = .03) were associated with inferior treatment response for intensively treated patients, and poorer performance status (Eastern Cooperative Oncology Group) was associated with inferior treatment response in both intensively (OR 10.4 [95% CI 2.0, 78.5], P = .009) and nonintensively treated groups (OR 12 [95% CI 2.04, 230.3], P = .02). In patients with paired samples before and after therapy (N = 26), there was a significant residual mutation burden remaining irrespective of response to blast-reduction therapy.
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Affiliation(s)
- Marta B. Davidson
- Medical Oncology and Hematology, Princess Margaret Cancer Centre, Toronto, ON, Canada
| | - James A. Kennedy
- Medical Oncology and Hematology, Princess Margaret Cancer Centre, Toronto, ON, Canada
- Medical Oncology and Hematology, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Jose-Mario Capo-Chichi
- Department of Clinical Laboratory Genetics, Laboratory Medicine Program, Toronto, ON, Canada
| | - Yuliang Shi
- Biostatistics Department, University Health Network, Toronto, ON, Canada
| | - Wei Xu
- Biostatistics Department, University Health Network, Toronto, ON, Canada
| | - Verna Cheung
- Medical Oncology and Hematology, Princess Margaret Cancer Centre, Toronto, ON, Canada
| | - Andrea Arruda
- Medical Oncology and Hematology, Princess Margaret Cancer Centre, Toronto, ON, Canada
| | - Aniket Bankar
- Medical Oncology and Hematology, Princess Margaret Cancer Centre, Toronto, ON, Canada
| | | | - Steven Chan
- Medical Oncology and Hematology, Princess Margaret Cancer Centre, Toronto, ON, Canada
| | - Dawn Maze
- Medical Oncology and Hematology, Princess Margaret Cancer Centre, Toronto, ON, Canada
| | - Mark D. Minden
- Medical Oncology and Hematology, Princess Margaret Cancer Centre, Toronto, ON, Canada
| | - Aaron D. Schimmer
- Medical Oncology and Hematology, Princess Margaret Cancer Centre, Toronto, ON, Canada
| | - Andre C. Schuh
- Medical Oncology and Hematology, Princess Margaret Cancer Centre, Toronto, ON, Canada
| | - Hassan Sibai
- Medical Oncology and Hematology, Princess Margaret Cancer Centre, Toronto, ON, Canada
| | - Karen Yee
- Medical Oncology and Hematology, Princess Margaret Cancer Centre, Toronto, ON, Canada
| | - Anne Tierens
- Department of Hematopathology, Laboratory Medicine Program, University Health Network, Toronto, ON, Canada
| | - Auro Viswabandya
- Medical Oncology and Hematology, Princess Margaret Cancer Centre, Toronto, ON, Canada
| | - Vikas Gupta
- Medical Oncology and Hematology, Princess Margaret Cancer Centre, Toronto, ON, Canada
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2
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Zhang S, Yan J, He L, Jiang Z, Jiang H. STAT5a and SH2B3 novel mutations display malignancy roles in a triple-negative primary myelofibrosis patient. Cancer Gene Ther 2024; 31:484-494. [PMID: 38135698 DOI: 10.1038/s41417-023-00719-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2023] [Revised: 12/02/2023] [Accepted: 12/08/2023] [Indexed: 12/24/2023]
Abstract
Primary myelofibrosis (PMF) patients frequently have JAK2 (V617F), CALR (exon 9), or MPL (W515 or exon 10) strong driver gene mutation, which triggers abnormal activation of the JAK2-STATs signaling pathway that plays a complex role in the occurrence of PMF. However, about 10-15% of PMF patients have no above typical mutations in these strong driver genes, known as being "triple-negative", which are associated with poor prognosis. In this paper, we reported a unique secondary acute myeloid leukemia (sAML) case transformed from triple-negative PMF combined with lung cancer and erythroderma occurrence at the same time, which has not been reported so far. Through whole blood exome sequencing, four novel noncanonical mutations were detected in key regulatory genes SH2B3 (Q748 and S710) and STAT5a (C350 and K354). Meanwhile, STAT5a-S710 and SH2B3-K354 noncanonical mutations gained strong malignant biofunction on promoting cell growth and tumorigenesis by accelerating the G1/S transition. In the mechanistic study, these pernicious phenotypes driven by noncanonical mutations might be initial PMF by activating p-STAT5a/c-Myc/CyclinD1 and p-STAT3/p-AKT/p-ERK1/2 signaling axes. Therefore, our study explored the deleterious roles of novel noncanonical mutations in STAT5a and SH2B3, which may serve as susceptibility genes and display the oncogenic biofunction in the progression of PMF to acute myeloid leukemia-M2a (AML-M2a).
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Affiliation(s)
- Shubing Zhang
- Department of Cell Biology, School of Life Sciences, Central South University, 410013, Changsha, Hunan, P. R. China
- Hunan Key Laboratory of Animal Models for Human Diseases, Central South University, 410013, Changsha, Hunan, P. R. China
| | - Jinhua Yan
- Department of Cell Biology, School of Life Sciences, Central South University, 410013, Changsha, Hunan, P. R. China
| | - Lan He
- School of Biomedical Science, Hunan University, 410013, Changsha, Hunan, P. R. China
| | - Zhiping Jiang
- Department of Hematology, Central South University, Xiangya Hospital, 410013, Changsha, Hunan, P. R. China.
- Xiangya Hospital, Central South University, National Clinical Research Center for Geriatric Disorders, 410013, Changsha, Hunan, P. R. China.
- Hunan Hematology Oncology Clinical Medical Research Center, 410013, Changsha, Hunan, P. R. China.
| | - Hao Jiang
- Department of Biomedical Informatics, School of Life Sciences, Central South University, 410013, Changsha, Hunan, P. R. China.
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3
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Chen J, Wang K, Xiao Z, Xu Z. Efficacy and safety of combination therapies vs monotherapy of hypomethylating agents in accelerated or blast phase of Philadelphia negative myeloproliferative neoplasms: a systematic review and meta-analysis. Ann Med 2023; 55:348-360. [PMID: 36644935 PMCID: PMC9848335 DOI: 10.1080/07853890.2022.2164611] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/17/2023] Open
Abstract
BACKGROUND There is a lack of evidence regarding whether combination therapy of hypomethylating agents (HMAs) has better outcomes than HMA monotherapy in patients with Philadelphia chromosome-negative accelerated or blast phase myeloproliferative neoplasms (MPN-AP/BP). MATERIALS AND METHODS Pubmed, Embase, Web of Science and Cochrane library databases were searched for studies from inception of each database until 31 December 2021. Data extraction and synthesis were conducted following the PRISMA reporting guideline. RESULTS It was found that HMAs plus venetoclax therapy yielded a higher CR/CRi rate than HMAs alone [36% vs 19%, p = .0204] and a higher CR rate than HMAs plus ruxolitinib [22% vs 8%, p = .0313]. HMAs plus ruxolitinib combination showed a higher ORR than HMA monotherapy [45% vs 30%, p = .0395], but there was no improvement in CR/CRi. The one-year and two-year OS rate for patients treated with HMAs plus venetoclx/ruxolitinib demonstrated a trend towards prolonged survival than HMAs alone [HMAs plus venetoclax: 24% vs 11%, p = .1295 and 12% vs 3%, p = .2357; HMAs plus ruxolitinib: 25% vs 11%, p = .0774 and 33% vs 3%, p = .051]. CONCLUSION It was confirmed that HMA in combination with venetoclax is an effective and well-tolerated option in MPN-AP/BP patients in pre- as well as post-haematopoietic stem cell transplantation settings. HMA plus ruxolitinib therapy was revealed to be effective in patients with MPN-AP.Key MessagesCombination therapy with HMAs and venetoclax/ruxolitinib was associated with improved outcomes than HMAs alone in MPN-AP/BP patients.Further large-scale randomized controlled trials are needed to confirm regarding to the optimal treatment for this patient population.
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Affiliation(s)
- Jia Chen
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Institute of Hematology and Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin, China.,Tianjin Institutes of Health Science, Tianjin, China.,MDS and MPN Centre, Institute of Hematology and Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin, China
| | - Kefei Wang
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Institute of Hematology and Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin, China.,Tianjin Institutes of Health Science, Tianjin, China
| | - Zhijian Xiao
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Institute of Hematology and Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin, China.,Tianjin Institutes of Health Science, Tianjin, China.,MDS and MPN Centre, Institute of Hematology and Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin, China
| | - Zefeng Xu
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Institute of Hematology and Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin, China.,Tianjin Institutes of Health Science, Tianjin, China.,MDS and MPN Centre, Institute of Hematology and Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin, China
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4
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Tefferi A, Loscocco GG, Farrukh F, Szuber N, Mannelli F, Pardanani A, Hanson CA, Ketterling RP, De Stefano V, Carobbio A, Barbui T, Guglielmelli P, Gangat N, Vannucchi AM. A globally applicable "triple A" risk model for essential thrombocythemia based on Age, Absolute neutrophil count, and Absolute lymphocyte count. Am J Hematol 2023; 98:1829-1837. [PMID: 37665758 DOI: 10.1002/ajh.27079] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2023] [Accepted: 08/15/2023] [Indexed: 09/06/2023]
Abstract
We examined the individual prognostic contribution of absolute neutrophil (ANC), lymphocyte (ALC), and monocyte (AMC) counts, on overall (OS), leukemia-free (LFS), and myelofibrosis-free (MFFS) survival in essential thrombocythemia (ET). Informative cases (N = 598; median age 59 years; females 62%) were retrospectively accrued from a Mayo Clinic database: JAK2 59%, CALR 27%, triple-negative 11%, and MPL 3%; international prognostic scoring system for ET (IPSET) risk high 21%, intermediate 42%, and low 37%; 7% (37/515) had abnormal karyotype and 10% (21/205) adverse mutations (SF3B1/SRSF2/U2AF1/TP53). At median 8.4 years, 163 (27%) deaths, 71 (12%) fibrotic, and 20 (3%) leukemic transformations were recorded. Multivariable analysis resulted in HR (95% CI) of 16.5 (9.9-27.4) for age > 70 years, 3.7 (2.3-6.0) for age 50-70 years, 2.4 (1.7-3.3) for ANC ≥8 × 109 /L, and 1.9 (1.4-2.6) for ALC <1.7 × 109 /L. The corresponding HR-based scores were 4, 2, 1, and 1, resulting in an new 4-tiered AgeAncAlc (AAA; triple A) risk model: high (5-6 points; median survival 8 years; HR 30.1, 95% CI 17.6-54), intermediate-2 (4 points; median 13.5 years; HR 12.7, 95% CI 7.1-23.0), intermediate-1 (2-3 points; median 20.7 years; HR 3.8, 95% CI 2.3-6.4) and low (0-1 points; median 47 years). The AAA model (Akaike Information Criterion [AIC] 621) performed better than IPSET (AIC 647) and was subsequently validated by an external University of Florence ET cohort (N = 485). None of the AAA variables predicted LFS while ALC <1.7 × 109 /L was associated with inferior MFFS (p = .01). Adverse mutations (p < .01) and karyotype (p < .01) displayed additional prognostic value without disqualifying the prognostic integrity of the AAA model. This study proposes a simple and globally applicable survival model for ET, which can be used as a platform for further molecular refinement. This study also suggests a potential role for immune-related biomarkers, as a prognostic tool in myeloproliferative neoplasms.
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Affiliation(s)
- Ayalew Tefferi
- Divisions of Hematology and Hematopathology, Mayo Clinic, Rochester, Minnesota, USA
| | - Giuseppe G Loscocco
- Department of Experimental and Clinical Medicine, CRIMM, Center Research, and Innovation of Myeloproliferative Neoplasms, Azienda Ospedaliera Universitaria Careggi, University of Florence, Florence, Italy
| | - Faiqa Farrukh
- Divisions of Hematology and Hematopathology, Mayo Clinic, Rochester, Minnesota, USA
| | - Natasha Szuber
- Department of Hematology, Université de Montréal, Quebec, Canada
| | - Francesco Mannelli
- Department of Experimental and Clinical Medicine, CRIMM, Center Research, and Innovation of Myeloproliferative Neoplasms, Azienda Ospedaliera Universitaria Careggi, University of Florence, Florence, Italy
| | - Animesh Pardanani
- Divisions of Hematology and Hematopathology, Mayo Clinic, Rochester, Minnesota, USA
| | - Curtis A Hanson
- Divisions of Hematology and Hematopathology, Mayo Clinic, Rochester, Minnesota, USA
| | - Rhett P Ketterling
- Divisions of Hematology and Hematopathology, Mayo Clinic, Rochester, Minnesota, USA
| | - Valerio De Stefano
- Section of Hematology, Department of Radiological and Hematological Sciences, Catholic University, Rome, Italy
| | | | - Tiziano Barbui
- FROM esearch Foundation, Papa Giovanni XXIII Hospital, Bergamo, Italy
| | - Paola Guglielmelli
- Department of Experimental and Clinical Medicine, CRIMM, Center Research, and Innovation of Myeloproliferative Neoplasms, Azienda Ospedaliera Universitaria Careggi, University of Florence, Florence, Italy
| | - Naseema Gangat
- Divisions of Hematology and Hematopathology, Mayo Clinic, Rochester, Minnesota, USA
| | - Alessandro M Vannucchi
- Department of Experimental and Clinical Medicine, CRIMM, Center Research, and Innovation of Myeloproliferative Neoplasms, Azienda Ospedaliera Universitaria Careggi, University of Florence, Florence, Italy
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5
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Kröger N, Wolschke C, Gagelmann N. How I treat transplant-eligible patients with myelofibrosis. Blood 2023; 142:1683-1696. [PMID: 37647853 DOI: 10.1182/blood.2023021218] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2023] [Revised: 08/14/2023] [Accepted: 08/18/2023] [Indexed: 09/01/2023] Open
Abstract
Despite the approval of Janus kinase inhibitors and novel agents for patients with myelofibrosis (MF), disease-modifying responses remain limited, and hematopoietic stem cell transplantation (HSCT) remains the only potentially curative treatment option. The number of HSCTs for MF continues to increase worldwide, but its inherent therapy-related morbidity and mortality limit its use for many patients. Furthermore, patients with MF often present at an older age, with cytopenia, splenomegaly, and severe bone marrow fibrosis, posing challenges in managing them throughout the HSCT procedure. Although implementation of molecular analyses enabled improved understanding of disease mechanisms and subsequently sparked development of novel drugs with promising activity, prospective trials in the HSCT setting are often lacking, making an evidence-based decision process particularly difficult. To illustrate how we approach patients with MF with respect to HSCT, we present 3 different clinical scenarios to capture relevant aspects that influence our decision making regarding indication for, or against, HSCT. We describe how we perform HSCT according to different risk categories and, furthermore, discuss our up-to-date approach to reduce transplant-related complications. Last, we show how to harness graft-versus-MF effects, particularly in the posttransplant period to achieve the best possible outcomes for patients.
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Affiliation(s)
- Nicolaus Kröger
- Department of Stem Cell Transplantation, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Christine Wolschke
- Department of Stem Cell Transplantation, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Nico Gagelmann
- Department of Stem Cell Transplantation, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
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6
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Gangat N, Ajufo H, Abdelmagid M, Karrar O, McCullough K, Badar T, Foran J, Palmer J, Alkhateeb H, Mangaonkar A, Kuykendall A, Rampal RK, Tefferi A. IDH1/2 inhibitor monotherapy in blast-phase myeloproliferative neoplasms: A multicentre experience. Br J Haematol 2023; 203:e87-e92. [PMID: 37537750 DOI: 10.1111/bjh.19027] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2023] [Revised: 07/16/2023] [Accepted: 07/27/2023] [Indexed: 08/05/2023]
Affiliation(s)
- Naseema Gangat
- Division of Hematology, Mayo Clinic, Rochester, Minnesota, USA
| | - Helen Ajufo
- Leukemia Service, Department of Medicine, Memorial Sloan Kettering, New York, New York, USA
| | | | - Omer Karrar
- Division of Hematology, Mayo Clinic, Rochester, Minnesota, USA
| | | | - Talha Badar
- Division of Hematology, Mayo Clinic, Jacksonville, Florida, USA
| | - James Foran
- Division of Hematology, Mayo Clinic, Jacksonville, Florida, USA
| | - Jeanne Palmer
- Division of Hematology, Mayo Clinic, Scottsdale, Arizona, USA
| | | | | | | | - Raajit K Rampal
- Leukemia Service, Department of Medicine, Memorial Sloan Kettering, New York, New York, USA
| | - Ayalew Tefferi
- Division of Hematology, Mayo Clinic, Rochester, Minnesota, USA
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7
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Calabresi L, Carretta C, Romagnoli S, Rotunno G, Parenti S, Bertesi M, Bartalucci N, Rontauroli S, Chiereghin C, Castellano S, Gentili G, Maccari C, Vanderwert F, Mannelli F, Della Porta M, Manfredini R, Vannucchi AM, Guglielmelli P. Clonal dynamics and copy number variants by single-cell analysis in leukemic evolution of myeloproliferative neoplasms. Am J Hematol 2023; 98:1520-1531. [PMID: 37399248 DOI: 10.1002/ajh.27013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2023] [Accepted: 06/15/2023] [Indexed: 07/05/2023]
Abstract
Transformation from chronic (CP) to blast phase (BP) in myeloproliferative neoplasm (MPN) remains poorly characterized, and no specific mutation pattern has been highlighted. BP-MPN represents an unmet need, due to its refractoriness to treatment and dismal outcome. Taking advantage of the granularity provided by single-cell sequencing (SCS), we analyzed paired samples of CP and BP in 10 patients to map clonal trajectories and interrogate target copy number variants (CNVs). Already at diagnosis, MPN present as oligoclonal diseases with varying ratio of mutated and wild-type cells, including cases where normal hematopoiesis was entirely surmised by mutated clones. BP originated from increasing clonal complexity, either on top or independent of a driver mutation, through acquisition of novel mutations as well as accumulation of clones harboring multiple mutations, that were detected at CP by SCS but were missed by bulk sequencing. There were progressive copy-number imbalances from CP to BP, that configured distinct clonal profiles and identified recurrences in genes including NF1, TET2, and BCOR, suggesting an additional level of complexity and contribution to leukemic transformation. EZH2 emerged as the gene most frequently affected by single nucleotide and CNVs, that might result in EZH2/PRC2-mediated transcriptional deregulation, as supported by combined scATAC-seq and snRNA-seq analysis of the leukemic clone in a representative case. Overall, findings provided insights into the pathogenesis of MPN-BP, identified CNVs as a hitherto poorly characterized mechanism and point to EZH2 dysregulation as target. Serial assessment of clonal dynamics might potentially allow early detection of impending disease transformation, with therapeutic implications.
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Affiliation(s)
- Laura Calabresi
- Center Research and Innovation of Myeloproliferative Neoplasms (CRIMM), Azienda Ospedaliera-Universitaria Careggi, Florence, Italy
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
| | - Chiara Carretta
- Centre for Regenerative Medicine "S. Ferrari", University of Modena and Reggio Emilia, Modena, Italy
- Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Modena, Italy
| | - Simone Romagnoli
- Center Research and Innovation of Myeloproliferative Neoplasms (CRIMM), Azienda Ospedaliera-Universitaria Careggi, Florence, Italy
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
| | - Giada Rotunno
- Center Research and Innovation of Myeloproliferative Neoplasms (CRIMM), Azienda Ospedaliera-Universitaria Careggi, Florence, Italy
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
| | - Sandra Parenti
- Centre for Regenerative Medicine "S. Ferrari", University of Modena and Reggio Emilia, Modena, Italy
- Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Modena, Italy
| | - Matteo Bertesi
- Centre for Regenerative Medicine "S. Ferrari", University of Modena and Reggio Emilia, Modena, Italy
- Department of Life Sciences, University of Modena and Reggio Emilia, Modena, Italy
| | - Niccolò Bartalucci
- Center Research and Innovation of Myeloproliferative Neoplasms (CRIMM), Azienda Ospedaliera-Universitaria Careggi, Florence, Italy
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
| | - Sebastiano Rontauroli
- Centre for Regenerative Medicine "S. Ferrari", University of Modena and Reggio Emilia, Modena, Italy
- Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Modena, Italy
| | | | - Sara Castellano
- Centre for Regenerative Medicine "S. Ferrari", University of Modena and Reggio Emilia, Modena, Italy
- Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Modena, Italy
| | - Giulia Gentili
- Center Research and Innovation of Myeloproliferative Neoplasms (CRIMM), Azienda Ospedaliera-Universitaria Careggi, Florence, Italy
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
| | - Chiara Maccari
- Center Research and Innovation of Myeloproliferative Neoplasms (CRIMM), Azienda Ospedaliera-Universitaria Careggi, Florence, Italy
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
| | - Fiorenza Vanderwert
- Center Research and Innovation of Myeloproliferative Neoplasms (CRIMM), Azienda Ospedaliera-Universitaria Careggi, Florence, Italy
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
| | - Francesco Mannelli
- Center Research and Innovation of Myeloproliferative Neoplasms (CRIMM), Azienda Ospedaliera-Universitaria Careggi, Florence, Italy
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
| | | | - Rossella Manfredini
- Centre for Regenerative Medicine "S. Ferrari", University of Modena and Reggio Emilia, Modena, Italy
- Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Modena, Italy
| | - Alessandro Maria Vannucchi
- Center Research and Innovation of Myeloproliferative Neoplasms (CRIMM), Azienda Ospedaliera-Universitaria Careggi, Florence, Italy
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
| | - Paola Guglielmelli
- Center Research and Innovation of Myeloproliferative Neoplasms (CRIMM), Azienda Ospedaliera-Universitaria Careggi, Florence, Italy
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
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8
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Mahdi D, Spiers J, Rampotas A, Polverelli N, McLornan DP. Updates on accelerated and blast phase myeloproliferative neoplasms: Are we making progress? Br J Haematol 2023; 203:169-181. [PMID: 37527977 DOI: 10.1111/bjh.19010] [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: 04/30/2023] [Revised: 07/13/2023] [Accepted: 07/21/2023] [Indexed: 08/03/2023]
Abstract
Management approaches for accelerated and blast phase myeloproliferative neoplasms remain challenging for clinicians and patients alike. Despite many therapeutic advances, outcomes for those patients who are not allogeneic haematopoietic cell transplant eligible remain, in general, very poor. Estimated survival rates for such blast phase patients is frequently reported as less than 6 months. No specific immunological, genomic or clinicopathological signature currently exists that accurately predicts the risk and timing of transformation, which frequently induces a high degree of anxiety among patients and clinicians alike. Within this review article, we provide an up-to-date summary of current understanding of the underlying pathogenesis of accelerated and blast phase disease and discuss current therapeutic approaches and realistic outcomes. Finally, we discuss how the horizon may look with the introduction of more novel agents into the clinical arena.
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Affiliation(s)
- Dina Mahdi
- Department of Haematology, University College Hospital, London, UK
| | - Jessica Spiers
- Department of Haematology, University College Hospital, London, UK
| | | | - Nicola Polverelli
- Unit of Blood Diseases and Stem Cell Transplantation, University of Brescia, Brescia, Italy
| | - Donal P McLornan
- Department of Haematology, University College Hospital, London, UK
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9
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Abdelmagid MG, Al-Kali A, Begna KH, Hogan WJ, Litzow MR, Fleti F, Mangaonkar AA, Patnaik MS, Elliott MA, Alkhateeb H, Shi M, Howard MT, Reichard KK, Ketterling RP, Shah M, Pardanani A, Gangat N, Tefferi A. Blast phase myeloproliferative neoplasm with prior exposure to ruxolitinib: comparative analysis of mutations and survival. Haematologica 2023; 108:2542-2545. [PMID: 36794509 PMCID: PMC10483339 DOI: 10.3324/haematol.2022.282627] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2022] [Accepted: 02/07/2023] [Indexed: 02/17/2023] Open
Abstract
Not available.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | - Min Shi
- Divisions of Hematopathology, Departments of Laboratory Medicine, Mayo Clinic, Rochester, MN
| | - Matthew T Howard
- Divisions of Hematopathology, Departments of Laboratory Medicine, Mayo Clinic, Rochester, MN
| | - Kaaren K Reichard
- Divisions of Hematopathology, Departments of Laboratory Medicine, Mayo Clinic, Rochester, MN
| | - Rhett P Ketterling
- Divisions of Hematopathology, Departments of Laboratory Medicine, Mayo Clinic, Rochester, MN
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10
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Gerds AT, Castro C, Snopek F, Flynn MM, Ellis AG, Manning M, Urbanski R. Cost-effectiveness of ropeginterferon alfa-2b-njft for the treatment of polycythemia vera. J Comp Eff Res 2023; 12:e230066. [PMID: 37531245 PMCID: PMC10690394 DOI: 10.57264/cer-2023-0066] [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: 06/07/2023] [Accepted: 07/14/2023] [Indexed: 08/04/2023] Open
Abstract
Aim: Patients with polycythemia vera (PV), a rare and chronic blood cancer, are at a higher risk for thromboembolic events, progression to myelofibrosis, and leukemic transformation. In 2021, ropeginterferon alfa-2b-njft (BESREMi®) was approved in the US to treat adults with PV. The purpose of this study is to estimate the cost-effectiveness of ropeginterferon alfa-2b-njft, used as a first- or second-line treatment, for the treatment of patients with PV in the US. Materials & methods: A Markov cohort model was developed from the healthcare system perspective in the United States. Model inputs were informed by the PROUD-PV and CONTINUATION-PV studies and published literature. The model population included both low-risk and high-risk patients with PV. The model compared ropeginterferon alfa-2b-njft used either as first- or second-line versus an alternative treatment pathway of first-line hydroxyurea followed by ruxolitinib. Results: Over the modeled lifetime, ropeginterferon alfa-2b-njft provided an additional 0.4 higher quality-adjusted life years (QALYs) and 0.4 life-years with an added cost of USD60,175, resulting in a cost per QALY of USD141,783. The model was sensitive to treatment costs, the percentage of patients who discontinue hydroxyurea, the percentage of ropeginterferon alfa-2b-njft users who switch to monthly dosing, the percentage of ropeginterferon alfa-2b-njft users as 2nd line treatment, and the treatment response rates. A younger patient age at baseline and a higher percentage of patients with low-risk disease improved the cost-effectiveness of ropeginterferon alfa-2b-njft. Conclusion: Ropeginterferon alfa-2b-njft is a cost-effective treatment option for a broad range of patients with PV, including both low- and high-risk patients and patients with and without prior cytoreductive treatment with hydroxyurea.
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Affiliation(s)
- Aaron T Gerds
- Cleveland Clinic Taussig Cancer Institute, Cleveland, OH 44106, USA
| | - Claudia Castro
- PharmaEssentia USA Corporation, Burlington, MA 01803, USA
| | - Frank Snopek
- PharmaEssentia USA Corporation, Burlington, MA 01803, USA
| | - Megan M Flynn
- PharmaEssentia USA Corporation, Burlington, MA 01803, USA
| | | | | | - Ray Urbanski
- PharmaEssentia USA Corporation, Burlington, MA 01803, USA
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11
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Mora B, Maffioli M, Rumi E, Guglielmelli P, Caramella M, Kuykendall A, Palandri F, Iurlo A, De Stefano V, Kiladjian J, Elli EM, Polverelli N, Gotlib J, Albano F, Silver RT, Benevolo G, Ross DM, Devos T, Borsani O, Barbui T, Porta MGD, Bertù L, Komrokji R, Vannucchi AM, Passamonti F. Incidence of blast phase in myelofibrosis according to anemia severity. EJHAEM 2023; 4:679-689. [PMID: 37601878 PMCID: PMC10435699 DOI: 10.1002/jha2.745] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/21/2023] [Revised: 06/06/2023] [Accepted: 06/15/2023] [Indexed: 08/22/2023]
Abstract
Myelofibrosis (MF) is a clonal malignancy frequently characterized by anemia and in 10%-20% of cases it can evolve into blast phase (BP). Anemia in MF is associated with reduced survival and -in primary MF- also with an increased probability of BP. Conventional treatments for anemia have limited effectiveness in MF. Within a dataset of 1752 MF subjects largely unexposed to ruxolitinib (RUX), BP incidence was 2.5% patients per year (p-y). This rate reached respectively 4.3% and 4.5% p-y in case of patients with common terminology criteria for adverse events (CTCAE) grade 3/4 and grade 2 anemia, respectively, that represented together 32% of the cohort. Among 273 MF cases treated with RUX, BP incidence was 2.89% p-y and it reached 4.86% p-y in subjects who started RUX with CTCAE grade 2 anemia (one third of total). Within patients with red blood cell transfusion-dependency at 6 months of RUX (21% of the exposed), BP rate was 4.2% p-y. Our study highlights a relevant incidence of BP in anemic MF patients, with a similar rate whether treated with or without RUX. These findings will help treating physicians to make decisions on the safety profile of innovative anemia treatments.
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Affiliation(s)
- Barbara Mora
- Department of Oncology, ASST Sette LaghiOspedale di CircoloVareseItaly
| | | | - Elisa Rumi
- Department of Molecular MedicineUniversity of PaviaPaviaItaly
- HematologyFondazione IRCCS Policlinico San MatteoPaviaItaly
| | - Paola Guglielmelli
- Center of Research and Innovation of Myeloproliferative NeoplasmsUniversity of FlorenceFlorenceItaly
| | | | - Andrew Kuykendall
- Malignant Hematology Department, Blood and Marrow TransplantationH. Lee Moffitt Cancer Center and Research InstituteTampaFloridaUSA
| | - Francesca Palandri
- Institute of Hematology “Seràgnoli”IRCCS Azienda Ospedaliero‐Universitaria di BolognaBolognaItaly
| | - Alessandra Iurlo
- HematologyFoundation IRCCS Ca'Granda Ospedale Maggiore PoliclinicoMilanItaly
| | - Valerio De Stefano
- HematologyFondazione Policlinico Universitario A. Gemelli IRCCSRomeItaly
| | | | - Elena M. Elli
- Division of Hematology and Bone Marrow UnitIRCCS San Gerardo dei TintoriMonzaItaly
| | - Nicola Polverelli
- Unit of Blood Diseases and Stem Cell TransplantationASST Spedali Civili di BresciaBresciaItaly
| | - Jason Gotlib
- Division of Hematology, Stanford Cancer InstituteStanford University School of MedicineStanfordCaliforniaUSA
| | - Francesco Albano
- Hematology ‐ Department of Emergency and Organ TransplantationUniversity of BariBariItaly
| | - Richard T. Silver
- Richard T. Silver Myeloproliferative Neoplasms CenterNewYork‐Presbyterian Weill Cornell Medical CenterNew YorkNew YorkUSA
| | - Giulia Benevolo
- Hematology UnitAOU Città della Salute e della Scienza di TorinoTurinItaly
| | - David M. Ross
- Haematology Directorate, SA PathologyRoyal Adelaide HospitalAdelaideSouth AustraliaAustralia
| | - Timothy Devos
- Department of HematologyKU Leuven University Hospitals LeuvenLeuvenBelgium
| | - Oscar Borsani
- Department of Molecular MedicineUniversity of PaviaPaviaItaly
- HematologyFondazione IRCCS Policlinico San MatteoPaviaItaly
| | - Tiziano Barbui
- FROM Research FoundationASST Papa Giovanni XXIIIBergamoItaly
| | | | - Lorenza Bertù
- Department of Medicine and SurgeryUniversity of InsubriaVareseItaly
| | - Rami Komrokji
- Malignant Hematology Department, Blood and Marrow TransplantationH. Lee Moffitt Cancer Center and Research InstituteTampaFloridaUSA
| | - Alessandro M. Vannucchi
- Center of Research and Innovation of Myeloproliferative NeoplasmsUniversity of FlorenceFlorenceItaly
| | - Francesco Passamonti
- HematologyFoundation IRCCS Ca'Granda Ospedale Maggiore PoliclinicoMilanItaly
- Department of Oncology and Haemato‐OncologyUniversity of MilanMilanItaly
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12
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Tefferi A, Alkhateeb H, Gangat N. Blast phase myeloproliferative neoplasm: contemporary review and 2024 treatment algorithm. Blood Cancer J 2023; 13:108. [PMID: 37460550 DOI: 10.1038/s41408-023-00878-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2023] [Revised: 05/30/2023] [Accepted: 06/21/2023] [Indexed: 07/20/2023] Open
Abstract
Leukemic transformation in myeloproliferative neoplasms (MPN), also referred to as "blast-phase MPN", is the most feared disease complication, with incidence estimates of 1-4% for essential thrombocythemia, 3-7% for polycythemia vera, and 9-13% for primary myelofibrosis. Diagnosis of MPN-BP requires the presence of ≥20% circulating or bone marrow blasts; a lower level of excess blasts (10-19%) constitutes "accelerated phase" disease (MPN-AP). Neither "intensive" nor "less intensive" chemotherapy, by itself, secures long-term survival in MPN-BP. Large-scale retrospective series have consistently shown a dismal prognosis in MPN-BP, with 1- and 3-year survival estimates of <20% and <5%, respectively. Allogeneic hematopoietic stem cell transplant (AHSCT) offers the possibility of a >30% 3-year survival rate and should be pursued, ideally, while the patient is still in chronic phase disease. The value of pre-transplant bridging chemotherapy is uncertain in MPN-AP while it is advised in MPN-BP; in this regard, we currently favor combination chemotherapy with venetoclax (Ven) and hypomethylating agent (HMA); response is more likely in the absence of complex/monosomal karyotype and presence of TET2 mutation. Furthermore, in the presence of an IDH mutation, the use of IDH inhibitors, either alone or in combination with Ven-HMA, can be considered. Pre-transplant clearance of excess blasts is desired but not mandated; in this regard, additional salvage chemotherapy is more likely to compromise transplant eligibility rather than improve post-transplant survival. Controlled studies are needed to determine the optimal pre- and post-transplant measures that target transplant-associated morbidity and post-transplant relapse.
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Affiliation(s)
- Ayalew Tefferi
- Division of Hematology, Department of Medicine, Mayo Clinic, Rochester, Minnesota, USA.
| | - Hassan Alkhateeb
- Division of Hematology, Department of Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Naseema Gangat
- Division of Hematology, Department of Medicine, Mayo Clinic, Rochester, Minnesota, USA
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13
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Ajufo HO, Waksal JA, Mascarenhas JO, Rampal RK. Treating accelerated and blast phase myeloproliferative neoplasms: progress and challenges. Ther Adv Hematol 2023; 14:20406207231177282. [PMID: 37564898 PMCID: PMC10410182 DOI: 10.1177/20406207231177282] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/25/2022] [Accepted: 05/03/2023] [Indexed: 08/12/2023] Open
Abstract
Myeloproliferative neoplasms (MPNs) are a group of clonal hematologic malignancies that include polycythemia vera (PV), essential thrombocythemia (ET), and myelofibrosis (MF). MPNs are characterized by activating mutations in the JAK/STAT pathway and an increased risk of transformation to an aggressive form of acute leukemia, termed MPN-blast phase (MPN-BP). MPN-BP is characterized by the presence of ⩾20% blasts in the blood or bone marrow and is almost always preceded by an accelerated phase (MPN-AP) defined as ⩾10-19% blasts in the blood or bone marrow. These advanced forms of disease are associated with poor prognosis with a median overall survival (mOS) of 3-5 months in MPN-BP and 13 months in MPN-AP. MPN-AP/BP has a unique molecular landscape characterized by increased intratumoral complexity. Standard therapies used in de novo acute myeloid leukemia (AML) have not demonstrated improvement in OS. Allogeneic hematopoietic stem cell transplant (HSCT) remains the only curative therapy but is associated with significant morbidity and mortality and infrequently utilized in clinical practice. Therefore, an urgent unmet need persists for effective therapies in this advanced phase patient population. Here, we review the current management and future directions of therapy in MPN-AP/BP.
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Affiliation(s)
- Helen O. Ajufo
- Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Julian A. Waksal
- The Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - John O. Mascarenhas
- The Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, Box 1079, New York, NY 10029, USA
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14
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Ortí G, Gras L, Zinger N, Finazzi MC, Sockel K, Robin M, Forcade E, Avenoso D, Kröger N, Finke J, Radujkovic A, Hunault-Berger M, Schroyens W, Zuckerman T, Bourhis JH, Chalandon Y, Bloor A, Schots R, de Wreede LC, Drozd-Sokolowska J, Raj K, Polverelli N, Czerw T, Hernández-Boluda JC, McLornan D, Yakoub-Agha I. Outcomes after allogeneic hematopoietic cell transplant in patients diagnosed with blast phase of myeloproliferative neoplasms: A retrospective study from the Chronic Malignancies Working Party of the European Society for Blood and Marrow Transplantation. Am J Hematol 2023; 98:628-638. [PMID: 36606718 DOI: 10.1002/ajh.26833] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2022] [Revised: 12/27/2022] [Accepted: 01/01/2023] [Indexed: 01/07/2023]
Abstract
Allogeneic hematopoietic cell transplant (allo-HCT) provides the only potential route to long-term remission in patients diagnosed with blast phase transformation of myeloproliferative neoplasm (BP-MPN). We report on a large, retrospective European Society for Blood and Marrow Transplantation registry-based study of BP-MPN patients undergoing allo-HCT. BP-MPN patients undergoing first allo-HCT between 2005 and 2019 were included. A total of 663 patients were included. With a median follow-up of 62 months, the estimated 3-year overall survival (OS) was 36% (95% confidence interval [CI], 32-36). Factors associated with lower OS were Karnofsky Performance Score (KPS) <90 (hazard ratio [HR] 1.65, p < .001) and active disease at allo-HCT (HR 1.45, p < .001), whereas patients undergoing allo-HCT more recently associated with a higher OS (HR 0.96, p = .008). In a selected patient's population, the 3-year OS of patients undergoing allo-HCT in complete response (CR) and with a KPS ≥90 was 60%. KPS < 90 (HR 1.4, p = .001) and active disease (HR 1.44, p = .0004) were associated with a lower progression-free survival (PFS). Conversely, most recent allo-HCT associated with a higher PFS (HR 0.96, p = .008). Active disease at allo-HCT (HR 1.34, p = .03) was associated with a higher cumulative incidence of relapse (RI) and allo-HCT in earlier calendar years (HR 0.96, p = .02) associated with a lower RI. Last, KPS < 90 (HR 1.91, p < .001), active disease (HR 1.74, p = .003) and allo-HCT from mismatched related donors were associated with a higher non-relapse mortality (HR 2.66, p = .003). In this large series of BP-MPN patients, about one third were alive at 3 years after transplantation. Patients undergoing allo-HCT in the more recent era, with a KPS ≥90 and in CR at transplant had a better prognosis.
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Affiliation(s)
- Guillermo Ortí
- Department of Hematology, Vall d'Hebron University Hospital, Vall d'Hebron Institute of Oncology (VHIO), Barcelona, Spain
| | - Luuk Gras
- EBMT Statistical Unit, Leiden, The Netherlands
| | | | - Maria Chiara Finazzi
- Department of Oncology and Hematology, University of Milan and Papa Giovanni XXIII, Bergamo, Italy
| | - Katja Sockel
- Medical Clinic I, University Hospital Dresden, TU Dresden, Germany
| | - Marie Robin
- Hopital Saint Louis, APHP, Université de Paris Cité, Paris, France
| | - Edouard Forcade
- Service d'Hématologie Clinique et Thérapie Cellulaire, Bordeaux, France
| | | | | | | | | | | | | | | | | | - Yves Chalandon
- Hôpitaux Universitaire Genève, Département d'Oncologie, Service d'Hématologie, Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | | | - Rik Schots
- Universitair Ziekenhuis Brussel, Brussels, Belgium
| | | | | | - Kavita Raj
- University College London Hospital, London, UK
| | | | - Tomasz Czerw
- Maria Skłodowska-Curie National Research Institute of Oncology, Gliwice, Poland
| | | | - Donal McLornan
- Department of Stem Cell Transplantation, University College London Hospital, London, UK
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15
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Tefferi A, Bacigalup A. Blast phase myeloproliferative neoplasm: Transplant to the rescue. Am J Hematol 2023; 98:553-555. [PMID: 36655312 DOI: 10.1002/ajh.26849] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2023] [Accepted: 01/04/2023] [Indexed: 01/20/2023]
Affiliation(s)
- Ayalew Tefferi
- Division of Hematology, Mayo Clinic, Rochester, Minnesota, USA
| | - Andrea Bacigalup
- Istituto di Ematologia, Policlinico Universitario A Gemelli, Rome, Italy
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16
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Patnaik MM, Tefferi A. Atypical chronic myeloid leukemia and myelodysplastic/myeloproliferative neoplasm, not otherwise specified: 2023 update on diagnosis, risk stratification, and management. Am J Hematol 2023; 98:681-689. [PMID: 36601682 DOI: 10.1002/ajh.26828] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2022] [Revised: 12/19/2022] [Accepted: 12/21/2022] [Indexed: 01/06/2023]
Abstract
DISEASE OVERVIEW Atypical chronic myeloid leukemia (aCML) and myelodysplastic/myeloproliferative (MDS/MPN) neoplasms, not otherwise specified (NOS), are MDS/MPN overlap neoplasms characterized by leukocytosis, in the absence of monocytosis and eosinophilia, with <20% blasts in the blood and bone marrow. DIAGNOSIS aCML, previously known as aCML, BCR::ABL1 negative, was renamed as aCML by the ICC classification, and as MDS/MPN with neutrophilia by the 5th edition of the WHO classification. This entity is characterized by dysplastic neutrophilia with immature myeloid cells comprising ≥10% of the white blood cell count, with prominent dysgranulopoiesis. MDS/MPN-NOS consists of MDS/MPN overlap neoplasms not meeting criteria for defined categories such as chronic myelomonocytic leukemia (CMML), MDS/MPN-ring sideroblasts-thrombocytosis (MDS/MPN-RS-T), and aCML. MUTATIONS AND KARYOTYPE Cytogenetic abnormalities are seen in 40-50% of patients in both categories. In aCML, somatic mutations commonly encountered include ASXL1, SETBP1, ETNK1, and EZH2 whereas MDS/MPN-NOS can be further stratified by mutational profiles into CMML-like, MDS/MPN-RS-T-like, aCML-like, TP35-mutated, and "others", respectively. RISK STRATIFICATION The Mayo Clinic aCML model stratifies patients based on age >67 years, hemoglobin <10 g/dl, and the presence of TET2 mutations into low-risk (0-1 points) and high-risk (>2 points) groups, with median survivals of 18 and 7 months, respectively. MDS/MPN-NOS patients have traditionally been risk stratified using MDS risk models such as IPSS and IPSS-R. TREATMENT Leukocytosis and anemia are managed like lower risk MPN and MDS. DNMT inhibitors have been used in both entities with suboptimal response rates. Allogeneic stem cell transplant remains the only curative strategy but is associated with high morbidity and mortality.
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MESH Headings
- Humans
- Aged
- Leukemia, Myeloid, Chronic, Atypical, BCR-ABL Negative/diagnosis
- Leukemia, Myeloid, Chronic, Atypical, BCR-ABL Negative/genetics
- Leukemia, Myeloid, Chronic, Atypical, BCR-ABL Negative/therapy
- Myelodysplastic Syndromes/diagnosis
- Myelodysplastic Syndromes/genetics
- Myelodysplastic Syndromes/therapy
- Leukocytosis
- Myelodysplastic-Myeloproliferative Diseases/diagnosis
- Myelodysplastic-Myeloproliferative Diseases/genetics
- Myelodysplastic-Myeloproliferative Diseases/therapy
- Leukemia, Myelomonocytic, Chronic/diagnosis
- Leukemia, Myelomonocytic, Chronic/genetics
- Leukemia, Myelomonocytic, Chronic/therapy
- Thrombocytosis/genetics
- Mutation
- Risk Assessment
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Affiliation(s)
- Mrinal M Patnaik
- 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
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Subbotina TN, Maslyukova IE, Semashchenko KS, Khodos GA, Kurochkin DV, Shalyova AA, Mikhalev MA, Vasiliev EV, Osadchaya MG, Dunaeva EA, Esman AS, Mironov KO. Analysis of somatic mutations in the <i>JAK2</i>, <i>CALR</i>, <i>MPL</i> and <i>ASXL1</i> genes and evaluation of their impact on the survival of patients with myelofibrosis. ONCOHEMATOLOGY 2023. [DOI: 10.17650/1818-8346-2023-18-1-63-75] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 03/18/2023]
Abstract
Background. The development of myelofibrosis (MF) is driven by complex molecular genetic events that include driver somatic mutations responsible for the constitutive activation of the JAK/STAT signaling pathway (JAK2, CALR, and MPL), additional mutations affecting epigenetic regulators (TET2, ASXL1, IDH1/2, etc.) and RNA splicing (SRSF2, U2AF1, SF3B1, etc.), as well as genetic aberrations that contribute to genomic instability and disease progression.Aim. To analyze driver (JAK2, CALR, MPL) and prognostic (ASXL1) somatic mutations in patients with MF and evaluate their impact on survival.Materials and methods. The study included 29 patients diagnosed with MF, selected by hematologists from the City Clinical Hospital No. 7 and Regional Clinical Hospital (Krasnoyarsk).Results. 26 (89.6 %) out of 29 examined patients had some driver mutations in JAK2, CALR, MPL genes. The p.V617F mutation in the JAK2 gene was found in 20 (68.9 %) patients. Mutations in the CALR gene were detected in 4 (13.8 %) patients, mutations in the MPL gene were found in 3 patients (10.3 %). In 1 of 26 patients, 2 driver mutations were present simultaneously. 3 (10.3 %) patients were triple negative. Mutations in the ASXL1 gene were detected in 12 (41.4 %) out of 29 examined patients. Conducted targeted NGS (next generation sequencing) for 13 out of 29 patients revealed additional genetic variants that contribute to the understanding of the development mechanism and disease course. When evaluating the overall survival in the groups of patients diagnosed with MF examined by us, depending on the combination of driver (JAK2, CALR, MPL) and prognostic (ASXL1) mutations, no statistically significant differences were found (p = 0.12). This appears to be due to the small sample size. At the same time, assessment of patient survival depending on ASXL1 status showed that in the presence of mutations in the ASXL1 gene, the median survival was 45 months (range 7–120 months), while in the absence of mutations it was 48 months (range 21–359 months) (p = 0.03).Conclusion. The results obtained allow us to assume that the presence of mutations in the ASXL1 gene is an unfavorable factor in the course of the disease.
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Affiliation(s)
- T. N. Subbotina
- Siberian Federal University; Federal Siberian Research and Clinical Center, Federal Medical and Biological Agency
| | - I. E. Maslyukova
- Siberian Federal University; Federal Siberian Research and Clinical Center, Federal Medical and Biological Agency
| | | | | | - D. V. Kurochkin
- Siberian Federal University; Federal Siberian Research and Clinical Center, Federal Medical and Biological Agency
| | - A. A. Shalyova
- Siberian Federal University; Federal Siberian Research and Clinical Center, Federal Medical and Biological Agency
| | | | | | | | - E. A. Dunaeva
- Central Research Institute of Epidemiology of the Federal Service for Surveillance on Consumer Rights Protection and Human Wellbeing
| | - A. S. Esman
- Central Research Institute of Epidemiology of the Federal Service for Surveillance on Consumer Rights Protection and Human Wellbeing
| | - K. O. Mironov
- Central Research Institute of Epidemiology of the Federal Service for Surveillance on Consumer Rights Protection and Human Wellbeing
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18
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Ilyas R, McCullough K, Badar T, Patnaik MM, Alkhateeb H, Mangaonkar A, Pardanani A, Tefferi A, Gangat N. CPX-351 (Vyxeos™) treatment in blast-phase myeloproliferative neoplasm (MPN-BP): real-world experience in 12 consecutive cases. Blood Cancer J 2023; 13:26. [PMID: 36797234 PMCID: PMC9935849 DOI: 10.1038/s41408-023-00800-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2023] [Revised: 02/07/2023] [Accepted: 02/09/2023] [Indexed: 02/18/2023] Open
Affiliation(s)
- Rimal Ilyas
- Division of Hematology, Mayo Clinic, Rochester, MN, USA
| | | | - Talha Badar
- Division of Hematology, Mayo Clinic, Jacksonville, FL, USA
| | | | | | | | | | | | - Naseema Gangat
- Division of Hematology, Mayo Clinic, Rochester, MN, USA.
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19
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Abstract
OPINION STATEMENT Currently approved therapies for myelofibrosis (MF) consist of JAK inhibitors, which produce meaningful improvements in spleen size and symptom burden but do not significantly impact leukemic progression. In addition, many patients develop resistance or intolerance to existing therapies and are left without meaningful therapeutic options. There has been recent rapid development of agents in MF that may be able to fill these unmet needs. Importantly, most treatments currently in clinical development have targets outside the JAK-STAT pathway, including BET, BCL-2/BCL-xL, PI3k, HDM2, PIM-1, SINE, telomerase, LSD1, and CD123. These therapies are being tested in combination with JAK inhibitors in the front-line setting and in patients with a suboptimal response, as well as a single agent after JAK inhibitor failure. This next generation of agents is likely to produce a paradigm shift in MF treatment with a focus on combination treatment targeting multiple areas of MF pathophysiology.
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Affiliation(s)
- Douglas Tremblay
- Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Ruben Mesa
- UT Health San Antonio Cancer Center, San Antonio, TX, USA.
- Mays Cancer Center at UT Health San Antonio MD Anderson, San Antonio, TX, USA.
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20
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Patel AA, Odenike O. SOHO State of the Art Updates and Next Questions | Accelerated Phase of MPN: What It Is and What to Do About It. CLINICAL LYMPHOMA, MYELOMA & LEUKEMIA 2023; 23:303-309. [PMID: 36907766 DOI: 10.1016/j.clml.2023.01.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/05/2022] [Revised: 01/20/2023] [Accepted: 01/20/2023] [Indexed: 01/26/2023]
Abstract
Progression of Philadelphia-chromosome negative myeloproliferative neoplasms (MPNs) to the accelerated phase (AP) or blast phase (BP) is associated with poor outcomes. As our understanding of the molecular drivers of MPN progression has grown, there has been increasing investigation into the use of novel targeted approaches in the treatment of these diseases. In this review we summarize the clinical and molecular risk factors for progression to MPN-AP/BP followed by discussion of treatment approach. We also highlight outcomes using conventional approaches such as intensive chemotherapy and hypomethylating agents along with considerations around allogeneic hematopoietic stem cell transplant. We then focus on novel targeted approaches in MPN-AP/BP including venetoclax-based regimens, IDH inhibition, and ongoing prospective clinical trials.
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Affiliation(s)
- Anand A Patel
- Section of Hematology/Oncology, Department of Medicine, University of Chicago, Chicago, IL
| | - Olatoyosi Odenike
- Section of Hematology/Oncology, Department of Medicine, University of Chicago, Chicago, IL.
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21
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Mannelli F, Guglielmelli P, Fazi P, Crea E, Piciocchi A, Vignetti M, Amadori S, Pane F, Venditti A, Vannucchi AM. ENABLE: treatment combination including decitabine and venetoclax in acute myeloid leukemia secondary to myeloproliferative neoplasms. Future Oncol 2023; 19:103-111. [PMID: 36651780 DOI: 10.2217/fon-2022-0512] [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: 01/19/2023] Open
Abstract
The management of patients with acute myeloid leukemia (blast phase) secondary to myeloproliferative neoplasms (MPNs) is extremely challenging and the outcome dismal, with a median overall survival of about 3-6 months. Effective therapeutic approaches are lacking, especially when intensive strategies followed by allogeneic transplantation are not feasible. The combination of venetoclax and hypomethylating agents has recently been established as standard for newly diagnosed, unfit patients with de novo acute myeloid leukemia, but the application of this therapeutic modality has not been tested prospectively in the specific context of blast-phase MPNs. ENABLE is an open, phase II clinical trial aimed at verifying the efficacy and safety of the combination of venetoclax and decitabine in patients with post-MPN blast phase.
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Affiliation(s)
- Francesco Mannelli
- SOD Ematologia, AOU Careggi, Firenze, Italy.,Centro Ricerca e Innovazione Malattie Mieloproliferative (CRIMM), AOU Careggi, 50134, Firenze, Italy
| | - Paola Guglielmelli
- SOD Ematologia, AOU Careggi, Firenze, Italy.,Centro Ricerca e Innovazione Malattie Mieloproliferative (CRIMM), AOU Careggi, 50134, Firenze, Italy
| | | | | | | | | | | | - Fabrizio Pane
- UO di Ematologia e Trapianto di Cellule Staminali Emopoietiche, AOU 'Federico II', 80131, Napoli, Italy
| | - Adriano Venditti
- Ematologia, Dipartimento di Biomedicina e Prevenzione, Università di Tor Vergata, 00133, Roma, Italy.,Fondazione Policlinico Tor Vergata, 00133, Roma, Italy
| | - Alessandro M Vannucchi
- SOD Ematologia, AOU Careggi, Firenze, Italy.,Centro Ricerca e Innovazione Malattie Mieloproliferative (CRIMM), AOU Careggi, 50134, Firenze, Italy
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22
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Hitting the brakes on accelerated and blast-phase myeloproliferative neoplasms: current and emerging concepts. HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2022; 2022:218-224. [PMID: 36485103 PMCID: PMC9820986 DOI: 10.1182/hematology.2022000341] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
The BCR-ABL-negative myeloproliferative neoplasms (MPNs) have a variable risk of progressing to accelerated- or blast-phase MPN (MPN-AP/MPN-BP), defined by the presence of 10% to 19% and more than or equal to 20% myeloid blasts in the peripheral blood or bone marrow, respectively. The molecular processes underlying the progression to MPN-AP/MPN-BP are becoming increasingly understood with the acquisition of additional mutations in epigenetic modifiers (eg, ASXL1, EZH2, TET2), TP53, the Ras pathway, or splicing factors (eg, SRSF2, U2AF1), having been described as important steps in this evolutionary process. At least partially driven by the enrichment of these high-risk molecular features, the prognosis of patients with MPN-BP remains inferior to other patients with acute myeloid leukemia, with a median overall survival of 3 to 6 months. Allogeneic hematopoietic cell transplantation remains the only potentially curative therapeutic modality, but only a minority of patients are eligible. In the absence of curative intent, therapeutic strategies or palliative treatment with hypomethylating agents as monotherapy or in combination with ruxolitinib or venetoclax can be considered. Several novel agents are in various stages of clinical development but are not available for routine use at this point, highlighting the need for ongoing research and the prioritization of clinical trial enrollment when feasible.
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23
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Novel Molecular Insights into Leukemic Evolution of Myeloproliferative Neoplasms: A Single Cell Perspective. Int J Mol Sci 2022; 23:ijms232315256. [PMID: 36499582 PMCID: PMC9740017 DOI: 10.3390/ijms232315256] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2022] [Revised: 11/25/2022] [Accepted: 11/30/2022] [Indexed: 12/12/2022] Open
Abstract
Myeloproliferative neoplasms (MPNs) are clonal disorders originated by the serial acquisition of somatic mutations in hematopoietic stem/progenitor cells. The major clinical entities are represented by polycythemia vera (PV), essential thrombocythemia (ET), and primary myelofibrosis (PMF), that are caused by driver mutations affecting JAK2, MPL or CALR. Disease progression is related to molecular and clonal evolution. PV and ET can progress to secondary myelofibrosis (sMF) but can also evolve to secondary acute myeloid leukemia (sAML). PMF is associated with the highest frequency of leukemic transformation, which represents the main cause of death. sAML is associated with a dismal prognosis and clinical features that differ from those of de novo AML. The molecular landscape distinguishes sAML from de novo AML, since the most frequent hits involve TP53, epigenetic regulators, spliceosome modulators or signal transduction genes. Single cell genomic studies provide novel and accurate information about clonal architecture and mutation acquisition order, allowing the reconstruction of clonal dynamics and molecular events that accompany leukemic transformation. In this review, we examine our current understanding of the genomic heterogeneity in MPNs and how it affects disease progression and leukemic transformation. We focus on molecular events elicited by somatic mutations acquisition and discuss the emerging findings coming from single cell studies.
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24
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McKinnell Z, Karel D, Tuerff D, SH Abrahim M, Nassereddine S. Acute Myeloid Leukemia Following Myeloproliferative Neoplasms: A Review of What We Know, What We Do Not Know, and Emerging Treatment Strategies. J Hematol 2022; 11:197-209. [PMID: 36632576 PMCID: PMC9822656 DOI: 10.14740/jh1042] [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: 09/02/2022] [Accepted: 10/15/2022] [Indexed: 01/04/2023] Open
Abstract
Acute myeloid leukemia (AML) arising from myeloproliferative neoplasms (MPNs) represents a small subtype of secondary AML (sAML). This entity is well known to be associated with poor responses to available treatment options and dismal outcomes. To date, there are no standardized treatment options and there has been very little therapeutic advancement in recent years. This is a stark contrast to other subsets of AML for which there have been significant advances in therapeutic approaches, especially for patients with targetable mutations. We aim to focus our review on the incidence, risk factors for leukemogenesis, pathogenesis, molecular landscape, and emerging therapeutic options in post-myeloproliferative neoplasm acute myeloid leukemia (post-MPN AML).
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Affiliation(s)
- Zoe McKinnell
- Department of Hematology and Oncology, George Washington University Hospital, Washington, DC, USA
| | - Daniel Karel
- Department of Hematology and Oncology, George Washington University Hospital, Washington, DC, USA
| | - Daniel Tuerff
- Department of Hematology and Oncology, George Washington University Hospital, Washington, DC, USA
| | - Marwa SH Abrahim
- Department of Hematology and Oncology, George Washington University Hospital, Washington, DC, USA
| | - Samah Nassereddine
- Department of Hematology and Oncology, George Washington University Hospital, Washington, DC, USA,Corresponding Author: Samah Nassereddine, Department of Hematology and Oncology, George Washington University and George Washington Cancer Center, Washington, DC, USA.
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25
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Talarmain L, Clarke MA, Shorthouse D, Cabrera-Cosme L, Kent DG, Fisher J, Hall BA. HOXA9 has the hallmarks of a biological switch with implications in blood cancers. Nat Commun 2022; 13:5829. [PMID: 36192425 PMCID: PMC9530117 DOI: 10.1038/s41467-022-33189-w] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2021] [Accepted: 09/07/2022] [Indexed: 11/09/2022] Open
Abstract
Blood malignancies arise from the dysregulation of haematopoiesis. The type of blood cell and the specific order of oncogenic events initiating abnormal growth ultimately determine the cancer subtype and subsequent clinical outcome. HOXA9 plays an important role in acute myeloid leukaemia (AML) prognosis by promoting blood cell expansion and altering differentiation; however, the function of HOXA9 in other blood malignancies is still unclear. Here, we highlight the biological switch and prognosis marker properties of HOXA9 in AML and chronic myeloproliferative neoplasms (MPN). First, we establish the ability of HOXA9 to stratify AML patients with distinct cellular and clinical outcomes. Then, through the use of a computational network model of MPN, we show that the self-activation of HOXA9 and its relationship to JAK2 and TET2 can explain the branching progression of JAK2/TET2 mutant MPN patients towards divergent clinical characteristics. Finally, we predict a connection between the RUNX1 and MYB genes and a suppressive role for the NOTCH pathway in MPN diseases.
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Affiliation(s)
- Laure Talarmain
- Peter MacCallum Cancer Centre, 305 Grattan Street, Melbourne, VIC, 3000, Australia
| | - Matthew A Clarke
- UCL Cancer Institute, University College London, Paul O'Gorman Building, 72 Huntley Street, London, WC1E 6BT, United Kingdom
| | - David Shorthouse
- Department of Medical Physics and Biomedical Engineering, Malet Place Engineering Building, University College London, Gower Street, London, WC1E 6BT, United Kingdom
| | - Lilia Cabrera-Cosme
- York Biomedical Research Institute, Department of Biology, University of York, York, YO10 5DD, United Kingdom
| | - David G Kent
- York Biomedical Research Institute, Department of Biology, University of York, York, YO10 5DD, United Kingdom
| | - Jasmin Fisher
- UCL Cancer Institute, University College London, Paul O'Gorman Building, 72 Huntley Street, London, WC1E 6BT, United Kingdom
| | - Benjamin A Hall
- Department of Medical Physics and Biomedical Engineering, Malet Place Engineering Building, University College London, Gower Street, London, WC1E 6BT, United Kingdom.
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26
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Saliba AN, Gangat N. Accelerated and blast phase myeloproliferative neoplasms. Best Pract Res Clin Haematol 2022; 35:101379. [DOI: 10.1016/j.beha.2022.101379] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2022] [Accepted: 08/23/2022] [Indexed: 11/29/2022]
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27
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Hernández-Boluda JC, Czerw T. Transplantation algorithm for myelofibrosis in 2022 and beyond. Best Pract Res Clin Haematol 2022; 35:101369. [DOI: 10.1016/j.beha.2022.101369] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2022] [Accepted: 07/27/2022] [Indexed: 11/16/2022]
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28
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Pastor-Galán I, Martín I, Ferrer B, Hernández-Boluda JC. Impact of molecular profiling on the management of patients with myelofibrosis. Cancer Treat Rev 2022; 109:102435. [PMID: 35839532 DOI: 10.1016/j.ctrv.2022.102435] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2022] [Revised: 06/30/2022] [Accepted: 07/04/2022] [Indexed: 11/02/2022]
Abstract
Myelofibrosis (MF) is a chronic myeloproliferative neoplasm (MPN) characterized by a highly heterogeneous clinical course, which can be complicated by severe constitutional symptoms, massive splenomegaly, progressive bone marrow failure, cardiovascular events, and development of acute leukemia. Constitutive signaling through the JAK-STAT pathway plays a fundamental role in its pathogenesis, generally due to activating mutations of JAK2, CALR and MPL genes (i.e., the MPN driver mutations), present in most MF patients. Next Generation Sequencing (NGS) panel testing has shown that additional somatic mutations can already be detected at the time of diagnosis in more than half of patients, and that they accumulate along the disease course. These mutations, mostly affecting epigenetic modifiers or spliceosome components, may cooperate with MPN drivers to favor clonal dominance or influence the clinical phenotype, and some, such as high molecular risk mutations, correlate with a more aggressive clinical course with poor treatment response. The current main role of molecular profiling in clinical practice is prognostication, principally for selecting high-risk patients who may be candidates for transplantation, the only curative treatment for MF to date. To this end, contemporary prognostic models incorporating molecular data are useful tools to discriminate different risk categories. Aside from certain clinical situations, decisions regarding medical treatment are not based on patient molecular profiling, yet this approach may become more relevant in novel treatment strategies, such as the use of vaccines against the mutant forms of JAK2 or CALR, or drugs directed against actionable molecular targets.
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Affiliation(s)
| | - Iván Martín
- Hospital Clínico Universitario-INCLIVA, Valencia, Spain
| | - Blanca Ferrer
- Hospital Clínico Universitario-INCLIVA, Valencia, Spain
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29
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Brierley C, Psaila B. A tale of two alleles: TP53 and transformation in MPNs. Blood 2022; 139:3567-3568. [PMID: 35737408 PMCID: PMC9227100 DOI: 10.1182/blood.2022016490] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2022] [Revised: 04/05/2022] [Accepted: 04/06/2022] [Indexed: 11/20/2022] Open
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30
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Qu S, Xu Z, Qin T, Li B, Pan L, Chen J, Yan X, Wu J, Zhang Y, Zhang P, Gale RP, Xiao Z. Ruxolitinib combined with prednisone, thalidomide and danazol in patients with myelofibrosis: Results of a pilot study. Hematol Oncol 2022; 40:787-795. [PMID: 35609279 DOI: 10.1002/hon.3026] [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: 01/29/2022] [Revised: 04/26/2022] [Accepted: 05/21/2022] [Indexed: 11/07/2022]
Abstract
Ruxolitinib is a safe and effective therapy of myeloproliferative neoplasm-associated (MPN) myelofibrosis. However, often there are dose reductions and/or therapy interruptions because of therapy-related adverse events (AEs), especially anemia and thrombocytopenia. We previously reported combined therapy with prednisone, thalidomide and danazol (PTD) reversed anemia and thrombocytopenia in people with MPN-associated myelofibrosis. We wondered whether adding PTD to ruxolitinib might mitigate the hematologic AEs and thereby avoid the dose reduction of ruxolitinib and improve the efficacy. To test this hypothesis, we conducted a baseline hemoglobin and platelet concentration assignment prospective observational study in 72 patients comparing 3-month dose adjustment and efficacy of ruxolitinib with (N = 53, the study group) or without (N = 19, the control group) PTD. According to the platelet counts, the median daily ruxolitinib doses in the study group increased from 30 to 40 mg by week 12, whereas in the control group it remained at 30 mg (p = 0.019). In the study group 35 patients had a hemoglobin increase ≥10 g/L compared with no patient receiving ruxolitinib only (p < 0.001). Platelet increases >100 × 10E+9/L were seen in 56.6% and 5.3% of patients in the two groups, respectively (p < 0.001). In patients with anemia and thrombocytopenia, 18 patients in the study group had an anemia response at week 12 and 12 had a platelet increase of ≥50 × 10E+9/L. No patient in the control group achieved either response (p < 0.001 and p = 0.078). The study group had a more spleen response than the control group (p = 0.046). Peripheral edema and transaminase elevation were the main nonhematologic AEs of PTD. These AEs can be alleviated by adjusting the danazol dose. In conclusion, adding PTD to ruxolitinib improved ruxolitinib-associated anemia and thrombocytopenia, and resulted in a higher ruxolitinib dose.
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Affiliation(s)
- Shiqiang Qu
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Institute of Hematology and Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin, China.,MDS and MPN Centre, Institute of Hematology and Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin, China
| | - Zefeng Xu
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Institute of Hematology and Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin, China.,MDS and MPN Centre, Institute of Hematology and Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin, China
| | - Tiejun Qin
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Institute of Hematology and Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin, China.,MDS and MPN Centre, Institute of Hematology and Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin, China
| | - Bing Li
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Institute of Hematology and Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin, China.,MDS and MPN Centre, Institute of Hematology and Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin, China
| | - Lijuan Pan
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Institute of Hematology and Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin, China.,MDS and MPN Centre, Institute of Hematology and Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin, China
| | - Jia Chen
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Institute of Hematology and Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin, China
| | - Xin Yan
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Institute of Hematology and Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin, China
| | - Junying Wu
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Institute of Hematology and Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin, China
| | - Yudi Zhang
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Institute of Hematology and Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin, China
| | - Peihong Zhang
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Institute of Hematology and Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin, China.,Hematologic Pathology Center, Institute of Hematology and Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin, China
| | - Robert Peter Gale
- Department of Immunology and Inflammation, Haematology Research Centre, Imperial College London, London, UK
| | - Zhijian Xiao
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Institute of Hematology and Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin, China.,MDS and MPN Centre, Institute of Hematology and Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin, China.,Hematologic Pathology Center, Institute of Hematology and Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin, China
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31
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Pasca S, Chifotides HT, Verstovsek S, Bose P. Mutational landscape of blast phase myeloproliferative neoplasms (MPN-BP) and antecedent MPN. INTERNATIONAL REVIEW OF CELL AND MOLECULAR BIOLOGY 2022; 366:83-124. [PMID: 35153007 DOI: 10.1016/bs.ircmb.2021.02.008] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Myeloproliferative neoplasms (MPN) have an inherent tendency to evolve to the blast phase (BP), characterized by ≥20% myeloblasts in the blood or bone marrow. MPN-BP portends a dismal prognosis and currently, effective treatment modalities are scarce, except for allogeneic hematopoietic stem cell transplantation (allo-HSCT) in selected patients, particularly those who achieve complete/partial remission. The mutational landscape of MPN-BP differs from de novo acute myeloid leukemia (AML) in several key aspects, such as significantly lower frequencies of FLT3 and DNMT3A mutations, and higher incidence of IDH1/2 and TP53 in MPN-BP. Herein, we comprehensively review the impact of the three signaling driver mutations (JAK2 V617F, CALR exon 9 indels, MPL W515K/L) that constitutively activate the JAK/STAT pathway, and of the other somatic non-driver mutations (epigenetic, mRNA splicing, transcriptional regulators, and mutations in signal transduction genes) that cooperatively or independently promote MPN progression and leukemic transformation. The MPN subtype, harboring two or more high-molecular risk (HMR) mutations (epigenetic regulators and mRNA splicing factors) and "triple-negative" PMF are among the critical factors that increase risk of leukemic transformation and shorten survival. Primary myelofibrosis (PMF) is the most aggressive MPN; and polycythemia vera (PV) and essential thrombocythemia (ET) are relatively indolent subtypes. In PV and ET, mutations in splicing factor genes are associated with progression to myelofibrosis (MF), and in ET, TP53 mutations predict risk for leukemic transformation. The advent of targeted next-generation sequencing and improved prognostic scoring systems for PMF inform decisions regarding allo-HSCT. The emergence of treatments targeting mutant enzymes (e.g., IDH1/2 inhibitors) or epigenetic pathways (BET and LSD1 inhibitors) along with new insights into the mechanisms of leukemogenesis will hopefully lead the way to superior management strategies and outcomes of MPN-BP patients.
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Affiliation(s)
- Sergiu Pasca
- Leukemia Department, The University of Texas MD Anderson Cancer Center, Houston, TX, United States
| | - Helen T Chifotides
- Leukemia Department, The University of Texas MD Anderson Cancer Center, Houston, TX, United States
| | - Srdan Verstovsek
- Leukemia Department, The University of Texas MD Anderson Cancer Center, Houston, TX, United States
| | - Prithviraj Bose
- Leukemia Department, The University of Texas MD Anderson Cancer Center, Houston, TX, United States.
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32
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Genetic changes during leukemic transformation to secondary acute myeloid leukemia from myeloproliferative neoplasms. Leuk Res 2022; 118:106858. [DOI: 10.1016/j.leukres.2022.106858] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2021] [Revised: 04/30/2022] [Accepted: 05/07/2022] [Indexed: 11/22/2022]
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33
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Chauvet P, Nibourel O, Berthon C, Goursaud L, Carpentier B, Lionne-Huyghe P, Wemeau M, Quesnel B. Resurgence of myeloproliferative neoplasm in patients in remission from blast transformation after treatment with hypomethylating agents. Leuk Res 2022; 118:106871. [DOI: 10.1016/j.leukres.2022.106871] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2022] [Revised: 05/16/2022] [Accepted: 05/19/2022] [Indexed: 11/28/2022]
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34
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Loscocco GG, Vannucchi AM. Role of JAK inhibitors in myeloproliferative neoplasms: current point of view and perspectives. Int J Hematol 2022; 115:626-644. [PMID: 35352288 DOI: 10.1007/s12185-022-03335-7] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2022] [Revised: 03/06/2022] [Accepted: 03/15/2022] [Indexed: 12/29/2022]
Abstract
Classic Philadelphia-negative myeloproliferative neoplasms (MPN) include polycythemia vera (PV), essential thrombocythemia (ET), and myelofibrosis (MF), classified as primary (PMF), or secondary to PV or ET. All MPN, regardless of the underlying driver mutation in JAK2/CALR/MPL, are invariably associated with dysregulation of JAK/STAT pathway. The discovery of JAK2V617F point mutation prompted the development of small molecules inhibitors of JAK tyrosine kinases (JAK inhibitors-JAKi). To date, among JAKi, ruxolitinib (RUX) and fedratinib (FEDR) are approved for intermediate and high-risk MF, and RUX is also an option for high-risk PV patients inadequately controlled by or intolerant to hydroxyurea. While not yet registered, pacritinib (PAC) and momelotinib (MMB), proved to be effective particularly in thrombocytopenic and anemic MF patients, respectively. In most cases, JAKi are effective in reducing splenomegaly and alleviating disease-related symptoms. However, almost 50% lose response by three years and dose-dependent toxicities may lead to suboptimal dosing or treatment discontinuation. To date, although not being disease-modifying agents, JAKi represent the therapeutic backbone particularly in MF patient. To optimize therapeutic strategies, many trials with drug combinations of JAKi with novel molecules are ongoing. This review critically discusses the role of JAKi in the modern management of patients with MPN.
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Affiliation(s)
- Giuseppe G Loscocco
- Department of Experimental and Clinical Medicine, University of Florence, CRIMM, Center of Research and Innovation of Myeloproliferative Neoplasms, Azienda Ospedaliero-Universitaria Careggi, Largo Brambilla, 3 pad 27B, 50134, Florence, Italy
- Doctorate School GenOMec, University of Siena, Siena, Italy
| | - Alessandro M Vannucchi
- Department of Experimental and Clinical Medicine, University of Florence, CRIMM, Center of Research and Innovation of Myeloproliferative Neoplasms, Azienda Ospedaliero-Universitaria Careggi, Largo Brambilla, 3 pad 27B, 50134, Florence, Italy.
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35
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Acute leukemia arising from myeloproliferative or myelodysplastic/myeloproliferative neoplasms: a series of 372 patients from the PETHEMA AML registry. Leuk Res 2022; 115:106821. [DOI: 10.1016/j.leukres.2022.106821] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2022] [Revised: 03/02/2022] [Accepted: 03/04/2022] [Indexed: 12/30/2022]
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36
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Tefferi A, Gangat N, Pardanani A, Crispino JD. Myelofibrosis: Genetic Characteristics and the Emerging Therapeutic Landscape. Cancer Res 2022; 82:749-763. [PMID: 34911786 PMCID: PMC9306313 DOI: 10.1158/0008-5472.can-21-2930] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2021] [Revised: 10/18/2021] [Accepted: 11/30/2021] [Indexed: 01/07/2023]
Abstract
Primary myelofibrosis (PMF) is one of three myeloproliferative neoplasms (MPN) that are morphologically and molecularly inter-related, the other two being polycythemia vera (PV) and essential thrombocythemia (ET). MPNs are characterized by JAK-STAT-activating JAK2, CALR, or MPL mutations that give rise to stem cell-derived clonal myeloproliferation, which is prone to leukemic and, in case of PV and ET, fibrotic transformation. Abnormal megakaryocyte proliferation is accompanied by bone marrow fibrosis and characterizes PMF, while the clinical phenotype is pathogenetically linked to ineffective hematopoiesis and aberrant cytokine expression. Among MPN-associated driver mutations, type 1-like CALR mutation has been associated with favorable prognosis in PMF, while ASXL1, SRSF2, U2AF1-Q157, EZH2, CBL, and K/NRAS mutations have been shown to be prognostically detrimental. Such information has enabled development of exclusively genetic (GIPSS) and clinically integrated (MIPSSv2) prognostic models that facilitate individualized treatment decisions. Allogeneic stem cell transplantation remains the only treatment modality in MF with the potential to prolong survival, whereas drug therapy, including JAK2 inhibitors, is directed mostly at the inflammatory component of the disease and is therefore palliative in nature. Similarly, disease-modifying activity remains elusive for currently available investigational drugs, while their additional value in symptom management awaits controlled confirmation. There is a need for genetic characterization of clinical observations followed by in vitro and in vivo preclinical studies that will hopefully identify therapies that target the malignant clone in MF to improve patient outcomes.
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Affiliation(s)
- Ayalew Tefferi
- Division of Hematology, Department of Medicine, Mayo Clinic, Rochester, Minnesota.,Corresponding Author: Ayalew Tefferi, Division of Hematology, Department of Medicine, Mayo Clinic, 200 First St SW, Rochester, MN 55905. Phone: 507-284-2511; Fax: 507-266-4972; E-mail:
| | - Naseema Gangat
- Division of Hematology, Department of Medicine, Mayo Clinic, Rochester, Minnesota
| | - Animesh Pardanani
- Division of Hematology, Department of Medicine, Mayo Clinic, Rochester, Minnesota
| | - John D. Crispino
- Division of Experimental Hematology, St. Jude Children's Research Hospital, Memphis, Tennessee
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Saha C, Attwell L, Harrison CN, McLornan DP. Addressing the challenges of accelerated and blast phase myeloproliferative neoplasms in 2022 and beyond. Blood Rev 2022; 55:100947. [DOI: 10.1016/j.blre.2022.100947] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2022] [Revised: 02/18/2022] [Accepted: 02/18/2022] [Indexed: 02/08/2023]
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Koyuncu MB, Ilgan M, Basir H, Tombak A, Ucar MA, Koseci T, Akdeniz A, Tiftik EN, Erel Ö. Ruxolitinib Reduces Oxidative Stress in Patients With Primary Myelofibrosis: A Multicenter Study. Cureus 2022; 14:e20929. [PMID: 35145818 PMCID: PMC8812273 DOI: 10.7759/cureus.20929] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/04/2022] [Indexed: 11/26/2022] Open
Abstract
Introduction Primary myelofibrosis (PM) has a lower overall survival rate than other myeloproliferative neoplasms, and leukemic transformation is the most common cause of death. Increased oxidative stress has an important role in leukemic transformation in these patients. In this study, we aimed to find an answer to the question, "Could Ruxolitinib, which has been widely used in patients with myelofibrosis in recent years, have a role in reducing oxidative stress in these patients?". Methods A total of 106 patients with PM and 111 healthy volunteers were included in this study. We collected the serum samples of healthy volunteers and patients with myelofibrosis at the time of diagnosis and one month after the initiation of Ruxolitinib treatment. Ischemia modified albumin (IMA), native thiol, total thiol, and disulfide levels were studied. The disulfide/native thiol, disulfide/total thiol, and native thiol/total thiol ratios were calculated. Results IMA, native thiol, total thiol, disulfide levels, disulfide/native thiol, and disulfide/total thiol ratios at the time of diagnosis were significantly different in patients with myelofibrosis compared to the control group (p=0.001). Ruxolitinib significantly reduced oxidative stress when the measurements in the first month after Ruxolitinib were compared with those at the time of diagnosis (p=0.001). In patients with ASXL1 mutation, intermediate-2 risk, and high-risk according to the Dipps-plus score, the decrease in oxidative stress in the first month of treatment was more significant than at the time of diagnosis. Conclusion Ruxolitinib may be an effective treatment for reducing oxidative stress in patients with PM. The reduction in oxidative stress parameters with treatment in patients with ASXL1 mutation, intermediate-2, and high-risk patients was observed to be higher.
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Calabresi L, Balliu M, Bartalucci N. Immunoblotting-assisted assessment of JAK/STAT and PI3K/Akt/mTOR signaling in myeloproliferative neoplasms CD34+ stem cells. Methods Cell Biol 2022; 171:81-109. [DOI: 10.1016/bs.mcb.2022.04.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/16/2022]
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King AC, Weis TM, Derkach A, Ball S, Pandey M, Mauro MJ, Goldberg AD, Stahl M, Famulare C, Tallman MS, Wang ES, Kuykendall AT, Rampal RK. Multicenter evaluation of efficacy and toxicity of venetoclax-based combinations in patients with accelerated and blast phase myeloproliferative neoplasms. Am J Hematol 2022; 97:E7-E10. [PMID: 34674293 DOI: 10.1002/ajh.26381] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2021] [Revised: 10/07/2021] [Accepted: 10/17/2021] [Indexed: 11/10/2022]
Affiliation(s)
- Amber C. King
- Department of Pharmacy Leukemia Service, Memorial Sloan Kettering Cancer Center New York New York USA
| | - Taylor M. Weis
- Department of Pharmacy Leukemia Service, Memorial Sloan Kettering Cancer Center New York New York USA
| | - Andriy Derkach
- Department of Epidemiology and Biostatistics Memorial Sloan Kettering Cancer Center New York New York USA
| | - Somedeb Ball
- Department of Malignant Hematology Moffitt Cancer Center Tampa Florida USA
| | - Manu Pandey
- Department of Medicine Leukemia Service, Roswell Park Cancer Center Buffalo New York USA
| | - Michael J. Mauro
- Department of Medicine Leukemia Service, Memorial Sloan Kettering Cancer Center New York New York USA
| | - Aaron D. Goldberg
- Department of Medicine Leukemia Service, Memorial Sloan Kettering Cancer Center New York New York USA
| | - Maximilian Stahl
- Department of Medicine Leukemia Service, Memorial Sloan Kettering Cancer Center New York New York USA
| | - Christopher Famulare
- Department of Medicine Leukemia Service, Memorial Sloan Kettering Cancer Center New York New York USA
| | - Martin S. Tallman
- Department of Medicine Leukemia Service, Memorial Sloan Kettering Cancer Center New York New York USA
| | - Eunice S. Wang
- Department of Medicine Leukemia Service, Roswell Park Cancer Center Buffalo New York USA
| | | | - Raajit K. Rampal
- Department of Medicine Leukemia Service, Memorial Sloan Kettering Cancer Center New York New York USA
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Progression of Myeloproliferative Neoplasms (MPN): Diagnostic and Therapeutic Perspectives. Cells 2021; 10:cells10123551. [PMID: 34944059 PMCID: PMC8700229 DOI: 10.3390/cells10123551] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2021] [Revised: 12/10/2021] [Accepted: 12/13/2021] [Indexed: 12/21/2022] Open
Abstract
Classical BCR-ABL-negative myeloproliferative neoplasms (MPN) are a heterogeneous group of hematologic malignancies, including essential thrombocythemia (ET), polycythemia vera (PV), and primary myelofibrosis (PMF), as well as post-PV-MF and post-ET-MF. Progression to more symptomatic disease, such as overt MF or acute leukemia, represents one of the major causes of morbidity and mortality. There are clinically evident but also subclinical types of MPN progression. Clinically evident progression includes evolution from ET to PV, ET to post-ET-MF, PV to post-PV-MF, or pre-PMF to overt PMF, and transformation of any of these subtypes to myelodysplastic neoplasms or acute leukemia. Thrombosis, major hemorrhage, severe infections, or increasing symptom burden (e.g., pruritus, night sweats) may herald progression. Subclinical types of progression may include increases in the extent of bone marrow fibrosis, increases of driver gene mutational allele burden, and clonal evolution. The underlying causes of MPN progression are diverse and can be attributed to genetic alterations and chronic inflammation. Particularly, bystander mutations in genes encoding epigenetic regulators or splicing factors were associated with progression. Finally, comorbidities such as systemic inflammation, cardiovascular diseases, and organ fibrosis may augment the risk of progression. The aim of this review was to discuss types and mechanisms of MPN progression and how their knowledge might improve risk stratification and therapeutic intervention. In view of these aspects, we discuss the potential benefits of early diagnosis using molecular and functional imaging and exploitable therapeutic strategies that may prevent progression, but also highlight current challenges and methodological pitfalls.
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Cattaneo D, Iurlo A. Immune Dysregulation and Infectious Complications in MPN Patients Treated With JAK Inhibitors. Front Immunol 2021; 12:750346. [PMID: 34867980 PMCID: PMC8639501 DOI: 10.3389/fimmu.2021.750346] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2021] [Accepted: 11/01/2021] [Indexed: 12/12/2022] Open
Abstract
BCR-ABL1-negative myeloproliferative neoplasms are burdened by a reduced life expectancy mostly due to an increased risk of thrombo-hemorrhagic events, fibrotic progression/leukemic evolution, and infectious complications. In these clonal myeloid malignancies, JAK2V617F is the main driver mutation, leading to an aberrant activation of the Janus kinase-signal transducer and activator of transcription (JAK-STAT) signaling pathway. Therefore, its inhibition represents an attractive therapeutic strategy for these disorders. Several JAK inhibitors have entered clinical trials, including ruxolitinib, the first JAK1/2 inhibitor to become commercially available for the treatment of myelofibrosis and polycythemia vera. Due to interference with the JAK-STAT pathway, JAK inhibitors affect several components of the innate and adaptive immune systems such as dendritic cells, natural killer cells, T helper cells, and regulatory T cells. Therefore, even though the clinical use of these drugs in MPN patients has led to a dramatic improvement of symptoms control, organ involvement, and quality of life, JAK inhibitors–related loss of function in JAK-STAT signaling pathway can be a cause of different adverse events, including those related to a condition of immune suppression or deficiency. This review article will provide a comprehensive overview of the current knowledge on JAK inhibitors’ effects on immune cells as well as their clinical consequences, particularly with regards to infectious complications.
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Affiliation(s)
- Daniele Cattaneo
- Hematology Division, Foundation Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy.,Department of Oncology and Hemato-Oncology, University of Milan, Milan, Italy
| | - Alessandra Iurlo
- Hematology Division, Foundation Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
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Coltro G, Loscocco GG, Vannucchi AM. Classical Philadelphia-negative myeloproliferative neoplasms (MPNs): A continuum of different disease entities. INTERNATIONAL REVIEW OF CELL AND MOLECULAR BIOLOGY 2021; 365:1-69. [PMID: 34756241 DOI: 10.1016/bs.ircmb.2021.09.001] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Classical Philadelphia-negative myeloproliferative neoplasms (MPNs) are clonal hematopoietic stem cell-derived disorders characterized by uncontrolled proliferation of differentiated myeloid cells and close pathobiologic and clinical features. According to the 2016 World Health Organization (WHO) classification, MPNs include polycythemia vera (PV), essential thrombocythemia (ET), and primary myelofibrosis (PMF). The 2016 revision aimed in particular at strengthening the distinction between masked PV and JAK2-mutated ET, and between prefibrotic/early (pre-PMF) and overt PMF. Clinical manifestations in MPNs include constitutional symptoms, microvascular disorders, thrombosis and bleeding, splenomegaly secondary to extramedullary hematopoiesis, cytopenia-related symptoms, and progression to overt MF and acute leukemia. A dysregulation of the JAK/STAT pathway is the unifying mechanistic hallmark of MPNs, and is guided by somatic mutations in driver genes including JAK2, CALR and MPL. Additional mutations in myeloid neoplasm-associated genes have been also identified, with established prognostic relevance, particularly in PMF. Prognostication of MPN patients relies on disease-specific clinical models. The increasing knowledge of MPN biology led to the development of integrated clinical and molecular prognostic scores that allow a more refined stratification. Recently, the therapeutic landscape of MPNs has been revolutionized by the introduction of potent, selective JAK inhibitors (ruxolitinib, fedratinib), that proved effective in controlling disease-related symptoms and splenomegaly, yet leaving unmet critical needs, owing the lack of disease-modifying activity. In this review, we will deal with molecular, clinical, and therapeutic aspects of the three classical MPNs aiming at highlighting either shared characteristics, that overall define a continuum within a single disease family, and uniqueness, at the same time.
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Affiliation(s)
- Giacomo Coltro
- CRIMM, Center for Research and Innovation of Myeloproliferative Neoplasms, AOU Careggi, Florence, Italy; Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
| | - Giuseppe G Loscocco
- CRIMM, Center for Research and Innovation of Myeloproliferative Neoplasms, AOU Careggi, Florence, Italy; Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
| | - Alessandro M Vannucchi
- CRIMM, Center for Research and Innovation of Myeloproliferative Neoplasms, AOU Careggi, Florence, Italy; Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy.
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Chen D, Fuda F, Weinberg O. A case of a primary myelofibrosis with progression and related literature review of progression phase genetics. Int J Lab Hematol 2021; 43 Suppl 1:78-81. [PMID: 34288445 DOI: 10.1111/ijlh.13565] [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: 02/26/2021] [Revised: 03/24/2021] [Accepted: 04/06/2021] [Indexed: 11/30/2022]
Abstract
Philadelphia (BCR-ABL)-negative myeloproliferative neoplasms (MPNs) include polycythemia vera (PV), essential thrombocythemia (ET), and primary myelofibrosis (PMF). MPN can transform into an accelerated or a blast phase, which is associated with poor response to standard therapy and low overall median survival. We present an interesting case of a patient with a history of PMF and progression and summarize the current studies on genetic features of myeloproliferative neoplasms in blast phase (MPN-BP) with an emphasis on PMF. Although MPN-BP show ≥20% blasts in peripheral blood or bone marrow, it is not considered as acute myeloid leukemia (AML) according to the WHO classification. While MPNs-BP typically lack genetic mutations seen in de novo AML, they commonly harbor IDH1/2, SRSF2, ASXL1, and TP53 mutations, similar to the genetic profiles of acute myeloid leukemia with myelodysplasia-related changes (AML-MRC).
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Affiliation(s)
- Dong Chen
- Department of Pathology, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Franklin Fuda
- Department of Pathology, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Olga Weinberg
- Department of Pathology, University of Texas Southwestern Medical Center, Dallas, TX, USA
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3+7 Combined Chemotherapy for Acute Myeloid Leukemia: Is It Time to Say Goodbye? Curr Oncol Rep 2021; 23:120. [PMID: 34350512 DOI: 10.1007/s11912-021-01108-9] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/16/2021] [Indexed: 12/17/2022]
Abstract
PURPOSE OF REVIEW With the recent approval of multiple new drugs for the treatment of acute myeloid leukemia (AML), the relevance of conventional treatment approaches, such as daunorubicin and cytarabine ("3+7") induction chemotherapy, has been challenged. We review the AML risk stratification, the efficacy of the newly approved drugs, and the role of "3+7". RECENT FINDINGS Treatment of AML is becoming more niched with specific subtypes more appropriately treated with gemtuzumab, midostaurin, and CPX-351. Although lower intensity therapies can yield high response rates, they are less efficient at preventing relapses. The only curative potential for poor-risk AML is still an allogeneic stem cell transplant. The number of AML subtypes where 3+7 alone is an appropriate therapeutic option is shrinking. However, it remains the backbone for combination therapy with newer agents in patients suitable for intensive chemotherapy.
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Integration of Molecular Information in Risk Assessment of Patients with Myeloproliferative Neoplasms. Cells 2021; 10:cells10081962. [PMID: 34440731 PMCID: PMC8391705 DOI: 10.3390/cells10081962] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2021] [Revised: 07/27/2021] [Accepted: 07/30/2021] [Indexed: 12/30/2022] Open
Abstract
Philadelphia chromosome-negative myeloproliferative neoplasms (MPN) are clonal disorders of a hematopoietic stem cell, characterized by an abnormal proliferation of largely mature cells driven by mutations in JAK2, CALR, and MPL. All these mutations lead to a constitutive activation of the JAK-STAT signaling, which represents a target for therapy. Beyond driver ones, most patients, especially with myelofibrosis, harbor mutations in an array of "myeloid neoplasm-associated" genes that encode for proteins involved in chromatin modification and DNA methylation, RNA splicing, transcription regulation, and oncogenes. These additional mutations often arise in the context of clonal hematopoiesis of indeterminate potential (CHIP). The extensive characterization of the pathologic genome associated with MPN highlighted selected driver and non-driver mutations for their clinical informativeness. First, driver mutations are enlisted in the WHO classification as major diagnostic criteria and may be used for monitoring of residual disease after transplantation and response to treatment. Second, mutation profile can be used, eventually in combination with cytogenetic, histopathologic, hematologic, and clinical variables, to risk stratify patients regarding thrombosis, overall survival, and rate of transformation to secondary leukemia. This review outlines the molecular landscape of MPN and critically interprets current information for their potential impact on patient management.
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Gangat N, Guglielmelli P, Szuber N, Begna KH, Patnaik MM, Litzow MR, Al‐Kali A, Foran JM, Palmer JM, Alkhateeb H, Elliott MA, Hanson CA, Pardanani A, Mannelli F, Vannucchi AM, Tefferi A. Venetoclax with azacitidine or decitabine in blast-phase myeloproliferative neoplasm: A multicenter series of 32 consecutive cases. Am J Hematol 2021; 96:781-789. [PMID: 33844862 PMCID: PMC8251544 DOI: 10.1002/ajh.26186] [Citation(s) in RCA: 40] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2021] [Revised: 04/07/2021] [Accepted: 04/08/2021] [Indexed: 12/19/2022]
Abstract
Venetoclax (Ven) combined with a hypomethylating agent (HMA) has now emerged as an effective treatment regimen for acute myeloid leukemia, in both de novo and relapsed/refractory setting. The current multicenter study retrospectively examined Ven + HMA treatment outcome among 32 patients (median age 69 years; 59% males) with blast‐phase myeloproliferative neoplasm (MPN‐BP). Pre‐leukemic phenotype included essential thrombocythemia (ET)/post‐ET myelofibrosis (34%), polycythemia vera (PV)/post‐PV myelofibrosis (38%) and primary myelofibrosis (28%). Twenty‐nine study patients were fully annotated cytogenetically and molecularly (NGS): 69% harbored complex karyotype and/or mutations, including TP53 (41%), IDH1/2 (21%), ASXL1 (21%), N/KRAS (14%), SRSF2 (10%), EZH2 (10%) and U2AF1 (7%). All patients received Ven combined with either azacitidine (n = 12) or decitabine (n = 20); either up front (n = 23) or after failing another induction therapy (n = 9). Complete remission with (CR) or without (CRi) count recovery was achieved in 14 (44%) patients and was more likely to occur in the absence of pre‐leukemic PV/post‐PV myelofibrosis phenotype (p < .01), complex karyotype (p < .01) or K/NRAS (p = .03) mutations; seven of eight patients (88%) without vs four of 21 (19%) with complex karyotype or K/NRAS mutation achieved CR/CRi (p < .01); all 11 informative patients with pre‐leukemic PV/post‐PV myelofibrosis phenotype displayed complex karyotype (p < .01). In contrast, neither TP53 (p = .45) nor IDH1/2 (p = .63) mutations affected response. Compared to historical controls treated with HMA alone (n = 26), the CR/CRi rate (44% vs 4%) and median survival (8 vs 5.5 months) were more favorable with Ven + HMA, but without significant difference in overall survival. Importantly, six patients with CR/CRi subsequently received allogeneic hematopoietic stem cell transplant (AHSCT). Note, Ven + HMA produces robust CR/CRi rates in MPN‐BP, especially in the absence of RAS mutations and complex karyotype, thus enabling AHSCT, in some patients.
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Affiliation(s)
- Naseema Gangat
- Division of Hematology Mayo Clinic Rochester Minnesota USA
| | - Paola Guglielmelli
- Department of Experimental and Clinical Medicine, CRIMM, Center Research and Innovation of Myeloproliferative Neoplasms, Azienda Ospedaliera Universitaria Careggi University of Florence Florence Italy
| | - Natasha Szuber
- Department of Hematology Université de Montréal Quebec Canada
| | | | | | - Mark R. Litzow
- Division of Hematology Mayo Clinic Rochester Minnesota USA
| | - Aref Al‐Kali
- Division of Hematology Mayo Clinic Rochester Minnesota USA
| | - James M. Foran
- Division of Hematology Mayo Clinic Jacksonville Florida USA
| | | | | | | | | | | | - Francesco Mannelli
- Department of Experimental and Clinical Medicine, CRIMM, Center Research and Innovation of Myeloproliferative Neoplasms, Azienda Ospedaliera Universitaria Careggi University of Florence Florence Italy
| | - Alessandro M. Vannucchi
- Department of Experimental and Clinical Medicine, CRIMM, Center Research and Innovation of Myeloproliferative Neoplasms, Azienda Ospedaliera Universitaria Careggi University of Florence Florence Italy
| | - Ayalew Tefferi
- Division of Hematology Mayo Clinic Rochester Minnesota USA
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Marinaccio C, Suraneni P, Celik H, Volk A, Wen QJ, Ling T, Bulic M, Lasho T, Koche RP, Famulare CA, Farnoud N, Stein B, Schieber M, Gurbuxani S, Root DE, Younger ST, Hoffman R, Gangat N, Ntziachristos P, Chandel NS, Levine RL, Rampal RK, Challen GA, Tefferi A, Crispino JD. LKB1/ STK11 Is a Tumor Suppressor in the Progression of Myeloproliferative Neoplasms. Cancer Discov 2021; 11:1398-1410. [PMID: 33579786 PMCID: PMC8178182 DOI: 10.1158/2159-8290.cd-20-1353] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2020] [Revised: 12/18/2020] [Accepted: 02/09/2021] [Indexed: 12/30/2022]
Abstract
The myeloproliferative neoplasms (MPN) frequently progress to blast phase disease, an aggressive form of acute myeloid leukemia. To identify genes that suppress disease progression, we performed a focused CRISPR/Cas9 screen and discovered that depletion of LKB1/Stk11 led to enhanced in vitro self-renewal of murine MPN cells. Deletion of Stk11 in a mouse MPN model caused rapid lethality with enhanced fibrosis, osteosclerosis, and an accumulation of immature cells in the bone marrow, as well as enhanced engraftment of primary human MPN cells in vivo. LKB1 loss was associated with increased mitochondrial reactive oxygen species and stabilization of HIF1α, and downregulation of LKB1 and increased levels of HIF1α were observed in human blast phase MPN specimens. Of note, we observed strong concordance of pathways that were enriched in murine MPN cells with LKB1 loss with those enriched in blast phase MPN patient specimens, supporting the conclusion that STK11 is a tumor suppressor in the MPNs. SIGNIFICANCE: Progression of the myeloproliferative neoplasms to acute myeloid leukemia occurs in a substantial number of cases, but the genetic basis has been unclear. We discovered that loss of LKB1/STK11 leads to stabilization of HIF1a and promotes disease progression. This observation provides a potential therapeutic avenue for targeting progression.This article is highlighted in the In This Issue feature, p. 1307.
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Affiliation(s)
| | | | - Hamza Celik
- Division of Oncology, Department of Medicine, Washington University School of Medicine, St. Louis, Missouri
| | - Andrew Volk
- Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | | | - Te Ling
- St. Jude Children's Research Hospital, Memphis, Tennessee
| | | | | | - Richard P Koche
- Center for Epigenetics Research, Memorial Sloan Kettering Cancer Center, New York, New York
| | | | - Noushin Farnoud
- Center for Hematologic Malignancies, Memorial Sloan Kettering, New York, New York
| | | | | | | | - David E Root
- Broad Institute of Harvard and MIT, Cambridge, Massachusetts
| | - Scott T Younger
- Broad Institute of Harvard and MIT, Cambridge, Massachusetts
| | | | | | - Panagiotis Ntziachristos
- Northwestern University, Chicago, Illinois
- Department of Biochemistry and Molecular Genetics, Northwestern University, Chicago, Illinois
- Simpson Querrey Center for Epigenetics, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | | | - Ross L Levine
- Leukemia Service, Department of Medicine, Memorial Sloan Kettering, New York, New York
| | - Raajit K Rampal
- Center for Hematologic Malignancies, Memorial Sloan Kettering, New York, New York
- Leukemia Service, Department of Medicine, Memorial Sloan Kettering, New York, New York
| | - Grant A Challen
- Division of Oncology, Department of Medicine, Washington University School of Medicine, St. Louis, Missouri
| | | | - John D Crispino
- Northwestern University, Chicago, Illinois.
- St. Jude Children's Research Hospital, Memphis, Tennessee
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Acute promyelocyte leukemia arose from CALR 1 mutated post essential thrombocythemia- myelofibrosis with splanchnic vein thrombosis: A case report. Leuk Res Rep 2021; 15:100243. [PMID: 34040959 PMCID: PMC8142272 DOI: 10.1016/j.lrr.2021.100243] [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: 03/10/2021] [Revised: 04/19/2021] [Accepted: 05/02/2021] [Indexed: 11/23/2022] Open
Abstract
Major disease complications for patients with essential thrombocythemia (ET) include thrombosis and fibrotic or leukemic transformation. Calreticulin (CALR) mutation type 1 frequencies in ET are estimated between 7% and 11% and ET patients carrying CALR type 1 mutation are associated with lower risk of thrombosis but higher risk of myelofibrosis transformation compared to ET patients with JAK2 mutation. Leukemic transformation rates at 20 years are estimated at less than 5% for ET and risk factors for leukemic transformation are advanced age, thrombosis history, leukocytosis, and anemia. Amongst the subtypes of blast phase myeloproliferative neoplasms, acute promyelocytic leukemia is extremely rare. Herein, we present a case of a promyelocytic blast crisis of post-ET myelofibrosis with associated life-threatening splanchnic vein thrombosis. This case suggests that inflammation plays a key role in thrombotic events and fibrotic/leukemic transformation in ET patients, regardless the molecular landscape.
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Genetic factors rather than blast reduction determine outcomes of allogeneic HCT in BCR-ABL-negative MPN in blast phase. Blood Adv 2021; 4:5562-5573. [PMID: 33170935 DOI: 10.1182/bloodadvances.2020002727] [Citation(s) in RCA: 28] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2020] [Accepted: 10/05/2020] [Indexed: 12/22/2022] Open
Abstract
There is a limited understanding of the clinical and molecular factors associated with outcomes of hematopoietic cell transplantation (HCT) in patients with BCR-ABL-negative myeloproliferative neoplasms in blast phase (MPN-BP). Using the Center for International Blood and Marrow Transplant Research database, we evaluated HCT outcomes in 177 patients with MPN-BP. Ninety-five (54%) had sufficient DNA for targeted next-generation sequencing of 49 genes clinically relevant in hematologic malignancies. At 5 years, overall survival (OS), cumulative incidence of relapse, and nonrelapse mortality of the study cohort was 18%, 61%, and 25%, respectively. In a multivariable model, poor-risk cytogenetics was associated with inferior OS (hazard ratio [HR], 1.71; 95% CI, 1.21-2.41) due to increased relapse (HR, 1.93; 95% CI, 1.32-2.82). Transplants using mobilized peripheral blood (PB) were associated with better OS (HR, 0.60; 95% CI, 0.38-0.96). No difference in outcomes was observed in patients undergoing HCT with PB/BM blasts <5% vs those with active leukemia. Among the 95 patients with molecular data, mutation of TP53, present in 23%, was the only genetic alteration associated with outcomes. In a multivariate model, TP53-mutant patients had inferior OS (HR, 1.99; 95% CI, 1.14-3.49) and increased incidence of relapse (HR, 2.59; 95% CI, 1.41-4.74). There were no differences in the spectrum of gene mutations, number of mutations, or variant allele frequency between patients undergoing HCT with PB/BM blasts <5% vs those with active leukemia. Genetic factors, namely cytogenetic alterations and TP53 mutation status, rather than degree of cytoreduction predict outcomes of HCT in MPN-BP. No meaningful benefit of conventional HCT was observed in patients with MPN-BP and mutated TP53.
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