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Coltoff A, Mascarenhas J. Fedratinib in 2025 and beyond: indications and future applications. Blood Adv 2025; 9:1907-1915. [PMID: 39951613 PMCID: PMC12008686 DOI: 10.1182/bloodadvances.2024015365] [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: 11/14/2024] [Revised: 01/13/2025] [Accepted: 02/08/2025] [Indexed: 02/16/2025] Open
Abstract
ABSTRACT Dysregulated JAK/STAT signaling underlies the pathogenesis of myelofibrosis, a myeloproliferative neoplasm characterized by cytopenias, splenomegaly, and constitutional symptoms. JAK inhibitors, such as fedratinib, are the primary therapeutic option for patients with high-risk or symptomatic myelofibrosis. Fedratinib has characteristics that distinguish it from other commercially available JAK inhibitors, such as its preferential inhibition of JAK2 and its inhibitory effects on kinases such as Fms-like tyrosine kinase 3 and BRD4. Fedratinib is most often used in the second-line setting after intolerance or resistance to other JAK inhibitors, but there is substantial evidence that it is an effective first-line option in the appropriate patient population. Prevention and early treatment of fedratinib-related gastrointestinal toxicity is key to maintaining adequate drug exposure, and clinicians must remain vigilant for Wernicke encephalopathy during treatment. Fedratinib's JAK2 selectivity and kinome profile make it an appealing agent for alternative indications, such as myelodysplastic/myeloproliferative neoplasms and maintenance after bone marrow transplantation, which are under active investigation.
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Affiliation(s)
- Alexander Coltoff
- Hollings Cancer Center, Medical University of South Carolina, Charleston, SC
| | - John Mascarenhas
- The Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY
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2
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Masarova L, Chifotides HT. How I individualize selection of JAK inhibitors for patients with myelofibrosis. Blood 2025; 145:1724-1737. [PMID: 39357058 PMCID: PMC12060163 DOI: 10.1182/blood.2023022415] [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: 02/07/2024] [Revised: 09/16/2024] [Accepted: 09/19/2024] [Indexed: 10/04/2024] Open
Abstract
ABSTRACT The advent of Janus kinase inhibitors (JAKis) inaugurated a novel era in the treatment of myelofibrosis (MF), a myeloproliferative neoplasm with heterogeneous clinical manifestations. Four JAKis have been approved for intermediate or high-risk MF, in the United States. Regulatory approval of the first JAK1/2 inhibitor, ruxolitinib, in 2011, transformed the landscape of MF by markedly controlling splenomegaly and constitutional symptoms, improving patients' quality of life, and prolonging survival. Fedratinib, the second approved JAKi, is preferred in the second-line setting. Ruxolitinib and fedratinib can cause myelosuppression and are recommended for patients with the myeloproliferative phenotype. The approval of 2 less-myelosuppressive JAKis, pacritinib and momelotinib, provided essential treatment options for patients with severe thrombocytopenia and anemia, respectively. Momelotinib and pacritinib are potent activin A receptor, type 1 inhibitors with consequent significant benefits for patients with anemia. Transfusion independence was achieved with momelotinib in patients who were severely anemic, and the association of transfusion independence with prolonged overall survival was demonstrated. Judicious treatment decisions regarding JAKis can be made with in-depth understanding of the pivotal clinical trials that evaluated JAKis and their therapeutic attributes and should be guided by the dominant clinical manifestations and the type/degree of cytopenia(s) (myeloproliferative/cytopenic phenotypes). This article reviews our clinical approach to treatment with JAKis and their sequencing in patients with MF by presenting 3 clinical vignettes.
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Affiliation(s)
- Lucia Masarova
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Helen T. Chifotides
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX
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3
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Petit C, de Lavallade H, Harrison C. What are the therapeutic options for previously treated myelofibrosis? Expert Rev Hematol 2025; 18:387-398. [PMID: 39494849 DOI: 10.1080/17474086.2024.2423367] [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: 09/04/2024] [Accepted: 10/27/2024] [Indexed: 11/05/2024]
Abstract
INTRODUCTION The disruption of the JAK/STAT signaling pathway is a defining feature of myelofibrosis (MF). The introduction of JAK inhibitors (JAKi) has transformed the therapeutic approach to MF, becoming essential to treatment and reshaping the management landscape. While JAKi are now the preferred first-line treatment for most patients, various management options are available for those who do not respond to initial therapy. AREAS COVERED This review focuses on management options for patients with MF, with particular emphasis on therapeutic strategies following the failure of first-line JAKi. It provides a comprehensive overview of the current treatment landscape, including alternative JAKi and other approaches. The review is based on an extensive literature search using available databases (PubMed, Cochrane …) and relevant web resources (clinicaltrials.gov). EXPERT OPINION Ruxolitinib benefits in MF often diminish after 3-4 years, with complications like thrombocytopenia and anemia. Three newer JAKi offer alternatives with similar efficacy and varied side effects. Stem cell transplantation is a curative option for a minority, ideally timed at peak response to JAKi. Research aims to enhance first-line treatments and restore responses in resistant patients. Future therapies may include novel combinations or immunotherapies targeting specific mutations, requiring collaboration between patient, clinical, and pharmaceutical communities.
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Affiliation(s)
- Cassandre Petit
- Department of Haematology, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Hugues de Lavallade
- Department of Haematology, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Claire Harrison
- Department of Haematology, Guy's and St Thomas' NHS Foundation Trust, London, UK
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4
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Wall SA, Tamari R, DeFilipp Z, Hobbs GS. Optimization of allogeneic hematopoietic cell transplantation for patients with myelofibrosis treated with ruxolitinib: eligibility, best practices, and improving transplant outcomes. Ann Hematol 2025; 104:2125-2141. [PMID: 40119918 PMCID: PMC12053210 DOI: 10.1007/s00277-025-06270-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2024] [Accepted: 02/16/2025] [Indexed: 03/25/2025]
Abstract
Allogeneic hematopoietic cell transplantation (HCT) is the only curative treatment for myelofibrosis (MF), and current guidelines recommend assessing all patients with MF for eligibility. Several patient- and disease-specific factors impact transplantation outcomes, and timely assessment of potential transplant candidates is key to optimizing post-HCT outcomes. The role of HCT in the treatment of MF continues to evolve, with the adoption of newer and safer approaches, enhanced donor availability, use of reduced-intensity conditioning, improvements in graft-versus-host disease (GVHD) prophylaxis and treatment, and greater understanding of high-risk clinical and molecular features of the disease. These developments highlight the importance of early and ongoing assessment throughout the MF disease course to optimize eligibility and consideration for HCT. Ruxolitinib is approved for first-line treatment of intermediate- or high-risk MF, and emerging data have clarified the important role of ruxolitinib in not only optimizing clinical status before HCT but also mitigating and treating post-HCT complications in patients with MF, notably acute and chronic GVHD and relapse. Here we review strategies for optimizing clinical outcomes in patients considered for and undergoing HCT for MF treated with ruxolitinib. We discuss strategies for appropriate patient and donor selection, optimization of ruxolitinib therapy in the pre- and peri-HCT periods, choice of conditioning regimen, GVHD prophylaxis, post-HCT management of GVHD, continued monitoring for MF relapse, and the role of post-HCT ruxolitinib maintenance to reduce risks of GVHD and disease relapse.
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Affiliation(s)
- Sarah A Wall
- Division of Hematology, The Ohio State University, 2121 Kenny Road, James Outpatient Care, Office 7226, Columbus, OH, 43210, USA.
| | - Roni Tamari
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Zachariah DeFilipp
- Hematopoietic Cell Transplant and Cell Therapy Program, Massachusetts General Hospital, Boston, MA, USA
| | - Gabriela S Hobbs
- Division of Hematology/Oncology, Massachusetts General Hospital, Boston, MA, USA
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5
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Hochman MJ, Vale CA, Hunter AM. SOHO State of the Art Updates and Next Questions | Choosing and Properly Using a JAK Inhibitor in Myelofibrosis. CLINICAL LYMPHOMA, MYELOMA & LEUKEMIA 2025; 25:226-239. [PMID: 39358153 DOI: 10.1016/j.clml.2024.09.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/13/2024] [Revised: 08/30/2024] [Accepted: 09/03/2024] [Indexed: 10/04/2024]
Abstract
Myelofibrosis (MF) is a chronic myeloid neoplasm characterized by myeloproliferation, bone marrow fibrosis, splenomegaly, and constitutional symptoms related to pro-inflammatory cytokine signaling. Biologically, MF is characterized by constitutive activation of JAK-STAT signaling; accordingly, JAK inhibitors have been rationally developed to treat MF. Following the initial approval of ruxolitinib in 2011, three additional agents have been approved: fedratinib, pacritinib, and momelotinib. As these therapies are noncurative, allogeneic stem cell transplantation remains a key treatment modality and patients with MF who are deemed candidates should be referred to a transplant center. This potentially curative but toxic approach is typically reserved for patients with higher-risk disease, and JAK inhibitors are recommended in the pretransplant setting. JAK inhibitors have proven effective at managing splenomegaly and constitutional symptoms and should be started early in the disease course in patients presenting with these clinical manifestations; asymptomatic patients may initially be followed with close surveillance. Drug-related myelosuppression has been a challenge with initial JAK inhibitors, particularly in patients presenting with a cytopenic phenotype. However, newer agents, namely pacritinib and momelotinib, have proven more effective in this setting and are approved for patients with significant thrombocytopenia and anemia, respectively. Resistance or disease progression is clinically challenging and may be defined by several possible events, such as increasing splenomegaly or progression to accelerated or blast phase disease. However, with multiple JAK inhibitors now approved, sequencing of these agents appears poised to improve outcomes. Additionally, novel JAK inhibitors and JAK inhibitor-based combinations are in clinical development.
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Affiliation(s)
- Michael J Hochman
- Department of Hematology and Medical Oncology, Winship Cancer Institute of Emory University, Atlanta, GA
| | - Colin A Vale
- Department of Hematology and Medical Oncology, Winship Cancer Institute of Emory University, Atlanta, GA
| | - Anthony M Hunter
- Department of Hematology and Medical Oncology, Winship Cancer Institute of Emory University, Atlanta, GA.
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Sharma N, Loscocco GG, Gangat N, Guglielmelli P, Pardanani A, Vannucchi AM, Alkhateeb HB, Tefferi A, Ho VT. When and how to transplant in myelofibrosis - recent trends. Leuk Lymphoma 2025; 66:359-377. [PMID: 39540360 DOI: 10.1080/10428194.2024.2422835] [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: 07/08/2024] [Revised: 09/27/2024] [Accepted: 10/11/2024] [Indexed: 11/16/2024]
Abstract
Allogeneic hematopoietic stem cell transplantation (AHSCT) is currently the only treatment modality that is capable of curing myelofibrosis (MF). Although outcomes of AHSCT have improved vastly in recent years owing to advancements in HLA typing, conditioning regimens, and supportive care, it remains a procedure with a considerable risk in MF patients due to conditioning regimen related toxicity, higher rates of graft failure, infections, and graft versus host disease (GVHD). Recent progress in the treatment and prevention of GVHD with post-transplant cyclophosphamide has also rendered transplantation from alternative donors feasible and safer, thus improving access to patients without HLA-identical donors. Accordingly, all patients with intermediate or high-risk MF today should be referred for potential transplant evaluation to consider the pros and cons of an early versus a delayed transplant strategy. Individual risk assessment in MF is best facilitated by contemporary prognostic models that incorporate both clinical and genetic risk factors. The current review highlights new information regarding risk stratification in MF, anchored by practical algorithms that facilitate patient selection for specific treatment actions, including AHSCT.
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Affiliation(s)
- Naman Sharma
- Department of Hematology and Oncology, University of Massachusetts-Baystate Medical Center, Springfield, MA, USA
| | - Giuseppe G Loscocco
- Division of Hematology, Mayo Clinic, Rochester, MN, USA
- Department of Experimental and Clinical Medicine, CRIMM, Center Research and Innovation of Myeloproliferative Neoplasms, Azienda Ospedaliera Universitaria Careggi, University of Florence, Florence, 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
| | | | - 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
| | | | | | - Vincent T Ho
- Department of Medical Oncology, Division of Hematologic Malignancies, Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA, USA
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Shirane S, Yasuda H, Uchimura A, Mori Y, Inano T, Tsutsui M, Hamano Y, Ando M. Splenic Irradiation Preceding Allogeneic Hematopoietic Stem Cell Transplantation as a Possible Risk Factor of Sinusoidal Obstruction Syndrome: A Report of Three Cases. Case Rep Oncol 2025; 18:1-6. [PMID: 39980503 PMCID: PMC11627584 DOI: 10.1159/000542608] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2024] [Accepted: 11/12/2024] [Indexed: 02/22/2025] Open
Abstract
Introduction Splenomegaly is frequently encountered in patients with myeloproliferative neoplasms. Splenomegaly is associated with an increased incidence of engraftment failure during allogeneic hematopoietic stem cell transplantation (allo-HSCT), and some centers perform prior low-dose splenic irradiation (LDSI) which has been reported to be both safe and effective. However, we report conflicting results by presenting three allo-HSCT patients undergoing LDSI that subsequently developed sinusoidal obstruction syndrome (SOS). Case Presentation The underlying diseases of the presented cases were atypical chronic myeloid leukemia, secondary myelofibrosis following essential thrombocythemia, and acute myeloid leukemia transforming from myeloproliferative neoplasm, unclassifiable. Endothelial Activation and Stress Index (EASIX) scores of the 3 patients were 0.40, 3.82, and 4.40, respectively. Conclusion SOS is a potentially fatal complication of allo-HSCT, and the mortality rates of severe cases are reported to be above 80%. LDSI has not been recognized as a risk factor of SOS to date. Alternative management methods of splenomegaly during allo-HSCT such as ruxolitinib administration may be safer compared to LDSI.
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Affiliation(s)
- Shuichi Shirane
- Department of Hematology, Juntendo University School of Medicine, Tokyo, Japan
| | - Hajime Yasuda
- Department of Hematology, Juntendo University School of Medicine, Tokyo, Japan
| | - Ayana Uchimura
- Department of Hematology, Juntendo University School of Medicine, Tokyo, Japan
| | - Yosuke Mori
- Department of Hematology, Juntendo University School of Medicine, Tokyo, Japan
| | - Tadaaki Inano
- Department of Hematology, Juntendo University School of Medicine, Tokyo, Japan
| | - Miyuki Tsutsui
- Department of Hematology, Juntendo University School of Medicine, Tokyo, Japan
| | - Yasuharu Hamano
- Department of Hematology, Juntendo University School of Medicine, Tokyo, Japan
| | - Miki Ando
- Department of Hematology, Juntendo University School of Medicine, Tokyo, Japan
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Polverelli N, Hernández-Boluda JC, Gagelmann N, Gurnari C, Malagola M, Duarte FB, Funke VAM, Zerbi C, McLornan DP. Navigating 'grey areas' and challenges during evaluation of transplant eligibility in specific myelofibrosis populations: a perspective on behalf of the Chronic Malignancies Working Party of the EBMT. Bone Marrow Transplant 2025; 60:10-18. [PMID: 39402189 DOI: 10.1038/s41409-024-02437-6] [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: 07/22/2024] [Revised: 10/03/2024] [Accepted: 10/07/2024] [Indexed: 01/12/2025]
Abstract
Significant efforts have been made to effectively select myelofibrosis (MF) patients who can benefit from allogeneic hematopoietic cell transplantation (allo-HCT), the only current cure for MF. The recent EBMT/ELN 2024 recommendations offer valuable guidance for hematologists and transplant physicians. However, several grey areas remain in day-to-day clinical practice regarding the feasibility and optimal preparation for transplantation in patients with this disease. Effective spleen size reduction, often achieved with JAK inhibitors, appears crucial for transplant success. For resistant cases, switching JAK inhibitors, splenectomy, or spleen irradiation may be considered, taking into account patient profiles, treatment availability and center preferences. Managing splanchnic vein thromboses, portal, and pulmonary hypertension is critical as these conditions may affect transplant outcomes. Cytopenias, particularly transfusion-dependent anemia and thrombocytopenia, complicate treatment and impact on outcomes, though new drugs show promise. Comorbidities play a significant role and tools like the Hematopoietic Cell Transplantation-Comorbidity Index (HCT-CI) and frailty assessments are useful for evaluating transplant risks while allowing the implementation of corrective measures. Especially in low- and medium-income countries where access to novel therapies may be challenging, allo-HCT still represents an attractive therapeutic option for MF. Future directions include integrating new therapeutics into the transplant algorithm and leveraging artificial intelligence for more informed risk assessment, highlighting the need for tailored approaches to improve allo-HCT outcomes in such a setting.
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Affiliation(s)
- Nicola Polverelli
- Unit of Bone Marrow Transplantation and Cellular Therapies - Division of Hematology, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy.
| | | | - Nico Gagelmann
- Department of Stem Cell Transplantation, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Carmelo Gurnari
- Department of Biomedicine and Prevention, University of Rome Tor Vergata, Rome, Italy
- Translational Hematology and Oncology Research Department, Taussig Cancer Center, Cleveland Clinic, Cleveland, OH, USA
| | - Michele Malagola
- Chair of Hematology, Department of Clinical and Experimental Sciences, University of Brescia, Unit of Blood Disease and Stem Cell Transplantation, ASST Spedali Civili, Brescia, Italy
| | | | - Vaneuza A M Funke
- Blood and Marrow Transplantation Programme, Hospital de Clínicas, Federal University of Parana, Curitiba, Paraná, Brazil
- Hospital Nossa Senhora das Graças, Curitiba, Brazil
| | - Caterina Zerbi
- Unit of Bone Marrow Transplantation and Cellular Therapies - Division of Hematology, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Donal P McLornan
- Department of Haematology and Stem Cell transplantation, University College London Hospitals NHS Foundation Trust, London, UK.
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9
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Tefferi A, Ho VT. Peri-Transplant Management of JAK Inhibitor Therapy in Myelofibrosis. Am J Hematol 2024. [PMID: 39668604 DOI: 10.1002/ajh.27559] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2024] [Accepted: 11/28/2024] [Indexed: 12/14/2024]
Affiliation(s)
- Ayalew Tefferi
- Division of Hematology, Department of Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Vincent T Ho
- Department of Medical Oncology, Division of Hematologic Malignancies, Dana-Farber Cancer Institute, Harvard Medical School, Boston, Massachusetts, USA
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10
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Rajendra A, Gupta V. Advances in Stem Cell Transplantation for Myelofibrosis. Curr Hematol Malig Rep 2024; 19:256-263. [PMID: 39240494 DOI: 10.1007/s11899-024-00742-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/05/2024] [Indexed: 09/07/2024]
Abstract
PURPOSE OF REVIEW Allogeneic hematopoietic cell transplantation is the only potentially curative treatment for myelofibrosis. This review discusses issues not well-covered by existing guidelines: timing of transplant, pre-transplant spleen management and alternative donors; providing our approach to these situations. RECENT FINDINGS Research continues to allow better identification, by better risk stratification and advances in understanding likelihood of durable JAKi response, which patients are likely to derive benefit from upfront transplant versus those for whom delayed transplant may be more appropriate. Several options of JAKi therapy provide a non-surgical option for pre-HCT splenomegaly management, allowing some patients to avoid risks associated with splenectomy. Recent years have also seen a sharp spike in haploidentical donor transplants, along with narrowing of the gap in outcomes between donor types. Continuous enrollment in prospective studies or well-designed registries is required to generate the high-quality data needed to develop better decision tools for these scenarios.
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Affiliation(s)
- Akhil Rajendra
- Medical Oncology and Hematology, Princess Margaret Cancer Centre, University of Toronto, Toronto, ON, M5G 2M9, Canada
| | - Vikas Gupta
- Medical Oncology and Hematology, Princess Margaret Cancer Centre, University of Toronto, Toronto, ON, M5G 2M9, Canada.
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11
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Swaminathan M, Jain A, Choi SD, Pemmaraju N. Janus kinase inhibitor monotherapy and combination therapies for myelofibrosis: what's the current standard of care? Expert Rev Hematol 2024; 17:769-780. [PMID: 39344987 DOI: 10.1080/17474086.2024.2409438] [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: 06/10/2024] [Revised: 08/30/2024] [Accepted: 09/23/2024] [Indexed: 10/01/2024]
Abstract
INTRODUCTION JAK inhibitors (JAKi) have changed the treatment paradigm of myelofibrosis (MF). Currently, 4 JAKis are approved in the US as monotherapy (mono) to treat patients with MF. JAKis are also being studied in combination (combo) with novel agents. Herein, we review some of the key studies that evaluated JAKi as mono and combo in MF. AREAS COVERED We performed a Pubmed search for 'JAK inhibitors' and 'myelofibrosis' from 1/2010 to 12/2023. For mono, we included only the unique phase II/III studies of the approved JAKi. Selective studies that evaluated JAKi in combo with the novel agents were also included. EXPERT OPINION JAKis aim to provide clinical benefit to patients via spleen size reduction and MPN symptom improvement. In order to potentially increase clinical benefit for patients with MF, several novel agents are being partnered with ruxolitinib (RUX) with the ongoing hypothesis to augment greater measures of MF disease modification. The novel agents are either 'added-on' to RUX or as a combo in JAKi naïve patients. Also, the mutant-targeting era of therapies is now beginning with novel CALR-mutated, novel JAK2 V617F mutation-specific and type II JAK2i in the initial stages of drug development, representing a new approach to treatment.
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Affiliation(s)
- Mahesh Swaminathan
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Akhil Jain
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Sungchul Daniel Choi
- Department of Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Naveen Pemmaraju
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
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12
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Okada Y, Nakasone H, Kawamura S, Takano K, Yoshimura K, Tamaki M, Matsuoka A, Ishikawa T, Meno T, Nakamura Y, Kawamura M, Takeshita J, Yoshino N, Misaki Y, Kusuda M, Tanihara A, Kimura SI, Kako S, Kanda Y. Decision analysis for transplant candidates with primary myelofibrosis in the ruxolitinib era. Haematologica 2024; 109:3593-3601. [PMID: 38899343 PMCID: PMC11532692 DOI: 10.3324/haematol.2024.285256] [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: 02/11/2024] [Accepted: 06/07/2024] [Indexed: 06/21/2024] Open
Abstract
The recent progress with ruxolitinib treatment might improve quality of life as well as overall survival in patients with primary myelofibrosis. Therefore, the optimal timing of allogeneic hematopoietic cell transplantation (HCT) in the ruxolitinib era remains to be elucidated. We constructed a Markov model to simulate the 5-year clinical course of transplant candidates with primary myelofibrosis and compared outcomes between those who underwent immediate HCT and those whose HCT was delayed until after ruxolitinib failure. Since older age was associated with an increased risk of mortality, we analyzed patients aged <60 and ≥60 years separately in subgroup analyses. Life expectancy was consistently longer in the groups undergoing delayed HCT after ruxolitinib failure regardless of the patients' age. Regarding quality-adjusted life years, a baseline analysis showed that immediate HCT was inferior to delayed HCT after ruxolitinib failure (2.19 vs. 2.26). In patients aged <60 years, immediate HCT was equivalent to delayed HCT after ruxolitinib failure (2.31 vs. 2.31). On the other hand, in patients aged ≥60 years, immediate HCT was inferior to delayed HCT after ruxolitinib failure (1.98 vs. 2.21). A one-way sensitivity analysis showed that the utility of being alive without chronic graft-versus-host disease after immediate HCT was the most influential parameter for quality-adjusted life years, and that a value higher than 0.836 could reverse the superiority of delayed HCT after ruxolitinib failure. As a result, delayed HCT after ruxolitinib failure is expected to be superior to immediate HCT, especially in patients aged ≥60 years, and is also a promising strategy even in those aged <60 years.
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Affiliation(s)
- Yosuke Okada
- Division of Hematology, Jichi Medical University Saitama Medical Center, Saitama
| | - Hideki Nakasone
- Division of Hematology, Jichi Medical University Saitama Medical Center, Saitama, Japan; Division of Emerging Medicine for Integrated Therapeutics (EMIT), Center for Molecular Medicine, Jichi Medical University, Shimotsuke
| | - Shunto Kawamura
- Division of Hematology, Jichi Medical University Saitama Medical Center, Saitama
| | - Kosuke Takano
- Division of Hematology, Jichi Medical University Saitama Medical Center, Saitama
| | - Kazuki Yoshimura
- Division of Hematology, Jichi Medical University Saitama Medical Center, Saitama
| | - Masaharu Tamaki
- Division of Hematology, Jichi Medical University Saitama Medical Center, Saitama
| | - Akari Matsuoka
- Division of Hematology, Jichi Medical University Saitama Medical Center, Saitama
| | - Takuto Ishikawa
- Division of Hematology, Jichi Medical University Saitama Medical Center, Saitama
| | - Tomohiro Meno
- Division of Hematology, Jichi Medical University Saitama Medical Center, Saitama
| | - Yuhei Nakamura
- Division of Hematology, Jichi Medical University Saitama Medical Center, Saitama
| | - Masakatsu Kawamura
- Division of Hematology, Jichi Medical University Saitama Medical Center, Saitama
| | - Junko Takeshita
- Division of Hematology, Jichi Medical University Saitama Medical Center, Saitama
| | - Nozomu Yoshino
- Division of Hematology, Jichi Medical University Saitama Medical Center, Saitama
| | - Yukiko Misaki
- Division of Hematology, Jichi Medical University Saitama Medical Center, Saitama
| | - Machiko Kusuda
- Division of Hematology, Jichi Medical University Saitama Medical Center, Saitama
| | - Aki Tanihara
- Division of Hematology, Jichi Medical University Saitama Medical Center, Saitama
| | - Shun-Ichi Kimura
- Division of Hematology, Jichi Medical University Saitama Medical Center, Saitama
| | - Shinichi Kako
- Division of Hematology, Jichi Medical University Saitama Medical Center, Saitama
| | - Yoshinobu Kanda
- Division of Hematology, Jichi Medical University Saitama Medical Center, Saitama.
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Machherndl-Spandl S, Hannouf S, Nikoloudis A, Zach O, Strassl I, Kaynak E, Webersinke G, Gruber-Rossipal C, Rumpold H, Schimetta W, Clausen J, Buxhofer-Ausch V. Improved Outcomes in Myelofibrosis after Allogeneic Stem-Cell Transplantation in the Era of Ruxolitinib Pretreatment and Intensified Conditioning Regimen-Single-Center Analysis. Cancers (Basel) 2024; 16:3257. [PMID: 39409879 PMCID: PMC11482566 DOI: 10.3390/cancers16193257] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2024] [Revised: 09/11/2024] [Accepted: 09/20/2024] [Indexed: 10/19/2024] Open
Abstract
(1) Background: Allogeneic hematopoietic stem-cell transplantation (allo-HSCT) is the only treatment with the potential for cure in patients with myelofibrosis (MF). However, the risk of graft rejection, which is particularly high in MF, and the risk of significant non-relapse mortality must be considered. (2) Methods: In this retrospective, single-center study, we compared allo-HSCT outcomes in 36 adult patients with MF transplanted at two-time intervals (2001-2015 versus 2016-2021). (3) Results: The estimated median overall survival was 48.9 months (95%CI 0.00-98.2) in the cohort transplanted before 2016 and not reached in the more recent years (p = 0.04) due to markedly lower non-relapse mortality (p = 0.02). The 3-year relapse incidence was low in both cohorts (11.1% and 12.5%, p > 0.99). When comparing only subgroups within the more recent cohort based on the presence or absence of total body irradiation (TBI) or the use of sequential regimens, OS and PFS were comparable. (4) Conclusion: Pretreatment with ruxolitinib, intensified conditioning, and the preferential use of haploidentical related instead of mismatched unrelated donors for patients lacking an HLA-identical donor are most likely responsible for the improved outcome after allo-HCT in MF in recent years.
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Affiliation(s)
- Sigrid Machherndl-Spandl
- Department of Internal Medicine I: Hematology with Stem-Cell Transplantation, Hemostaseology and Medical Oncology, Ordensklinikum Linz—Elisabethinen, 4020 Linz, Austria (A.N.); (I.S.); (E.K.); (H.R.); (V.B.-A.)
- Medical Faculty, Johannes Kepler University, 4020 Linz, Austria
| | - Sarah Hannouf
- Department of Internal Medicine I: Hematology with Stem-Cell Transplantation, Hemostaseology and Medical Oncology, Ordensklinikum Linz—Elisabethinen, 4020 Linz, Austria (A.N.); (I.S.); (E.K.); (H.R.); (V.B.-A.)
- Medical Faculty, Johannes Kepler University, 4020 Linz, Austria
| | - Alexander Nikoloudis
- Department of Internal Medicine I: Hematology with Stem-Cell Transplantation, Hemostaseology and Medical Oncology, Ordensklinikum Linz—Elisabethinen, 4020 Linz, Austria (A.N.); (I.S.); (E.K.); (H.R.); (V.B.-A.)
- Medical Faculty, Johannes Kepler University, 4020 Linz, Austria
| | - Otto Zach
- Laboratory for Molecular and Genetic Diagnostics, Ordensklinikum Linz, 4020 Linz, Austria; (O.Z.); (G.W.)
| | - Irene Strassl
- Department of Internal Medicine I: Hematology with Stem-Cell Transplantation, Hemostaseology and Medical Oncology, Ordensklinikum Linz—Elisabethinen, 4020 Linz, Austria (A.N.); (I.S.); (E.K.); (H.R.); (V.B.-A.)
- Medical Faculty, Johannes Kepler University, 4020 Linz, Austria
| | - Emine Kaynak
- Department of Internal Medicine I: Hematology with Stem-Cell Transplantation, Hemostaseology and Medical Oncology, Ordensklinikum Linz—Elisabethinen, 4020 Linz, Austria (A.N.); (I.S.); (E.K.); (H.R.); (V.B.-A.)
| | - Gerald Webersinke
- Laboratory for Molecular and Genetic Diagnostics, Ordensklinikum Linz, 4020 Linz, Austria; (O.Z.); (G.W.)
| | | | - Holger Rumpold
- Department of Internal Medicine I: Hematology with Stem-Cell Transplantation, Hemostaseology and Medical Oncology, Ordensklinikum Linz—Elisabethinen, 4020 Linz, Austria (A.N.); (I.S.); (E.K.); (H.R.); (V.B.-A.)
- Medical Faculty, Johannes Kepler University, 4020 Linz, Austria
| | - Wolfgang Schimetta
- Department of Applied Systems Research and Statistics, Johannes Kepler University, 4040 Linz, Austria;
| | - Johannes Clausen
- Department of Internal Medicine I: Hematology with Stem-Cell Transplantation, Hemostaseology and Medical Oncology, Ordensklinikum Linz—Elisabethinen, 4020 Linz, Austria (A.N.); (I.S.); (E.K.); (H.R.); (V.B.-A.)
- Medical Faculty, Johannes Kepler University, 4020 Linz, Austria
| | - Veronika Buxhofer-Ausch
- Department of Internal Medicine I: Hematology with Stem-Cell Transplantation, Hemostaseology and Medical Oncology, Ordensklinikum Linz—Elisabethinen, 4020 Linz, Austria (A.N.); (I.S.); (E.K.); (H.R.); (V.B.-A.)
- Medical Faculty, Johannes Kepler University, 4020 Linz, Austria
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14
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Wang Z, Jin X, Zeng J, Xiong Z, Chen X. The application of JAK inhibitors in the peri-transplantation period of hematopoietic stem cell transplantation for myelofibrosis. Ann Hematol 2024; 103:3293-3301. [PMID: 38494551 PMCID: PMC11358344 DOI: 10.1007/s00277-024-05703-1] [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: 11/26/2023] [Accepted: 03/06/2024] [Indexed: 03/19/2024]
Abstract
Myelofibrosis (MF) is a myeloproliferative neoplasm (MPN) with a poor prognosis, and allogeneic hematopoietic stem cell transplantation (allo-HSCT) is the only treatment with curative potential. Ruxolitinib, a JAK1/2 inhibitor, has shown promising results in improving patients' symptoms, overall survival, and quality of life, and can be used as a bridging therapy to HSCT that increases the proportion of transplantable patients. However, the effect of this and similar drugs on HSCT outcomes is unknown, and the reports on their efficacy and safety in the peri-transplantation period vary widely in the published literature. This paper reviews clinical data related to the use of JAK inhibitors in the peri-implantation phase of hematopoietic stem cell transplantation for primary myelofibrosis and discusses their efficacy and safety.
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Affiliation(s)
- Zerong Wang
- West China Hospital, Sichuan University, Chendu, Sichuan, China
| | - Xuelian Jin
- West China Hospital, Sichuan University, Chendu, Sichuan, China
| | - Jiajia Zeng
- West China Hospital, Sichuan University, Chendu, Sichuan, China
| | - Zilin Xiong
- West China Hospital, Sichuan University, Chendu, Sichuan, China
| | - Xinchuan Chen
- West China Hospital, Sichuan University, Chendu, Sichuan, China.
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15
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Zulch E, Inoue Y, Cioccio J, Rakszawski K, Songdej N, Nickolich M, Zheng H, Naik S, Rybka W, Ehmann C, Sivik J, Mierski J, Silar B, Vajdic C, Greiner R, Brown V, Hohl R, Claxton D, Shike H, Paules CI, Mineishi S, Minagawa K. Impact of post-transplant cyclophosphamide and splenomegaly on primary graft failure and multi-lineage cytopenia after allogeneic hematopoietic cell transplantation. Leuk Res 2024; 143:107530. [PMID: 38852515 DOI: 10.1016/j.leukres.2024.107530] [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: 02/12/2024] [Revised: 05/21/2024] [Accepted: 06/01/2024] [Indexed: 06/11/2024]
Abstract
Primary graft failure (PGF) and multi-lineage cytopenia (MLC) increase the risk of nonrelapse mortality in allogeneic hematopoietic cell transplants (HCT). We evaluated the impact of post-transplant cyclophosphamide (PTCy) and splenomegaly on PGF and MLC for hematological malignancies. This study included patients with PTCy (N=84) and conventional graft-vs.-host disease prophylaxis (N=199). The occurrence of splenomegaly varied widely, ranging from 17.1 % (acute myeloid leukemia) to 66.7 % (myeloproliferative neoplasms). Ten patients (N=8 in the PTCy and N=2 in the non- PTCy) developed PGF, and 44 patients developed MLC (both N=22). PTCy and severe splenomegaly (≥20 cm) were risk factors for PGF (odds ratio (OR): 10.40, p<0.01 and 6.74, p=0.01 respectively). Moreover, severe splenomegaly was a risk factor for PGF in PTCy patients (OR: 10.20, p=0.01). PTCy (hazard ratio (HR) 2.09, p=0.02), moderate (≥15, <20 cm, HR 4.36, p<0.01), and severe splenomegaly (HR 3.04, p=0.01) were independent risk factors for MLC. However, in subgroup analysis in PTCy patients, only mild splenomegaly (≥12, <15 cm, HR 4.62, p=0.01) was a risk factor for MLC. We recommend all patients be screened for splenomegaly before HCT, and PTCy is cautioned in those with splenomegaly.
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Affiliation(s)
- Emma Zulch
- Blood and Marrow Transplant Program, Division of Hematology and Oncology, Penn State Cancer Institute, Hershey, PA, USA; Penn State College of Medicine, Hershey, PA, USA
| | - Yoshitaka Inoue
- Blood and Marrow Transplant Program, Division of Hematology and Oncology, Penn State Cancer Institute, Hershey, PA, USA; Penn State College of Medicine, Hershey, PA, USA; Department of Hematology, Kumamoto University, Kumamoto, Japan.
| | - Joseph Cioccio
- Blood and Marrow Transplant Program, Division of Hematology and Oncology, Penn State Cancer Institute, Hershey, PA, USA
| | - Kevin Rakszawski
- Blood and Marrow Transplant Program, Division of Hematology and Oncology, Penn State Cancer Institute, Hershey, PA, USA
| | - Natthapol Songdej
- Blood and Marrow Transplant Program, Division of Hematology and Oncology, Penn State Cancer Institute, Hershey, PA, USA
| | - Myles Nickolich
- Blood and Marrow Transplant Program, Division of Hematology and Oncology, Penn State Cancer Institute, Hershey, PA, USA
| | - Hong Zheng
- Blood and Marrow Transplant Program, Division of Hematology and Oncology, Penn State Cancer Institute, Hershey, PA, USA
| | - Seema Naik
- Blood and Marrow Transplant Program, Division of Hematology and Oncology, Penn State Cancer Institute, Hershey, PA, USA
| | - Witold Rybka
- Blood and Marrow Transplant Program, Division of Hematology and Oncology, Penn State Cancer Institute, Hershey, PA, USA
| | - Christopher Ehmann
- Blood and Marrow Transplant Program, Division of Hematology and Oncology, Penn State Cancer Institute, Hershey, PA, USA
| | - Jeffrey Sivik
- Department of Pharmacy, Penn State Cancer Institute, Hershey, PA, USA
| | - Jseph Mierski
- Blood and Marrow Transplant Program, Division of Hematology and Oncology, Penn State Cancer Institute, Hershey, PA, USA
| | - Brooke Silar
- Blood and Marrow Transplant Program, Division of Hematology and Oncology, Penn State Cancer Institute, Hershey, PA, USA
| | - Caitlin Vajdic
- Blood and Marrow Transplant Program, Division of Hematology and Oncology, Penn State Cancer Institute, Hershey, PA, USA
| | - Robert Greiner
- Division of Pediatric Hematology/Oncology, Penn State Health Children's Hospital, Hershey, PA, USA
| | - Valerie Brown
- Division of Pediatric Hematology/Oncology, Penn State Health Children's Hospital, Hershey, PA, USA
| | - Raymond Hohl
- Blood and Marrow Transplant Program, Division of Hematology and Oncology, Penn State Cancer Institute, Hershey, PA, USA
| | - David Claxton
- Blood and Marrow Transplant Program, Division of Hematology and Oncology, Penn State Cancer Institute, Hershey, PA, USA
| | - Hiroko Shike
- Department of Pathology, Penn State Cancer Institute, Hershey, PA, USA
| | - Catharine I Paules
- Penn State College of Medicine, Hershey, PA, USA; Penn State Health Milton S. Hershey Medical Center, Hershey, PA, USA
| | - Shin Mineishi
- Blood and Marrow Transplant Program, Division of Hematology and Oncology, Penn State Cancer Institute, Hershey, PA, USA
| | - Kentaro Minagawa
- Blood and Marrow Transplant Program, Division of Hematology and Oncology, Penn State Cancer Institute, Hershey, PA, USA
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16
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Villar S, Chevret S, Poire X, Joris M, Chevallier P, Bourhis JH, Forcade E, Chantepie S, Beauvais D, Raus N, Bay JO, Loschi M, Devillier R, Duléry R, Ceballos P, Rubio MT, Servais S, Nguyen S, Robin M. Transplantation for myelofibrosis patients in the ruxolitinib era: a registry study from the Société Francophone de Greffe de Moelle et de Thérapie Cellulaire. Bone Marrow Transplant 2024; 59:965-973. [PMID: 38514813 DOI: 10.1038/s41409-024-02268-5] [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: 11/30/2023] [Revised: 03/05/2024] [Accepted: 03/06/2024] [Indexed: 03/23/2024]
Abstract
In this SFGM-TC registry study, we report the results after stem cell transplantation (HSCT) in 305 myelofibrosis patients, in order to determine potential risk factors associated with outcomes, especially regarding previous treatment with ruxolitinib. A total of 102 patients were transplanted from an HLA-matched-sibling donor (MSD), and 143 patients received ruxolitinib. In contrast with previous studies, our results showed significantly worse outcomes for ruxolitinib patients regarding overall survival (OS) and non-relapse mortality (NRM), especially in the context of unrelated donors (URD). When exploring reasons for potential confounders regarding the ruxolitinib effect, an interaction between the type of donor and the use of ATG was found, therefore subsequent analyses were performed separately for each type of donor. Multivariable analyses did not confirm a significant negative impact of ruxolitinib in transplantation outcomes. In the setting of URD, only age and Fludarabine-Melphalan (FM) conditioning were associated with increased NRM. For MSD, only Karnoksfy <70% was associated with reduced OS. However, a propensity score analysis showed that ruxolitinib had a negative impact on OS but only in non-responding patients, consistent with previous data. To conclude, with all the precautions due to confounders and bias, ruxolitinib itself does not appear to increase mortality after HSCT.
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Affiliation(s)
- Sara Villar
- Service d'hématologie - greffe, Hôpital Saint Louis, APHP, Université de Paris, Paris, France
- Hematology Department, Clínica Universidad de Navarra, Pamplona, Spain
| | - Sylvie Chevret
- APHP, Saint-Louis University Hospital, Department of Biostatistics, Paris, France
| | - Xavier Poire
- Cliniques Universitaires St-Luc, Brussels, Brussels, Belgium
| | | | | | | | - Edouard Forcade
- Service d'hématologie et thérapie Cellulaire, CHU Bordeaux, Hôpital Haut-Leveque, Pessac, France
| | | | | | | | - Jacques-Olivier Bay
- Department of Clinical Hematology and Cellular Therapy, CHU de Clermont-Ferrand, Site Estaing, Clermont-Ferrand, France
| | - Michael Loschi
- Hematology Department, Cote D'Azur University, CHU of Nice, Nice, France
| | | | - Remy Duléry
- Department of Clinical Hematology and Cellular Therapy, Centre de Recherche Saint-Antoine (CRSA), Saint-Antoine Hospital, Assistance Publique - Hôpitaux de Paris, INSERM UMRs 938 Sorbonne University, Paris, France
| | - Patrice Ceballos
- Hematology Department, Montpellier University Hospital, Montpellier, France, Montpellier, France
| | - Marie Thérèse Rubio
- Hematology Department, CHRU Brabois, Nancy, France
- CNRS UMR 7365, Équipe 6, Biopôle de L'Université de Lorraine, Vandoeuvre Les Nancy, France
| | - Sophie Servais
- Hematology Department, CHU Liege, University of Liege, Liege, Belgium
| | - Stephanie Nguyen
- Hematology Department, Pitié Salpêtrière Hospital, AP-HP, Paris, France
| | - Marie Robin
- Service d'hématologie - greffe, Hôpital Saint Louis, APHP, Université de Paris, Paris, France.
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17
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Ranalli P, Natale A, Guardalupi F, Santarone S, Cantò C, La Barba G, Di Ianni M. Myelofibrosis and allogeneic transplantation: critical points and challenges. Front Oncol 2024; 14:1396435. [PMID: 38966064 PMCID: PMC11222377 DOI: 10.3389/fonc.2024.1396435] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2024] [Accepted: 05/23/2024] [Indexed: 07/06/2024] Open
Abstract
New available drugs allow better control of systemic symptoms associated with myelofibrosis (MF) and splenomegaly but they do not modify the natural history of progressive and poor prognosis disease. Thus, hematopoietic stem cell transplantation (HSCT) is still considered the only available curative treatment for patients with MF. Despite the increasing number of procedures worldwide in recent years, HSCT for MF patients remains challenging. An increasingly complex network of the patient, disease, and transplant-related factors should be considered to understand the need for and the benefits of the procedure. Unfortunately, prospective trials are often lacking in this setting, making an evidence-based decision process particularly arduous. In the present review, we will analyze the main controversial points of allogeneic transplantation in MF, that is, the development of more sophisticated models for the identification of eligible patients; the need for tools offering a more precise definition of expected outcomes combining comorbidity assessment and factors related to the procedure; the decision-making process about the best transplantation time; the evaluation of the most appropriate platform for curative treatment; the impact of splenomegaly; and splenectomy on outcomes.
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Affiliation(s)
- Paola Ranalli
- Hematology Unit, Pescara Hospital, Pescara, Italy
- Department of Medicine and Aging Sciences, University of Chieti-Pescara, Chieti, Italy
| | | | - Francesco Guardalupi
- Department of Medicine and Aging Sciences, University of Chieti-Pescara, Chieti, Italy
| | | | - Chiara Cantò
- Hematology Unit, Pescara Hospital, Pescara, Italy
| | | | - Mauro Di Ianni
- Hematology Unit, Pescara Hospital, Pescara, Italy
- Department of Medicine and Aging Sciences, University of Chieti-Pescara, Chieti, Italy
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18
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Mata JR, Zahurak M, Rosen N, DeZern AE, Jones RJ, Ambinder AJ. Graft Failure Incidence, Risk Factors, and Outcomes in Patients Undergoing Non-Myeloablative Allogeneic Hematopoietic Cell Transplantation Using Post-Transplant Cyclophosphamide. Transplant Cell Ther 2024; 30:588-596. [PMID: 38521411 DOI: 10.1016/j.jtct.2024.03.018] [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: 01/03/2024] [Revised: 03/13/2024] [Accepted: 03/15/2024] [Indexed: 03/25/2024]
Abstract
Graft failure (GF) is a major complication of allogeneic hematopoietic cell transplantation (alloHCT) that results in significant morbidity and mortality. Post-transplant cyclophosphamide (PTCy)-based graft-versus-host disease (GVHD) prophylaxis has emerged as an effective regimen across the spectrum of donor-match settings, but few studies have investigated the characteristics of GF in the setting of PTCy-based GVHD prophylaxis. The objective was to detail the incidence, clinical features, risk factors, and outcomes for patients with primary graft failure (PGF) and secondary graft failure (SGF). In this retrospective study at a single institution, 958 consecutive patients undergoing first nonmyeloablative (NMA) alloHCT with PTCy-based GVHD prophylaxis were analyzed. PGF was defined as a failure to achieve an ANC ≥ 500 cells/m3 by day 30 of transplant in the absence of residual disease. SGF was defined as complete loss of donor chimerism after initial engraftment. The incidences of PGF and SGF were 3.8% (n = 37) and 1.8% (n = 17), respectively. Neither PGF nor SGF were associated with HLA disparity. In a multivariate analysis, risk factors for PGF in this cohort included age ≥ 65 (OR 2.4, 95% CI 1.2 to 4.8, P = .0120), an underlying diagnosis of MDS, MPN, or MDS/MPN overlap (OR 2.8, 95% CI 1.4 to 5.7, P = .0050), post-transplant viremia with HHV-6 (OR 2.9, 95% CI 1.5 to 5.7, P = .0030), and low CD34+ dose (OR 0.7, 95% CI 0.5 to 0.9, P = .0080). Patients with PGF had poor overall survival, driven primarily by a high rate of nonrelapse mortality (59% at 36 months). SGF was associated with use of a bone marrow graft source and a diagnosis of Hodgkin lymphoma. Patients with SGF had excellent clinical outcomes with only one of seventeen patients experiencing relapse and relapse-related mortality. The incidence of PGF and SGF in patients receiving NMA conditioning and PTCy is low and is not impacted by HLA disparities between donors and recipients. PGF is more common in recipients with age ≥ 65, a diagnosis of MDS, MPN, or MDS/MPN-overlap, post-transplant HHV-6 viremia, and low CD34+ cell dose. Low total nucleated cell dose is also a risk factor for PGF in patients receiving a bone marrow graft source. Patients who experience PGF have poor outcomes due to high rates of nonrelapse mortality, whereas patients who experience SGF have excellent long-term outcomes.
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Affiliation(s)
- Jonaphine Rae Mata
- Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins, The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Marianna Zahurak
- Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins, The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Natalie Rosen
- Division of Hematology and Medical Oncology, Department of Medicine, Columbia University Irving Medical Center, New York, New York
| | - Amy E DeZern
- Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins, The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Richard J Jones
- Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins, The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Alexander J Ambinder
- Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins, The Johns Hopkins University School of Medicine, Baltimore, Maryland.
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19
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Ali H, Bacigalupo A. 2024 update on allogeneic hematopoietic stem cell transplant for myelofibrosis: A review of current data and applications on risk stratification and management. Am J Hematol 2024; 99:938-945. [PMID: 38450790 DOI: 10.1002/ajh.27274] [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: 02/01/2024] [Accepted: 02/06/2024] [Indexed: 03/08/2024]
Abstract
BACKGROUND Allogeneic hemopoietic stem cell transplantation (HSCT) currently remains the only curative treatment for patients with myelofibrosis (MF). Transplant related mortality (TRM) and relapse, remain two significant complications which need to be addressed. AIMS The aim of this manuscript is to review current available reports on changes which have recently occurred, to improve the outcome of MF patients undergoing an allogeneic HSCT. METHODS Published papers were used to analyze different aspects of allogeneic HSCT. RESULTS Changes and updates are provided on selection of patients, prognostic systems, managing splenomegaly, conditioning regimens, predicting transplant outcome, stem cell sources, stem cell donors, graft versus host disease (GvHD) prophylaxis, patients with blast phase, hematopoietic reconstitution, disease markers, donor chimerism, and treatment of relapse. CONCLUSIONS The review outlines new transplant platforms which are now available for patients with myelofibrosis, together with persisting problems, among which, older age combined with marrow fibrosis and an inflammatory disease. Relapse also requires aggressive monitoring of drivers mutations, and early cellular therapy.
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Affiliation(s)
- Haris Ali
- Divison of Leukemia, Department of Hematology and Hemopoietic Cell Transplantation, City of Hope, Duarte, California, USA
| | - Andrea Bacigalupo
- Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, Fondazione Policlinico Universitario A. Gemelli IRCCS, Roma, Italy
- Sezione di Ematologia, Dipartimento di Scienze Radiologiche ed Ematologiche, Università Cattolica del Sacro Cuore, Roma, Italy
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20
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Gagelmann N, Hobbs GS, Campodonico E, Helbig G, Novak P, Schroeder T, Schneider A, Rautenberg C, Reinhardt HC, Bosques L, Heuser M, Panagiota V, Thol F, Gurnari C, Maciejewski JP, Ciceri F, Rathje K, Robin M, Pagliuca S, Rubio MT, Rocha V, Funke V, Hamerschlak N, Salit R, Scott BL, Duarte F, Mitrus I, Czerw T, Greco R, Kröger N. Splenic irradiation for myelofibrosis prior to hematopoietic cell transplantation: A global collaborative analysis. Am J Hematol 2024; 99:844-853. [PMID: 38357714 DOI: 10.1002/ajh.27252] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2023] [Revised: 01/11/2024] [Accepted: 01/31/2024] [Indexed: 02/16/2024]
Abstract
Splenomegaly is the clinical hallmark of myelofibrosis. Splenomegaly at the time of allogeneic hematopoietic cell transplantation (HCT) is associated with graft failure and poor graft function. Strategies to reduce spleen size before HCT especially after failure to Janus kinase (JAK) inhibition represent unmet clinical needs in the field. Here, we leveraged a global collaboration to investigate the safety and efficacy of splenic irradiation as part of the HCT platform for patients with myelofibrosis. We included 59 patients, receiving irradiation within a median of 2 weeks (range, 0.9-12 weeks) before HCT. Overall, the median spleen size prior to irradiation was 23 cm (range, 14-35). Splenic irradiation resulted in a significant and rapid spleen size reduction in 97% of patients (57/59), with a median decrease of 5.0 cm (95% confidence interval, 4.1-6.3 cm). The most frequent adverse event was thrombocytopenia, with no correlation between irradiation dose and hematological toxicities. The 3-year overall survival was 62% (95% CI, 48%-76%) and 1-year non-relapse mortality was 26% (95% CI, 14%-38%). Independent predictors for survival were severe thrombocytopenia and anemia before irradiation, transplant-specific risk score, higher-intensity conditioning, and present portal vein thrombosis. When using a propensity score matching adjusted for common confounders, splenic irradiation was associated with significantly reduced relapse (p = .01), showing a 3-year incidence of 12% for splenic irradiation versus 29% for patients with immediate HCT and 38% for patients receiving splenectomy. In conclusion, splenic irradiation immediately before HCT is a reasonable approach in patients experiencing JAK inhibition failure and is associated with a low incidence of relapse.
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Affiliation(s)
- Nico Gagelmann
- Department of Stem Cell Transplantation, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Gabriela S Hobbs
- Department of Medical Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Edoardo Campodonico
- Hematology and Bone Marrow Transplantation Unit, IRCCS San Raffaele Hospital, University Vita-Salute San Raffaele, Milan, Italy
| | - Grzegorz Helbig
- Department of Hematology and Bone Marrow Transplantation, School of Medicine in Katowice, Medical University of Silesia, Katowice, Poland
| | - Polona Novak
- Department of Hematology, University Medical Center Ljubljana, Ljubljana, Slovenia
| | - Thomas Schroeder
- Department of Hematology and Stem Cell Transplantation, West German Cancer Center, University Hospital of Essen, Germany
| | - Artur Schneider
- Department of Hematology and Stem Cell Transplantation, West German Cancer Center, University Hospital of Essen, Germany
| | - Christina Rautenberg
- Department of Hematology and Stem Cell Transplantation, West German Cancer Center, University Hospital of Essen, Germany
| | - Hans Christian Reinhardt
- Department of Hematology and Stem Cell Transplantation, West German Cancer Center, University Hospital of Essen, Germany
| | - Linette Bosques
- Department of Medical Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Michael Heuser
- Department of Hematology, Hemostasis, Oncology and Stem Cell Transplantation, Hannover Medical School, Hannover, Germany
| | - Victoria Panagiota
- Department of Hematology, Hemostasis, Oncology and Stem Cell Transplantation, Hannover Medical School, Hannover, Germany
| | - Felicitas Thol
- Department of Hematology, Hemostasis, Oncology and Stem Cell Transplantation, Hannover Medical School, Hannover, Germany
| | - Carmelo Gurnari
- Translational Hematology and Oncology Research Department, Taussig Cancer Center, Cleveland Clinic, Cleveland, Ohio, USA
- Department of Biomedicine and Prevention, Tor Vergata University of Rome, Rome, Italy
| | - Jaroslaw P Maciejewski
- Translational Hematology and Oncology Research Department, Taussig Cancer Center, Cleveland Clinic, Cleveland, Ohio, USA
- Leukemia Program, Department of Hematology and Medical Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Fabio Ciceri
- Hematology and Bone Marrow Transplantation Unit, IRCCS San Raffaele Hospital, University Vita-Salute San Raffaele, Milan, Italy
| | - Kristin Rathje
- Department of Stem Cell Transplantation, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Marie Robin
- Service d'Hématologie-Greffe, Hôpital Saint-Louis, Assistance Publique Hôpitaux de Paris, Paris, France
| | - Simona Pagliuca
- Department of Hematology, Brabois Hospital, Centre Hospitalier Régional Universitaire (CHRU), Nancy, France
| | - Marie-Thérèse Rubio
- Department of Hematology, Brabois Hospital, Centre Hospitalier Régional Universitaire (CHRU), Nancy, France
| | - Vanderson Rocha
- Hospital de Clinicas, Hematology, Transfusion and Cell Therapy Service, University of São Paulo, Sao Paulo, Brazil
| | - Vaneuza Funke
- Blood and Marrow Transplantation Programme, Hospital de Clínicas, Federal University of Parana, Curitiba, Paraná, Brazil; Hospital Nossa Senhora das Graças, Curitiba, Brazil
| | | | - Rachel Salit
- Fred Hutchinson Cancer Research Center, Seattle, USA
| | - Bart L Scott
- Fred Hutchinson Cancer Research Center, Seattle, USA
| | - Fernando Duarte
- Hospital Universitario Walter Cantídio, Universidade Federal do Ceara, Fortaleza, Brazil
| | - Iwona Mitrus
- Hematology Department, Maria Skłodowska-Curie National Research Institute of Oncology, Gliwice, Poland
| | - Tomasz Czerw
- Hematology Department, Maria Skłodowska-Curie National Research Institute of Oncology, Gliwice, Poland
| | - Raffaella Greco
- Hematology and Bone Marrow Transplantation Unit, IRCCS San Raffaele Hospital, University Vita-Salute San Raffaele, Milan, Italy
| | - Nicolaus Kröger
- Department of Stem Cell Transplantation, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
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21
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Oechsler S, Gagelmann N, Wolschke C, Janson D, Badbaran A, Klyuchnikov E, Massoud R, Rathje K, Richter J, Schäfersküpper M, Niederwieser C, Kunte A, Heidenreich S, Ayuk F, Kröger N. Graft-versus-host disease and impact on relapse in myelofibrosis undergoing hematopoietic stem cell transplantation. Bone Marrow Transplant 2024; 59:550-557. [PMID: 38321269 PMCID: PMC10994836 DOI: 10.1038/s41409-024-02220-7] [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: 11/19/2023] [Revised: 01/12/2024] [Accepted: 01/19/2024] [Indexed: 02/08/2024]
Abstract
Allogeneic hematopoietic stem cell transplantation (alloHSCT) remains the only curative treatment for myelofibrosis (MF). Relapse occurs in 10-30% and remains a major factor for dismal outcomes. Previous work suggested that graft-versus-host disease (GVHD) might be associated with risk of relapse. This study included 341 patients undergoing their first (n = 308) or second (n = 33) alloHSCT. Anti-T-lymphocyte or antithymocyte globulin was used for GVHD prophylaxis in almost all patients. Median time to neutrophile and platelet engraftment was 13 days and 19 days, respectively. The cumulative incidence of acute GVHD grade II-IV was 41% (median, 31 days; range, 7-112). Grade III-IV acute GVHD was observed in 22%. The cumulative incidence of chronic GVHD was 61%. Liver was affected in 23% of acute GVHD cases and 46% of chronic GVHD cases. Severe acute GVHD was associated with high non-relapse mortality. The development of acute GVHD grade II and moderate GVHD was an independent factor for reduced risk for relapse after transplantation without increased risk for non-relapse mortality, while especially acute GVHD grade IV was associated with high non-relapse mortality. Last, we identified that ongoing response to ruxolitinib, accelerated-phase MF at time of transplantation and splenectomy prior to transplantation were independent predictors for relapse.
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Affiliation(s)
- Sofia Oechsler
- University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Nico Gagelmann
- University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | | | | | - Anita Badbaran
- University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | | | - Radwan Massoud
- University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Kristin Rathje
- University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Johanna Richter
- University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | | | | | - Ameya Kunte
- University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | | | - Francis Ayuk
- University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Nicolaus Kröger
- University Medical Center Hamburg-Eppendorf, Hamburg, Germany.
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22
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McLornan DP, Psaila B, Ewing J, Innes A, Arami S, Brady J, Butt NM, Cargo C, Cross NCP, Francis S, Frewin R, Garg M, Godfrey AL, Green A, Khan A, Knapper S, Lambert J, McGregor A, McMullin MF, Nangalia J, Neelakantan P, Woodley C, Mead A, Somervaille TCP, Harrison CN. The management of myelofibrosis: A British Society for Haematology Guideline. Br J Haematol 2024; 204:136-150. [PMID: 38037886 DOI: 10.1111/bjh.19186] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2023] [Revised: 10/03/2023] [Accepted: 10/20/2023] [Indexed: 12/02/2023]
Affiliation(s)
- Donal P McLornan
- Department of Haematology, University College London Hospitals, London, UK
| | - Bethan Psaila
- MRC Weatherall Institute of Molecular Medicine, University of Oxford, Oxford, UK
- Department of Haematology, Churchill Hospital, Oxford University NHS Trust, Oxford, UK
| | - Joanne Ewing
- Department of Haematology, University Hospitals Birmingham Trust, London, UK
| | - Andrew Innes
- Department of Haematology, Imperial College, London, UK
| | - Siamak Arami
- Department of Haematology, London Northwest Healthcare University NHS Trust, London, UK
| | - Jessica Brady
- Department of Clinical Oncology, Guy's and St. Thomas' NHS Foundation Trust, London, UK
| | - Nauman M Butt
- Department of Haematology, The Clatterbridge Cancer Centre NHS Foundation Trust, Liverpool, UK
| | - Catherine Cargo
- Department of Haematology, Leeds Teaching Hospitals NHS Foundation Trust, Leeds, UK
| | | | - Sebastian Francis
- Department of Haematology, Sheffield Teaching Hospital NHS Foundation Trust, Sheffield, UK
| | - Rebecca Frewin
- Department of Haematology, Gloucestershire Hospitals NHS Foundation Trust, Gloucester, UK
| | - Mamta Garg
- Department of Haematology, University Hospitals Leicester NHS Trust, Leicester, UK
| | - Anna L Godfrey
- Haematopathology & Oncology Diagnostics Service, Department of Haematology, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Anna Green
- Department of Histopathology, Guy's and St. Thomas' NHS Foundation Trust, London, UK
| | - Alesia Khan
- Department of Haematology, Leeds Teaching Hospitals NHS Foundation Trust, Leeds, UK
| | - Steve Knapper
- Department of Haematology, Cardiff University, Cardiff, UK
| | - Jonathan Lambert
- Department of Haematology, University College London Hospitals, London, UK
| | | | | | - Jyoti Nangalia
- Wellcome Sanger Institute, University of Cambridge, Cambridge, UK
| | - Pratap Neelakantan
- Department of Haematology, Royal Berkshire NHS Foundation Trust, London, UK
| | - Claire Woodley
- Department of Haematology, Guy's and St. Thomas' NHS Foundation Trust, London, UK
| | - Adam Mead
- MRC Weatherall Institute of Molecular Medicine, University of Oxford, Oxford, UK
- Department of Haematology, Churchill Hospital, Oxford University NHS Trust, Oxford, UK
| | - Tim C P Somervaille
- Cancer Research UK Manchester Institute & The Christie NHS Foundation Trust, Manchester, UK
| | - Claire N Harrison
- Department of Haematology, Guy's and St. Thomas' NHS Foundation Trust, London, UK
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23
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Kröger N, Bacigalupo A, Barbui T, Ditschkowski M, Gagelmann N, Griesshammer M, Gupta V, Hamad N, Harrison C, Hernandez-Boluda JC, Koschmieder S, Jain T, Mascarenhas J, Mesa R, Popat UR, Passamonti F, Polverelli N, Rambaldi A, Robin M, Salit RB, Schroeder T, Scott BL, Tamari R, Tefferi A, Vannucchi AM, McLornan DP, Barosi G. Indication and management of allogeneic haematopoietic stem-cell transplantation in myelofibrosis: updated recommendations by the EBMT/ELN International Working Group. Lancet Haematol 2024; 11:e62-e74. [PMID: 38061384 DOI: 10.1016/s2352-3026(23)00305-8] [Citation(s) in RCA: 35] [Impact Index Per Article: 35.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2023] [Revised: 09/26/2023] [Accepted: 10/03/2023] [Indexed: 12/24/2023]
Abstract
New options for medical therapy and risk scoring systems containing molecular data are leading to increased complexity in the management of patients with myelofibrosis. To inform patients' optimal care, we updated the 2015 guidelines on indications for and management of allogeneic haematopoietic stem-cell transplantation (HSCT) with the support of the European Society for Blood and Marrow Transplantation (EBMT) and European LeukemiaNet (ELN). New recommendations were produced using a consensus-building methodology after a comprehensive review of articles released from January, 2015 to December, 2022. Seven domains and 18 key questions were selected through a series of questionnaires using a Delphi process. Key recommendations in this update include: patients with primary myelofibrosis and an intermediate-2 or high-risk Dynamic International Prognostic Scoring System score, or a high-risk Mutation-Enhanced International Prognostic Score Systems (MIPSS70 or MIPSS70-plus) score, or a low-risk or intermediate-risk Myelofibrosis Transplant Scoring System score should be considered candidates for allogeneic HSCT. All patients who are candidates for allogeneic HSCT with splenomegaly greater than 5 cm below the left costal margin or splenomegaly-related symptoms should receive a spleen-directed treatment, ideally with a JAK-inhibitor; HLA-matched sibling donors remain the preferred donor source to date. Reduced intensity conditioning and myeloablative conditioning are both valid options for patients with myelofibrosis. Regular post-transplantation driver mutation monitoring is recommended to detect and treat early relapse with donor lymphocyte infusion. In a disease where evidence-based guidance is scarce, these recommendations might help clinicians and patients in shared decision making.
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Affiliation(s)
- Nicolaus Kröger
- Department of Stem Cell Transplantation, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.
| | - Andrea Bacigalupo
- Department of Hematology, Fondazione Policlinico Universitario Gemelli IRCCS, Universita' Cattolica del Sacro Cuore, Rome, Italy
| | - Tiziano Barbui
- FROM Research Foundation, Papa Giovanni XXIII Hospital, Bergamo, Italy
| | - Markus Ditschkowski
- Department of Hematology and Stem Cell Transplantation, West German Cancer Center, University Hospital of Essen, Essen, Germany
| | - Nico Gagelmann
- Department of Stem Cell Transplantation, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Martin Griesshammer
- University Clinic for Hematology, Oncology, Haemostaseology and Palliative Care, Johannes Wesling Medical Center Minden, University of Bochum, Bochum, Germany
| | - Vikas Gupta
- Princess Margaret Cancer Centre, Toronto, ON, Canada
| | - Nada Hamad
- School of Clinical Medicine, Faculty of Medicine and Health, UNSW Sydney, Sydney, NSW, Australia; Department of Haematology, St Vincent's Hospital, Sydney, NSW, Australia; School of Medicine, University of Notre Dame, Sydney, NSW, Australia
| | | | | | - Steffen Koschmieder
- Center for Integrated Oncology Aachen Bonn Cologne Düsseldorf, Aachen, Germany; Department of Hematology, Oncology, Hemostaseology, and Stem Cell Transplantation, Faculty of Medicine, RWTH Aachen University, Aachen, Germany
| | - Tania Jain
- Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University, Baltimore, MD, USA
| | - John Mascarenhas
- Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Ruben Mesa
- Atrium Health Wake Forest Baptist Comprehensive Cancer Center, Winston-Salem, NC, USA
| | - Uday R Popat
- The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Francesco Passamonti
- Università degli Studi di Milano; Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Nicola Polverelli
- Division of Hematology, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Alessandro Rambaldi
- Department of Oncology and Hemato-Oncology, University of Milan, Milan, Italy; Azienda Socio-Sanitaria Territoriale Papa Giovanni XXIII, Bergamo, Italy
| | - Marie Robin
- Department of Hematology, University Hospital of Saint Louis, Paris, France
| | | | - Thomas Schroeder
- Department of Hematology and Stem Cell Transplantation, West German Cancer Center, University Hospital of Essen, Essen, Germany
| | | | - Roni Tamari
- Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Ayalew Tefferi
- Division of Hematology, Department of Medicine, Mayo Clinic, Rochester, MN, USA
| | - Alessandro M Vannucchi
- Centro Ricerca e Innovazione delle Malattie Mieloproliferative, Azienda Ospedaliera-Universitaria Careggi, Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
| | - Donal P McLornan
- Department of Haematology and Stem Cell Transplantation, University College London Hospitals NHS Trust, London, UK
| | - Giovanni Barosi
- Center for the Study of Myelofibrosis, IRCCS Policlinico S Matteo, Pavia, Italy
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24
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Palmer J. Are transplant indications changing for myelofibrosis? HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2023; 2023:676-681. [PMID: 38066916 PMCID: PMC10727025 DOI: 10.1182/hematology.2023000453] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/18/2023]
Abstract
Myelofibrosis is a devastating myeloid malignancy characterized by dysregulation of the JAK-STAT pathway, resulting in splenomegaly, constitutional symptoms, anemia, thrombocytopenia, leukocytosis, and an increased likelihood of progression to acute leukemia. The only curative option is allogeneic stem cell transplantation. The numbers of transplants have been increasing every year, and although there have been improvements in survival, there remain many unanswered questions. In this review, we will evaluate patient selection and appropriate timing for transplantation. We will cover the current prognostic scoring systems, which can aid in the decision of when to move forward with transplant. We will also review the different donor options, as well as the conditioning regimens. The peritransplant management of splenomegaly will be reviewed. We will discuss management of posttransplant complications such as loss of donor chimerism or disease relapse. Finally, we will review what is known about the outlook of patients who have undergone allogeneic stem cell transplant with regards to quality of life and long-term survival.
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Affiliation(s)
- Jeanne Palmer
- Division of Hematology/Medical Oncology, Mayo Clinic, Phoenix, AZ
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25
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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: 19] [Impact Index Per Article: 9.5] [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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26
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Tefferi A, Pardanani A, Gangat N. Momelotinib (JAK1/JAK2/ACVR1 inhibitor): mechanism of action, clinical trial reports, and therapeutic prospects beyond myelofibrosis. Haematologica 2023; 108:2919-2932. [PMID: 36861402 PMCID: PMC10620561 DOI: 10.3324/haematol.2022.282612] [Citation(s) in RCA: 34] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2023] [Accepted: 02/20/2023] [Indexed: 03/03/2023] Open
Abstract
Janus kinase (JAK) 2 inhibitors are now part of the therapeutic armamentarium for primary and secondary myelofibrosis (MF). Patients with MF endure shortened survival and poor quality of life. Allogeneic stem cell transplantation (ASCT) is currently the only treatment modality in MF with the potential to cure the disease or prolong survival. By contrast, current drug therapy in MF targets quality of life and does not modify the natural history of the disease. The discovery of JAK2 and other JAK-STAT activating mutations (i.e., CALR and MPL) in myeloproliferative neoplasms, including MF, has facilitated the development of several JAK inhibitors that are not necessarily specific to the oncogenic mutations themselves but have proven effective in countering JAK-STAT signaling, resulting in suppression of inflammatory cytokines and myeloproliferation. This non-specific activity resulted in clinically favorable effects on constitutional symptoms and splenomegaly and, consequently, approval by the Food and Drug Administration (FDA) of three small molecule JAK inhibitors: ruxolitinib, fedratinib, and pacritinib. A fourth JAK inhibitor, momelotinib, is poised for FDA approval soon and has been shown to provide additional benefit in alleviating transfusion-dependent anemia in MF. The salutary effect of momelotinib on anemia has been attributed to inhibition of activin A receptor, type 1 (ACVR1) and recent information suggests a similar effect from pacritinib. ACRV1 mediates SMAD2/3 signaling which contributes to upregulation of hepcidin production and iron-restricted erythropoiesis. Targeting ACRV1 raises therapeutic prospects in other myeloid neoplasms associated with ineffective erythropoiesis, such as myelodysplastic syndromes with ring sideroblasts or SF3B1 mutation, especially those with co-expression of a JAK2 mutation and thrombocytosis.
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Affiliation(s)
- Ayalew Tefferi
- Division of Hematology, Department of Medicine, Mayo Clinic, Rochester, MN.
| | - Animesh Pardanani
- Division of Hematology, Department of Medicine, Mayo Clinic, Rochester, MN
| | - Naseema Gangat
- Division of Hematology, Department of Medicine, Mayo Clinic, Rochester, MN
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27
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Duminuco A, Torre E, Palumbo GA, Harrison C. A Journey Through JAK Inhibitors for the Treatment of Myeloproliferative Diseases. Curr Hematol Malig Rep 2023; 18:176-189. [PMID: 37395943 DOI: 10.1007/s11899-023-00702-x] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/06/2023] [Indexed: 07/04/2023]
Abstract
PURPOSE OF REVIEW Chronic myeloproliferative neoplasms (MPN) represent a group of diseases characterised by constitutive activation of the JAK/STAT pathway in a clonal myeloid precursor. The therapeutic approach aims to treat the symptom burden (headache, itching, debilitation), splenomegaly, slow down the fibrotic proliferation in the bone marrow and reduce the risk of thrombosis/bleeding whilst avoiding leukaemic transformation. RECENT FINDINGS In recent years, the advent of JAK inhibitors (JAKi) has significantly broadened treatment options for these patients. In myelofibrosis, symptom control and splenomegaly reduction can improve quality of life with improved overall survival, not impacting progression into acute leukaemia. Several JAKi are available and used worldwide, and combination approaches are now being explored. In this chapter, we review the approved JAKi, highlighting its strengths, exploring potential guidelines in choosing which one to use and reasoning towards future perspectives, where the combinations of therapies seem to promise the best results.
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Affiliation(s)
- Andrea Duminuco
- Department of Haematology, Guy's and St Thomas' NHS Foundation Trust, London, SE1 9RT, UK
- Haematology with BMT Unit, A.O.U. Policlinico "G.Rodolico-San Marco", Catania, Italy
| | - Elena Torre
- Department of Haematology, Guy's and St Thomas' NHS Foundation Trust, London, SE1 9RT, UK
- Clinica di Ematologia, Università Politecnica delle Marche, Ancona, Italy
| | - Giuseppe A Palumbo
- Haematology with BMT Unit, A.O.U. Policlinico "G.Rodolico-San Marco", Catania, Italy
| | - Claire Harrison
- Department of Haematology, Guy's and St Thomas' NHS Foundation Trust, London, SE1 9RT, UK.
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28
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Duminuco A, Vetro C, Giallongo C, Palumbo GA. The pharmacotherapeutic management of patients with myelofibrosis: looking beyond JAK inhibitors. Expert Opin Pharmacother 2023; 24:1449-1461. [PMID: 37341682 DOI: 10.1080/14656566.2023.2228695] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2023] [Accepted: 06/20/2023] [Indexed: 06/22/2023]
Abstract
INTRODUCTION The approach to myelofibrosis (MF) has been revolutionized in recent years, overcoming the traditional therapies, often not very effective. Janus kinase inhibitors (JAKi - from ruxolitinib up to momelotinib) were the first class of drugs with considerable results. AREAS COVERED Ongoing, new molecules are being tested that promise to give hope even to those patients not eligible for bone marrow transplants who become intolerant or are refractory to JAKi, for which therapeutic hopes are currently limited. Telomerase, murine double minute 2 (MDM2), phosphatidylinositol 3-kinase δ (PI3Kδ), BCL-2/xL, and bromodomain and extra-terminal motif (BET) inhibitors are the drugs with promising results in clinical trials and close to closure with consequent placing on the market, finally allowing JAK to look beyond. The novelty of the MF field was searched in the PubMed database, and the recently completed/ongoing trials are extrapolated from the ClinicalTrial website. EXPERT OPINION From this point of view, the use of new molecules widely described in this review, probably in association with JAKi, will represent the future treatment of choice in MF, leaving, in any case, the potential new approaches actually in an early stage of development, such as the use of immunotherapy in targeting CALR, which is coming soon.
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Affiliation(s)
- Andrea Duminuco
- Hematology with BMT Unit, A.O.U. "G. Rodolico-San Marco", Catania, Italy
| | - Calogero Vetro
- Hematology with BMT Unit, A.O.U. "G. Rodolico-San Marco", Catania, Italy
| | - Cesarina Giallongo
- Dipartimento di Scienze Mediche Chirurgiche E Tecnologie Avanzate "G.F. Ingrassia", University of Catania, Catania, Italy
| | - Giuseppe Alberto Palumbo
- Hematology with BMT Unit, A.O.U. "G. Rodolico-San Marco", Catania, Italy
- Dipartimento di Scienze Mediche Chirurgiche E Tecnologie Avanzate "G.F. Ingrassia", University of Catania, Catania, Italy
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29
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Kirito K. Recent progress of JAK inhibitors for hematological disorders. Immunol Med 2023; 46:131-142. [PMID: 36305377 DOI: 10.1080/25785826.2022.2139317] [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: 07/23/2022] [Accepted: 10/19/2022] [Indexed: 10/31/2022] Open
Abstract
JAK inhibitors are important therapeutic options for hematological disorders, especially myeloproliferative neoplasms. Ruxolitinib, the first JAK inhibitor approved for clinical use, improves splenomegaly and ameliorates constitutional symptoms in both myelofibrosis and polycythemia vera patients. Ruxolitinib is also useful for controlling hematocrit levels in polycythemia vera patients who were inadequately controlled by conventional therapies. Furthermore, pretransplantation use of ruxolitinib may improve the outcome of allo-hematopoietic stem cell transplantation in myelofibrosis. In contrast to these clinical merits, evidence of the disease-modifying action of ruxolitinib, i.e., reduction of malignant clones or improvement of bone marrow pathological findings, is limited, and many myelofibrosis patients discontinued ruxolitinib due to adverse events or disease progression. To overcome these limitations of ruxolitinib, several new types of JAK inhibitors have been developed. Among them, fedratinib was proven to provide clinical merits even in patients who were resistant or intolerant to ruxolitinib. Pacritinib and momelotinib have shown merits for myelofibrosis patients with thrombocytopenia or anemia, respectively. In addition to treatment for myeloproliferative neoplasms, recent studies have demonstrated that JAK inhibitors are novel and attractive therapeutic options for corticosteroid-refractory acute as well as chronic graft versus host disease.
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Affiliation(s)
- Keita Kirito
- Department of Hematology and Oncology, University of Yamanashi, Yamanashi, Japan
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30
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Amé S, Barraco F, Ianotto J, Jourdan E, Rey J, Viallard J, Wémeau M, Kiladjian J. Advances in management of primary myelofibrosis and polycythaemia vera: Implications in clinical practice. EJHAEM 2023; 4:779-791. [PMID: 37601853 PMCID: PMC10435696 DOI: 10.1002/jha2.734] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/25/2023] [Accepted: 05/31/2023] [Indexed: 08/22/2023]
Abstract
Primary myelofibrosis (PMF) and polycythaemia vera (PV) are rare BCR-ABL1-negative myeloproliferative neoplasms, associated with an increased risk of thrombosis, haemorrhagic complications and progression to fibrosis or leukaemia or fibrosis for PV. Both diseases are characterised by biological and clinical heterogeneity, leading to great variability in their management in routine clinical practice. In this review, we present an updated overview of the diagnosis, prognosis and treatment of PMF and PV, and we discuss how our multidisciplinary expert group based across France translates this evidence-based knowledge into routine clinical practice.
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Affiliation(s)
- Shanti Amé
- Department of HaematologyInstitut de Cancérologie Strasbourg Europe (ICANS)StrasbourgFrance
| | - Fiorenza Barraco
- Department of HaematologyLyon Sud Hospital CentrePierre‐BéniteFrance
| | | | - Eric Jourdan
- Department of Clinical HaematologyUniversity Hospital of NimesNimesFrance
| | - Jérôme Rey
- Department of HaematologyInstitute Paoli‐CalmettesMarseilleFrance
| | | | - Mathieu Wémeau
- Department of HaematologyHospital Centre of RoubaixRoubaixFrance
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Luther M, Henes FO, Zabelina T, Massoud R, Janson D, Wolschke C, Klyuchnikov E, Gagelmann N, Fehse B, Adam G, Kröger N, Ayuk F. Spleen volume and length determined by computed tomography impact outcome after allogeneic stem cell transplantation for myelofibrosis. Bone Marrow Transplant 2023; 58:755-761. [PMID: 37002409 DOI: 10.1038/s41409-023-01968-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2022] [Revised: 02/22/2023] [Accepted: 03/20/2023] [Indexed: 04/03/2023]
Abstract
Splenomegaly is a hallmark of myelofibrosis (MF), and reports on the impact of spleen size on the outcome of allo-HSCT have been conflicting, possibly due to differences in methods of assessment. We retrospectively analysed the impact of spleen volume and length measured by computed tomography on allo-HSCT outcome in 93 patients, 74% of whom had prior ruxolitinib treatment. Median spleen volume and length were 1.58 dm3 and 20 cm, respectively. We found a strong correlation between spleen volume and length (Pearson's r = 0.95, p < 0.001), Spearman (rho = 0.96, p < 0.001). After a median follow-up of 41.7 months, 5-year overall and disease-free survival were 66% and 59%, respectively. Spleen size did not impact overall survival or non-relapse mortality. Larger spleen volume and length as continuous variables were associated with slower platelet and leucocyte engraftment and a higher risk of disease relapse in univariate and multivariate analyses. Spleen length measured precisely by imaging is a good surrogate for spleen volume. In the era of JAK inhibitors, larger spleen size reflects advanced disease in MF and is associated with an increased risk of relapse but has no impact on non-relapse mortality and overall survival after allo-HSCT.
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Affiliation(s)
- Marlene Luther
- Department of Stem Cell Transplantation, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany
| | - Frank Oliver Henes
- Department of Diagnostic and Interventional Radiology and Nuclear Medicine, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany
| | - Tatjana Zabelina
- Department of Stem Cell Transplantation, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany
| | - Radwan Massoud
- Department of Stem Cell Transplantation, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany
| | - Dietlinde Janson
- Department of Stem Cell Transplantation, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany
| | - Christine Wolschke
- Department of Stem Cell Transplantation, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany
| | - Evgeny Klyuchnikov
- Department of Stem Cell Transplantation, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany
| | - Nico Gagelmann
- Department of Stem Cell Transplantation, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany
| | - Boris Fehse
- Department of Stem Cell Transplantation, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany
| | - Gerhard Adam
- Department of Diagnostic and Interventional Radiology and Nuclear Medicine, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany
| | - Nicolaus Kröger
- Department of Stem Cell Transplantation, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany
| | - Francis Ayuk
- Department of Stem Cell Transplantation, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany.
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Campodonico E, Xue E, Piemontese S, Chiara A, Bruno A, Scorpio G, Nitti R, Sannipoli D, Orofino G, Fiore P, Quattrocchi MC, Diral E, Clerici D, Farina F, Corti C, Lunghi F, Lupo-Stanghellini MT, Di Muzio N, Ciceri F, Greco R, Peccatori J. Splenic irradiation prior to allogeneic transplant conditioning in myelofibrosis: A pilot experience. Curr Res Transl Med 2023; 71:103400. [PMID: 37331224 DOI: 10.1016/j.retram.2023.103400] [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: 04/05/2023] [Revised: 06/02/2023] [Accepted: 06/08/2023] [Indexed: 06/20/2023]
Abstract
INTRODUCTION In the era of JAK inhibitors, allogeneic stem cell transplantation (HSCT) remains the only curative treatment for patients with Myelofibrosis (MF). Splenic irradiation (SI) may be used to reduce spleen size and related symptoms. METHODS We conducted a retrospective analysis on 14 patients with MF who underwent HSCT with SI from any donor source at our center between June 2016 and March 2021. All patients received a conditioning backbone based on treosulfan and fludarabine, with post-transplant cyclophosphamide (PTCy) and sirolimus as graft-versus-host disease (GvHD) prophylaxis. Patients received SI with 10 Gy involved-field radiotherapy in five 2-Gy fractions over the course of a week prior to the beginning of conditioning. RESULTS At transplant all patients were transfusion-dependent and had splenomegaly (median bipolar diameter by ultrasound: 20.75 cm). Overall, 12 patients had received ruxolitinib prior to transplant. Re-evaluation of spleen dimensions was available for 13 patients: median splenic bipolar diameter after at least 3 months from transplant decreased by a median of 25%. With a median post-transplant follow-up of 25 months, 6 patients remain in CR with full-donor chimerism, 3 patients died due to NRM. Overall, 4 patients relapsed. At last follow-up, nine patients are currently alive and achieved transfusion-independence. CONCLUSIONS In a small cohort of mostly ruxolitinib pre-treated patients, SI and treosulfan-based conditioning appeared a safe and effective tool to reduce spleen dimensions and ameliorate symptoms. Future prospective studies with adequate sample size are warranted to further investigate the usefulness and safety of this approach in MF.
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Affiliation(s)
- Edoardo Campodonico
- Hematology and Bone Marrow Transplantation Unit, IRCCS San Raffaele Hospital, via Olgettina 60, Milano 20132, Italy; University Vita-Salute San Raffaele, Milan, Italy
| | - Elisabetta Xue
- Hematology and Bone Marrow Transplantation Unit, IRCCS San Raffaele Hospital, via Olgettina 60, Milano 20132, Italy
| | - Simona Piemontese
- Hematology and Bone Marrow Transplantation Unit, IRCCS San Raffaele Hospital, via Olgettina 60, Milano 20132, Italy
| | - Anna Chiara
- Department of radiotherapy, IRCCS San Raffaele Hospital, Milan, Italy
| | - Alessandro Bruno
- Hematology and Bone Marrow Transplantation Unit, IRCCS San Raffaele Hospital, via Olgettina 60, Milano 20132, Italy; University Vita-Salute San Raffaele, Milan, Italy
| | - Gianluca Scorpio
- Hematology and Bone Marrow Transplantation Unit, IRCCS San Raffaele Hospital, via Olgettina 60, Milano 20132, Italy; University Vita-Salute San Raffaele, Milan, Italy
| | - Rosamaria Nitti
- Hematology and Bone Marrow Transplantation Unit, IRCCS San Raffaele Hospital, via Olgettina 60, Milano 20132, Italy; University Vita-Salute San Raffaele, Milan, Italy
| | - Daniele Sannipoli
- Hematology and Bone Marrow Transplantation Unit, IRCCS San Raffaele Hospital, via Olgettina 60, Milano 20132, Italy; University Vita-Salute San Raffaele, Milan, Italy
| | - Giorgio Orofino
- Hematology and Bone Marrow Transplantation Unit, IRCCS San Raffaele Hospital, via Olgettina 60, Milano 20132, Italy; University Vita-Salute San Raffaele, Milan, Italy
| | - Paolo Fiore
- Hematology and Bone Marrow Transplantation Unit, IRCCS San Raffaele Hospital, via Olgettina 60, Milano 20132, Italy; University Vita-Salute San Raffaele, Milan, Italy
| | - Maria Chiara Quattrocchi
- Hematology and Bone Marrow Transplantation Unit, IRCCS San Raffaele Hospital, via Olgettina 60, Milano 20132, Italy; University Vita-Salute San Raffaele, Milan, Italy
| | - Elisa Diral
- Hematology and Bone Marrow Transplantation Unit, IRCCS San Raffaele Hospital, via Olgettina 60, Milano 20132, Italy
| | - Daniela Clerici
- Hematology and Bone Marrow Transplantation Unit, IRCCS San Raffaele Hospital, via Olgettina 60, Milano 20132, Italy
| | - Francesca Farina
- Hematology and Bone Marrow Transplantation Unit, IRCCS San Raffaele Hospital, via Olgettina 60, Milano 20132, Italy
| | - Consuelo Corti
- Hematology and Bone Marrow Transplantation Unit, IRCCS San Raffaele Hospital, via Olgettina 60, Milano 20132, Italy
| | - Francesca Lunghi
- Hematology and Bone Marrow Transplantation Unit, IRCCS San Raffaele Hospital, via Olgettina 60, Milano 20132, Italy
| | | | - Nadia Di Muzio
- Department of radiotherapy, IRCCS San Raffaele Hospital, Milan, Italy
| | - Fabio Ciceri
- Hematology and Bone Marrow Transplantation Unit, IRCCS San Raffaele Hospital, via Olgettina 60, Milano 20132, Italy; University Vita-Salute San Raffaele, Milan, Italy
| | - Raffaella Greco
- Hematology and Bone Marrow Transplantation Unit, IRCCS San Raffaele Hospital, via Olgettina 60, Milano 20132, Italy.
| | - Jacopo Peccatori
- Hematology and Bone Marrow Transplantation Unit, IRCCS San Raffaele Hospital, via Olgettina 60, Milano 20132, Italy
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Murthy GSG, Kim S, Estrada-Merly N, Abid MB, Aljurf M, Assal A, Badar T, Badawy SM, Ballen K, Beitinjaneh A, Cerny J, Chhabra S, DeFilipp Z, Dholaria B, Perez MAD, Farhan S, Freytes CO, Gale RP, Ganguly S, Gupta V, Grunwald MR, Hamad N, Hildebrandt GC, Inamoto Y, Jain T, Jamy O, Juckett M, Kalaycio M, Krem MM, Lazarus HM, Litzow M, Munker R, Murthy HS, Nathan S, Nishihori T, Ortí G, Patel SS, Van der Poel M, Rizzieri DA, Savani BN, Seo S, Solh M, Verdonck LF, Wirk B, Yared JA, Nakamura R, Oran B, Scott B, Saber W. Association between the choice of the conditioning regimen and outcomes of allogeneic hematopoietic cell transplantation for myelofibrosis. Haematologica 2023; 108:1900-1908. [PMID: 36779595 PMCID: PMC10316233 DOI: 10.3324/haematol.2022.281958] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2020] [Accepted: 02/01/2023] [Indexed: 02/11/2023] Open
Abstract
Allogeneic hematopoietic cell transplantation (allo-HCT) remains the only curative treatment for myelofibrosis. However, the optimal conditioning regimen either with reduced-intensity conditioning (RIC) or myeloablative conditioning (MAC) is not well known. Using the Center for International Blood and Marrow Transplant Research database, we identified adults aged ≥18 years with myelofibrosis undergoing allo-HCT between 2008-2019 and analyzed the outcomes separately in the RIC and MAC cohorts based on the conditioning regimens used. Among 872 eligible patients, 493 underwent allo-HCT using RIC (fludarabine/ busulfan n=166, fludarabine/melphalan n=327) and 379 using MAC (fludarabine/busulfan n=247, busulfan/cyclophosphamide n=132). In multivariable analysis with RIC, fludarabine/melphalan was associated with inferior overall survival (hazard ratio [HR]=1.80; 95% confidenec interval [CI]: 1.15-2.81; P=0.009), higher early non-relapse mortality (HR=1.81; 95% CI: 1.12-2.91; P=0.01) and higher acute graft-versus-host disease (GvHD) (grade 2-4 HR=1.45; 95% CI: 1.03-2.03; P=0.03; grade 3-4 HR=2.21; 95%CI: 1.28-3.83; P=0.004) compared to fludarabine/busulfan. In the MAC setting, busulfan/cyclophosphamide was associated with a higher acute GvHD (grade 2-4 HR=2.33; 95% CI: 1.67-3.25; P<0.001; grade 3-4 HR=2.31; 95% CI: 1.52-3.52; P<0.001) and inferior GvHD-free relapse-free survival (GRFS) (HR=1.94; 95% CI: 1.49-2.53; P<0.001) as compared to fludarabine/busulfan. Hence, our study suggests that fludarabine/busulfan is associated with better outcomes in RIC (better overall survival, lower early non-relapse mortality, lower acute GvHD) and MAC (lower acute GvHD and better GRFS) in myelofibrosis.
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Affiliation(s)
| | - Soyoung Kim
- Division of Biostatistics, Institute for Health and Equity, Medical College of Wisconsin, Milwaukee, WI; CIBMTR® (Center for International Blood and Marrow Transplant Research), Department of Medicine, Medical College of Wisconsin, Milwaukee
| | - Noel Estrada-Merly
- CIBMTR® (Center for International Blood and Marrow Transplant Research), Department of Medicine, Medical College of Wisconsin, Milwaukee
| | - Muhammad Bilal Abid
- Divisions of Hematology/Oncology, and Infectious Diseases, Department of Medicine, Medical College of Wisconsin, Milwaukee
| | - Mahmoud Aljurf
- Department of Oncology, King Faisal Specialist Hospital Center and Research, Riyadh
| | - Amer Assal
- Columbia University Irving Medical Center, Department of Medicine, Bone Marrow Transplant and Cell Therapy Program
| | | | - Sherif M Badawy
- Division of Hematology, Oncology and Stem Cell Transplantation, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, IL; Department of Pediatrics, Northwestern University Feinberg School of Medicine
| | - Karen Ballen
- Division of Hematology/Oncology, University of Virginia Health System, Charlottesville, VA
| | - Amer Beitinjaneh
- Division of Transplantation and Cellular Therapy, University of Miami Hospital and Clinics, Slyvester Comprehensive Cancer Center, Miami, FL
| | - Jan Cerny
- Division of Hematology/Oncology, Department of Medicine, University of Massachusetts Medical Center, Worcester, MA
| | - Saurabh Chhabra
- CIBMTR® (Center for International Blood and Marrow Transplant Research), Department of Medicine, Medical College of Wisconsin, Milwaukee
| | - Zachariah DeFilipp
- Hematopoietic Cell Transplant and Cellular Therapy Program, Massachusetts General Hospital
| | | | | | - Shatha Farhan
- Henry Ford Health System Stem Cell Transplant and Cellular Therapy Program, Detroit, MI
| | - Cesar O Freytes
- University of Texas Health Science Center at San Antonio, San Antonio, TX
| | - Robert Peter Gale
- Haematology Research Centre, Department of Immunology and Inflammation, Imperial College London, London
| | - Siddhartha Ganguly
- Division of Hematological Malignancy and Cellular Therapeutics, University of Kansas Health System, Kansas City, KS
| | - Vikas Gupta
- MPN Program, Princess Margaret Cancer Centre, University of Toronto, Toronto, ON
| | - Michael R Grunwald
- Department of Hematologic Oncology and Blood Disorders, Levine Cancer Institute, Atrium Health, Charlotte, NC
| | | | | | - Yoshihiro Inamoto
- Division of Hematopoietic Stem Cell Transplantation, National Cancer Center, Tokyo
| | - Tania Jain
- John Hopkins University School of Medicine, Baltimore, MD
| | - Omer Jamy
- University of Alabama at Birmingham, Birmingham, AL
| | - Mark Juckett
- University of Minnesota Blood and Marrow Transplant Program - Adults
| | - Matt Kalaycio
- Cleveland Clinic Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH
| | | | - Hillard M Lazarus
- University Hospitals Cleveland Medical Center, Case Western Reserve University, Cleveland, OH
| | - Mark Litzow
- Division of Hematology and Transplant Center, Mayo Clinic Rochester, Rochester, MN
| | | | - Hemant S Murthy
- Division of Hematology-Oncology, Blood and Marrow Transplantation Program, Mayo Clinic, Jacksonville, FL
| | - Sunita Nathan
- Section of Bone Marrow Transplant and Cell Therapy, Rush University Medical Center
| | - Taiga Nishihori
- Department of Blood and Marrow Transplant and Cellular Immunotherapy (BMT CI), Moffitt Cancer Center, Tampa, FL
| | | | - Sagar S Patel
- Blood and Marrow Transplant Program, Huntsman Cancer Institute, University of Utah, Salt Lake City, UT
| | - Marjolein Van der Poel
- Department of Internal Medicine, Division of Hematology, GROW School for Oncology and Developmental Biology, Masstricht University Medical Center, Maastricht
| | - David A Rizzieri
- Division of Hematologic Malignancies and Cellular Therapy, Duke University, Durham, NC
| | - Bipin N Savani
- Division of Hematology/Oncology, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN
| | - Sachiko Seo
- Department of Hematology and Oncology, Dokkyo Medical University, Tochigo
| | - Melhem Solh
- The Blood and Marrow Transplant Group of Georgia, Northside Hospital, Atlanta, GA
| | - Leo F Verdonck
- Department of Hematology/Oncology, Isala, Clinic, Zwolle
| | - Baldeep Wirk
- Bone Marrow Transplant Program, Penn State Cancer Institute, Hershey, Pennsylvania
| | - Jean A Yared
- Transplantation and Cellular Therapy Program, Division of Hematology/Oncology, Department of Medicine, Greenebaum Comprehensive Cancer Center, University of Maryland, Baltimore, MD
| | - Ryotaro Nakamura
- Department of Hematology and Hematopoietic Cell Transplantation, City of Hope, Duarte, CA
| | - Betul Oran
- Department of Stem Cell Transplantation, Division of Cancer Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Bart Scott
- Fred Hutchinson Cancer Research Center, Seattle, WA
| | - Wael Saber
- CIBMTR® (Center for International Blood and Marrow Transplant Research), Department of Medicine, Medical College of Wisconsin, Milwaukee
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Passamonti F, Mora B. Myelofibrosis. Blood 2023; 141:1954-1970. [PMID: 36416738 PMCID: PMC10646775 DOI: 10.1182/blood.2022017423] [Citation(s) in RCA: 55] [Impact Index Per Article: 27.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2022] [Revised: 11/15/2022] [Accepted: 11/18/2022] [Indexed: 11/24/2022] Open
Abstract
The clinical phenotype of primary and post-polycythemia vera and postessential thrombocythemia myelofibrosis (MF) is dominated by splenomegaly, symptomatology, a variety of blood cell alterations, and a tendency to develop vascular complications and blast phase. Diagnosis requires assessing complete cell blood counts, bone marrow morphology, deep genetic evaluations, and disease history. Driver molecular events consist of JAK2V617F, CALR, and MPL mutations, whereas about 8% to 10% of MF are "triple-negative." Additional myeloid-gene variants are described in roughly 80% of patients. Currently available clinical-based and integrated clinical/molecular-based scoring systems predict the survival of patients with MF and are applied for conventional treatment decision-making, indication to stem cell transplant (SCT) and allocation in clinical trials. Standard treatment consists of anemia-oriented therapies, hydroxyurea, and JAK inhibitors such as ruxolitinib, fedratinib, and pacritinib. Overall, spleen volume reduction of 35% or greater at week 24 can be achieved by 42% of ruxolitinib-, 47% of fedratinib-, 19% of pacritinib-, and 27% of momelotinib-treated patients. Now, it is time to move towards new paradigms for evaluating efficacy like disease modification, that we intend as a robust and unequivocal effect on disease biology and/or on patient survival. The growing number of clinical trials potentially pave the way for new strategies in patients with MF. Translational studies of some molecules showed an early effect on bone marrow fibrosis and on variant allele frequencies of myeloid genes. SCT is still the only curative option, however, it is associated with relevant challenges. This review focuses on the diagnosis, prognostication, and treatment of MF.
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Affiliation(s)
- Francesco Passamonti
- Department of Medicine and Surgery, University of Insubria, Varese, Italy
- Department of Oncology, ASST Sette Laghi, Ospedale di Circolo, Varese, Italy
| | - Barbara Mora
- Department of Oncology, ASST Sette Laghi, Ospedale di Circolo, Varese, Italy
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35
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Polverelli N, Hernández-Boluda JC, Czerw T, Barbui T, D'Adda M, Deeg HJ, Ditschkowski M, Harrison C, Kröger NM, Mesa R, Passamonti F, Palandri F, Pemmaraju N, Popat U, Rondelli D, Vannucchi AM, Verstovsek S, Robin M, Colecchia A, Grazioli L, Damiani E, Russo D, Brady J, Patch D, Blamek S, Damaj GL, Hayden P, McLornan DP, Yakoub-Agha I. Splenomegaly in patients with primary or secondary myelofibrosis who are candidates for allogeneic hematopoietic cell transplantation: a Position Paper on behalf of the Chronic Malignancies Working Party of the EBMT. Lancet Haematol 2023; 10:e59-e70. [PMID: 36493799 DOI: 10.1016/s2352-3026(22)00330-1] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2022] [Revised: 09/25/2022] [Accepted: 10/04/2022] [Indexed: 12/12/2022]
Abstract
Splenomegaly is a hallmark of myelofibrosis, a debilitating haematological malignancy for which the only curative option is allogeneic haematopoietic cell transplantation (HCT). Considerable splenic enlargement might be associated with a higher risk of delayed engraftment and graft failure, increased non-relapse mortality, and worse overall survival after HCT as compared with patients without significantly enlarged splenomegaly. Currently, there are no standardised guidelines to assist transplantation physicians in deciding optimal management of splenomegaly before HCT. Therefore, the aim of this Position Paper is to offer a shared position statement on this issue. An international group of haematologists, transplantation physicians, gastroenterologists, surgeons, radiotherapists, and radiologists with experience in the treatment of myelofibrosis contributed to this Position Paper. The key issues addressed by this group included the assessment, prevalence, and clinical significance of splenomegaly, and the need for a therapeutic intervention before HCT for the control of splenomegaly. Specific scenarios, including splanchnic vein thrombosis and COVID-19, are also discussed. All patients with myelofibrosis must have their spleen size assessed before allogeneic HCT. Myelofibrosis patients with splenomegaly measuring 5 cm and larger, particularly when exceeding 15 cm below the left costal margin, or with splenomegaly-related symptoms, could benefit from treatment with the aim of reducing the spleen size before HCT. In the absence of, or loss of, response, patients with increasing spleen size should be evaluated for second-line options, depending on availability, patient fitness, and centre experience. Splanchnic vein thrombosis is not an absolute contraindication for HCT, but a multidisciplinary approach is warranted. Finally, prevention and treatment of COVID-19 should adhere to standard recommendations for immunocompromised patients.
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Affiliation(s)
- Nicola Polverelli
- Unit of Blood Diseases and Bone Marrow Transplantation, Cell Therapies and Hematology Research Program, Department of Clinical and Experimental Sciences, University of Brescia, ASST Spedali Civili di Brescia, Brescia, Italy.
| | | | - Tomasz Czerw
- Department of Hematology, Maria Skłodowska-Curie National Research Institute of Oncology, Gliwice, Poland
| | - Tiziano Barbui
- FROM Research Foundation, Papa Giovanni XXIII Hospital, Bergamo, Italy
| | - Mariella D'Adda
- Hematology Division, Department of Oncology, ASST Spedali Civili di Brescia, Brescia, Italy
| | - Hans Joachim Deeg
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, WA, USA
| | - Markus Ditschkowski
- Department of Hematology and Stem Cell Transplantation, West German Cancer Center, University Hospital of Essen, Essen, Germany
| | - Claire Harrison
- Department of Clinical Haematology, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | | | - Ruben Mesa
- Mays Cancer Center at UT Health San Antonio, San Antonio, TX, USA
| | - Francesco Passamonti
- Department of Medicine and Surgery, University of Insubria, ASST Sette Laghi, Varese, Italy
| | - Francesca Palandri
- Institute of Hematology L and A Seràgnoli, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Naveen Pemmaraju
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Uday Popat
- Department of Stem Cell Transplantation and Cellular Therapy, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Damiano Rondelli
- Blood and Marrow Transplant Program, and Center for Global Health, University of Illinois at Chicago, Chicago, IL, USA
| | - Alessandro Maria Vannucchi
- Center for Innovation and Research in Myeloproliferative Neoplasms, Hematology Unit, Azienda Ospedaliera Universitaria Careggi, University of Florence, Florence, Italy
| | - Srdan Verstovsek
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Marie Robin
- Hôpital Saint-Louis, APHP, Université de Paris Cité, Paris, France
| | | | - Luigi Grazioli
- Department of Radiology, ASST Spedali Civili di Brescia, Brescia, Italy
| | - Enrico Damiani
- 2nd Division of General Surgery, Department of Medical and Surgical Sciences, ASST Spedali Civili di Brescia, Brescia, Italy
| | - Domenico Russo
- Unit of Blood Diseases and Bone Marrow Transplantation, Cell Therapies and Hematology Research Program, Department of Clinical and Experimental Sciences, University of Brescia, ASST Spedali Civili di Brescia, Brescia, Italy
| | - Jessica Brady
- Department of Clinical Oncology, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - David Patch
- Hepatology and Liver Transplantation, Royal Free London NHS Foundation Trust, London, UK
| | - Slawomir Blamek
- Department of Radiotherapy, Maria Skłodowska-Curie National Research Institute of Oncology, Gliwice, Poland
| | - Gandhi Laurent Damaj
- Unit of Hematology, Centre Hospitalier Universitaire de Caen, University of Caen-Normandie, Caen, France
| | - Patrick Hayden
- Department of Haematology, Trinity College Dublin, St James's Hospital, Dublin, Ireland
| | - Donal P McLornan
- Department of Stem Cell Transplantation and Haematology, University College London Hospitals, London, UK
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Haploidentical Hematopoietic Cell Transplantation for Myelofibrosis in the Ruxolitinib Era. Transplant Cell Ther 2023; 29:49.e1-49.e7. [PMID: 36288760 DOI: 10.1016/j.jtct.2022.10.015] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2022] [Revised: 10/17/2022] [Accepted: 10/19/2022] [Indexed: 11/05/2022]
Abstract
Haploidentical stem cell transplantation is a viable strategy in the absence of an HLA-identical donor, but in myelofibrosis (MF), concerns may rise due to the risk of graft failure. Considering that engraftment is a major issue in MF, we sought to highlight its impact on survival outcomes. In addition, we explored the impact of pretransplantation ruxolitinib administration as an independent variable on outcomes. Here we report the results of a retrospective, monocentric experience with T cell-replete haploidentical bone marrow transplantation with post-transplantation cyclophosphamide as graft-versus-host disease (GVHD) prophylaxis in 51 consecutive MF-affected patients. The median duration of follow-up was 47 months. All 51 patients received a double-alkylating conditioning regimen, and 21 patients (41%) received pretransplantation ruxolitinib. Thirty-seven of 49 evaluable patients (76%) achieved full donor chimerism with neutrophil engraftment, 8 of 49 (16%) experienced graft rejection, and 4 of 49 (8%) had primary poor graft function. Splenectomy was more frequent among patients who engrafted (P = .06). Graft rejection was the sole factor negatively impacting overall survival (hazard ratio [HR], 4.19; 95% confidence interval [CI], 1.37 to 12.80; P = .01) and the major determinant for nonrelapse mortality (HR, 10.31; 95% CI, 2.54 to 41.82; P = .001). The 24-month incidence of relapse was 19% and was negatively impacted by splenectomy (HR, 5.84; 95% CI, 1.28 to 26.72; P = .02). The cumulative incidence of grade II-IV acute GVHD was 27% (95% CI, 20% to 33%), and that of grade III-IV acute GVHD was 8% (95% CI, 4% to 12%). The 24-month cumulative incidence of all-grade chronic GVHD was 28% (95% CI, 21% to 35%). Our data show that T cell-replete haploidentical bone marrow transplantation following double-alkylating conditioning in patients with MF is associated with favorable rates of GVHD and an acceptable relapse risk; nevertheless, rejection is not negligible and is associated with significant mortality. Splenectomy, which favors engraftment, is predictive of a higher risk of relapse.
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Perram J, Ross DM, McLornan D, Gowin K, Kröger N, Gupta V, Lewis C, Gagelmann N, Hamad N. Innovative strategies to improve hematopoietic stem cell transplant outcomes in myelofibrosis. Am J Hematol 2022; 97:1464-1477. [PMID: 35802782 PMCID: PMC9796730 DOI: 10.1002/ajh.26654] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2022] [Revised: 06/28/2022] [Accepted: 07/05/2022] [Indexed: 01/28/2023]
Abstract
Myelofibrosis (MF) is a clonal myeloproliferative neoplasm characterized by inflammation, marrow fibrosis, and an inherent risk of blastic transformation. Hematopoietic allogeneic stem cell transplant is the only potentially curative therapy for this disease, however, survival gains observed for other transplant indications over the past two decades have not been realized for MF. The role of transplantation may also evolve with the use of novel targeted agents. The chronic inflammatory state associated with MF necessitates pretransplantation assessment of end-organ function. Applying the transplant methodology employed for other myeloid disorders to patients with MF fails to acknowledge differences in the underlying disease pathophysiology. Limited understanding of the causes of poor transplant outcomes in this cohort has prevented refinement of transplant eligibility criteria in MF. There is increasing evidence of heterogeneity in molecular disease grade, beyond the clinical manifestations which have traditionally guided transplant timing. Exploring the physiological consequences of disease chronicity unique to MF, acknowledging the heterogeneity in disease grade, and using advanced prognostic models, molecular diagnostics and other organ function diagnostic tools, we present an innovative review of strategies with the potential to improve transplant outcomes in this disease. Larger, prospective studies which consider the impact of molecular-based disease grade are needed for MF transplantation.
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Affiliation(s)
- Jacinta Perram
- Department of Bone Marrow Transplantation and HaematologySt Vincent's HospitalDarlinghurstNew South WalesAustralia,School of Clinical Medicine, UNSW Medicine & HealthKensingtonNew South WalesAustralia
| | - David M. Ross
- Department of Haematology and Bone Marrow TransplantationRoyal Adelaide HospitalAdelaideSouth AustraliaAustralia,Centre for Cancer BiologySA Pathology and University of South AustraliaAdelaideSouth AustraliaAustralia
| | - Donal McLornan
- Department of Haematology and Stem Cell TransplantationUniversity College London Hospitals NHSLondonUK
| | - Krisstina Gowin
- Department of Hematology and OncologyBone Marrow Transplant and Cellular Therapy, University of ArizonaTucsonArizonaUSA
| | - Nicolas Kröger
- Department of Stem Cell TransplantationUniversity Medical Center Hamburg‐EppendorfHamburgGermany
| | - Vikas Gupta
- Medical Oncology and HaematologyPrincess Margaret Cancer CentreTorontoOntarioCanada
| | - Clinton Lewis
- Department of HaematologyAuckland City HospitalAucklandNew Zealand
| | - Nico Gagelmann
- Department of Stem Cell TransplantationUniversity Medical Center Hamburg‐EppendorfHamburgGermany
| | - Nada Hamad
- Department of Bone Marrow Transplantation and HaematologySt Vincent's HospitalDarlinghurstNew South WalesAustralia,School of Clinical Medicine, UNSW Medicine & HealthKensingtonNew South WalesAustralia,School of MedicineUniversity of Notre Dame AustraliaFremantleWestern AustraliaAustralia
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Mora B, Passamonti F. Towards a Personalized Definition of Prognosis in Philadelphia-Negative Myeloproliferative Neoplasms. Curr Hematol Malig Rep 2022; 17:127-139. [PMID: 36048275 PMCID: PMC9499895 DOI: 10.1007/s11899-022-00672-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/22/2022] [Indexed: 11/29/2022]
Abstract
Purpose of Review Philadelphia-negative myeloproliferative neoplasms (MPNs) include polycythemia vera (PV), essential thrombocythemia (ET), prefibrotic (pre-), and overt-primary myelofibrosis (primary MF, PMF). PV and ET could evolve into secondary MF (SMF), whose early diagnosis relies on monitoring signs of possible progression. All MPNs have a risk of blast phase (BP), that is associated with a very dismal outcome. Overall survival (OS) is different among MPNs, and disease-specific prognostic scores should be applied for a correct clinical management. In this review, an overview of current prognostic scores in MPNs will be provided. Recent Findings The biological complexity of MPNs and its role on the trajectory of disease outcome have led to the design of integrated prognostic models that are nowadays of common use in PMF patients. As for PV and ET, splicing gene mutations could have a detrimental role, but with the limit of the not routinary recommended application of extensive molecular analysis in these diseases. SMF is recognized as a distinct entity compared to PMF, and OS estimates should be calculated by the MYSEC-PM (Myelofibrosis SECondary-prognostic model). Both in PMF and SMF, decisions as selection of patients potentially candidates to allogenic stem cell transplant or that could benefit from an early shift from standard treatment are based not only on conventional prognostic scores, but also on multivariable algorithms. Summary The expanding landscape of risk prediction for OS, evolution to BP, and SMF progression from PV/ET informs personalized approach to the management of patients affected by MPNs.
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Affiliation(s)
- Barbara Mora
- Hematology, Ospedale Di Circolo, A.S.S.T. Sette Laghi, Viale Borri 57, 21100, Varese, Italy.,Department of Medicine and Surgery, University of Insubria, Via Guicciardini 9, 21100, Varese, Italy
| | - Francesco Passamonti
- Hematology, Ospedale Di Circolo, A.S.S.T. Sette Laghi, Viale Borri 57, 21100, Varese, Italy. .,Department of Medicine and Surgery, University of Insubria, Via Guicciardini 9, 21100, Varese, Italy.
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Considerations to comprehensive care for the older individual with myelofibrosis. Best Pract Res Clin Haematol 2022; 35:101371. [DOI: 10.1016/j.beha.2022.101371] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2022] [Accepted: 07/30/2022] [Indexed: 11/17/2022]
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40
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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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Breccia M, Palandri F, Guglielmelli P, Palumbo GA, Malato A, Mendicino F, Ricco A, Sant’Antonio E, Tiribelli M, Iurlo A. Management of Myelofibrosis during Treatment with Ruxolitinib: A Real-World Perspective in Case of Resistance and/or Intolerance. Curr Oncol 2022; 29:4970-4980. [PMID: 35877255 PMCID: PMC9325304 DOI: 10.3390/curroncol29070395] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2022] [Revised: 07/04/2022] [Accepted: 07/12/2022] [Indexed: 11/16/2022] Open
Abstract
The development and approval of ruxolitinib, the first JAK1/2 inhibitor indicated to treat myelofibrosis, has improved patient outcomes, with higher spleen and symptoms responses, improved quality of life, and overall survival. Despite this, several unmet needs remain, including the absence of resistance criteria, suboptimal response, the timing of allogeneic transplant, and the management of patients in case of intolerance. Here, we report the results of the second survey led by the "MPN Lab" collaboration, which aimed to report physicians' perspectives on these topics. As in our first survey, physicians were selected throughout Italy, and we included those with extensive experience in treating myeloproliferative neoplasms and those with less experience representing clinical practice in the real world. The results presented here, summarized using descriptive analyses, highlight the need for a clear definition of response to ruxolitinib as well as recommendations to guide the management of ruxolitinib under specific conditions including anemia, thrombocytopenia, infections, and non-melanoma skin cancers.
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Affiliation(s)
- Massimo Breccia
- Hematology, Department of Precision and Translational Medicine, Policlinico Umberto 1, Sapienza University, 00161 Rome, Italy
| | - Francesca Palandri
- Istituto di Ematologia “Seràgnoli”, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy;
| | - Paola Guglielmelli
- Center of Research and Innovation of Myeloproliferative Neoplasms, AOU Careggi, University of Florence, 50134 Florence, Italy;
| | - Giuseppe Alberto Palumbo
- Dipartimento di Scienze Mediche, Chirurgiche e Tecnologie Avanzate “G.F. Ingrassia”, University of Catania, 95124 Catania, Italy;
| | - Alessandra Malato
- UOC di Oncoematologia Ospedali Riuniti Villa Sofia-Cervello Palermo, 90146 Palermo, Italy;
| | - Francesco Mendicino
- Hematology Unit, Department of Hemato-Oncology, Ospedale Annunziata, 87100 Cosenza, Italy;
| | - Alessandra Ricco
- Department of Emergency and Organ Transplantation (DETO), Hematology Section, University of Bari, 70121 Bari, Italy;
| | - Emanuela Sant’Antonio
- Department of Oncology, Division of Hematology, Azienda USL Toscana Nord Ovest, 55100 Lucca, Italy;
- Medical Genetics, University of Siena, 53100 Siena, Italy
| | - Mario Tiribelli
- Division of Hematology and Bone Marrow Transplantation, Department of Medical Area, University of Udine, 33100 Udine, Italy;
| | - Alessandra Iurlo
- Hematology Division, Foundation IRCCS Ca’ Granda Ospedale Maggiore Policlinico, 20122 Milan, Italy;
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Downes CEJ, McClure BJ, McDougal DP, Heatley SL, Bruning JB, Thomas D, Yeung DT, White DL. JAK2 Alterations in Acute Lymphoblastic Leukemia: Molecular Insights for Superior Precision Medicine Strategies. Front Cell Dev Biol 2022; 10:942053. [PMID: 35903543 PMCID: PMC9315936 DOI: 10.3389/fcell.2022.942053] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2022] [Accepted: 06/16/2022] [Indexed: 11/13/2022] Open
Abstract
Acute lymphoblastic leukemia (ALL) is the most common pediatric cancer, arising from immature lymphocytes that show uncontrolled proliferation and arrested differentiation. Genomic alterations affecting Janus kinase 2 (JAK2) correlate with some of the poorest outcomes within the Philadelphia-like subtype of ALL. Given the success of kinase inhibitors in the treatment of chronic myeloid leukemia, the discovery of activating JAK2 point mutations and JAK2 fusion genes in ALL, was a breakthrough for potential targeted therapies. However, the molecular mechanisms by which these alterations activate JAK2 and promote downstream signaling is poorly understood. Furthermore, as clinical data regarding the limitations of approved JAK inhibitors in myeloproliferative disorders matures, there is a growing awareness of the need for alternative precision medicine approaches for specific JAK2 lesions. This review focuses on the molecular mechanisms behind ALL-associated JAK2 mutations and JAK2 fusion genes, known and potential causes of JAK-inhibitor resistance, and how JAK2 alterations could be targeted using alternative and novel rationally designed therapies to guide precision medicine approaches for these high-risk subtypes of ALL.
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Affiliation(s)
- Charlotte EJ. Downes
- Blood Cancer Program, Precision Cancer Medicine Theme, South Australian Health and Medical Research Institute (SAHMRI), Adelaide, SA, Australia
- School of Biological Sciences, Faculty of Sciences, University of Adelaide, Adelaide, SA, Australia
| | - Barbara J. McClure
- Blood Cancer Program, Precision Cancer Medicine Theme, South Australian Health and Medical Research Institute (SAHMRI), Adelaide, SA, Australia
- Adelaide Medical School, Faculty of Health and Medical Sciences, University of Adelaide, Adelaide, SA, Australia
| | - Daniel P. McDougal
- School of Biological Sciences, Faculty of Sciences, University of Adelaide, Adelaide, SA, Australia
- Institute for Photonics and Advanced Sensing (IPAS), University of Adelaide, Adelaide, SA, Australia
| | - Susan L. Heatley
- Blood Cancer Program, Precision Cancer Medicine Theme, South Australian Health and Medical Research Institute (SAHMRI), Adelaide, SA, Australia
- Adelaide Medical School, Faculty of Health and Medical Sciences, University of Adelaide, Adelaide, SA, Australia
- Australian and New Zealand Children’s Oncology Group (ANZCHOG), Clayton, VIC, Australia
| | - John B. Bruning
- School of Biological Sciences, Faculty of Sciences, University of Adelaide, Adelaide, SA, Australia
- Institute for Photonics and Advanced Sensing (IPAS), University of Adelaide, Adelaide, SA, Australia
| | - Daniel Thomas
- Blood Cancer Program, Precision Cancer Medicine Theme, South Australian Health and Medical Research Institute (SAHMRI), Adelaide, SA, Australia
- Adelaide Medical School, Faculty of Health and Medical Sciences, University of Adelaide, Adelaide, SA, Australia
| | - David T. Yeung
- Blood Cancer Program, Precision Cancer Medicine Theme, South Australian Health and Medical Research Institute (SAHMRI), Adelaide, SA, Australia
- Adelaide Medical School, Faculty of Health and Medical Sciences, University of Adelaide, Adelaide, SA, Australia
- Department of Haematology, Royal Adelaide Hospital and SA Pathology, Adelaide, SA, Australia
| | - Deborah L. White
- Blood Cancer Program, Precision Cancer Medicine Theme, South Australian Health and Medical Research Institute (SAHMRI), Adelaide, SA, Australia
- School of Biological Sciences, Faculty of Sciences, University of Adelaide, Adelaide, SA, Australia
- Adelaide Medical School, Faculty of Health and Medical Sciences, University of Adelaide, Adelaide, SA, Australia
- Australian and New Zealand Children’s Oncology Group (ANZCHOG), Clayton, VIC, Australia
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Salit RB. The role of JAK inhibitors in hematopoietic cell transplantation. Bone Marrow Transplant 2022; 57:857-865. [PMID: 35388118 DOI: 10.1038/s41409-022-01649-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2021] [Revised: 02/07/2022] [Accepted: 03/16/2022] [Indexed: 01/03/2023]
Abstract
The Janus Kinase (JAK)/Signal Transducers and Activators of Transcription (STAT) pathway is essential for both the regulation of hematopoiesis and the control of inflammation. Disruption of this pathway can lead to inflammatory and malignant disease processes. JAK inhibitors, designed to control the downstream effects of pro-inflammatory and pro-angiogenic cytokines, have been successfully used in pre-clinical models and clinical studies of patients with autoimmune diseases, hematologic malignancies, and the hematopoietic cell transplantation (HCT) complication graft versus host disease (GVHD). In the last decade, JAK inhibitors Ruxolitinib, Fedratinib, and most recently Pacritinib have been United States Federal Drug Administration (FDA) approved for the treatment of myelofibrosis (MF). Ruxolitinib was also recently approved for the treatment of steroid refractory acute as well as chronic GVHD; JAK inhibitors are currently under evaluation in the pre-HCT setting in MF and for the prevention of GVHD. This review will focus on the role of JAK inhibitors in the treatment of hematologic malignancies, the potential function of pre-HCT JAK inhibitors in patients with MF, and the role of JAK inhibitors in the prevention and treatment of acute and chronic GVHD.
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Affiliation(s)
- Rachel B Salit
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, WA, USA.
- Department of Medicine, University of Washington Medical Center, Seattle, WA, USA.
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44
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Indications for haematopoietic cell transplantation for haematological diseases, solid tumours and immune disorders: current practice in Europe, 2022. Bone Marrow Transplant 2022; 57:1217-1239. [PMID: 35589997 PMCID: PMC9119216 DOI: 10.1038/s41409-022-01691-w] [Citation(s) in RCA: 185] [Impact Index Per Article: 61.7] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2022] [Revised: 04/15/2022] [Accepted: 04/20/2022] [Indexed: 12/17/2022]
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45
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The Use of Allogeneic Hematopoietic Stem Cell Transplantation in Primary Myelofibrosis. J Pers Med 2022; 12:jpm12040571. [PMID: 35455686 PMCID: PMC9025208 DOI: 10.3390/jpm12040571] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2022] [Revised: 03/04/2022] [Accepted: 03/14/2022] [Indexed: 01/27/2023] Open
Abstract
Primary myelofibrosis (PMF) is a BCR-ABL1 negative myeloproliferative neoplasm characterized by clonal proliferation of myeloid cells. This leads to reactive bone marrow fibrosis, ultimately resulting in progressive marrow failure, hepatosplenomegaly, and extramedullary hematopoiesis. PMF is considered the most aggressive of the BCR-ABL1 negative myeloproliferative neoplasms with the least favorable prognosis. Constitutional symptoms are common, which can impact an individual’s quality of life and leukemic transformation remains an important cause of death in PMF patients. The development of the Janus kinase 2 (JAK2) inhibitors have provided a good option for management of PMF-related symptoms. Unfortunately, these agents have not been shown to improve overall survival or significantly alter the course of disease. Allogenic hematopoietic stem cell transplantation (allo-HSCT) remains the only curative treatment option in PMF. However, allo-HSCT is associated with significant treatment-related morbidity and mortality and has historically been reserved for younger, high-risk patients. This review examines patient, disease, and transplant-specific factors which may impact transplant-related outcomes in PMF. Through the vast improvements in donor selection, conditioning regimens, and post-transplant care, allo-HSCT may provide a safe and effective curative option for a broader range of PMF patients in the future.
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46
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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: 19] [Impact Index Per Article: 6.3] [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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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: 23] [Impact Index Per Article: 7.7] [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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How We Manage Myelofibrosis Candidates for Allogeneic Stem Cell Transplantation. Cells 2022; 11:cells11030553. [PMID: 35159362 PMCID: PMC8834299 DOI: 10.3390/cells11030553] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/25/2021] [Revised: 01/31/2022] [Accepted: 02/03/2022] [Indexed: 02/01/2023] Open
Abstract
Moving from indication to transplantation is a critical process in myelofibrosis. Most of guidelines specifically focus on either myelofibrosis disease or transplant procedure, and, currently, no distinct indication for the management of MF candidates to transplant is available. Nevertheless, this period of time is crucial for the transplant outcome because engraftment, non-relapse mortality, and relapse incidence are greatly dependent upon the pre-transplant management. Based on these premises, in this review, we will go through the path of identification of the MF patients suitable for a transplant, by using disease-specific prognostic scores, and the evaluation of eligibility for a transplant, based on performance, comorbidity, and other combined tools. Then, we will focus on the process of donor and conditioning regimens’ choice. The pre-transplant management of splenomegaly and constitutional symptoms, cytopenias, iron overload and transplant timing will be comprehensively discussed. The principal aim of this review is, therefore, to give a practical guidance for managing MF patients who are potential candidates for allo-HCT.
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Reduced intensity hematopoietic stem cell transplantation for myelofibrosis in accelerated-phase. Blood Adv 2022; 6:1222-1231. [PMID: 35051996 PMCID: PMC8864646 DOI: 10.1182/bloodadvances.2021006827] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2021] [Accepted: 01/06/2022] [Indexed: 11/20/2022] Open
Abstract
Results of this first report in accelerated-phase myelofibrosis may encourage clinicians to refer these patients for curative treatment. Accelerated-phase myelofibrosis without prior cytoreduction showed excellent 5-year survival (65%) but higher relapse vs chronic phase.
Accelerated-phase myelofibrosis, currently defined by circulating blasts 10% to 19%, usually confers very high risk for progression and poor outcome. The outcome of hematopoietic stem cell transplantation for accelerated-phase myelofibrosis has not been evaluated yet. We analyzed the outcome of 349 clinically and genetically annotated patients with primary or secondary myelofibrosis undergoing reduced intensity transplantation, of whom 35 had accelerated-phase myelofibrosis. In comparison with chronic-phase (<10% blasts) myelofibrosis, median leukocyte counts were higher, more patients had constitutional symptoms, and RAS mutations were detected more frequently in the accelerated-phase group. After a median follow-up of 5.9 years, estimated 5-year overall survival was 65% (95% confidence interval [CI], 49% to 81%) vs 64% (95% CI, 59% to 69%) for the chronic-phase group (P = .91), and median overall survival was not reached. In terms of relapse-free survival, estimated 5-year outcome for the accelerated-phase group was 49% (95% CI, 32% to 67%) vs 55% (95% CI, 50% to 61%) for the chronic-phase group (P = .65). Estimated 5-year nonrelapse mortality was 20% (95% CI, 8% to 33%) for the accelerated-phase group vs 30% (95% CI, 24% to 35%; P = .25) for the chronic-phase group. In terms of relapse, 5-year incidence was 30% (95% CI, 14% to 46%) for the accelerated-phase group vs 15% (95% CI, 11% to 19%) for the chronic-phase group (P = .02). Results were confirmed in multivariable analysis and propensity score matching. In conclusion, reduced intensity transplantation showed excellent survival but higher relapse for accelerated-phase myelofibrosis.
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Chifotides HT, Bose P, Verstovsek S. Momelotinib: an emerging treatment for myelofibrosis patients with anemia. J Hematol Oncol 2022; 15:7. [PMID: 35045875 PMCID: PMC8772195 DOI: 10.1186/s13045-021-01157-4] [Citation(s) in RCA: 53] [Impact Index Per Article: 17.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2021] [Accepted: 08/30/2021] [Indexed: 12/11/2022] Open
Abstract
The suite of marked anemia benefits that momelotinib has consistently conferred on myelofibrosis (MF) patients stem from its unique inhibitory activity on the BMP6/ACVR1/SMAD and IL-6/JAK/STAT3 pathways, resulting in decreased hepcidin (master iron regulator) expression, higher serum iron and hemoglobin levels, and restored erythropoiesis. Clinical data on momelotinib from the phase 2 and the two phase 3 SIMPLIFY trials consistently demonstrated high rates of sustained transfusion-independence. In a recent phase 2 translational study, 41% of the patients achieved transfusion independence for ≥ 12 weeks. In the phase 3 trials SIMPLIFY-1 and SIMPLIFY-2, 17% more JAK inhibitor-naïve patients and two-fold more JAK inhibitor-treated patients achieved or maintained transfusion independence with momelotinib versus ruxolitinib and best available therapy (89% ruxolitinib), respectively. Anemia is present in approximately a third of MF patients at diagnosis, eventually developing in nearly all patients. The need for red blood cell transfusions is an independent adverse risk factor for both overall survival and leukemic transformation. Presently, FDA-approved medications to address anemia are lacking. Momelotinib is one of the prime candidates to durably address the critical unmet needs of MF patients with moderate/severe anemia. Importantly, momelotinib may have overall survival benefits in frontline and second-line MF patients. MOMENTUM is an international registration-track phase 3 trial further assessing momelotinib’s unique constellation of anemia and other benefits in second-line MF patients; the results of the MOMENTUM trial are keenly awaited and may lead to regulatory approval of momelotinib.
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