1
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Putnam CM, Kondeti L, Kesler MBA, Varney ME. Modulating the immune system as a therapeutic target for myelodysplastic syndromes and acute myeloid leukemia. Biochem Cell Biol 2023; 101:481-495. [PMID: 37566901 DOI: 10.1139/bcb-2022-0374] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/13/2023] Open
Abstract
Modulating the immune system to treat diseases, including myeloid malignancies, has resulted in the development of a multitude of novel therapeutics in recent years. Myelodysplastic syndromes or neoplasms (MDS) and acute myeloid leukemia (AML) are hematologic malignancies that arise from defects in hematopoietic stem and progenitor cells (HSPCs). Dysregulated immune responses, especially in innate immune and inflammatory pathways, are highly associated with the acquisition of HSPC defects in MDS and AML pathogenesis. In addition to utilizing the immune system in immunotherapeutic interventions such as chimeric antigen receptor T cell therapy, vaccines, and immune checkpoint inhibitors, mitigating dysregulation of innate immune and inflammatory responses in MDS and AML remains a priority in slowing the initiation and progression of these myeloid malignancies. This review provides a comprehensive summary of the current progress of diverse strategies to utilize or modulate the immune system in the treatment of MDS and AML.
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Affiliation(s)
- Caroline M Putnam
- Department of Pharmaceutical Sciences, Marshall University School of Pharmacy, Huntington, WV, USA
| | - Lahari Kondeti
- Department of Pharmaceutical Sciences, Marshall University School of Pharmacy, Huntington, WV, USA
| | - Meredith B A Kesler
- Department of Pharmaceutical Sciences, Marshall University School of Pharmacy, Huntington, WV, USA
| | - Melinda E Varney
- Department of Pharmaceutical Sciences, Marshall University School of Pharmacy, Huntington, WV, USA
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2
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Zhang X, Yang X, Ma L, Zhang Y, Wei J. Immune dysregulation and potential targeted therapy in myelodysplastic syndrome. Ther Adv Hematol 2023; 14:20406207231183330. [PMID: 37547364 PMCID: PMC10399277 DOI: 10.1177/20406207231183330] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2022] [Accepted: 06/02/2023] [Indexed: 08/08/2023] Open
Abstract
Myelodysplastic syndrome (MDS) is a heterogeneous group of clonal hematological diseases and a high risk for transformation to acute myeloid leukemia (AML). The identification of key genetic alterations in MDS has enhanced our understanding of the pathogenesis and evolution. In recent years, it has been found that both innate and adaptive immune signaling are activated in the hematopoietic niche of MDS with aberrant cytokine secretion in the bone marrow microenvironment. It is also clear that immune dysregulation plays an important role in the occurrence and progression of MDS, especially the destruction of the bone marrow microenvironment, including hematopoiesis and stromal components. The purpose of this review is to explore the role of immune cells, the immune microenvironment, and cytokines in the pathogenesis of MDS. Insights into the mechanisms of these variants may facilitate the development of novel effective treatments to prevent disease progression.
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Affiliation(s)
- Xiaoying Zhang
- Department of Hematology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Xingcheng Yang
- Department of Hematology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Ling Ma
- Department of Clinical Laboratory, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Yicheng Zhang
- Department of Hematology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, 1095 Jiefang Avenue, Wuhan, Hubei 430030, China
- Key Laboratory of Organ Transplantation, Ministry of Education
- National Health Commission (NHC)
- Key Laboratory of Organ Transplantation, Chinese Academy of Medical Sciences, Wuhan, Hubei 430030, China
| | - Jia Wei
- Department of Hematology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, 1095 Jiefang Avenue, Wuhan, Hubei 430030, China
- Key Laboratory of Organ Transplantation, Ministry of Education
- National Health Commission (NHC)
- Key Laboratory of Organ Transplantation, Chinese Academy of Medical Sciences, Wuhan, Hubei 430030, China
- Department of Hematology, Shanxi Bethune Hospital, Shanxi Academy of Medical Sciences, and Tongji Shanxi Hospital, Third Hospital of Shanxi Medical University, Taiyuan, Shanxi 030032, China
- Sino-German Joint Oncological Research Laboratory, Shanxi Bethune Hospital, Shanxi Academy of Medical Sciences, Taiyuan, Shanxi 030032, China
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3
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Lynch OF, Calvi LM. Immune Dysfunction, Cytokine Disruption, and Stromal Changes in Myelodysplastic Syndrome: A Review. Cells 2022; 11:580. [PMID: 35159389 PMCID: PMC8834462 DOI: 10.3390/cells11030580] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2021] [Revised: 01/12/2022] [Accepted: 01/27/2022] [Indexed: 02/04/2023] Open
Abstract
Myelodysplastic syndromes (MDS) are myeloid neoplasms characterized by bone marrow dysfunction and increased risk of transformation to leukemia. MDS represent complex and diverse diseases that evolve from malignant hematopoietic stem cells and involve not only the proliferation of malignant cells but also the dysfunction of normal bone marrow. Specifically, the marrow microenvironment-both hematopoietic and stromal components-is disrupted in MDS. While microenvironmental disruption has been described in human MDS and murine models of the disease, only a few current treatments target the microenvironment, including the immune system. In this review, we will examine current evidence supporting three key interdependent pillars of microenvironmental alteration in MDS-immune dysfunction, cytokine skewing, and stromal changes. Understanding the molecular changes seen in these diseases has been, and will continue to be, foundational to developing effective novel treatments that prevent disease progression and transformation to leukemia.
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Affiliation(s)
- Olivia F. Lynch
- School of Medicine and Dentistry, University of Rochester, Rochester, NY 14642, USA;
| | - Laura M. Calvi
- Division of Endocrinology and Metabolism, Department of Medicine, School of Medicine and Dentistry, University of Rochester, Rochester, NY 14642, USA
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4
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Autoimmune disease in CMML-the chicken or the egg? Best Pract Res Clin Haematol 2019; 33:101136. [PMID: 32460986 DOI: 10.1016/j.beha.2019.101136] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2019] [Revised: 12/09/2019] [Accepted: 12/10/2019] [Indexed: 12/14/2022]
Abstract
Chronic myelomonocytic leukemia (CMML) is a clonal disorder that is associated with a wide range of systemic inflammatory and autoimmune diseases (SIADs). Approximately 20% of patients with CMML will have an associated SIAD and recognizing this association is critical to the evaluation, prognostication and management of patients with CMML. In this paper, we review the evidence supporting a causative link between these two entities as well as the direction of this relationship. We argue that the data favors CMML as the antecedent and causative disease state with a few notable exceptions. Better understanding of this relationship aids clinicians in the education of their patients and in determining the optimal management approach at the bedside. It is important to recognize opportunities to harmonize the treatments of these disease processes, which may enhance the effectiveness of treatment while reducing the burden of adverse effects from redundant therapies.
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5
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Steensma DP. Does early diagnosis and treatment of myelodysplastic syndromes make a difference? Best Pract Res Clin Haematol 2019; 32:101099. [DOI: 10.1016/j.beha.2019.101099] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
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6
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Stahl M, Bewersdorf JP, Giri S, Wang R, Zeidan AM. Use of immunosuppressive therapy for management of myelodysplastic syndromes: a systematic review and meta-analysis. Haematologica 2019; 105:102-111. [PMID: 31004015 PMCID: PMC6939518 DOI: 10.3324/haematol.2019.219345] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2019] [Accepted: 04/15/2019] [Indexed: 12/11/2022] Open
Abstract
Immunosuppressive therapy (IST) is one therapy option for treatment of patients with lower-risk myelodysplastic syndromes (MDS). However, the use of several different immunosuppressive regimens, the lack of high-quality studies, and the absence of validated predictive biomarkers pose important challenges. We conducted a systematic review and meta-analysis according to the Meta-Analysis of Observational Studies in Epidemiology (MOOSE) guidelines and searched MEDLINE via PubMed, Ovid EMBASE, COCHRANE registry of clinical trials (CENTRAL), and the Web of Science without language restriction from inception through September 2018, as well as relevant conference proceedings and abstracts, for prospective cohort studies or clinical trials investigating IST in MDS. Fixed and Random-effects models were used to pool response rates. We identified nine prospective cohort studies and 13 clinical trials with a total of 570 patients. Overall response rate was 42.5% [95% confidence interval (CI): 36.1-49.2%] including a complete remission rate of 12.5% (95%CI: 9.3-16.6%) and red blood cell transfusion independence rate of 33.4% (95% CI: 25.1-42.9%). The most commonly used forms of IST were anti-thymocyte globulin alone or in combination with cyclosporin A with a trend towards higher response rates with combination therapy. Progression rate to acute myeloid leukemia was 8.6% per patient year (95%CI: 3.3-13.9%). Overall survival and adverse events were only inconsistently reported. We were unable to validate any biomarkers predictive of a therapeutic response to IST. IST for treatment of lower-risk MDS patients can be successful to alleviate transfusion burden and associated sequelae.
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Affiliation(s)
- Maximilian Stahl
- Leukemia Service, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Jan Philipp Bewersdorf
- Department of Internal Medicine, Section of Hematology, Yale School of Medicine, New Haven, CT
| | - Smith Giri
- Department of Internal Medicine, Section of Hematology, Yale School of Medicine, New Haven, CT
| | - Rong Wang
- Cancer Outcomes, Public Policy, and Effectiveness Research (COPPER) Center, Yale University, New Haven, CT.,Department of Chronic Disease Epidemiology, School of Public Health, Yale University, New Haven, CT, USA
| | - Amer M Zeidan
- Department of Internal Medicine, Section of Hematology, Yale School of Medicine, New Haven, CT .,Cancer Outcomes, Public Policy, and Effectiveness Research (COPPER) Center, Yale University, New Haven, CT
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7
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Banerjee T, Calvi LM, Becker MW, Liesveld JL. Flaming and fanning: The Spectrum of inflammatory influences in myelodysplastic syndromes. Blood Rev 2019; 36:57-69. [PMID: 31036385 DOI: 10.1016/j.blre.2019.04.004] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2018] [Revised: 02/11/2019] [Accepted: 04/16/2019] [Indexed: 12/22/2022]
Abstract
The myelodysplastic syndromes (MDS) represent neoplasms derived from the expansion of mutated clonal hematopoietic cells which often demonstrate aberrant differentiation potential with resultant cytopenias and a propensity to evolve into acute myelogenous leukemia. While multiple mutations have been identified which may serve as drivers of the MDS clone, there is accumulating evidence that MDS clones and subclones are subject to modulation by the marrow microenvironment and its inflammatory milieu. There is also a strong link between autoimmune disorders and MDS. In this review, we examine the role of inflammatory cytokines, toll like receptors, pyroptosis, stromal cells, and cellular inflammatory mediators in MDS initiation, propagation, and progression. These contributions in a background of mutational, epigenetic, and aging changes in the marrow are also reviewed. Such inflammatory mediators may be subject to therapeutic agents which will enhance suppression of the MDS clone with potential to improve therapeutic outcomes in this disease which is usually incurable in aged patients not eligible for stem cell transplantation.
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Affiliation(s)
- Titas Banerjee
- Department of Medicine, University of Rochester, Rochester, NY, USA.
| | - Laura M Calvi
- Division of Endocrinology and Metabolism, Department of Medicine, and the James P Wilmot Cancer Institute, USA.
| | - Michael W Becker
- Division of Hematology/Oncology, Department of Medicine, James P Wilmot Cancer Institute, USA.
| | - Jane L Liesveld
- Division of Hematology/Oncology, Department of Medicine, James P Wilmot Cancer Institute, USA.
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8
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Retuning the immune system in myelodysplastic syndromes: from immunomodulatory approaches to vaccination strategies and non myeloablative hemopoietic cell transplant. Crit Rev Oncol Hematol 2019; 133:112-119. [DOI: 10.1016/j.critrevonc.2018.11.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2018] [Revised: 08/09/2018] [Accepted: 11/05/2018] [Indexed: 12/24/2022] Open
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9
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Shallis RM, Chokr N, Stahl M, Pine AB, Zeidan AM. Immunosuppressive therapy in myelodysplastic syndromes: a borrowed therapy in search of the right place. Expert Rev Hematol 2018; 11:715-726. [PMID: 30024293 DOI: 10.1080/17474086.2018.1503049] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
INTRODUCTION Myelodysplastic syndromes (MDS) encompass a heterogenous collection of clonal hematopoietic stem cell disorders defined by dysregulated hematopoiesis, peripheral cytopenias, and a risk of leukemic progression. Increasing data support the role of innate and adaptive immune pathways in the pathogenesis and disease course of MDS. The role of immunosuppressive therapy has an established role in the treatment of other hematologic diseases, such as aplastic anemia whose pathogenesis is postulated to reflect that of MDS with regards to many aspects of immune activation. Areas covered: This paper discusses the current understanding of immune dysregulation as it pertains to MDS, the clinical experience with immunosuppressive therapy in the management of MDS, as well as future prospects which will likely improve therapeutic options and outcomes for patients with MDS. Expert commentary: Though limited by paucity of high quality data, immunomodulatory and immunosuppressive therapies for the treatment of MDS have shown meaningful clinical activity in selected patients. Continued clarification of the immune pathways that are dysregulated in MDS and establishing predictors for clinical benefit of immunosuppressive therapy are vital to improve the use and outcomes with these therapies.
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Affiliation(s)
- Rory M Shallis
- a Division of Hematology/Medical Oncology, Department of Medicine , Yale University School of Medicine , New Haven , USA
| | - Nora Chokr
- a Division of Hematology/Medical Oncology, Department of Medicine , Yale University School of Medicine , New Haven , USA
| | - Maximilian Stahl
- a Division of Hematology/Medical Oncology, Department of Medicine , Yale University School of Medicine , New Haven , USA
| | - Alexander B Pine
- a Division of Hematology/Medical Oncology, Department of Medicine , Yale University School of Medicine , New Haven , USA
| | - Amer M Zeidan
- a Division of Hematology/Medical Oncology, Department of Medicine , Yale University School of Medicine , New Haven , USA.,b Cancer Outcomes, Public Policy, and Effectiveness Research (COPPER) Center , Yale University , New Haven , USA
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10
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Ivy KS, Brent Ferrell P. Disordered Immune Regulation and its Therapeutic Targeting in Myelodysplastic Syndromes. Curr Hematol Malig Rep 2018; 13:244-255. [PMID: 29934935 PMCID: PMC6560359 DOI: 10.1007/s11899-018-0463-9] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
PURPOSE OF REVIEW Immune dysregulation is a defining feature of myelodysplastic syndromes (MDS). Recently, several studies have further defined the complex role of immune alterations within MDS. Herein, we will summarize some of these findings and discuss the therapeutic strategies currently in development. RECENT FINDINGS Immune alterations in MDS are complex, heterogeneous, and intertwined with clonal hematopoiesis and stromal cell dysfunction. Inflammation in MDS proceeds as a vicious cycle, mediated in large part by secreted factors, which induce cell death and activate innate immune signaling. Therapeutic targeting of this variable immune dysregulation has led to modest responses thus far, but incorporation of the growing repertoire of immunotherapy brings new potential for improved outcomes. The immune milieu is variable across the spectrum of MDS subtypes, with a changing balance of inflammatory and suppressive cellular forces from low- to high-risk disease.
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Affiliation(s)
- Kathryn S Ivy
- Boston University School of Medicine, Boston, MA, USA
- Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - P Brent Ferrell
- Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA.
- Vanderbilt-Ingram Cancer Center, Vanderbilt University Medical Center, Nashville, TN, USA.
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11
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Dawoud NM, Ayoub OH, Essa ES, Dawoud DM. Myelodysplasia in a psoriasis patient receiving etanercept: Cause or coincidence? Indian J Dermatol Venereol Leprol 2018; 84:463-465. [PMID: 29770787 DOI: 10.4103/ijdvl.ijdvl_463_17] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Affiliation(s)
- Noha Mohammed Dawoud
- Department of Dermatology, Andrology and STDs, Faculty of Medicine, Menoufia University, Menoufia, Egypt; Department of Dermatology, Al Hada Armed Forces Hospital, Taif, Kingdom of Saudi Arabia
| | - Othman Hadi Ayoub
- Department of Hematology, Al Hada Armed Forces Hospital, Taif, Kingdom of Saudi Arabia
| | - Enas Said Essa
- Department of Clinical Pathology, Faculty of Medicine, Menoufia University, Menoufia, Egypt
| | - Dalia Mohamed Dawoud
- Department of Clinical Pharmacy, Faculty of Pharmacy, Cairo University, Giza, Egypt
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12
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Geyh S, Rodríguez-Paredes M, Jäger P, Koch A, Bormann F, Gutekunst J, Zilkens C, Germing U, Kobbe G, Lyko F, Haas R, Schroeder T. Transforming growth factor β1-mediated functional inhibition of mesenchymal stromal cells in myelodysplastic syndromes and acute myeloid leukemia. Haematologica 2018; 103:1462-1471. [PMID: 29773599 PMCID: PMC6119130 DOI: 10.3324/haematol.2017.186734] [Citation(s) in RCA: 43] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2017] [Accepted: 05/14/2018] [Indexed: 12/15/2022] Open
Abstract
Mesenchymal stromal cells are involved in the pathogenesis of myelodysplastic syndromes and acute myeloid leukemia, but the underlying mechanisms are incompletely understood. To further characterize the pathological phenotype we performed RNA sequencing of mesenchymal stromal cells from patients with myelodysplastic syndromes and acute myeloid leukemia and found a specific molecular signature of genes commonly deregulated in these disorders. Pathway analysis showed a strong enrichment of genes related to osteogenesis, senescence, inflammation and inhibitory cytokines, thereby reflecting the structural and functional deficits of mesenchymal stromal cells in myelodysplastic syndromes and acute myeloid leukemia on a molecular level. Further analysis identified transforming growth factor β1 as the most probable extrinsic trigger factor for this altered gene expression. Following exposure to transforming growth factor β1, healthy mesenchymal stromal cells developed functional deficits and adopted a phenotype reminiscent of that observed in patient-derived stromal cells. These suppressive effects of transforming growth factor β1 on stromal cell functionality were abrogated by SD-208, an established inhibitor of transforming growth factor β receptor signaling. Blockade of transforming growth factor β signaling by SD-208 also restored the osteogenic differentiation capacity of patient-derived stromal cells, thus confirming the role of transforming growth factor β1 in the bone marrow microenvironment of patients with myelodysplastic syndromes and acute myeloid leukemia. Our findings establish transforming growth factor β1 as a relevant trigger causing functional inhibition of mesenchymal stromal cells in myelodysplastic syndromes and acute myeloid leukemia and identify SD-208 as a candidate to revert these effects.
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Affiliation(s)
- Stefanie Geyh
- Department of Hematology, Oncology and Clinical Immunology, University of Duesseldorf, Medical Faculty, Germany
| | - Manuel Rodríguez-Paredes
- Department of Hematology, Oncology and Clinical Immunology, University of Duesseldorf, Medical Faculty, Germany.,Division of Epigenetics, DKFZ-ZMBH Alliance, German Cancer Research Center, Heidelberg, Germany
| | - Paul Jäger
- Department of Hematology, Oncology and Clinical Immunology, University of Duesseldorf, Medical Faculty, Germany
| | - Annemarie Koch
- Department of Hematology, Oncology and Clinical Immunology, University of Duesseldorf, Medical Faculty, Germany
| | - Felix Bormann
- Division of Epigenetics, DKFZ-ZMBH Alliance, German Cancer Research Center, Heidelberg, Germany
| | - Julian Gutekunst
- Division of Epigenetics, DKFZ-ZMBH Alliance, German Cancer Research Center, Heidelberg, Germany
| | - Christoph Zilkens
- Department of Orthopedic Surgery, University of Duesseldorf, Medical Faculty, Germany
| | - Ulrich Germing
- Department of Hematology, Oncology and Clinical Immunology, University of Duesseldorf, Medical Faculty, Germany
| | - Guido Kobbe
- Department of Hematology, Oncology and Clinical Immunology, University of Duesseldorf, Medical Faculty, Germany
| | - Frank Lyko
- Division of Epigenetics, DKFZ-ZMBH Alliance, German Cancer Research Center, Heidelberg, Germany
| | - Rainer Haas
- Department of Hematology, Oncology and Clinical Immunology, University of Duesseldorf, Medical Faculty, Germany
| | - Thomas Schroeder
- Department of Hematology, Oncology and Clinical Immunology, University of Duesseldorf, Medical Faculty, Germany
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14
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Mekinian A, Dervin G, Lapidus N, Kahn JE, Terriou L, Liozon E, Grignano E, Piette JC, Rauzy OB, Grobost V, Godmer P, Gillard J, Rossignol J, Launay D, Aouba A, Cardon T, Bouillet L, Broner J, Vinit J, Ades L, Carrat F, Salvado C, Toussirot E, Versini M, Costedoat-Chalumeau N, Fraison JB, Guilpain P, Fenaux P, Fain O. Biologics in myelodysplastic syndrome-related systemic inflammatory and autoimmune diseases: French multicenter retrospective study of 29 patients. Autoimmun Rev 2017; 16:903-910. [DOI: 10.1016/j.autrev.2017.07.003] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2017] [Accepted: 05/17/2017] [Indexed: 12/23/2022]
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15
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Galletti G, Scielzo C, Barbaglio F, Rodriguez TV, Riba M, Lazarevic D, Cittaro D, Simonetti G, Ranghetti P, Scarfò L, Ponzoni M, Rocchi M, Corti A, Anselmo A, van Rooijen N, Klein C, Ries CH, Ghia P, De Palma M, Caligaris-Cappio F, Bertilaccio MTS. Targeting Macrophages Sensitizes Chronic Lymphocytic Leukemia to Apoptosis and Inhibits Disease Progression. Cell Rep 2016; 14:1748-1760. [PMID: 26876171 DOI: 10.1016/j.celrep.2016.01.042] [Citation(s) in RCA: 82] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2014] [Revised: 12/08/2015] [Accepted: 01/09/2016] [Indexed: 01/30/2023] Open
Abstract
The role of monocytes/macrophages in the development and progression of chronic lymphocytic leukemia (CLL) is poorly understood. Transcriptomic analyses show that monocytes/macrophages and leukemic cells cross talk during CLL progression. Macrophage depletion impairs CLL engraftment, drastically reduces leukemic growth, and favorably impacts mouse survival. Targeting of macrophages by either CSF1R signaling blockade or clodrolip-mediated cell killing has marked inhibitory effects on established leukemia also. Macrophage killing induces leukemic cell death mainly via the TNF pathway and reprograms the tumor microenvironment toward an antitumoral phenotype. CSF1R inhibition reduces leukemic cell load, especially in the bone marrow, and increases circulating CD20(+) leukemic cells. Accordingly, co-targeting TAMs and CD20-expressing leukemic cells provides a survival benefit in the mice. These results establish the important role of macrophages in CLL and suggest therapeutic strategies based on interfering with leukemia-macrophage interactions.
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MESH Headings
- Animals
- Antibodies, Monoclonal/pharmacology
- Apoptosis/drug effects
- Apoptosis/immunology
- B-Lymphocytes/immunology
- B-Lymphocytes/pathology
- Cell Communication/drug effects
- Cell Line, Tumor
- Clodronic Acid/pharmacology
- Disease Progression
- Gene Expression Regulation, Leukemic
- Humans
- Leukemia, Lymphocytic, Chronic, B-Cell/drug therapy
- Leukemia, Lymphocytic, Chronic, B-Cell/genetics
- Leukemia, Lymphocytic, Chronic, B-Cell/immunology
- Leukemia, Lymphocytic, Chronic, B-Cell/mortality
- Liposomes/pharmacology
- Macrophages/drug effects
- Macrophages/immunology
- Macrophages/pathology
- Mice
- Mice, Transgenic
- Neoplasm Transplantation
- Primary Cell Culture
- Receptors, Granulocyte-Macrophage Colony-Stimulating Factor/antagonists & inhibitors
- Receptors, Granulocyte-Macrophage Colony-Stimulating Factor/genetics
- Receptors, Granulocyte-Macrophage Colony-Stimulating Factor/immunology
- Signal Transduction
- Survival Analysis
- Transplantation, Heterologous
- Tumor Microenvironment/drug effects
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Affiliation(s)
- Giovanni Galletti
- Unit of Lymphoid Malignancies, Division of Experimental Oncology, IRCCS San Raffaele Scientific Institute, 20132 Milan, Italy; Vita-Salute San Raffaele University, 20132 Milan, Italy
| | - Cristina Scielzo
- Unit of Lymphoid Malignancies, Division of Experimental Oncology, IRCCS San Raffaele Scientific Institute, 20132 Milan, Italy; Vita-Salute San Raffaele University, 20132 Milan, Italy
| | - Federica Barbaglio
- Unit of Lymphoid Malignancies, Division of Experimental Oncology, IRCCS San Raffaele Scientific Institute, 20132 Milan, Italy
| | - Tania Véliz Rodriguez
- Unit of Lymphoid Malignancies, Division of Experimental Oncology, IRCCS San Raffaele Scientific Institute, 20132 Milan, Italy
| | - Michela Riba
- Center for Translational Genomics and Bioinformatics, IRCCS San Raffaele Scientific Institute, 20132 Milan, Italy
| | - Dejan Lazarevic
- Center for Translational Genomics and Bioinformatics, IRCCS San Raffaele Scientific Institute, 20132 Milan, Italy
| | - Davide Cittaro
- Center for Translational Genomics and Bioinformatics, IRCCS San Raffaele Scientific Institute, 20132 Milan, Italy
| | - Giorgia Simonetti
- Department of Experimental, Diagnostic and Specialty Medicine, Institute of Hematology "L. e A. Seràgnoli," Università di Bologna, 40138 Bologna, Italy
| | - Pamela Ranghetti
- Unit of Lymphoid Malignancies, Division of Experimental Oncology, IRCCS San Raffaele Scientific Institute, 20132 Milan, Italy
| | - Lydia Scarfò
- Unit of B Cell Neoplasia, Division of Experimental Oncology, IRCCS San Raffaele Scientific Institute, 20132 Milan, Italy; Unit of Lymphoid Malignancies, Department of Onco-Hematology, IRCCS San Raffaele Hospital, Milan, Italy
| | - Maurilio Ponzoni
- Unit of Lymphoid Malignancies, Department of Onco-Hematology, IRCCS San Raffaele Hospital, Milan, Italy; Pathology Unit, IRCCS San Raffaele Scientific Institute, 20132 Milan, Italy
| | - Martina Rocchi
- Unit of Lymphoid Malignancies, Department of Onco-Hematology, IRCCS San Raffaele Hospital, Milan, Italy; Pathology Unit, IRCCS San Raffaele Scientific Institute, 20132 Milan, Italy
| | - Angelo Corti
- Tumor Biology and Vascular Targeting Unit, Division of Experimental Oncology, IRCCS San Raffaele Scientific Institute, 20132 Milan, Italy
| | - Achille Anselmo
- Humanitas Clinical and Research Center, 20089 Rozzano, Milan, Italy
| | - Nico van Rooijen
- Department of Molecular Cell Biology, Vrije University Medical Center, 1081 BT Amsterdam, the Netherlands
| | - Christian Klein
- Roche Pharma Research and Early Development, Oncology Discovery, Roche Innovation Center Zurich, 8952 Zurich, Switzerland
| | - Carola H Ries
- Roche Pharmaceutical Research and Early Development, Roche Innovation Center Penzberg, Oncology Discovery, 82377 Penzberg, Germany
| | - Paolo Ghia
- Vita-Salute San Raffaele University, 20132 Milan, Italy; Unit of B Cell Neoplasia, Division of Experimental Oncology, IRCCS San Raffaele Scientific Institute, 20132 Milan, Italy; Unit of Lymphoid Malignancies, Department of Onco-Hematology, IRCCS San Raffaele Hospital, Milan, Italy
| | - Michele De Palma
- The Swiss Institute for Experimental Cancer Research (ISREC), School of Life Sciences, École Polytechnique Fédérale de Lausanne (EPFL), 1015 Lausanne, Switzerland; Division of Regenerative Medicine, Stem Cells and Gene Therapy, IRCCS San Raffaele Scientific Institute, 20132 Milan, Italy
| | - Federico Caligaris-Cappio
- Unit of Lymphoid Malignancies, Division of Experimental Oncology, IRCCS San Raffaele Scientific Institute, 20132 Milan, Italy; Vita-Salute San Raffaele University, 20132 Milan, Italy; Unit of Lymphoid Malignancies, Department of Onco-Hematology, IRCCS San Raffaele Hospital, Milan, Italy.
| | - Maria Teresa Sabrina Bertilaccio
- Unit of Lymphoid Malignancies, Division of Experimental Oncology, IRCCS San Raffaele Scientific Institute, 20132 Milan, Italy; Vita-Salute San Raffaele University, 20132 Milan, Italy.
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16
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Abstract
Myelodysplastic syndromes (MDS) are characterized by cytopenias resulting from ineffective hematopoiesis with a predisposition to transform to acute myeloid leukemia (AML). Recent evidence suggests that the hematopoietic stem cell microenvironment contributes to the pathogenesis of MDS. Inflammation and hypoxia within the bone marrow are key regulators of hematopoietic stem and progenitor cells that can lead to several bone marrow failure syndromes, including MDS. In this brief review, we provide an overview of the clinical and molecular features of MDS, the bone marrow microenvironment, and specific pathways that lead to abnormal blood cell development in MDS. Characterization of key steps in the pathogenesis of MDS will lead to new approaches to treat patients with this disease.
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Affiliation(s)
- Erinn B Rankin
- Department of Obstetrics & Gynecologic Oncology, Stanford University School of Medicine, Stanford, CA, USA; Department of Radiation Oncology, Stanford University School of Medicine, Stanford, CA, USA
| | - Anupama Narla
- Division of Hematology/Oncology, Department of Pediatrics, Stanford University School of Medicine, Stanford, CA, USA
| | - Joseph K Park
- Division of Hematology/Oncology, Department of Pediatrics, Stanford University School of Medicine, Stanford, CA, USA
| | - Shuo Lin
- Department of Molecular, Cell & Developmental Biology, University of California, Los Angeles, CA, USA
| | - Kathleen M Sakamoto
- Division of Hematology/Oncology, Department of Pediatrics, Stanford University School of Medicine, Stanford, CA, USA.
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17
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Yang L, Qian Y, Eksioglu E, Epling-Burnette PK, Wei S. The inflammatory microenvironment in MDS. Cell Mol Life Sci 2015; 72:1959-66. [PMID: 25662443 PMCID: PMC11113192 DOI: 10.1007/s00018-015-1846-x] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2014] [Revised: 12/23/2014] [Accepted: 01/26/2015] [Indexed: 12/16/2022]
Abstract
Myelodysplastic syndromes (MDS) are a collection of pre-malignancies characterized by impaired proliferation and differentiation of hematopoietic stem cells and a tendency to evolve into leukemia. Among MDS's pathogenic mechanisms are genetic, epigenetic, apoptotic, differentiation, and cytokine milieu abnormalities. Inflammatory changes are a prominent morphologic feature in some cases, with increased populations of plasma cells, mast cells, and lymphocytes in bone marrow aspirates. Accumulating evidence suggests that the bone marrow microenvironment contributes to MDS disease pathology, with microenvironment alterations and abnormality preceding, and facilitating clonal evolution in MDS patients. In this review, we focus on the inflammatory changes involved in the pathology of MDS, with an emphasis on immune dysfunction, stromal microenvironment, and cytokine imbalance in the microenvironment as well as activation of innate immune signaling in MDS patients. A better understanding of the mechanism of MDS pathophysiology will be beneficial to the development of molecular-targeted therapies in the future.
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Affiliation(s)
- Lili Yang
- Department of Immunology, Tianjin Cancer Institute and Hospital, Tianjin Medical University, Tianjin, China
- Key Laboratory of Cancer Immunology and Biotherapy, National Clinical Research Center of Cancer, Tianjin, China
| | - Yaqin Qian
- Department of Immunology, Tianjin Cancer Institute and Hospital, Tianjin Medical University, Tianjin, China
- Key Laboratory of Cancer Immunology and Biotherapy, National Clinical Research Center of Cancer, Tianjin, China
| | - Erika Eksioglu
- Immunology Program at the H Lee Moffitt Cancer Center, 12902 Magnolia Dr., Tampa, FL 33612 USA
| | | | - Sheng Wei
- Department of Immunology, Tianjin Cancer Institute and Hospital, Tianjin Medical University, Tianjin, China
- Key Laboratory of Cancer Immunology and Biotherapy, National Clinical Research Center of Cancer, Tianjin, China
- Immunology Program at the H Lee Moffitt Cancer Center, 12902 Magnolia Dr., Tampa, FL 33612 USA
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18
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Gauthier J, Damaj G, Yakoub-Agha I. [The role of pre-transplant debulking treatment in patients undergoing allogeneic stem cell transplantation for high-risk myelodysplastic syndrome]. Bull Cancer 2015; 102:340-8. [PMID: 25799164 DOI: 10.1016/j.bulcan.2015.02.009] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2014] [Accepted: 11/17/2014] [Indexed: 12/23/2022]
Abstract
Treatment of myelodysplastic syndromes (MDS) remains unsatisfactory. Variable success in the correction of blood cytopenias, reduction of the proportion of marrow myeloblasts, and normalization of cytogenetics has been achieved with a variety of treatment strategies, including the use of immunosuppressive drugs, differentiating agents, conventional chemotherapy, and hypomethylating agents (HMAs) However, in general, responses have not been complete and have been of limited duration; prolongation of survival, if achieved, on average has been in the range of months. Currently, allogeneic hematopoietic stem-cell transplantation (allo-SCT) remains the only approach with curative potential for patients with higher risk/advanced MDS. Yet, despite the beneficial effects of allo-SCT, post-transplant relapse is a major cause of failure. Debulking prior to transplant treatment in patients with MDS is a matter of debate. The achievement of complete remission (CR) before allo-SCT improves post-transplantation outcome, although it is not clear whether this reflects the selection of patients with more responsive disease or is related to a reduction in disease burden. Higher CR rates in patients with MDS are obtained with induction chemotherapy (ICT) than with hypomethylating agents (HMAs), although HMAs may be active in patients with complex karyotypes in whom ICT almost invariably fails. Furthermore, HMAs have a good toxicity profile compared with ICT and may therefore be considered especially in older patients and in patients with comorbidities. However, all interventions aimed at reducing disease burden before allo-SCT expose patients to the risk of complications, which may prevent them from undergoing transplantation. Therefore, up-front allo-SCT is an option, particularly for patients with life-threatening cytopenias. In the absence of prospective randomized trials, the main therapeutic approaches are discussed in this review.
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Affiliation(s)
- Jordan Gauthier
- CHRU de Lille, pôle spécialités médicales et gérontologie, service des maladies du sang, secteur allogreffe de cellules souches hématopoïétiques, 59037 Lille, France; Université de Lille, UFR médecine, 59000 Lille, France
| | - Gandhi Damaj
- CHU de Caen, service d'hématologie clinique, 14033 Caen, France
| | - Ibrahim Yakoub-Agha
- CHRU de Lille, pôle spécialités médicales et gérontologie, service des maladies du sang, secteur allogreffe de cellules souches hématopoïétiques, 59037 Lille, France; Université de Lille, UFR médecine, 59000 Lille, France; Lyric U995, 59000 Lille, France.
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19
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Abstract
DNA methylation and histone modification are epigenetic mechanisms that result in altered gene expression and cellular phenotype. The exact role of methylation in myelodysplastic syndromes (MDS) and acute myeloid leukemia (AML) remains unclear. However, aberrations (e.g. loss-/gain-of-function or up-/down-regulation) in components of epigenetic transcriptional regulation in general, and of the methylation machinery in particular, have been implicated in the pathogenesis of these diseases. In addition, many of these components have been identified as therapeutic targets for patients with MDS/AML, and are also being assessed as potential biomarkers of response or resistance to hypomethylating agents (HMAs). The HMAs 5-azacitidine (AZA) and 2'-deoxy-5-azacitidine (decitabine, DAC) inhibit DNA methylation and have shown significant clinical benefits in patients with myeloid malignancies. Despite being viewed as mechanistically similar drugs, AZA and DAC have differing mechanisms of action. DAC is incorporated 100% into DNA, whereas AZA is incorporated into RNA (80-90%) as well as DNA (10-20%). As such, both drugs inhibit DNA methyltransferases (DNMTs; dependently or independently of DNA replication) resulting in the re-expression of tumor-suppressor genes; however, AZA also has an impact on mRNA and protein metabolism via its inhibition of ribonucleotide reductase, resulting in apoptosis. Herein, we first give an overview of transcriptional regulation, including DNA methylation, post-translational histone-tail modifications, the role of micro-RNA and long-range epigenetic gene silencing. We place special emphasis on epigenetic transcriptional regulation and discuss the implication of various components in the pathogenesis of MDS/AML, their potential as therapeutic targets, and their therapeutic modulation by HMAs and other substances (if known). The main focus of this review is laid on dissecting the rapidly evolving knowledge of AZA and DAC with a special focus on their differing mechanisms of action, and the effect of HMAs on transcriptional regulation.
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Affiliation(s)
- Lisa Pleyer
- 3rd Medical Department with Hematology and Medical Oncology, Hemostaseology, Rheumatology and Infectious Diseases, Laboratory for Immunological and Molecular Cancer Research, Oncologic Center, Paracelsus Medical University Hospital Salzburg, Center for Clinical Cancer and Immunology Trials at Salzburg Cancer Research Institute , Salzburg , Austria
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20
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Ornstein MC, Mukherjee S, Sekeres MA. More is better: combination therapies for myelodysplastic syndromes. Best Pract Res Clin Haematol 2014; 28:22-31. [PMID: 25659727 DOI: 10.1016/j.beha.2014.11.002] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2014] [Accepted: 11/04/2014] [Indexed: 12/19/2022]
Abstract
The myelodysplastic syndromes (MDS) are a heterogenous collection of clonal hematopoietic malignancies that exist as a subgroup of the myeloid neoplasms as classified by the World Health Organization (WHO). They are characterized by ineffective hematopoiesis, subsequent cytopenias, transformation to acute myeloid leukemia (AML), and poor overall survival. There are currently three FDA-approved medications for MDS; lenalidomide, azacitidine, and decitabine. The role of these agents is to diminish the clinical impact of MDS and delay its progression to AML. However, despite known results with these monotherapies, recent clinical trials with a variety of combinations for MDS have demonstrated promising results. These trials include combinations of hypomethylating agents, histone deacetylase inhibitors, growth factors, and chemotherapy among others. In this paper we review the current literature on combination therapies in MDS, analyze on-going and concluded trials, and suggest future possibilities for combination strategies in MDS.
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Affiliation(s)
- Moshe C Ornstein
- Leukemia Program, Department of Hematologic Oncology and Blood Disorders, Cleveland Clinic Taussig Cancer Institute, 9500 Euclid Avenue, NA10, Cleveland, OH 44195, USA.
| | - Sudipto Mukherjee
- Leukemia Program, Department of Hematologic Oncology and Blood Disorders, Cleveland Clinic Taussig Cancer Institute, 9500 Euclid Avenue, NA10, Cleveland, OH 44195, USA.
| | - Mikkael A Sekeres
- Leukemia Program, Department of Hematologic Oncology and Blood Disorders, Cleveland Clinic Taussig Cancer Institute, 9500 Euclid Avenue, NA10, Cleveland, OH 44195, USA.
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21
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Yakoub-Agha I, Deeg J. Are hypomethylating agents replacing induction-type chemotherapy before allogeneic stem cell transplantation in patients with myelodysplastic syndrome? Biol Blood Marrow Transplant 2014; 20:1885-90. [PMID: 24972253 DOI: 10.1016/j.bbmt.2014.06.023] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2014] [Accepted: 06/18/2014] [Indexed: 01/12/2023]
Abstract
Cytoreductive treatment before allogeneic hematopoietic stem cell transplantation (allo-SCT) with the objective of reducing the incidence of disease relapse post-transplant in patients with myelodysplastic syndrome (MDS) is a matter of debate. The achievement of complete remission (CR) before allo-SCT improves post-transplantation outcome, although it is not clear whether this reflects the selection of patients with more responsive disease or is related to a reduction in disease burden. Higher CR rates in patients with MDS are obtained with induction chemotherapy (ICT) than with hypomethylating agents (HMAs), although HMAs may be active in patients with complex karyotypes in whom ICT almost invariably fails. Furthermore, HMAs have a good toxicity profile compared with ICT and may therefore be considered especially in older patients and in patients with comorbidities. However, all interventions aimed at reducing disease burden before allo-SCT expose patients to the risk of complications, which may prevent them from undergoing transplantation. Therefore, up-front allo-SCT is an option, particularly for patients with life-threatening cytopenias. In this review we discuss the main pretransplant therapeutic approaches and propose a decision-model based on clinical considerations. However, only prospective randomized trials can address the issue definitively.
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Affiliation(s)
- Ibrahim Yakoub-Agha
- Bone Marrow Transplantation Unit, University-Hospital, Lille, France; INSERM U995, Lille, France.
| | - Joachim Deeg
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington; University of Washington School of Medicine, Seattle, Washington
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22
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Tian T, Wang M, Ma D. TNF-α, a good or bad factor in hematological diseases? Stem Cell Investig 2014; 1:12. [PMID: 27358858 PMCID: PMC4923506 DOI: 10.3978/j.issn.2306-9759.2014.04.02] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2013] [Accepted: 04/20/2014] [Indexed: 01/22/2023]
Abstract
Tumor necrosis factor-alpha (TNF-α) is a highly pleiotropic cytokine involved in a spectrum of physiological processes that control inflammation, anti-tumor responses and homeostasis through two receptors, TNF-R1 and TNF-R2. In general, TNF-R1 mediates cytotoxicity, resistance to infection and stimulation of NF-κB. By contrast, TNF-R2 has been implicated in proliferation of T-cell line, thymocytes and human mononuclear cells. Hematological malignancies are the types of cancer that affect normal hematopoiesis, have a speedy development, high lethal rate and until now still have no effective treatment. Several studies have shown that inflammatory cytokines play an important role in the onset and progress of these diseases. In this review, we summarize the recent studies and evaluate the positive or negative role of TNF-α in some hematological malignancies or diseases with a malignant tendency.
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Affiliation(s)
- Tian Tian
- Department of Hematology, Qilu Hospital, Shandong University, Jinan 250012, China
| | - Min Wang
- Department of Hematology, Qilu Hospital, Shandong University, Jinan 250012, China
| | - Daoxin Ma
- Department of Hematology, Qilu Hospital, Shandong University, Jinan 250012, China
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23
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Prica A, Buckstein R. Myelodysplastic syndrome successfully treated with adalimumab. J Clin Oncol 2014; 33:e4-6. [PMID: 24567429 DOI: 10.1200/jco.2013.49.4948] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023] Open
Affiliation(s)
- Anca Prica
- Sunnybrook Health Sciences Centre/Odette Cancer Centre, University of Toronto, Toronto, Ontario, Canada
| | - Rena Buckstein
- Sunnybrook Health Sciences Centre/Odette Cancer Centre, University of Toronto, Toronto, Ontario, Canada
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24
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Bachegowda L, Gligich O, Mantzaris I, Schinke C, Wyville D, Carrillo T, Braunschweig I, Steidl U, Verma A. Signal transduction inhibitors in treatment of myelodysplastic syndromes. J Hematol Oncol 2013; 6:50. [PMID: 23841999 PMCID: PMC3716523 DOI: 10.1186/1756-8722-6-50] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2013] [Accepted: 05/29/2013] [Indexed: 12/22/2022] Open
Abstract
Myelodysplastic syndromes (MDS) are a group of hematologic disorders characterized by ineffective hematopoiesis that results in reduced blood counts. Although MDS can transform into leukemia, most of the morbidity experienced by these patients is due to chronically low blood counts. Conventional cytotoxic agents used to treat MDS have yielded some encouraging results but are characterized by many adverse effects in the predominantly elderly patient population. Targeted interventions aimed at reversing the bone marrow failure and increasing the peripheral blood counts would be advantageous in this cohort of patients. Studies have demonstrated over-activated signaling of myelo-suppressive cytokines such as TGF-β, TNF-α and Interferons in MDS hematopoietic stem cells. Targeting these signaling cascades could be potentially therapeutic in MDS. The p38 MAP kinase pathway, which is constitutively activated in MDS, is an example of cytokine stimulated kinase that promotes aberrant apoptosis of stem and progenitor cells in MDS. ARRY-614 and SCIO-469 are p38 MAPK inhibitors that have been used in clinical trials and have shown activity in a subset of MDS patients. TGF-β signaling has been therapeutically targeted by small molecule inhibitor of the TGF-β receptor kinase, LY-2157299, with encouraging preclinical results. Apart from TGF-β receptor kinase inhibition, members of TGF-β super family and BMP ligands have also been targeted by ligand trap compounds like Sotatercept (ACE-011) and ACE-536. The multikinase inhibitor, ON-01910.Na (Rigosertib) has demonstrated early signs of efficacy in reducing the percentage of leukemic blasts and is in advanced stages of clinical testing. Temsirolimus, Deforolimus and other mTOR inhibitors are being tested in clinical trials and have shown preclinical efficacy in CMML. EGF receptor inhibitors, Erlotinib and Gefitinib have shown efficacy in small trials that may be related to off target effects. Cell cycle regulator inhibitors such as Farnesyl transferase inhibitors (Tipifarnib, Lonafarnib) and MEK inhibitor (GSK1120212) have shown acceptable toxicity profiles in small studies and efforts are underway to select mutational subgroups of MDS and AML that may benefit from these inhibitors. Altogether, these studies show that targeting various signal transduction pathways that regulate hematopoiesis offers promising therapeutic potential in this disease. Future studies in combination with high resolution correlative studies will clarify the subgroup specific efficacies of these agents.
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Affiliation(s)
- Lohith Bachegowda
- Division of Oncology, Montefiore Medical Center, 110, E 210 Street, Bronx, NY 10467, USA
- Albert Einstein College of Medicine, 1300 Morris Park Ave, Bronx, NY 10467, USA
| | - Oleg Gligich
- Albert Einstein College of Medicine, 1300 Morris Park Ave, Bronx, NY 10467, USA
- Jacobi Medical Center, 1400 Pelham Pkwy S, New York, NY 10461, USA
| | - Ionnis Mantzaris
- Division of Oncology, Montefiore Medical Center, 110, E 210 Street, Bronx, NY 10467, USA
- Albert Einstein College of Medicine, 1300 Morris Park Ave, Bronx, NY 10467, USA
| | - Carolina Schinke
- Division of Oncology, Montefiore Medical Center, 110, E 210 Street, Bronx, NY 10467, USA
- Albert Einstein College of Medicine, 1300 Morris Park Ave, Bronx, NY 10467, USA
| | - Dale Wyville
- Division of Oncology, Montefiore Medical Center, 110, E 210 Street, Bronx, NY 10467, USA
| | - Tatiana Carrillo
- Division of Oncology, Montefiore Medical Center, 110, E 210 Street, Bronx, NY 10467, USA
| | - Ira Braunschweig
- Division of Oncology, Montefiore Medical Center, 110, E 210 Street, Bronx, NY 10467, USA
| | - Ulrich Steidl
- Albert Einstein College of Medicine, 1300 Morris Park Ave, Bronx, NY 10467, USA
| | - Amit Verma
- Division of Oncology, Montefiore Medical Center, 110, E 210 Street, Bronx, NY 10467, USA
- Albert Einstein College of Medicine, 1300 Morris Park Ave, Bronx, NY 10467, USA
- Medicine/Oncology, Developmental & Molecular Biology, 1300 Morris Park Ave, Bronx, NY 10461, USA
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25
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Greenberg PL, Attar E, Bennett JM, Bloomfield CD, Borate U, De Castro CM, Deeg HJ, Frankfurt O, Gaensler K, Garcia-Manero G, Gore SD, Head D, Komrokji R, Maness LJ, Millenson M, O'Donnell MR, Shami PJ, Stein BL, Stone RM, Thompson JE, Westervelt P, Wheeler B, Shead DA, Naganuma M. Myelodysplastic syndromes: clinical practice guidelines in oncology. J Natl Compr Canc Netw 2013; 11:838-74. [PMID: 23847220 PMCID: PMC4000017 DOI: 10.6004/jnccn.2013.0104] [Citation(s) in RCA: 78] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
The myelodysplastic syndromes (MDS) represent a heterogeneous group of clonal hematopoietic disorders characterized by cytopenias, dysplasia in one or more myeloid lineages, and the potential for development of acute myeloid leukemia. These disorders primarily affect older adults. The NCCN Clinical Practice Guidelines in Oncology for MDS provide recommendations on the diagnostic evaluation and classification of MDS, risk evaluation according to established prognostic assessment tools (including the new revised International Prognostic Scoring System), treatment options according to risk categories, and management of related anemia.
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26
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Epling-Burnette PK, McDaniel J, Wei S, List AF. Emerging immunosuppressive drugs in myelodysplastic syndromes. Expert Opin Emerg Drugs 2012; 17:519-41. [PMID: 23163589 DOI: 10.1517/14728214.2012.736487] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
INTRODUCTION Myelodysplastic syndromes (MDS) are characterized by dysplastic morphologic features and ineffective hematopoiesis. Pathophysiological characteristics change over time making therapeutic development a major challenge. In early MDS, cytopenias arise or are exacerbated by humoral and cellular immune-mediators that suppress hematopoietic progenitor survival and alter the bone marrow microenvironment. AREAS COVERED In this review, current immunosuppressive regimens are described. To identify new therapies that may enhance immunosuppressive therapy (IST) response and identify pharmacodynamic biomarkers for patient selection, the inflammasome, cytokines, metabolic pathways and signaling events are described. EXPERT OPINION Agents with the potential to induce early, durable hematologic remissions are needed and many new immunosuppressive agents are available for investigation. An immune-mediated mechanism is likely to contribute to MDS early after diagnosis. New approaches that interfere with inflammatory pathways in the bone marrow microenvironment may move closer toward sustained disease control in MDS.
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Affiliation(s)
- Pearlie K Epling-Burnette
- H. Lee Moffitt Cancer Center & Research Institute, Immunology Department, SRB 23033, 12902 Magnolia Dr, Tampa, FL 33612, USA.
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27
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Kulasekararaj AG, Mufti GJ. The Non-transplant Treatment of Myelodysplastic Syndromes—What's on the Horizon? Semin Hematol 2012; 49:350-60. [DOI: 10.1053/j.seminhematol.2012.07.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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28
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Ornstein MC, Sekeres MA. Combination strategies in myelodysplastic syndromes. Int J Hematol 2012; 95:26-33. [PMID: 22218883 DOI: 10.1007/s12185-011-0987-4] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2011] [Accepted: 12/01/2011] [Indexed: 11/30/2022]
Abstract
The myelodysplastic syndromes (MDS) consist of an array of clonal hematological malignancies resulting from disorders of pluripotent hematopoietic stem cells. MDS is associated with a poor overall prognosis and patients are categorized as higher risk and lower risk on the basis of the International Prognostic Scoring System. Currently, lenalidomide, azacitidine, and decitabine are the only three FDA-approved drugs for MDS. Traditional therapies for MDS involve the administration of single agents providing either supportive measures or disease-modifying effects directed to slowing progression to acute myeloid leukemia (AML) and improving survival. Recently, however, there has been increasing evidence suggesting that the combination of drugs with different mechanisms of action offers substantial benefit in the form of diminished side effects, improved overall survival, and delayed progression to AML. Multiple studies indicate that when compared with traditional monotherapies, combining various medications with non-overlapping mechanisms of action and toxicities may result in significant benefit for patients with MDS. A variety of combination therapies with growth factors, DNA methytransferase inhibitors, histone deacetylase inhibitors, and immunosuppressant treatments provide encouraging data indicating that the successful future of MDS treatment rests in the combination of multiple treatments modalities to achieve improved clinical outcomes.
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Affiliation(s)
- Moshe C Ornstein
- Leukemia Program, Department of Hematologic Oncology and Blood Disorders, Cleveland Clinic Taussig Cancer Institute, Desk R35, 9500 Euclid Avenue, Cleveland, OH 44195, USA
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29
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Belli CB, Bestach Y, Sieza Y, Gelemur M, Giunta M, Flores MG, Watman N, Bengió R, Larripa I. The presence of -308A TNFα is associated with anemia and thrombocytopenia in patients with myelodysplastic syndromes. Blood Cells Mol Dis 2011; 47:255-8. [DOI: 10.1016/j.bcmd.2011.09.003] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2011] [Revised: 08/23/2011] [Accepted: 09/01/2011] [Indexed: 10/16/2022]
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30
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Baron F, Suciu S, Amadori S, Muus P, Zwierzina H, Denzlinger C, Delforge M, Thyss A, Selleslag D, Indrak K, Ossenkoppele G, de Witte T. Value of infliximab (Remicade®) in patients with low-risk myelodysplastic syndrome: final results of a randomized phase II trial (EORTC trial 06023) of the EORTC Leukemia Group. Haematologica 2011; 97:529-33. [PMID: 22102701 DOI: 10.3324/haematol.2011.044347] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
Tumor-necrosis factor alpha activity has been correlated to ineffective erythropoiesis in lower risk myelodysplastic syndromes. Infliximab (Remicade(®)) is an anti-tumor necrosis factor alpha chimeric antibody that is used in the treatment of patients with rheumatoid arthritis or Crohn's disease. Forty-six patients with myelodysplastic syndromes and a relatively low risk of developing acute leukemia were included in a randomized phase II study assessing the therapeutic activity of two dosages of infliximab administration (3 mg/kg vs. 5 mg/kg). The primary end point was the response rate. Responses were observed in 3 of 22 patients (13.1%) randomized to the 3 mg/kg arm, versus 0 of 21 patients randomized in the 5 mg/kg arm. According to the statistical design of the current study, neither of the two infliximab dose schedules tested showed sufficient activity as a single agent in this cohort of unselected patients with early myelodysplastic syndrome.
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31
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Reversal of Transfusion Dependence by Tumor Necrosis Factor Inhibitor Treatment in a Patient With Concurrent Rheumatoid Arthritis and Primary Myelofibrosis. J Clin Rheumatol 2011; 17:211-3. [PMID: 21617547 DOI: 10.1097/rhu.0b013e31821c7ef6] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
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32
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Sloand EM, Melenhorst JJ, Tucker ZCG, Pfannes L, Brenchley JM, Yong A, Visconte V, Wu C, Gostick E, Scheinberg P, Olnes MJ, Douek DC, Price DA, Barrett AJ, Young NS. T-cell immune responses to Wilms tumor 1 protein in myelodysplasia responsive to immunosuppressive therapy. Blood 2011; 117:2691-9. [PMID: 21097671 PMCID: PMC3062357 DOI: 10.1182/blood-2010-04-277921] [Citation(s) in RCA: 71] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2010] [Accepted: 11/04/2010] [Indexed: 12/21/2022] Open
Abstract
Clinical observations and laboratory evidence link bone marrow failure in myelodysplastic syndrome (MDS) to a T cell-mediated immune process that is responsive to immunosuppressive treatment (IST) in some patients. Previously, we showed that trisomy 8 MDS patients had clonally expanded CD8(+) T-cell populations that recognized aneuploid hematopoietic progenitor cells (HPC). Furthermore, microarray analyses showed that Wilms tumor 1 (WT1) gene was overexpressed by trisomy 8 hematopoietic progenitor (CD34(+)) cells compared with CD34(+) cells from healthy donors. Here, we show that WT1 mRNA expression is up-regulated in the bone marrow mononuclear cells of MDS patients with trisomy 8 relative to healthy controls and non-trisomy 8 MDS; WT1 protein levels were also significantly elevated. In addition, using a combination of physical and functional assays to detect the presence and reactivity of specific T cells, respectively, we demonstrate that IST-responsive MDS patients exhibit significant CD4(+) and CD8(+) T-cell responses directed against WT1. Finally, WT1-specific CD8(+) T cells were present within expanded T-cell receptor Vβ subfamilies and inhibited hematopoiesis when added to autologous patient bone marrow cells in culture. Thus, our results suggest that WT1 is one of the antigens that triggers T cell-mediated myelosuppression in MDS.
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MESH Headings
- Bone Marrow Cells/immunology
- Bone Marrow Cells/pathology
- CD8-Positive T-Lymphocytes/immunology
- Case-Control Studies
- Chromosomes, Human, Pair 8/genetics
- Chromosomes, Human, Pair 8/immunology
- Gene Expression Regulation
- HLA-A Antigens/chemistry
- HLA-A Antigens/immunology
- HLA-A2 Antigen
- Humans
- Immunodominant Epitopes/immunology
- Immunosuppression Therapy
- Myelodysplastic Syndromes/immunology
- Myelodysplastic Syndromes/therapy
- Protein Structure, Quaternary
- RNA, Messenger/genetics
- RNA, Messenger/metabolism
- Receptors, Antigen, T-Cell, alpha-beta/immunology
- Trisomy/genetics
- Trisomy/immunology
- WT1 Proteins/genetics
- WT1 Proteins/immunology
- WT1 Proteins/metabolism
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Affiliation(s)
- Elaine M Sloand
- Hematology Branch, National Heart, Lung and Blood Institute, National Institutes of Health, Bethesda, MD 20892, USA
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Parnes A, Nikiforow S, Berliner N, Vanasse GJ. Single nucleotide polymorphisms in the human TNF gene are associated with anaemia and neutropenia in a cohort of patients with de novo myelodysplastic syndrome. Br J Haematol 2010; 150:700-1. [PMID: 20618340 DOI: 10.1111/j.1365-2141.2010.08254.x] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Abstract
IMPORTANCE OF THE FIELD Despite the remarkable progress in the treatment of patients with myelodysplastic syndromes (MDS) in the past decade, response to the hypomethylating agents azacitidine and decitabine in non-del(5q) MDS patients remains at approximately 50%, leaving half of patients needing treatment with essentially no options. As biologic insight into the molecular pathways that account for disease evolution and clinical heterogeneity is expanded, the arsenal of potential drugs that may elicit significant response is also increasing. One of the greatest challenges for the treating physician is to decide when to initiate therapy and which therapy (approved drug or newer agents still in clinical trial) is likely to be the most beneficial. While there is no single answer to these issues, there are several approaches that may be considered, and these are addressed in this review. AREAS COVERED IN THIS REVIEW This review examines the clinical outcomes of the FDA-approved drugs as well as of the promising new therapies that are in current clinical trials. WHAT THE READER WILL GAIN The clinician now has multiple treatment options for patients with MDS. It is important to consider multiple factors before initiating therapy with disease-modifying drugs. This review presents some of the decision-making approaches that are in practice at present. TAKE HOME MESSAGE For the first time, various treatment options are available for patients with MDS. In light of the intense efforts now in progress, the next decade promises to be one of hope and excitement for both MDS patients and treating clinicians.
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Affiliation(s)
- Naomi Galili
- St. Vincent's Comprehensive Cancer Center, 325 West 15th Street, New York 10011, USA
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Sloand EM, Barrett AJ. Immunosuppression for myelodysplastic syndrome: how bench to bedside to bench research led to success. Hematol Oncol Clin North Am 2010; 24:331-41. [PMID: 20359629 PMCID: PMC3793398 DOI: 10.1016/j.hoc.2010.02.009] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Laboratory evidence and clinical evidence suggest that some patients with myelodysplastic syndrome (MDS) have immunologically mediated disease. This article describes the laboratory evidence supporting a role for the immune system in the marrow failure of MDS and clinical trials using IST in these patients.
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Affiliation(s)
- Elaine M Sloand
- Hematology Branch, Division of Intramural Research, National Heart, Lung and Blood Institute, 10 Center Drive, Bethesda, MD 20892, USA.
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Scott BL, Ramakrishnan A, Fosdal M, Storer B, Becker P, Petersdorf S, Deeg HJ. Anti-thymocyte globulin plus etanercept as therapy for myelodysplastic syndromes (MDS): a phase II study. Br J Haematol 2010; 149:706-10. [PMID: 20331464 DOI: 10.1111/j.1365-2141.2010.08145.x] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Immunosuppressive therapies have proven valuable in treating patients with myelodysplastic syndromes (MDS). We evaluated the combination of equine anti-thymocyte globulin (ATGAM) and the soluble tumour necrosis factor receptor, etanercept (Enbrel), in a phase II trial. Twenty-five patients with MDS [4-refractory anaemia (RA), 2-RA with ring sideroblasts, 15-refractory cytopenia with multilineage dysplasia (RCMD), 3-RCMD and ring sideroblasts, 1-RA with excess blasts type 1] in International Prognostic Staging System risk groups low (n = 11) or intermediate-1 (n = 14) were enrolled. All patients were platelet or red cell transfusion-dependent. Nineteen patients completed therapy with ATG at 40 mg/kg per day for four consecutive days, followed by etanercept, 25 mg subcutaneous twice a week for 2 weeks, every month for 4 months. Thirteen patients had haematological improvement (HI)-erythroid, 2 HI-neutrophil, and 6 HI-platelet. One patient with a co-existing diagnosis of multiple sclerosis and rheumatoid arthritis had a complete remission. The overall response by intent to treat analysis among the 25 patients was 56% (95% confidence interval 35-56%). Four patients did not complete their first course of therapy and one patient did not survive to the 8-week post-treatment assessment. Among patients who completed treatment and survived to the 8-week assessment, 70% had at least haematological responses lasting for at least 5 to more than 36 months. Thus, combination therapy with ATG and etanercept was active and safe in patients with MDS.
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Affiliation(s)
- Bart L Scott
- Fred Hutchinson Cancer Research Center, Seattle, WA 98109-1024, USA.
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TNF-alpha regulates the effects of irradiation in the mouse bone marrow microenvironment. PLoS One 2010; 5:e8980. [PMID: 20126546 PMCID: PMC2813873 DOI: 10.1371/journal.pone.0008980] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2009] [Accepted: 01/12/2010] [Indexed: 12/14/2022] Open
Abstract
Background Secondary bone marrow (BM) myelodysplastic syndromes (MDS) are increasingly common, as a result of radio or chemotherapy administered to a majority of cancer patients. Patients with secondary MDS have increased BM cell apoptosis, which results in BM dysfunction (cytopenias), and an increased risk of developing fatal acute leukemias. In the present study we asked whether TNF-α, known to regulate cell apoptosis, could modulate the onset of secondary MDS. Principal Findings We show that TNF-α is induced by irradiation and regulates BM cells apoptosis in vitro and in vivo. In contrast to irradiated wild type (WT) mice, TNF-α deficient (TNF-α KO) mice or WT mice treated with a TNF-α-neutralizing antibody were partially protected from the apoptotic effects of irradiation. Next we established a 3-cycle irradiation protocol, in which mice were sub-lethally irradiated once monthly over a 3 month period. In this model, irradiated WT mice presented loss of microsatellite markers on BM cells, low white blood cell (WBC) counts, reduced megakaryocyte (MK) and platelet levels (thrombocytopenia) and macrocytic anemia, phenoypes that suggest the irradiation protocol resulted in BM dysfunction with clinical features of MDS. In contrast, TNF-α KO mice were protected from the irradiation effects: BM cell apoptosis following irradiation was significantly reduced, concomitant with sustained BM MK numbers and absence of other cytopenias. Moreover, irradiated WT mice with long term (≥5 months) BM dysfunction had increased BM angiogenesis, MMPs and VEGF and NFkB p65, suggestive of disease progression. Conclusion Taken together, our data shows that TNF-α induction following irradiation modulates BM cell apoptosis and is a crucial event in BM dysfunction, secondary MDS onset and progression.
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Scott BL, Ramakrishnan A, Storer B, Becker PS, Petersdorf S, Estey EH, Deeg HJ. Prolonged responses in patients with MDS and CMML treated with azacitidine and etanercept. Br J Haematol 2010; 148:944-7. [PMID: 20064151 DOI: 10.1111/j.1365-2141.2009.08061.x] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Combination therapy with azacitidine and etanercept was hypothesized to lead to improved responses in myelodysplastic syndrome (MDS) patients. Thirty-two patients with MDS/chronic myelomonocytic leukaemia were treated with azacitidine + etanercept; 30 completed at least three therapy cycles. At 3 months, nine patients had achieved complete response (CR), two had partial response, 10 had marrow CRs, seven had stable disease, two patients had haematological improvement without marrow response and two patients had disease progression. The overall response rate was 72%; median duration of response was not reached at 2 years. Marrow response rates and duration were improved with azacitidine + etanercept compared to azacitidine alone.
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Affiliation(s)
- Bart L Scott
- Fred Hutchinson Cancer Research Center, 1100 Fairview Avenue N., Seattle, WA 98109-1024, USA.
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Anargyrou K, Vassilakopoulos TP, Angelopoulou MK, Terpos E. Incorporating novel agents in the treatment of myelodysplastic syndromes. Leuk Res 2009; 34:6-17. [PMID: 19656566 DOI: 10.1016/j.leukres.2009.07.021] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2009] [Revised: 07/11/2009] [Accepted: 07/13/2009] [Indexed: 01/19/2023]
Abstract
Myelodysplastic syndromes (MDS) are a group of heterogeneous clonal stem cell (SC) disorders that mainly affect the elderly population. They are characterized by ineffective hematopoiesis which results in quantitative and qualitative cellular defects and high incidence of leukemic transformation. Recent advances in MDS research have led to the development of novel agents which appears to improve remission rates and survival when compared to best supportive care. Currently azacitidine, decitabine, and lenalidomide are approved by the US FDA for the treatment of MDS, while the activity of other novel agents such as histone deacetylase inhibitors, farnesyl-transferase inhibitors, novel thrombopoietic agents, and anti-angiogenesis molecules is under evaluation. Erythropoietin-stimulating agents, iron chelating therapy and thrombopoietin receptor ligands may also improve quality of life and possibly prolong survival in MDS patients. The only treatment modality that can achieve long-term survival is the allogeneic SC transplantation which is given only in selected patients. Moreover the heterogeneity of MDS and the patient's advanced age and co-morbidity are significant factors besides cytogenetics, IPSS and WPSS that should be taken into account during the decision-making process. Therefore clinicians should treat patients with MDS on an individual basis aiming the increase of the response rates and the decrease of treatment-associated toxicities. This can only be achieved through the better understanding of the MDS subgroups. If we can better define MDS subgroups we will be able to identify patients who will benefit from the incorporation of the novel agents, as monotherapy or in combinations regimens along with supportive care.
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40
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Stasi R, Amadori S, Newland AC, Provan D. Infliximab chimeric antitumor necrosis factor-α monoclonal antibody as potential treatment for myelodysplastic syndromes. Leuk Lymphoma 2009; 46:509-16. [PMID: 16019478 DOI: 10.1080/10428190400027829] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Accumulating evidence indicates tumor necrosis factor-a (TNF-a) as a key cytokine in the pathogenesis of the myelodysplastic syndromes (MDS). The identification of TNF-a as a regulator of apoptosis and the increased susceptibility of MDS cells to this cytokine provided the basis for several clinical trials of TNF inhibitors. Infliximab is an IgG1 chimeric anti-TNF-a monoclonal antibody composed of human constant and murine variable regions that bind specifically to both soluble and membrane-bound TNF-a. To date, only 2 studies have investigated the use of infliximab in patients with low-risk MDS. In both reports the drug showed a limited but significant activity and a favorable side-effect profile. In some patients, hematopoietic response was associated with decreased apoptosis as well as a decrease in abnormal metaphases by 50%. Further studies are currently underway and should provide useful information to define the more responsive subtypes of MDS, the patient characteristics, and the proper dosing regimen.
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Affiliation(s)
- Roberto Stasi
- Department of Medical Sciences, Regina Apostolorum Hospital, Albano Laziale, Italy.
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41
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Dufour C, Giacchino R, Ghezzi P, Tonelli R, Ferretti E, Pitto A, Pistoia V, Lanza T, Svahn J. Etanercept as a salvage treatment for refractory aplastic anemia. Pediatr Blood Cancer 2009; 52:522-5. [PMID: 19061218 DOI: 10.1002/pbc.21886] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
About 10-15% of patients with acquired aplastic anemia (AAA) have resistant/recurrent disease not eligible for standard treatment like hematopoietic stem cell transplantation and/or combined immunosuppression. We report a 17-year-old male with an 11 years history of AAA who, after two courses of immunosuppression, was red cell transfusion-dependent, severely thrombocytopenic, refractory to platelet transfusion, had iron overload and post-transfusion HCV infection. This patient achieved transfusion independence from platelets and normalized Hb after treatment with the anti-TNF agent Etanercept. Over a 12 months follow-up he experienced only transient increase of liver transaminases.
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Affiliation(s)
- Carlo Dufour
- Haematology Unit, G.Gaslini Children's Hospital, Genova, Italy.
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42
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Ramakrishnan A, Deeg HJ. A novel role for the marrow microenvironment in initiating and sustaining hematopoietic disease. Expert Opin Biol Ther 2009; 9:21-8. [PMID: 19063690 DOI: 10.1517/14712590802603093] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
BACKGROUND The marrow microenvironment is composed of a complex network of cells and extra cellular matrix that cooperate to regulate normal hematopoiesis. There is growing evidence that microenvironmental defects can contribute to the pathogenesis of hematological malignancies. OBJECTIVE/METHODS We review the role of the microenvironment in inducing and sustaining hematological malignancies. RESULTS/CONCLUSIONS Two basic mechanisms could explain the role of microenvironmental defects in the evolution of hematopoietic neoplasms. There is significant data to support the first mechanism, in which the malignant hematopoietic clone induces reversible functional changes in the microenvironment that result in improved growth conditions for the malignant cells. More recent studies from mouse models have indicated that a second mechanism involving primary microenvironmental defects can also result in malignancy.
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Affiliation(s)
- Aravind Ramakrishnan
- University of Washington School of Medicine, Fred Hutchinson Cancer Research Center, Seattle, Washington 98109, USA
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43
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Gore SD, Hermes-DeSantis ER. Future directions in myelodysplastic syndrome: newer agents and the role of combination approaches. Cancer Control 2008; 15 Suppl:40-9. [PMID: 18813208 DOI: 10.1177/107327480801504s05] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
Myelodysplastic syndrome (MDS) is not a single disease, but a collection of hematopoietic disorders that require newer strategies. Currently, azacitidine, decitabine, and lenalidomide are approved by the US Food and Drug Administration for the treatment of MDS. A recent study demonstrated an improved overall survival (24.4 months vs 15 months) in high-risk MDS patients receiving azacitidine plus best supportive care vs conventional care which has resulted in an updated label for this product. Conventional care consisted of supportive care alone or either low-dose ara-C or standard chemotherapy plus best supportive care. While these data are encouraging, newer agents such as vorinostat, MGCD0103, MS-275, and tipifarnib are currently being studied as monotherapy or in combinations with approved treatments for MDS. The goal of combining pharmacotherapy, such as the combination of DNA methylation inhibitors and histone deacetylase inhibitors, in the management of MDS is to increase the response rates and decrease the toxicities associated with treatment. Clinical experience in the use of combination products has given practitioners the empirical knowledge necessary to better treat patients with MDS. Utilizing convergent or complementary molecular mechanisms with in vitro or in vivo evidence of synergy is a fresher and maybe a more efficacious approach to combination therapy.
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Affiliation(s)
- Steven D Gore
- Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins, Baltimore, MD 21231, USA.
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44
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Takamatsu H, Espinoza JL, Lu X, Qi Z, Okawa K, Nakao S. Anti-Moesin Antibodies in the Serum of Patients with Aplastic Anemia Stimulate Peripheral Blood Mononuclear Cells to Secrete TNF-α and IFN-γ. THE JOURNAL OF IMMUNOLOGY 2008; 182:703-10. [DOI: 10.4049/jimmunol.182.1.703] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
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45
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Tsimberidou AM, Estey E, Wen S, Pierce S, Kantarjian H, Albitar M, Kurzrock R. The prognostic significance of cytokine levels in newly diagnosed acute myeloid leukemia and high-risk myelodysplastic syndromes. Cancer 2008; 113:1605-13. [PMID: 18683214 DOI: 10.1002/cncr.23785] [Citation(s) in RCA: 87] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
BACKGROUND Tumor necrosis factor (TNF)-alpha and other cytokines are involved in the pathogenesis of acute myeloid leukemia (AML) and high-risk myelodysplastic syndromes (MDS), but their prognostic significance in these diseases is unknown. In the current study, the authors assessed the association between serum levels of various cytokines and clinical outcomes in patients with untreated AML or high-risk MDS. METHODS Serum levels of TNF-alpha, interleukin (IL)-1 receptor antagonist, IL-6, IL-10, and endostatin were measured in patients with AML or high-risk MDS who presented for treatment at The University of Texas M. D. Anderson Cancer Center from September 1994 through January 2001. Univariate and multivariate analyses were performed to test for correlations with clinical outcomes. RESULTS Higher TNF-alpha levels were found to correlate with poorer performance status; higher leukocyte counts; higher levels of beta2-microglobulin, creatinine, uric acid, and alkaline phosphatase; lower levels of creatinine clearance and albumin; baseline infection; and M4-M5 AML subtypes. TNF-alpha levels <10 pg/mL were associated with higher rates of complete remission (P = .003), survival (P = .0003), and event-free survival (EFS) (P = .0009). However, on multivariate analyses, TNF-alpha level > or =10 pg/mL was not found to be an independent factor predicting clinical outcomes, but became statistically significant when leukocyte count was excluded from the models. The other cytokines were not found to be predictive of clinical outcomes. CONCLUSIONS High serum TNF-alpha level is an adverse prognostic factor for survival and EFS in patients with untreated AML or high-risk MDS.
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Affiliation(s)
- Apostolia Maria Tsimberidou
- Department of Investigational Cancer Therapeutics, The University of Texas M. D. Anderson Cancer Center, Houston, Texas 77030, USA.
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46
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Powers MP, Nishino H, Luo Y, Raza A, Vanguri A, Rice L, Zu Y, Chang CCJ. Polymorphisms in TGFbeta and TNFalpha are associated with the myelodysplastic syndrome phenotype. Arch Pathol Lab Med 2008; 131:1789-93. [PMID: 18081437 DOI: 10.5858/2007-131-1789-pitata] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/09/2007] [Indexed: 11/06/2022]
Abstract
CONTEXT Myelodysplastic syndromes (MDSs) are characterized by ineffective hematopoiesis, excessive apoptosis, and the aberrant expression of a number of cytokines. The genes encoding these cytokines are significantly polymorphic. It is unknown whether these cytokine polymorphisms are associated with, and may therefore be playing a role in the pathogenesis of, MDS. OBJECTIVE To determine if certain polymorphisms in the tumor necrosis factor alpha (TNF-alpha) and transforming growth factor beta (TGF-beta) cytokines are overrepresented in a cohort of patients with MDSs. DESIGN DNA was isolated from the peripheral blood or bone marrow aspirate of 21 patients with MDS. The genotypes for 4 different polymorphisms, 2 in TNFalpha and 2 in TGFbeta1, were determined using single-specific-primer polymerase chain reaction. The allele and genotype frequencies were compared with similar populations in the National Cancer Institute SNP500 database. RESULTS In our MDS population, the -308A/A genotype of the TNFalpha gene and the TGFbeta1 allele +29T and genotype +29T/T, each associated with higher levels of expression, were overrepresented in our MDS population. CONCLUSIONS Polymorphisms associated with increased expression in the cytokines TNFalpha and TGFbeta1 are overrepresented in the MDS population suggesting that increased TNF-alpha and TGF-beta1 activity may contribute to the susceptibility and/or pathogenesis of MDS. Further studies with larger sample sizes are warranted to confirm our observation.
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Affiliation(s)
- Martin P Powers
- Department of Pathology and Laboratory Medicine, The Methodist Hospital Research Institute and The Weill Medical College of Cornell University at The Methodist Hospital, Houston, Tex 77030, USA
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Apoptosis and antiapoptotic mechanisms in the progression of myelodysplastic syndrome. Exp Hematol 2008; 35:1739-46. [PMID: 17976524 DOI: 10.1016/j.exphem.2007.09.007] [Citation(s) in RCA: 92] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2007] [Revised: 09/12/2007] [Accepted: 09/17/2007] [Indexed: 11/20/2022]
Abstract
Myelodysplastic syndrome (MDS), previously known as preleukemia, comprises a spectrum of heterogeneous, clonal disorders of hematopoiesis. A patient's life expectancy can range from a few months to more than a decade. Recent studies provide some insight into the pathophysiology of MDS. One mechanism contributing to the constellation of hypercellular marrow and peripheral blood cytopenia is a significant increase in programmed cell death (apoptosis) in hematopoietic cells. Tumor necrosis factor (TNF)-alpha, Fas ligand, TNF-related apoptosis-inducing ligand, and other proapoptotic cytokines are upregulated in early-stage/low-risk MDS, and neutralization of these signals can improve hematopoiesis. TNF-related apoptosis inducing ligand induces apoptosis preferentially in clonal cells, which can contribute to containment of the clone. In a proportion of patients, MDS will eventually evolve to acute leukemia. This progression has been correlated with upregulation of nuclear factor kappaB; altered expression of adaptor molecules, such as Flice inhibitory protein; and enhanced activity of antiapoptotic members of the Bcl-2 and inhibitors of apoptosis protein families. Also, the ratio of TNF receptors 1 and 2 changes in favor of receptor 2. The role of the microenvironment in the pathophysiology and progression of MDS has remained controversial, although there is evidence that stroma and matrix components, and their interactions with clonal cells, play an important role. Microarray gene-expression studies are consistent with dysregulation of apoptosis, but not all data are in agreement.
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48
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Sloand EM, Rezvani K. The Role of the Immune System in Myelodysplasia: Implications for Therapy. Semin Hematol 2008; 45:39-48. [DOI: 10.1053/j.seminhematol.2007.11.006] [Citation(s) in RCA: 50] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
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49
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Stirewalt DL, Mhyre AJ, Marcondes M, Pogosova-Agadjanyan E, Abbasi N, Radich JP, Deeg HJ. Tumour necrosis factor-induced gene expression in human marrow stroma: clues to the pathophysiology of MDS? Br J Haematol 2007; 140:444-53. [PMID: 18162123 DOI: 10.1111/j.1365-2141.2007.06923.x] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Aberrant regulation of the tumour necrosis factor alpha gene (TNF) and stroma-derived signals are involved in the pathophysiology of myelodysplasia. Therefore, KG1a, a myeloid leukaemia cell line, was exposed to Tnf in the absence or presence of either HS-5 or HS-27a cells, two human stroma cell lines. While KG1a cells were resistant to Tnf-induced apoptosis in the absence of stroma cells, Tnf-promoted apoptosis of KG1a cells in co-culture experiments with stroma cells. To investigate the Tnf-induced signals from the stroma cells, we examined expression changes in HS-5 and HS-27a cells after Tnf exposure. DNA microarray studies found both discordant and concordant Tnf-induced expression responses in the two stroma cell lines. Tnf promoted an increased mRNA expression of pro-inflammatory cytokines [e.g. interleukin (IL)6, IL8 and IL32]. At the same time, Tnf decreased the mRNA expression of anti-apoptotic genes (e.g. BCL2L1) and increased the mRNA expression of pro-apoptotic genes (e.g. BID). Overall, the results suggested that Tnf induced a complex set of pro-inflammatory and pro-apoptotic signals in stroma cells that promote apoptosis in malignant myeloid clones. Additional studies will be required to determine which of these signals are critical for the induction of apoptosis in the malignant clones. Those insights, in turn, may point the way to novel therapeutic approaches.
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Affiliation(s)
- Derek L Stirewalt
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, WA, USA.
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50
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Navas TA, Mohindru M, Estes M, Ma JY, Sokol L, Pahanish P, Parmar S, Haghnazari E, Zhou L, Collins R, Kerr I, Nguyen AN, Xu Y, Platanias LC, List AA, Higgins LS, Verma A. Inhibition of overactivated p38 MAPK can restore hematopoiesis in myelodysplastic syndrome progenitors. Blood 2006; 108:4170-7. [PMID: 16940419 PMCID: PMC1895446 DOI: 10.1182/blood-2006-05-023093] [Citation(s) in RCA: 101] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
The myelodysplastic syndromes (MDSs) are collections of heterogeneous hematologic diseases characterized by refractory cytopenias as a result of ineffective hematopoiesis. Development of effective treatments has been impeded by limited insights into any unifying pathogenic pathways. We provide evidence that the p38 MAP kinase is constitutively activated or phosphorylated in MDS bone marrows. Such activation is uniformly observed in varied morphologic subtypes of low-risk MDS and correlates with enhanced apoptosis observed in MDS hematopoietic progenitors. Most importantly, pharmacologic inhibition of p38alpha by a novel small molecule inhibitor, SCIO-469, decreases apoptosis in MDS CD34+ progenitors and leads to dose-dependant increases in erythroid and myeloid colony formation. Down-regulation of the dominant p38alpha isoform by siRNA also leads to enhancement of hematopoiesis in MDS bone marrow progenitors in vitro. These data implicate p38 MAPK in the pathobiology of ineffective hematopoiesis in lowrisk MDS and provide a strong rationale for clinical investigation of SCIO-469 in MDS.
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Affiliation(s)
- Tony A Navas
- Albert Einstein College of Medicine, Bronx, NY, USA
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