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Lucero J, Al-Harbi S, Yee KWL. Management of Patients with Lower-Risk Myelodysplastic Neoplasms (MDS). Curr Oncol 2023; 30:6177-6196. [PMID: 37504319 PMCID: PMC10377892 DOI: 10.3390/curroncol30070459] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2023] [Revised: 06/15/2023] [Accepted: 06/25/2023] [Indexed: 07/29/2023] Open
Abstract
Myelodysplastic neoplasms (MDS) are a heterogenous group of clonal hematologic disorders characterized by morphologic dysplasia, ineffective hematopoiesis, and cytopenia. In the past year, the classification of MDS has been updated in the 5th edition of the World Health Organization (WHO) Classification of Haematolymphoid Tumours and the International Consensus Classification (ICC) of Myeloid Neoplasms and Acute Leukemia with incorporation of morphologic, clinical, and genomic data. Furthermore, the more comprehensive International Prognostic Scoring System-Molecular (IPSS-M) allows for improved risk stratification and prognostication. These three developments allow for more tailored therapeutic decision-making in view of the expanding treatment options in MDS. For patients with lower risk MDS, treatment is aimed at improving cytopenias, usually anemia. The recent approval of luspatercept and decitabine/cedazuridine have added on to the current armamentarium of erythropoietic stimulating agents and lenalidomide (for MDS with isolated deletion 5q). Several newer agents are being evaluated in phase 3 clinical trials for this group of patients, such as imetelstat and oral azacitidine. This review provides a summary of the classification systems, the prognostic scores and clinical management of patients with lower risk MDS.
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Affiliation(s)
- Josephine Lucero
- Division of Medical Oncology and Hematology, Princess Margaret Cancer Centre, University Health Network, 700 University Avenue, 6th Floor, Toronto, ON M5G 1Z5, Canada
| | - Salman Al-Harbi
- Division of Medical Oncology and Hematology, Princess Margaret Cancer Centre, University Health Network, 700 University Avenue, 6th Floor, Toronto, ON M5G 1Z5, Canada
| | - Karen W L Yee
- Division of Medical Oncology and Hematology, Princess Margaret Cancer Centre, University Health Network, 700 University Avenue, 6th Floor, Toronto, ON M5G 1Z5, Canada
- Division of Hematology, University of Toronto, Toronto, ON M5S 3H2, Canada
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2
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Barone P, Patel S. Myelodysplastic syndrome: Approach to diagnosis in the era of personalized medicine. Semin Diagn Pathol 2023; 40:172-181. [PMID: 37121781 DOI: 10.1053/j.semdp.2023.04.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2023] [Revised: 04/11/2023] [Accepted: 04/12/2023] [Indexed: 05/02/2023]
Affiliation(s)
- Paul Barone
- NewYork-Presbyterian Hospital, Weill Cornell Campus, United States of America.
| | - Sanjay Patel
- Weill Cornell Medicine, United States of America
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3
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Chen M, Fu M, Zhao W, Wang A, Wu X, Gong M, Zhen J, Yue G, Wang H. Full spectral flow cytometry analysis of the bone marrow immune cells in patients with myelodysplastic syndrome. Int J Lab Hematol 2023; 45:e10-e14. [PMID: 35950633 DOI: 10.1111/ijlh.13945] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2022] [Accepted: 07/25/2022] [Indexed: 01/18/2023]
Affiliation(s)
- Man Chen
- Hebei Yanda Lu Daopei Hospital, Langfang, China
| | - Minjing Fu
- Beijing Lu Daopei Hospital, Beijing, China
| | - Wei Zhao
- Beijing Lu Daopei Hospital, Beijing, China
| | - Aixian Wang
- Hebei Yanda Lu Daopei Hospital, Langfang, China
| | - Xueying Wu
- Hebei Yanda Lu Daopei Hospital, Langfang, China
| | - Meiwei Gong
- Hebei Yanda Lu Daopei Hospital, Langfang, China
| | - Junyi Zhen
- Hebei Yanda Lu Daopei Hospital, Langfang, China
| | | | - Hui Wang
- Hebei Yanda Lu Daopei Hospital, Langfang, China
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Novel THPO variant in hereditary thrombocytopenia: A potential candidate variant for predisposition to myeloid neoplasm. PLoS One 2022; 17:e0271624. [PMID: 36534659 PMCID: PMC9762605 DOI: 10.1371/journal.pone.0271624] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2022] [Accepted: 07/05/2022] [Indexed: 12/23/2022] Open
Abstract
Hereditary thrombocytopenia is a heterogeneous group of congenital disorders with a wide range of symptoms depending on the severity of platelet dysfunction or thrombocytopenia. Because of its clinical phenotypes and the bone marrow morphology associated with this condition, hereditary thrombocytopenia can be misdiagnosed as primary immune thrombocytopenia and myelodysplastic syndrome. Therefore, genetic evidence is necessary for the accurate diagnosis of hereditary thrombocytopenia. Refractory cytopenia of childhood is a subgroup of myelodysplastic syndrome that was added to the World Health Organization classification in 2008. To investigate the germline and somatic variants associated with refractory cytopenia of childhood, we performed targeted multigene sequencing in three patients with refractory cytopenia of childhood. Of the three patients, one progressed from megakaryocytic hypoplasia with thrombocytopenia, and targeted multigene sequencing revealed THPO variants in this patient and his sister. We propose that the monoallelic deletion of THPO is a potential candidate for germline predisposition to myeloid malignancy.
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Peng X, Zhu X, Di T, Tang F, Guo X, Liu Y, Bai J, Li Y, Li L, Zhang L. The yin-yang of immunity: Immune dysregulation in myelodysplastic syndrome with different risk stratification. Front Immunol 2022; 13:994053. [PMID: 36211357 PMCID: PMC9537682 DOI: 10.3389/fimmu.2022.994053] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2022] [Accepted: 09/07/2022] [Indexed: 11/13/2022] Open
Abstract
Myelodysplastic syndrome (MDS) is a heterogeneous group of myeloid clonal diseases with diverse clinical courses, and immune dysregulation plays an important role in the pathogenesis of MDS. However, immune dysregulation is complex and heterogeneous in the development of MDS. Lower-risk MDS (LR-MDS) is mainly characterized by immune hyperfunction and increased apoptosis, and the immunosuppressive therapy shows a good response. Instead, higher-risk MDS (HR-MDS) is characterized by immune suppression and immune escape, and the immune activation therapy may improve the survival of HR-MDS. Furthermore, the immune dysregulation of some MDS changes dynamically which is characterized by the coexistence and mutual transformation of immune hyperfunction and immune suppression. Taken together, the authors think that the immune dysregulation in MDS with different risk stratification can be summarized by an advanced philosophical thought “Yin-Yang theory” in ancient China, meaning that the opposing forces may actually be interdependent and interconvertible. Clarifying the mechanism of immune dysregulation in MDS with different risk stratification can provide the new basis for diagnosis and clinical treatment. This review focuses on the manifestations and roles of immune dysregulation in the different risk MDS, and summarizes the latest progress of immunotherapy in MDS.
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Affiliation(s)
- Xiaohuan Peng
- Department of Hematology, Lanzhou University Second Hospital, Lanzhou University, Lanzhou, China
- Key Laboratory of the Hematology of Gansu Province, Lanzhou University Second Hospital, Lanzhou University, Lanzhou, China
| | - Xiaofeng Zhu
- Department of Hematology, Lanzhou University Second Hospital, Lanzhou University, Lanzhou, China
- Key Laboratory of the Hematology of Gansu Province, Lanzhou University Second Hospital, Lanzhou University, Lanzhou, China
| | - Tianning Di
- Department of Hematology, Lanzhou University Second Hospital, Lanzhou University, Lanzhou, China
- Key Laboratory of the Hematology of Gansu Province, Lanzhou University Second Hospital, Lanzhou University, Lanzhou, China
| | - Futian Tang
- Key Laboratory of the Digestive System Tumors of Gansu Province, Lanzhou University Second Hospital, Lanzhou University, Lanzhou, China
| | - Xiaojia Guo
- Department of Hematology, Lanzhou University Second Hospital, Lanzhou University, Lanzhou, China
| | - Yang Liu
- Department of Hematology, Lanzhou University Second Hospital, Lanzhou University, Lanzhou, China
| | - Jun Bai
- Key Laboratory of the Hematology of Gansu Province, Lanzhou University Second Hospital, Lanzhou University, Lanzhou, China
| | - Yanhong Li
- Key Laboratory of the Hematology of Gansu Province, Lanzhou University Second Hospital, Lanzhou University, Lanzhou, China
| | - Lijuan Li
- Department of Hematology, Lanzhou University Second Hospital, Lanzhou University, Lanzhou, China
- Key Laboratory of the Hematology of Gansu Province, Lanzhou University Second Hospital, Lanzhou University, Lanzhou, China
- *Correspondence: Lijuan Li, ; Liansheng Zhang,
| | - Liansheng Zhang
- Department of Hematology, Lanzhou University Second Hospital, Lanzhou University, Lanzhou, China
- Key Laboratory of the Hematology of Gansu Province, Lanzhou University Second Hospital, Lanzhou University, Lanzhou, China
- *Correspondence: Lijuan Li, ; Liansheng Zhang,
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Simoni Y, Chapuis N. Diagnosis of Myelodysplastic Syndromes: From Immunological Observations to Clinical Applications. Diagnostics (Basel) 2022; 12:diagnostics12071659. [PMID: 35885563 PMCID: PMC9324119 DOI: 10.3390/diagnostics12071659] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2022] [Revised: 07/04/2022] [Accepted: 07/04/2022] [Indexed: 11/24/2022] Open
Abstract
Myelodysplastic syndromes (MDS) constitute a very heterogeneous group of diseases with a high prevalence in elderly patients and a propensity for progression to acute myeloid leukemia. The complexity of these hematopoietic malignancies is revealed by the multiple recurrent somatic mutations involved in MDS pathogenesis and the paradoxical common phenotype observed in these patients characterized by ineffective hematopoiesis and cytopenia. In the context of population aging, the incidence of MDS will strongly increase in the future. Thus, precise diagnosis and evaluation of the progression risk of these diseases are imperative to adapt the treatment. Dysregulations of both innate and adaptive immune systems are frequently detected in MDS patients, and their critical role in MDS pathogenesis is now commonly accepted. However, different immune dysregulations and/or dysfunctions can be dynamically observed during the course of the disease. Monitoring the immune system therefore represents a new attractive tool for a more precise characterization of MDS at diagnosis and for identifying patients who may benefit from immunotherapy. We review here the current knowledge of the critical role of immune dysfunctions in both MDS and MDS precursor conditions and discuss the opportunities offered by the detection of these dysregulations for patient stratification.
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Affiliation(s)
- Yannick Simoni
- Institut Cochin, Université Paris Cité, CNRS UMR8104, INSERM U1016, 75014 Paris, France;
| | - Nicolas Chapuis
- Institut Cochin, Université Paris Cité, CNRS UMR8104, INSERM U1016, 75014 Paris, France;
- Assistance Publique-Hôpitaux de Paris, Centre-Université Paris Cité, Service d’Hématologie Biologique, Hôpital Cochin, 75014 Paris, France
- Correspondence:
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Leone S, Rubino V, Palatucci AT, Giovazzino A, Carriero F, Cerciello G, Pane F, Ruggiero G, Terrazzano G. Bone Marrow CD3 + CD56 + Regulatory T lymphocytes (T R3-56 cells) are inversely associated with activation and expansion of Bone Marrow cytotoxic T cells in IPSS-R very-low/low risk MDS patients. Eur J Haematol 2022; 109:398-405. [PMID: 35775392 PMCID: PMC9543123 DOI: 10.1111/ejh.13822] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2022] [Revised: 06/27/2022] [Accepted: 06/28/2022] [Indexed: 12/04/2022]
Abstract
Background Emergence of dysplastic haematopoietic precursor/s, cytopenia and variable leukaemia risk characterise myelodysplastic syndromes (MDS). Impaired immune‐regulation, preferentially affecting cytotoxic T cells (CTL), has been largely observed in MDS. Recently, we described the TR3−56 T cell subset, characterised by the co‐expression of CD3 and CD56, as a novel immune‐regulatory population, able to modulate cytotoxic functions. Here, we address the involvement of TR3−56 cells in MDS pathogenesis/progression. Objectives To analyse the relationship between TR3−56 and CTL activation/expansion in bone marrow (BM) of very‐low/low‐risk MDS subjects. Methods Peripheral blood and BM specimens, obtained at disease onset in a cohort of 58 subjects, were analysed by immune‐fluorescence and flow cytometry, to preserve the complexity of the biological sample. Results We observed that a trend‐increase of BM TR3−56 in high/very‐high MDS stage, as compared with very‐low/low group, associates with a decreased activation of BM resident CTL; significant correlation of TR3−56 with BM blasts has been also revealed. In addition, in very‐low/low‐risk subjects the TR3−56 amount in BM inversely correlates with the presence of activated BM CTL showing a skewed Vβ T‐cell repertoire. Conclusions These data add TR3−56 to the immune‐regulatory network involved in MDS pathogenesis/progression. Better knowledge of the immune‐mediated processes associated with the disease might improve MDS clinical management.
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Affiliation(s)
- Stefania Leone
- Divisione di Ematologia, Dipartimento di Medicina Clinica e Chirurgia, Università di Napoli "Federico II"
| | - Valentina Rubino
- Dipartimento di Scienze Mediche Traslazionali, Università di Napoli "Federico II", Napoli, Italy
| | | | - Angela Giovazzino
- Dipartimento di Scienze Mediche Traslazionali, Università di Napoli "Federico II", Napoli, Italy
| | - Flavia Carriero
- Ph.D course in Science, Università della Basilicata, Via dell'Ateneo Lucano, Potenza, Italy
| | - Giuseppe Cerciello
- Divisione di Ematologia, Dipartimento di Medicina Clinica e Chirurgia, Università di Napoli "Federico II"
| | - Fabrizio Pane
- Divisione di Ematologia, Dipartimento di Medicina Clinica e Chirurgia, Università di Napoli "Federico II"
| | - Giuseppina Ruggiero
- Dipartimento di Scienze Mediche Traslazionali, Università di Napoli "Federico II", Napoli, Italy
| | - Giuseppe Terrazzano
- Dipartimento di Scienze Mediche Traslazionali, Università di Napoli "Federico II", Napoli, Italy.,Dipartimento di Scienze, Università della Basilicata, Potenza, Italy
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Comont T, Treiner E, Vergez F. From Immune Dysregulations to Therapeutic Perspectives in Myelodysplastic Syndromes: A Review. Diagnostics (Basel) 2021; 11:diagnostics11111982. [PMID: 34829329 PMCID: PMC8620222 DOI: 10.3390/diagnostics11111982] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2021] [Revised: 10/21/2021] [Accepted: 10/22/2021] [Indexed: 12/12/2022] Open
Abstract
The pathophysiology of myelodysplastic syndromes (MDSs) is complex and often includes immune dysregulation of both the innate and adaptive immune systems. Whereas clonal selection mainly involves smoldering inflammation, a cellular immunity dysfunction leads to increased apoptosis and blast proliferation. Addressing immune dysregulations in MDS is a recent concept that has allowed the identification of new therapeutic targets. Several approaches targeting the different actors of the immune system have therefore been developed. However, the results are very heterogeneous, indicating the need to improve our understanding of the disease and interactions between chronic inflammation, adaptive dysfunction, and somatic mutations. This review highlights current knowledge of the role of immune dysregulation in MDS pathophysiology and the field of new drugs.
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Affiliation(s)
- Thibault Comont
- Department of Internal Medicine, IUCT-Oncopole, Toulouse University Hospital (CHU-Toulouse), 31300 Toulouse, France
- Cancer Research Center of Toulouse, Unité Mixte de Recherche (UMR) 1037 INSERM, ERL5294 Centre National de La Recherche Scientifique, 31100 Toulouse, France;
- School of Medicine, Université Toulouse III—Paul Sabatier, 31062 Toulouse, France;
- Correspondence: ; Tel.: +33-531-15-62-66; Fax: +33-531-15-62-58
| | - Emmanuel Treiner
- School of Medicine, Université Toulouse III—Paul Sabatier, 31062 Toulouse, France;
- Laboratory of Immunology, Toulouse University Hospital (CHU-Toulouse), 31300 Toulouse, France
- Infinity, Inserm UMR1291, 31000 Toulouse, France
| | - François Vergez
- Cancer Research Center of Toulouse, Unité Mixte de Recherche (UMR) 1037 INSERM, ERL5294 Centre National de La Recherche Scientifique, 31100 Toulouse, France;
- School of Medicine, Université Toulouse III—Paul Sabatier, 31062 Toulouse, France;
- Laboratory of Hematology, IUCT-Oncopole, Toulouse University Hospital (CHU-Toulouse), 31300 Toulouse, France
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[Prognostic factors of cyclosporine A combined with danazol with or without thalidomide in myelodysplastic syndrome treatment with low-percentage bone marrow blasts]. ZHONGHUA XUE YE XUE ZA ZHI = ZHONGHUA XUEYEXUE ZAZHI 2021; 42:376-382. [PMID: 34218579 PMCID: PMC8293001 DOI: 10.3760/cma.j.issn.0253-2727.2021.05.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
目的 探讨环孢素A(CsA)联合达那唑±沙利度胺治疗原始细胞不增高骨髓增生异常综合征(MDS)疗效及其影响因素。 方法 收集2011年12月至2019年12月在中国医学科学院血液病医院确诊且接受CsA联合达那唑±沙利度胺治疗的115例原始细胞不增高初诊原发性MDS患者临床资料,回顾性分析其临床特征、疗效及疗效影响因素,并建立疗效预测模型。 结果 55例(47.8%)患者获得治疗反应,其中11例获得完全缓解,44例获得血液学改善[红系反应率为49.5%(52/105),血小板反应率为40.7%(35/86),中性粒细胞反应率为35.0%(14/40)]。29例红细胞输注依赖的患者中7例(24.1%)脱离输血依赖。总体中位疗效持续时间为20(3~84)个月。单因素分析显示年龄<60岁较≥60岁患者疗效好(52.5%对22.2%,P=0.018),而伴红细胞输注依赖较非红细胞输注依赖患者(24.1%对55.8%,P=0.003)、U2AF1突变型患者较U2AF1野生型患者(26.1%对53.2%,P=0.020)疗效差。多因素分析显示年龄<60岁(OR=4.302, 95%CI 1.245~14.820,P=0.021)、无红细胞输注依赖(OR=3.774,95%CI 1.400~10.177,P=0.009)和无U2AF1突变(OR=3.414,95%CI 1.168~9.978,P=0.025)均为获得血液学改善的独立预后因素。联合上述影响疗效的独立预后因素建立疗效预测模型,具有0、1、2、3个危险因素患者的总有效率分别为65%、30%~35%、10%~15%、3%。 结论 CsA联合达那唑±沙利度胺可有效改善原始细胞不增高MDS患者的血细胞减少症状。年龄<60岁、不伴红细胞输注依赖且无U2AF1突变患者治疗反应较好。
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Fenaux P, Haase D, Santini V, Sanz GF, Platzbecker U, Mey U. Myelodysplastic syndromes: ESMO Clinical Practice Guidelines for diagnosis, treatment and follow-up †☆. Ann Oncol 2021; 32:142-156. [PMID: 33221366 DOI: 10.1016/j.annonc.2020.11.002] [Citation(s) in RCA: 67] [Impact Index Per Article: 22.3] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2020] [Revised: 10/30/2020] [Accepted: 11/02/2020] [Indexed: 12/14/2022] Open
Affiliation(s)
- P Fenaux
- Service d'Hématologie Clinique, Groupe Francophone des Myélodysplasies (GFM), Department of Hematology, Hôpital St. Louis (Assistance Publique, Hôpitaux de Paris), Paris, France; Paris 7 University, Paris, France
| | - D Haase
- Department of Hematology and Medical Oncology, University Medical Center, Göttingen, Germany
| | - V Santini
- MDS Unit, Haematology, AOU Careggi, University of Florence, Florence, Italy
| | - G F Sanz
- Department of Haematology, Hospital Universitario La Fe, Valencia, Spain; Centro de Investigación Biomédica en Red de Cáncer, CIBERONC, Instituto de Salud Carlos III, Madrid, Spain
| | - U Platzbecker
- Department of Hematology and Cellular Therapy, Medical Clinic and Policlinic 1, University Hospital Leipzig, Germany
| | - U Mey
- Department of Oncology and Haematology, Kantonsspital Graubuenden, Chur, Switzerland
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Hypoplastic Myelodysplastic Syndromes: Just an Overlap Syndrome? Cancers (Basel) 2021; 13:cancers13010132. [PMID: 33401595 PMCID: PMC7795441 DOI: 10.3390/cancers13010132] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2020] [Revised: 12/29/2020] [Accepted: 12/29/2020] [Indexed: 12/15/2022] Open
Abstract
Simple Summary Hypoplastic myelodysplastic syndromes (hMDS) represent a diagnostic conundrum. They share morphologic and clinical features of both MDS (dysplasia, genetic lesions and cytopenias) and aplastic anemia (AA; i.e., hypocellularity and autoimmunity) and are not comprised in the last WHO classification. In this review we recapitulate the main clinical, pathogenic and therapeutic aspects of hypo-MDS and discuss why they deserve to be distinguished from normo/hypercellular MDS and AA. We conclude that hMDS may present in two phenotypes: one more proinflammatory and autoimmune, more similar to AA, responding to immunosuppression; and one MDS-like dominated by genetic lesions, suppression of immune surveillance, and tumor escape, more prone to leukemic evolution. Abstract Myelodysplasias with hypocellular bone marrow (hMDS) represent about 10–15% of MDS and are defined by reduced bone marrow cellularity (i.e., <25% or an inappropriately reduced cellularity for their age in young patients). Their diagnosis is still an object of debate and has not been clearly established in the recent WHO classification. Clinical and morphological overlaps with both normo/hypercellular MDS and aplastic anemia include cytopenias, the presence of marrow hypocellularity and dysplasia, and cytogenetic and molecular alterations. Activation of the immune system against the hematopoietic precursors, typical of aplastic anemia, is reckoned even in hMDS and may account for the response to immunosuppressive treatment. Finally, the hMDS outcome seems more favorable than that of normo/hypercellular MDS patients. In this review, we analyze the available literature on hMDS, focusing on clinical, immunological, and molecular features. We show that hMDS pathogenesis and clinical presentation are peculiar, albeit in-between aplastic anemia (AA) and normo/hypercellular MDS. Two different hMDS phenotypes may be encountered: one featured by inflammation and immune activation, with increased cytotoxic T cells, increased T and B regulatory cells, and better response to immunosuppression; and the other, resembling MDS, where T and B regulatory/suppressor cells prevail, leading to genetic clonal selection and an increased risk of leukemic evolution. The identification of the prevailing hMDS phenotype might assist treatment choice, inform prognosis, and suggest personalized monitoring.
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12
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Garcia‐Manero G, Chien KS, Montalban‐Bravo G. Myelodysplastic syndromes: 2021 update on diagnosis, risk stratification and management. Am J Hematol 2020; 95:1399-1420. [PMID: 32744763 DOI: 10.1002/ajh.25950] [Citation(s) in RCA: 104] [Impact Index Per Article: 26.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2020] [Revised: 07/30/2020] [Accepted: 07/30/2020] [Indexed: 12/12/2022]
Abstract
DISEASE OVERVIEW The myelodysplastic syndromes (MDS) are a very heterogeneous group of myeloid disorders characterized by peripheral blood cytopenias and increased risk of transformation to acute myelogenous leukemia (AML). Myelodysplastic syndromes occur more frequently in older males and in individuals with prior exposure to cytotoxic therapy. DIAGNOSIS Diagnosis of MDS is based on morphological evidence of dysplasia upon visual examination of a bone marrow aspirate and biopsy. Information obtained from additional studies such as karyotype, flow cytometry and molecular genetics is usually complementary and may help refine diagnosis. RISK-STRATIFICATION Prognosis of patients with MDS can be calculated using a number of scoring systems. In general, all these scoring systems include analysis of peripheral cytopenias, percentage of blasts in the bone marrow and cytogenetic characteristics. The most commonly accepted system is the Revised International Prognostic Scoring System (IPSS-R). Somatic mutations can help define prognosis and therapy. RISK-ADAPTED THERAPY Therapy is selected based on risk, transfusion needs, percent of bone marrow blasts, cytogenetic and mutational profiles, comorbidities, potential for allogeneic stem cell transplantation (alloSCT) and prior exposure to hypomethylating agents (HMA). Goals of therapy are different in lower-risk patients than in higher-risk individuals and in those with HMA failure. In lower-risk MDS, the goal is to decrease transfusion needs and transformation to higher risk disease or AML, as well as to improve survival. In higher-risk disease, the goal is to prolong survival. In 2020, we witnessed an explosion of new agents and investigational approaches. Current available therapies include growth factor support, lenalidomide, HMAs, intensive chemotherapy and alloSCT. Novel therapeutics approved in 2020 are luspatercept and the oral HMA ASTX727. At the present time, there are no approved interventions for patients with progressive or refractory disease particularly after HMA-based therapy. Options include participation in a clinical trial, cytarabine-based therapy or alloSCT.
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Affiliation(s)
- Guillermo Garcia‐Manero
- Section of MDS, Department of Leukemia University of Texas MD Anderson Cancer Center Houston Texas USA
| | - Kelly S. Chien
- Section of MDS, Department of Leukemia University of Texas MD Anderson Cancer Center Houston Texas USA
| | - Guillermo Montalban‐Bravo
- Section of MDS, Department of Leukemia University of Texas MD Anderson Cancer Center Houston Texas USA
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13
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Outcome of allogeneic hematopoietic stem cell transplantation for hypoplastic myelodysplastic syndrome. Int J Hematol 2020; 112:825-834. [PMID: 32803698 DOI: 10.1007/s12185-020-02969-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2020] [Revised: 08/04/2020] [Accepted: 08/07/2020] [Indexed: 12/16/2022]
Abstract
The prognosis of patients with hypoplastic myelodysplastic syndrome (hMDS) after receiving allogeneic hematopoietic stem cell transplantation (allo-HSCT) remains unclear. This study aimed to evaluate the outcomes of patients with hMDS after allo-HSCT. Between September 2013 and October 2019, a total of 20 consecutive patients with hMDS and 1 patient with clonal cytopenia of undermined significance (CCUS) who underwent allo-HSCT, which included procedures with 9 matched sibling donors, 2 matched unrelated donors, 4 mismatched unrelated donors and 6 haploidentical donors, were enrolled in this study. The median time for myeloid engraftment was 11 days (range 9-17 days), and that for platelet engraftment was 10 days (range 7-17 days). The cumulative incidence (CI) of myeloid and platelet recovery was 95.2 ± 6.0% and 90.5 ± 7.3%, respectively. The CI rates were 40.0 ± 11.3% for grades II-III acute graft-versus-host disease (GVHD), 36.8 ± 11.5% for chronic GVHD and 23.8 ± 9.6% for nonrelapse mortality. No patients experienced relapse. Sixteen surviving patients were followed up for a median of 1113 days (range 110-2305 days), and the overall survival and relapse-free survival rates were both 72.7 ± 10.6%. This limited retrospective analysis suggests that patients with hMDS had a favorable survival after allo-HSCT.
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Long-term outcomes in myelodysplastic syndrome patients treated with alemtuzumab. Blood Adv 2020; 3:980-983. [PMID: 30936058 DOI: 10.1182/bloodadvances.2018030411] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2018] [Accepted: 02/15/2019] [Indexed: 11/20/2022] Open
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15
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Evolving therapies for lower-risk myelodysplastic syndromes. Ann Hematol 2020; 99:677-692. [PMID: 32078008 DOI: 10.1007/s00277-020-03963-1] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2020] [Accepted: 02/10/2020] [Indexed: 12/16/2022]
Abstract
The development in the therapeutic landscape of myelodysplastic syndromes (MDS) has substantially lagged behind other hematologic malignancies with no new drug approvals for MDS for 13 years since the approval of decitabine in the United States in 2006. While therapeutic concepts for MDS patients continue to be primarily defined by clinical-pathologic risk stratification tools such as the International Prognostic Scoring System (IPSS) and its revised version IPSS-R, our understanding of the genetic landscape and the molecular pathogenesis of MDS has greatly evolved over the last decade. It is expected that the therapeutic approach to MDS patients will become increasingly individualized based on prognostic and predictive genetic features and other biomarkers. Herein, we review the current treatment of lower-risk MDS patients and discuss promising agents in advanced clinical testing for the treatment of symptomatic anemia in lower-risk MDS patients such as luspatercept and imetelstat. Lastly, we review the clinical development of new agents and the implications of the wider availability of mutational analysis for the management of individual MDS patients.
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Winter S, Shoaie S, Kordasti S, Platzbecker U. Integrating the "Immunome" in the Stratification of Myelodysplastic Syndromes and Future Clinical Trial Design. J Clin Oncol 2020; 38:1723-1735. [PMID: 32058844 DOI: 10.1200/jco.19.01823] [Citation(s) in RCA: 51] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Myelodysplastic syndromes (MDS) are characterized by ineffective hematopoiesis and often include a dysregulation and dysfunction of the immune system. In the context of population aging, MDS incidence is set to increase substantially, with exponential increases in health care costs, given the limited and expensive treatment options for these patients. Treatment selection is mainly based on calculated risk categories according to a Revised International Prognostic Scoring System (IPSS-R). However, although IPSS-R is an excellent predictor of disease progression, it is an ineffective predictor of response to disease-modifying therapies. Redressing these unmet needs, the "immunome" is a key, multifaceted component in the initiation and overall response against malignant cells in MDS, and the current omission of immune status monitoring may in part explain the insufficiencies of current prognostic stratification methods. Nevertheless, integrating these and other recent molecular advances into clinical practice proves difficult. This review highlights the complexity of immune dysregulation in MDS pathophysiology and the fine balance between smoldering inflammation, adaptive immunity, and somatic mutations in promoting or suppressing malignant clones. We review the existing knowledge and discuss how state-of-the-art immune monitoring strategies could potentially permit novel patient substratification, thereby empowering practical predictions of response to treatment in MDS. We propose novel multicenter studies, which are needed to achieve this goal.
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Affiliation(s)
- Susann Winter
- Department of Internal Medicine I, University Hospital Carl Gustav Carus, Technical University Dresden, Dresden, Germany.,German Cancer Consortium (DKTK), partner site Dresden, German Cancer Research Center (DKFZ), Heidelberg, Germany.,Comprehensive Cancer Centre, School of Cancer and Pharmaceutical Sciences, King's College London, London, United Kingdom
| | - Saeed Shoaie
- Centre for Host-Microbiome Interactions, Faculty of Dentistry, Oral & Craniofacial Sciences, King's College London, United Kingdom.,Science for Life Laboratory, KTH-Royal Institute of Technology, Stockholm, Sweden
| | - Shahram Kordasti
- Comprehensive Cancer Centre, School of Cancer and Pharmaceutical Sciences, King's College London, London, United Kingdom.,Haematology Department, Guy's Hospital, London, United Kingdom
| | - Uwe Platzbecker
- German Cancer Consortium (DKTK), partner site Dresden, German Cancer Research Center (DKFZ), Heidelberg, Germany.,Comprehensive Cancer Centre, School of Cancer and Pharmaceutical Sciences, King's College London, London, United Kingdom.,Haematology Department, Guy's Hospital, London, United Kingdom.,Medical Clinic and Policlinic 1, Hematology and Cellular Therapy, University of Leipzig Medical Center, Leipzig, Germany.,German MDS Study Group (G-MDS), Leipzig, Germany
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17
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Li X, Wu YH, Cai SS, Li WM, You Y, Zhang M. Early Detection of Myelodysplastic Syndrome/Leukemia-associated Mutations Using NGS Is Critical in Treating Aplastic Anemia. Curr Med Sci 2019; 39:217-221. [DOI: 10.1007/s11596-019-2022-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2018] [Revised: 12/24/2018] [Indexed: 12/19/2022]
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18
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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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19
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Clinical, histopathological and molecular characterization of hypoplastic myelodysplastic syndrome. Leukemia 2019; 33:2495-2505. [PMID: 30940907 DOI: 10.1038/s41375-019-0457-1] [Citation(s) in RCA: 49] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2018] [Revised: 02/22/2019] [Accepted: 03/14/2019] [Indexed: 11/08/2022]
Abstract
Diagnostic criteria for hypoplastic myelodysplasic syndrome (h-MDS) have not been clearly established, making the differential diagnosis from other bone marrow failure syndromes (BMF) challenging. In this study, we aimed to delineate clinical, histopathological, and molecular features of h-MDS, based on a large and well-annotated cohort of patients with bone marrow (BM) hypocellularity. The study included 534 consecutive adult patients with hypocellular BM (278 h-MDS and 136 aplastic anemia), and 727 with normo- or hypercellular MDS (n-MDS). Comparison of clinical features of patients with h-MDS as defined by BM cellularity ≤25% (n = 204) or reduced age-adjusted cellularity (n = 74) did not reveal significant differences. We developed a diagnostic score to discriminate h-MDS from non-malignant BMF based on histological and cytological variables with the highest specificity for MDS (h-score). The information from chromosomal abnormalities and somatic mutation patterns was then integrated into a cyto-histological/genetic score (hg-score). This score was able to segregate two groups of h-MDS with a significantly different risk of blast progression (P < 0.001). The integration of cyto-histological and genetic features in adult patients with hypocellular BM facilitated segregation into two distinct groups, one with clinical and genetic features highly consistent with myeloid neoplasm, and one with features more consistent with non-malignant BMF.
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20
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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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21
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Outcomes and mutational analysis of patients with lower-risk non-del5q myelodysplastic syndrome treated with antithymocyte globulin with or without ciclosporine A. Leuk Res 2018; 71:67-74. [DOI: 10.1016/j.leukres.2018.05.007] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2018] [Revised: 05/15/2018] [Accepted: 05/22/2018] [Indexed: 01/28/2023]
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22
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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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23
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Stahl M, DeVeaux M, de Witte T, Neukirchen J, Sekeres MA, Brunner AM, Roboz GJ, Steensma DP, Bhatt VR, Platzbecker U, Cluzeau T, Prata PH, Itzykson R, Fenaux P, Fathi AT, Smith A, Germing U, Ritchie EK, Verma V, Nazha A, Maciejewski JP, Podoltsev NA, Prebet T, Santini V, Gore SD, Komrokji RS, Zeidan AM. The use of immunosuppressive therapy in MDS: clinical outcomes and their predictors in a large international patient cohort. Blood Adv 2018; 2:1765-1772. [PMID: 30037803 PMCID: PMC6058241 DOI: 10.1182/bloodadvances.2018019414] [Citation(s) in RCA: 89] [Impact Index Per Article: 14.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2018] [Accepted: 06/02/2018] [Indexed: 11/20/2022] Open
Abstract
Most studies of immunosuppressive therapy (IST) in myelodysplastic syndromes (MDS) are limited by small numbers and their single-center nature, and report conflicting data regarding predictors for response to IST. We examined outcomes associated with IST and predictors of benefit in a large international cohort of patients with MDS. Data were collected from 15 centers in the United States and Europe. Responses, including red blood cell (RBC) transfusion independence (TI), were assessed based on the 2006 MDS International Working Group criteria, and overall survival (OS) was estimated by Kaplan-Meier methods. Logistic regression models estimated odds for response and TI, and Cox Proportional Hazard models estimated hazards ratios for OS. We identified 207 patients with MDS receiving IST, excluding steroid monotherapy. The most common IST regimen was anti-thymocyte globulin (ATG) plus prednisone (43%). Overall response rate (ORR) was 48.8%, including 11.2% (95% confidence interval [CI], 6.5%-18.4%) who achieved a complete remission and 30% (95% CI, 22.3%-39.5%) who achieved RBC TI. Median OS was 47.4 months (95% CI, 37-72.3 months) and was longer for patients who achieved a response or TI. Achievement of RBC TI was associated with a hypocellular bone marrow (cellularity < 20%); horse ATG plus cyclosporine was more effective than rabbit ATG or ATG without cyclosporine. Age, transfusion dependence, presence of paroxysmal nocturnal hemoglobinuria or large granular lymphocyte clones, and HLA DR15 positivity did not predict response to IST. IST leads to objective responses in nearly half the selected patients with the highest rate of RBC TI achieved in patients with hypocellular bone marrows.
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Affiliation(s)
- Maximilian Stahl
- Section of Hematology, Department of Internal Medicine, Yale University School of Medicine, New Haven, CT
| | - Michelle DeVeaux
- Department of Biostatistics, Yale School of Public Health, New Haven, CT
| | - Theo de Witte
- Department of Tumorimmunology, Radboudumc, Nijmegen, The Netherlands
| | - Judith Neukirchen
- Department of Hematology, Oncology and Clinical Immunology, Heinrich Heine University Duesseldorf, Duesseldorf, Germany
| | | | - Andrew M Brunner
- Massachusetts General Hospital Cancer Center, Harvard Medical School, Boston, MA
| | - Gail J Roboz
- Weill Cornell Medicine and The New York Presbyterian Hospital, New York, NY
| | | | | | - Uwe Platzbecker
- Universitätsklinikum "Carl Gustav Carus" der Technischen Universität Dresden, Dresden, Germany
- German Cancer Consortium and National Center for Tumor Diseases Dresden, Dresden, Germany
| | | | - Pedro H Prata
- Saint-Louis Hospital, University Paris 7, Paris, France
| | | | - Pierre Fenaux
- Saint-Louis Hospital, University Paris 7, Paris, France
| | - Amir T Fathi
- Massachusetts General Hospital Cancer Center, Harvard Medical School, Boston, MA
| | - Alexandra Smith
- Epidemiology & Cancer Statistics Group, Department of Health Sciences, University of York, York, United Kingdom
| | - Ulrich Germing
- Department of Hematology, Oncology and Clinical Immunology, Heinrich Heine University Duesseldorf, Duesseldorf, Germany
| | - Ellen K Ritchie
- Weill Cornell Medicine and The New York Presbyterian Hospital, New York, NY
| | - Vivek Verma
- University of Nebraska Medical Center, Omaha, NE
| | - Aziz Nazha
- Leukemia Program, Cleveland Clinic, Cleveland, OH
| | | | - Nikolai A Podoltsev
- Section of Hematology, Department of Internal Medicine, Yale University School of Medicine, New Haven, CT
| | - Thomas Prebet
- Section of Hematology, Department of Internal Medicine, Yale University School of Medicine, New Haven, CT
| | - Valeria Santini
- Division of Hematology, University of Florence, Azienda Ospedaliero Universitaria Carreggi, Florence, Italy; and
| | - Steven D Gore
- Section of Hematology, Department of Internal Medicine, Yale University School of Medicine, New Haven, CT
| | - Rami S Komrokji
- Department of Malignant Hematology, Moffitt Cancer Center and Research Institute, Tampa, FL
| | - Amer M Zeidan
- Section of Hematology, Department of Internal Medicine, Yale University School of Medicine, New Haven, CT
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Montalban-Bravo G, Garcia-Manero G. Myelodysplastic syndromes: 2018 update on diagnosis, risk-stratification and management. Am J Hematol 2018; 93:129-147. [PMID: 29214694 DOI: 10.1002/ajh.24930] [Citation(s) in RCA: 123] [Impact Index Per Article: 20.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2017] [Accepted: 10/02/2017] [Indexed: 12/12/2022]
Abstract
DISEASE OVERVIEW The myelodysplastic syndromes (MDS) are a very heterogeneous group of myeloid disorders characterized by peripheral blood cytopenias and increased risk of transformation to acute myelogenous leukemia (AML). MDS occurs more frequently in older males and in individuals with prior exposure to cytotoxic therapy. DIAGNOSIS Diagnosis of MDS is based on morphological evidence of dysplasia upon visual examination of a bone marrow aspirate and biopsy. Information obtained from additional studies such as karyotype, flow cytometry or molecular genetics is usually complementary and may help refine diagnosis. RISK-STRATIFICATION Prognosis of patients with MDS can be calculated using a number of scoring systems. In general, all these scoring systems include analysis of peripheral cytopenias, percentage of blasts in the bone marrow and cytogenetic characteristics. The most commonly used system is probably the International Prognostic Scoring System (IPSS). IPSS is now replaced by the revised IPSS-R score. Although not systematically incorporated into new validated prognostic systems, somatic mutations can help define prognosis and should be considered as new prognostic factors. RISK-ADAPTED THERAPY Therapy is selected based on risk, transfusion needs, percent of bone marrow blasts and cytogenetic and mutational profiles. Goals of therapy are different in lower risk patients than in higher risk. In lower risk, the goal is to decrease transfusion needs and transformation to higher risk disease or AML, as well as to improve survival. In higher risk, the goal is to prolong survival. Current available therapies include growth factor support, lenalidomide, hypomethylating agents, intensive chemotherapy and allogeneic stem cell transplantation. The use of lenalidomide has significant clinical activity in patients with lower risk disease, anemia and a chromosome 5 alteration. 5-azacitidine and decitabine have activity in both lower and higher-risk MDS. 5-azacitidine has been shown to improve survival in higher risk MDS. A number of new molecular lesions have been described in MDS that may serve as new therapeutic targets or aid in the selection of currently available agents. Additional supportive care measures may include the use of prophylactic antibiotics and iron chelation. MANAGEMENT OF PROGRESSIVE OR REFRACTORY DISEASE At the present time there are no approved interventions for patients with progressive or refractory disease particularly after hypomethylating based therapy. Options include participation in a clinical trial or cytarabine based therapy and stem cell transplantation.
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Barcellini W. The relationship between idiopathic cytopenias/dysplasias of uncertain significance (ICUS/IDUS) and autoimmunity. Expert Rev Hematol 2017; 10:649-657. [PMID: 28586251 DOI: 10.1080/17474086.2017.1339597] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
INTRODUCTION This review examines the several lines of evidence that support the relationship between myelodysplasia and autoimmunity, i.e. their epidemiologic association, the existence of common immune-mediated physiopathologic mechanisms, and the response to similar immunosuppressive therapies. The same relationship is reviewed here considering idiopathic cytopenia of uncertain significance (ICUS) and idiopathic dysplasia of uncertain significance (IDUS), two recently recognized provisional conditions characterized by isolated/unexplained cytopenia and/or dysplasia in <10% bone marrow cells. Areas covered: The review focuses on alterations of cytokine profiles, telomere/telomerase and toll-like receptors, and on increased myelosuppressive mediators and apoptotic markers in both myelodysplasia and autoimmunity. In addition, the presence of an autoimmune reaction directed against marrow precursors is described in refractory/relapsing autoimmune cytopenias (autoimmune hemolytic anemia, immune thrombocytopenia, chronic idiopathic neutropenia), possibly contributing to their evolution to ICUS/IDUS/bone marrow failure syndromes. Expert commentary: The increasing availability of omics methods has fuelled the discussion on the role of somatic mutations in the pathogenesis of IDUS/ICUS, clonal hematopoiesis of indeterminate potential, and clonal cytopenias of undetermined significance, and in their possible evolution. Even more attracting is the involvement of the genetic background/accumulating somatic mutations in cytopenias with autoimmune alterations.
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Affiliation(s)
- Wilma Barcellini
- a Onco-hematology Unit , IRCCS Ca' Granda - Maggiore Policlinico Hospital Foundation , Milan , Italy
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26
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Stahl M, Zeidan AM. Management of lower-risk myelodysplastic syndromes without del5q: current approach and future trends. Expert Rev Hematol 2017; 10:345-364. [PMID: 28277851 DOI: 10.1080/17474086.2017.1297704] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
INTRODUCTION Myelodysplastic syndromes (MDS) are characterized by progressive bone marrow failure manifesting as blood cytopenia and a variable risk of progression into acute myeloid leukemia. MDS is heterogeneous in biology and clinical behavior. MDS are generally divided into lower-risk (LR) and higher-risk (HR) MDS. Goals of care in HR-MDS focus on changing the natural history of the disease, whereas in LR-MDS symptom control and quality of life are the main goals. Areas covered: We review the epidemiology, tools of risk assessment, and the available therapeutic modalities for LR-MDS. We discuss the use of erythropoiesis stimulating agents (ESAs), immunosuppressive therapy (IST), lenalidomide and the hypomethylating agents (HMAs). We also discuss the predictors of response, combination treatment modalities, and management of iron overload. Lastly, we overview the most promising investigational agents for LR-MDS. Expert commentary: It remains unclear how to best incorporate a wealth of new genetic and epigenetic prognostic markers into risk assessment tools especially for LR-MDS patients. Only a subset of patients respond to current treatment modalities and most responders eventually lose their response. Once standard therapeutic options fail, management becomes more challenging. Combination-based approaches have been largely unsuccessful. Among the most promising investigational are the TPO agonists, TGF- β pathway inhibitors, telomerase inhibitors, and the splicing modifiers.
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Affiliation(s)
- Maximilian Stahl
- a Section of Hematology, Department of Internal Medicine, Section of Hematology, Yale University and the Yale Comprehensive Cancer Center , Yale University School of Medicine , New Haven , CT , USA
| | - Amer M Zeidan
- a Section of Hematology, Department of Internal Medicine, Section of Hematology, Yale University and the Yale Comprehensive Cancer Center , Yale University School of Medicine , New Haven , CT , USA
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Evaluation of efficacy of alemtuzumab in 5 patients with aplastic anemia and/or myelodysplastic neoplasm. Wien Klin Wochenschr 2016; 129:404-410. [PMID: 27743175 PMCID: PMC5486731 DOI: 10.1007/s00508-016-1091-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2015] [Accepted: 09/01/2016] [Indexed: 11/25/2022]
Abstract
Patients with aplastic anemia or hypoplastic myelodysplastic syndrome (MDS) may respond to immunosuppressive therapy, including the anti-CD52 antibody alemtuzumab. We analyzed treatment responses to alemtuzumab in 5 patients with MDS or aplastic anemia (AA) evolving to MDS. Two patients with hypoplastic MDS (hMDS) showed a partial response (PR) to alemtuzumab. In both responding patients, a concomitant paroxysmal nocturnal hemoglobinuria (PNH) clone was detected before therapy. One responder relapsed after 15 months and underwent successful allogeneic stem cell transplantation. Both patients are still alive and in remission after 40 and 20 months, respectively. The other patients showed no response to alemtuzumab. One patient died from pneumonia 4 months after treatment. In summary, our data confirm that alemtuzumab is an effective treatment option for a subset of patients with MDS, even in the presence of a PNH clone.
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28
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Zeidan AM, Stahl M, Komrokji R. Emerging biological therapies for the treatment of myelodysplastic syndromes. Expert Opin Emerg Drugs 2016; 21:283-300. [DOI: 10.1080/14728214.2016.1220534] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
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Wolach O, Stone R. Autoimmunity and Inflammation in Myelodysplastic Syndromes. Acta Haematol 2016; 136:108-17. [PMID: 27337745 DOI: 10.1159/000446062] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2016] [Accepted: 04/06/2016] [Indexed: 01/28/2023]
Abstract
Autoimmune and inflammatory conditions (AICs) are encountered in up to 25% of patients with myelodysplastic syndromes (MDS). A wide range of AICs have been reported in association with MDS and can range from limited clinical manifestations to systemic diseases affecting multiple organs. Vasculitides, connective tissue diseases, and inflammatory arthritis are frequently reported in different studies; noninfectious fever and constitutional symptoms at presentation are common. Associations between AICs and specific MDS characteristics vary by study, but the available data suggest that AICs cluster more often in younger patients with higher-risk MDS. In general, AICs do not seem to confer worse survival, although certain AICs may be associated with adverse outcome (e.g. vasculitis) or progression of MDS (Sweet's syndrome). Nonetheless, these complications may have a significant impact on quality of life and affect the timing and type of MDS-directed therapy. The mainstay of management of these complications in the short term relies on immunosuppressive drugs. Increasing evidence suggests that hypomethylating agents may be effective in treating these complications and reduce steroid dependence. While the pathogenesis of AICs is incompletely understood, growing appreciation of cellular immune deregulation, cytokine hypersecretion, and the genetic heterogeneity underlying MDS may improve our understanding of common pathways linking MDS, inflammation, and autoimmunity.
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Affiliation(s)
- Ofir Wolach
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Mass., USA
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Glenthøj A, Ørskov AD, Hansen JW, Hadrup SR, O'Connell C, Grønbæk K. Immune Mechanisms in Myelodysplastic Syndrome. Int J Mol Sci 2016; 17:ijms17060944. [PMID: 27314337 PMCID: PMC4926477 DOI: 10.3390/ijms17060944] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2016] [Revised: 05/31/2016] [Accepted: 06/08/2016] [Indexed: 12/12/2022] Open
Abstract
Myelodysplastic syndrome (MDS) is a spectrum of diseases, characterized by debilitating cytopenias and a propensity of developing acute myeloid leukemia. Comprehensive sequencing efforts have revealed a range of mutations characteristic, but not specific, of MDS. Epidemiologically, autoimmune diseases are common in patients with MDS, fueling hypotheses of common etiological mechanisms. Both innate and adaptive immune pathways are overly active in the hematopoietic niche of MDS. Although supportive care, growth factors, and hypomethylating agents are the mainstay of MDS treatment, some patients—especially younger low-risk patients with HLA-DR15 tissue type—demonstrate impressive response rates after immunosuppressive therapy. This is in contrast to higher-risk MDS patients, where several immune activating treatments, such as immune checkpoint inhibitors, are in the pipeline. Thus, the dual role of immune mechanisms in MDS is challenging, and rigorous translational studies are needed to establish the value of immune manipulation as a treatment of MDS.
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Affiliation(s)
- Andreas Glenthøj
- Epi-/Genome Laboratory, Department of Hematology, Rigshospitalet, Copenhagen University Hospital, Copenhagen 2100, Denmark.
| | - Andreas Due Ørskov
- Epi-/Genome Laboratory, Department of Hematology, Rigshospitalet, Copenhagen University Hospital, Copenhagen 2100, Denmark.
| | - Jakob Werner Hansen
- Epi-/Genome Laboratory, Department of Hematology, Rigshospitalet, Copenhagen University Hospital, Copenhagen 2100, Denmark.
| | - Sine Reker Hadrup
- Section for Immunology and Vaccinology, National Veterinary Institute, Technical University of Denmark, Frederiksberg 1870, Denmark.
| | - Casey O'Connell
- Jane Anne Nohl Division of Hematology, USC Norris Comprehensive Cancer Center, Los Angeles, CA 90033, USA.
- Stand up to Cancer Epigenetics Dream Team, Van Andel Research Institute, Grand Rapids, MI 49503, USA.
| | - Kirsten Grønbæk
- Epi-/Genome Laboratory, Department of Hematology, Rigshospitalet, Copenhagen University Hospital, Copenhagen 2100, Denmark.
- Stand up to Cancer Epigenetics Dream Team, Van Andel Research Institute, Grand Rapids, MI 49503, USA.
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Wang J, Qin T, Xu Z, Zhang Y, Zhang H, Fang L, Pan L, Hu N, Qu S, Li B, Xiao Z. [Long- term outcome of thalidomide and cyclosporine in patients with IPSS low/intermediate- 1 myelodysplastic syndromes]. ZHONGHUA XUE YE XUE ZA ZHI = ZHONGHUA XUEYEXUE ZAZHI 2016; 36:942-6. [PMID: 26632468 PMCID: PMC7342423 DOI: 10.3760/cma.j.issn.0253-2727.2015.11.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
目的 评价环孢素(CsA)联合沙利度胺治疗国际预后积分系统(IPSS)低危/中危-1骨髓增生异常综合征(MDS)患者的远期疗效及预后影响因素。 方法 回顾性分析CsA联合沙利度胺治疗的76例IPSS低危/中危-1 MDS患者临床资料。采用PCR联合直接测序法检测患者cereblon基因rs1672753位点基因型。 结果 76例患者中,男48例,女28例,中位年龄41(18~70)岁。CsA联合沙利度胺治疗后,40例(53%)获得血液学改善(HI),其中红系反应(HI-E)率为43%(73例中31例),中性粒细胞反应(HI-N)率为30%(50例中15例),血小板反应(HI-P)率为31%(58例中18例)。59例红细胞输注依赖患者中27例(46%)获得HI-E并脱离输血。HI中位维持时间为22(1~131+)个月。单因素分析显示骨髓原始细胞≤2%的患者疗效持续时间更长(P=0.010)。cereblon基因rs1672753位点基因型与HI率及治疗反应的维持时间均无明显相关性(P值均>0.05)。67例未行造血干细胞移植患者中位生存时间为82(95% CI 38~126)个月。多因素分析显示IPSS-R分组(HR=3.461,95% CI 1.126~10.639,P= 0.030)、年龄≥60岁(HR=4.120,95% CI 1.070~15.867,P=0.040)以及HI-N(HR=7.733,95% CI 1.007~59.396,P=0.049)为影响患者生存时间的独立预后因素。 结论 CsA联合沙利度胺治疗能长期改善IPSS低危/中危-1 MDS患者贫血症状,不良反应轻。在此组患者中未能验证cereblon基因rs1672753位点基因型对疗效的预测价值。
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Affiliation(s)
- Jingya Wang
- Institute of Hematology and Blood Disease Hospital, CAMS & PUMC, State Key Laboratory of Experimental Hematology, Tianjin 300020, China
| | - Tiejun Qin
- Institute of Hematology and Blood Disease Hospital, CAMS & PUMC, State Key Laboratory of Experimental Hematology, Tianjin 300020, China
| | - Zefeng Xu
- Institute of Hematology and Blood Disease Hospital, CAMS & PUMC, State Key Laboratory of Experimental Hematology, Tianjin 300020, China
| | - Yue Zhang
- Institute of Hematology and Blood Disease Hospital, CAMS & PUMC, State Key Laboratory of Experimental Hematology, Tianjin 300020, China
| | - Hongli Zhang
- Institute of Hematology and Blood Disease Hospital, CAMS & PUMC, State Key Laboratory of Experimental Hematology, Tianjin 300020, China
| | - Liwei Fang
- Institute of Hematology and Blood Disease Hospital, CAMS & PUMC, State Key Laboratory of Experimental Hematology, Tianjin 300020, China
| | - Lijuan Pan
- Institute of Hematology and Blood Disease Hospital, CAMS & PUMC, State Key Laboratory of Experimental Hematology, Tianjin 300020, China
| | - Naibo Hu
- Institute of Hematology and Blood Disease Hospital, CAMS & PUMC, State Key Laboratory of Experimental Hematology, Tianjin 300020, China
| | - Shiqiang Qu
- Institute of Hematology and Blood Disease Hospital, CAMS & PUMC, State Key Laboratory of Experimental Hematology, Tianjin 300020, China
| | - Bing Li
- Institute of Hematology and Blood Disease Hospital, CAMS & PUMC, State Key Laboratory of Experimental Hematology, Tianjin 300020, China
| | - Zhijian Xiao
- Institute of Hematology and Blood Disease Hospital, CAMS & PUMC, State Key Laboratory of Experimental Hematology, Tianjin 300020, China
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Harnan S, Ren S, Gomersall T, Everson-Hock ES, Sutton A, Dhanasiri S, Kulasekararaj A. Association between Transfusion Status and Overall Survival in Patients with Myelodysplastic Syndromes: A Systematic Literature Review and Meta-Analysis. Acta Haematol 2016; 136:23-42. [PMID: 27160308 DOI: 10.1159/000445163] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2015] [Accepted: 03/02/2016] [Indexed: 02/06/2023]
Abstract
INTRODUCTION Multiple studies show that transfusion independence (TI) in myelodysplastic syndrome (MDS) has a positive impact on overall survival (OS). To assess this, a systematic review and meta-analysis of the association between TI and OS in patients with MDS was conducted (PROSPERO ID: CRD42014007264). METHODS Comprehensive searches of 5 key bibliographic databases were conducted and supplemented with additional search techniques. Included were studies that had recruited adults aged >18 years with MDS and had examined the impact of transfusion status on OS. RESULTS Fifty-five studies (89 citations) were included. The vast majority reported a statistically significant hazard ratio (HR) for OS in favor of TI patients or in patients who acquired TI after treatment. A random-effects meta-analysis was conducted. Patients classed as TI at baseline showed a 59% decrease in the risk of death compared with transfusion-dependent (TD) patients [HR 0.41; 95% credible interval (CrI) 0.29-0.56], and this effect did not appear to interact significantly with illness severity (interaction coefficient HR 1.38; 95% CrI 0.62-3.41). A meta-analysis of studies where patients acquired TI was not possible, but those studies consistently reported a survival benefit for those who acquired TI. CONCLUSION The findings revealed a 59% pooled reduction in mortality among TI patients when compared with TD patients.
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Affiliation(s)
- Sue Harnan
- Health Economics and Decision Science, School of Health and Related Research, University of Sheffield, Sheffield, UK
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Li X, Shi J, Wang M, Nie N, Shao Y, Ge M, Huang J, Huang Z, Zhang J, Zheng Y. Cyclosporine Combined with Levamisole for Lower-Risk Myelodysplastic Syndromes. Acta Haematol 2015; 134:138-45. [PMID: 25925993 DOI: 10.1159/000370097] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2014] [Accepted: 11/25/2014] [Indexed: 11/19/2022]
Abstract
Clinical and experimental evidence suggests an immune-mediated pathophysiology in subjects with lower-risk myelodysplastic syndromes (MDS) in whom immunosuppressive therapy may be effective. The novel immunosuppressive strategy of cyclosporine A (CsA) alternately combined with levamisole (LMS; CsA + LMS regimen) can dramatically improve the response rate and survival in aplastic anemia from those of our previous study. Herein, we retrospectively analyzed the data of 89 lower-risk MDS patients who received the CsA + LMS regimen. A total of 63 patients (70.8%) achieved either complete remission or hematological improvement at 4 months. Overall, 51, 41 and 19 patients had erythroid, platelet and neutrophil responses, respectively. Following the CsA + LMS regimen, 6 patients progressed to more advanced MDS at a median interval of 5 months (range, 3-42 months). The estimated 24-month progression-free survival was 82.2% (95% CI, 72.84-91.56) for all patients. Within the median follow-up of 18.5 months (range, 7.0-61.0), 6 patients died. In conclusion, the CsA + LMS regimen alleviated cytopenias and improved survival and freedom from evolution, suggesting that it could be reserved as an alternative choice for lower-risk MDS.
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Affiliation(s)
- Xingxin Li
- Severe Aplastic Anemia Studying Program, State Key Laboratory of Experimental Hematology, Institute of Hematology and Blood Diseases Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Tianjin, PR China
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Garcia-Manero G. Myelodysplastic syndromes: 2015 Update on diagnosis, risk-stratification and management. Am J Hematol 2015; 90:831-41. [PMID: 26294090 DOI: 10.1002/ajh.24102] [Citation(s) in RCA: 85] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2015] [Accepted: 06/24/2015] [Indexed: 02/03/2023]
Abstract
DISEASE OVERVIEW The myelodysplastic syndromes (MDS) are a very heterogeneous group of myeloid disorders characterized by peripheral blood cytopenias and increased risk of transformation to acute myelogenous leukemia (AML). MDS occurs more frequently in older males and in individuals with prior exposure to cytotoxic therapy. DIAGNOSIS Diagnosis of MDS is based on morphological evidence of dysplasia upon visual examination of a bone marrow aspirate and biopsy. Information obtained from additional studies such as karyotype, flow cytometry, or molecular genetics is complementary but not diagnostic. Risk-stratification: Prognosis of patients with MDS can be calculated using a number of scoring systems. In general, all these scoring systems include analysis of peripheral cytopenias, percentage of blasts in the bone marrow, and cytogenetic characteristics. The most commonly used system still is probably the International Prognostic Scoring System (IPSS). IPSS is being replaced by the new revised score IPSS-R. RISK-ADAPTED THERAPY Therapy is selected based on risk, transfusion needs, percent of bone marrow blasts, and more recently cytogenetic and mutational profiles. Goals of therapy are different in lower risk patients than in higher risk. In lower risk, the goal is to decrease transfusion needs and transformation to higher risk disease or AML, as well as to improve survival. In higher risk, the goal is to prolong survival. Current available therapies include growth factor support, lenalidomide, hypomethylating agents, intensive chemotherapy, and allogeneic stem cell transplantation. The use of lenalidomide has significant clinical activity in patients with lower risk disease, anemia, and a chromosome 5 alteration. 5-Azacitidine and decitabine have activity in higher risk MDS. 5-Azacitidine has been shown to improve survival in higher risk MDS. A number of new molecular lesions have been described in MDS that may serve as new therapeutic targets or aid in the selection of currently available agents. Additional supportive care measures may include the use of prophylactic antibiotics and iron chelation. Management of progressive or refractory disease: At the present time there are no approved interventions for patients with progressive or refractory disease particularly after hypomethylating based therapy. Options include participation in a clinical trial or cytarabine based therapy and stem cell transplantation.
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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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Odenike O, Onida F, Padron E. Myelodysplastic syndromes and myelodysplastic/myeloproliferative neoplasms: an update on risk stratification, molecular genetics, and therapeutic approaches including allogeneic hematopoietic stem cell transplantation. Am Soc Clin Oncol Educ Book 2015:e398-e412. [PMID: 25993202 DOI: 10.14694/edbook_am.2015.35.e398] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
Myelodysplastic syndromes are a heterogeneous group of clonal hematopoietic stem cell disorders characterized by ineffective hematopoiesis, peripheral cytopenias, and a variable propensity for leukemic transformation. In recent years there has been an explosion of information on the molecular genetic changes underlying these disorders. This information has substantial prognostic implications, and the influence on therapeutic approaches and the treatment of patients is evolving. Allogeneic hematopoietic stem cell transplantation (alloSCT) is the only known cure for these diseases, but appropriate patient selection is of utmost importance from a risk-benefit perspective. This review focuses on the factors influencing risk stratification in MDS and optimal choice of front-line therapy in the current era, including the interplay of clinical factors and molecular genetic factors, and factors that determine eligibility for alloSCT. The myelodysplastic/myeloproliferative diseases also will be discussed, including the increasing effort to understand the molecular genetics and natural history of these disorders and treatment approaches.
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Affiliation(s)
- Olatoyosi Odenike
- From the Section of Hematology/Oncology, and the Comprehensive Cancer Center, The University of Chicago, Chicago, IL; Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, University of Milan, Milan, Italy; Moffitt Cancer Center, Tampa, FL
| | - Francesco Onida
- From the Section of Hematology/Oncology, and the Comprehensive Cancer Center, The University of Chicago, Chicago, IL; Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, University of Milan, Milan, Italy; Moffitt Cancer Center, Tampa, FL
| | - Eric Padron
- From the Section of Hematology/Oncology, and the Comprehensive Cancer Center, The University of Chicago, Chicago, IL; Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, University of Milan, Milan, Italy; Moffitt Cancer Center, Tampa, FL
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Babushok DV, Bessler M. Genetic predisposition syndromes: when should they be considered in the work-up of MDS? Best Pract Res Clin Haematol 2014; 28:55-68. [PMID: 25659730 DOI: 10.1016/j.beha.2014.11.004] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2014] [Accepted: 11/04/2014] [Indexed: 01/04/2023]
Abstract
Myelodysplastic syndromes (MDS) are clonal hematopoietic disorders characterized by cytopenias, ineffective hematopoiesis, myelodysplasia, and an increased risk of acute myeloid leukemia (AML). While sporadic MDS is primarily a disease of the elderly, MDS in children and young and middle-aged adults is frequently associated with underlying genetic predisposition syndromes. In addition to the classic hereditary bone marrow failure syndromes (BMFS) such as Fanconi Anemia and Dyskeratosis Congenita, in recent years there has been an increased awareness of non-syndromic familial MDS/AML predisposition syndromes such as those caused by mutations in GATA2, RUNX1, CEBPA, and SRP72 genes. Here, we will discuss the importance of recognizing an underlying genetic predisposition syndrome a patient with MDS, will review clinical scenarios when genetic predisposition should be considered, and will provide a practical overview of the common BMFS and familial MDS/AML syndromes which may be encountered in adult patients with MDS.
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Affiliation(s)
- Daria V Babushok
- Comprehensive Bone Marrow Failure Center, Division of Hematology, Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, PA, USA; Division of Hematology, Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, PA, USA.
| | - Monica Bessler
- Comprehensive Bone Marrow Failure Center, Division of Hematology, Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, PA, USA; Division of Hematology, Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, PA, USA.
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Abstract
Abstract
Once thought to be rare disorders, the myelodysplastic syndromes (MDS) are now recognized as among the most common hematological neoplasms, probably affecting >30 000 patients per year in the United States. US regulatory approval of azacitidine, decitabine, and lenalidomide between 2004 and 2006 seemed to herald a new era in the development of disease-modifying therapies for MDS, but there have been no further drug approvals for MDS indications in the United States in the last 8 years. The available drugs are not curative, and few of the compounds that are currently in development are likely to be approved in the near future. As a result, MDS diagnoses continue to place a heavy burden on both patients and health care systems. Incomplete understanding of disease pathology, the inherent biological complexity of MDS, and the presence of comorbid conditions and poor performance status in the typical older patient with MDS have been major impediments to development of effective novel therapies. Here we discuss new insights from genomic discoveries that are illuminating MDS pathogenesis, increasing diagnostic accuracy, and refining prognostic assessment, and which will one day contribute to more effective treatments and improved patient outcomes.
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Meers S. The myelodysplastic syndromes: the era of understanding. Eur J Haematol 2014; 94:379-90. [PMID: 25186093 DOI: 10.1111/ejh.12443] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/26/2014] [Indexed: 12/28/2022]
Abstract
Myelodysplastic syndromes are a heterogeneous group of clonal haematological stem cell disorders. Allogeneic stem cells transplantation remains the only curative treatment but only a minority of patients are eligible for this treatment. In spite of this, it has become clear that treatment with lenalidomide and azanucleotides can lead to increased overall survival in particular subsets of patients with MDS. The relative silence on the therapeutic side is counter-balanced by major advances in the understanding of this heterogeneous disease. The introduction of high-throughput molecular techniques has resulted in the discovery that most patients harbour molecular aberrations, including pathways such as the spliceosome machinery previously not known to be involved. These newly discovered pathways will undoubtedly result in new therapeutic strategies for this difficult to treat disease.
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Affiliation(s)
- Stef Meers
- AZ KLINA, Iridium Cancer Network, Brasschaat, Belgium
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40
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Somatic mutations identify a subgroup of aplastic anemia patients who progress to myelodysplastic syndrome. Blood 2014; 124:2698-704. [PMID: 25139356 DOI: 10.1182/blood-2014-05-574889] [Citation(s) in RCA: 184] [Impact Index Per Article: 18.4] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
The distinction between acquired aplastic anemia (AA) and hypocellular myelodysplastic syndrome (hMDS) is often difficult, especially nonsevere AA. We postulated that somatic mutations are present in a subset of AA, and predict malignant transformation. From our database, we identified 150 AA patients with no morphological evidence of MDS, who had stored bone marrow (BM) and constitutional DNA. We excluded Fanconi anemia, mutations of telomere maintenance, and a family history of BM failure (BMF) or cancer. The initial cohort of 57 patients was screened for 835 known genes associated with BMF and myeloid cancer; a second cohort of 93 patients was screened for mutations in ASXL1, DNMT3A, BCOR, TET2, and MPL. Somatic mutations were detected in 19% of AA, and included ASXL1 (n = 12), DNMT3A (n = 8) and BCOR (n = 6). Patients with somatic mutations had a longer disease duration (37 vs 8 months, P < .04), and shorter telomere lengths (median length, 0.9 vs 1.1, P < .001), compared with patients without mutations. Somatic mutations in AA patients with a disease duration of >6 months were associated with a 40% risk of transformation to MDS (P < .0002). Nearly one-fifth of AA patients harbor mutations in genes typically seen in myeloid malignancies that predicted for later transformation to MDS.
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Duong VH, Komrokji RS, List AF. Update on the pharmacotherapy for myelodysplastic syndromes. Expert Opin Pharmacother 2014; 15:1811-25. [DOI: 10.1517/14656566.2014.937705] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
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Fenaux P, Haase D, Sanz GF, Santini V, Buske C. Myelodysplastic syndromes: ESMO Clinical Practice Guidelines for diagnosis, treatment and follow-up. Ann Oncol 2014; 25 Suppl 3:iii57-69. [PMID: 25185242 DOI: 10.1093/annonc/mdu180] [Citation(s) in RCA: 66] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023] Open
Affiliation(s)
- P Fenaux
- Service d'Hématologie Clinique, Groupe Francophone des Myélodysplasies (GFM), Hôpital St Louis (Assistance Publique, Hôpitaux de Paris) and Paris 7 University, Paris, France
| | - D Haase
- Clinics of Hematology and Medical Oncology, University Medicine, Goettingen, Germany
| | - G F Sanz
- Department of Haematology, Hospital Universitario y Politécnico La Fe, Valencia, Spain
| | - V Santini
- Functional Unit of Haematology, AOU Careggi, University of Florence, Firenze, Italy
| | - C Buske
- Comprehensive Cancer Center Ulm, Institute of Experimental Cancer Research, University Hospital, Ulm, Germany
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Abstract
Myelodysplastic syndromes are clonal marrow stem-cell disorders, characterised by ineffective haemopoiesis leading to blood cytopenias, and by progression to acute myeloid leukaemia in a third of patients. 15% of cases occur after chemotherapy or radiotherapy for a previous cancer; the syndromes are most common in elderly people. The pathophysiology involves cytogenetic changes with or without gene mutations and widespread gene hypermethylation at advanced stages. Clinical manifestations result from cytopenias (anaemia, infection, and bleeding). Diagnosis is based on examination of blood and bone marrow showing blood cytopenias and hypercellular marrow with dysplasia, with or without excess of blasts. Prognosis depends largely on the marrow blast percentage, number and extent of cytopenias, and cytogenetic abnormalities. Treatment of patients with lower-risk myelodysplastic syndromes, especially for anaemia, includes growth factors, lenalidomide, and transfusions. Treatment of higher-risk patients is with hypomethylating agents and, whenever possible, allogeneic stem-cell transplantation.
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Affiliation(s)
- Lionel Adès
- Service d'hématologie, Hôpital St Louis (Assistance Publique Hôpitaux de Paris) and Paris 7 University, Paris, France
| | - Raphael Itzykson
- Service d'hématologie, Hôpital St Louis (Assistance Publique Hôpitaux de Paris) and Paris 7 University, Paris, France
| | - Pierre Fenaux
- Service d'hématologie, Hôpital St Louis (Assistance Publique Hôpitaux de Paris) and Paris 7 University, Paris, France.
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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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Killick SB, Carter C, Culligan D, Dalley C, Das-Gupta E, Drummond M, Enright H, Jones GL, Kell J, Mills J, Mufti G, Parker J, Raj K, Sternberg A, Vyas P, Bowen D. Guidelines for the diagnosis and management of adult myelodysplastic syndromes. Br J Haematol 2014; 164:503-25. [PMID: 24372298 DOI: 10.1111/bjh.12694] [Citation(s) in RCA: 67] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Affiliation(s)
- Sally B Killick
- The Royal Bournemouth and Christchurch Hospitals NHS Foundation Trust, Bournemouth, UK
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Komrokji RS, Mailloux AW, Chen DT, Sekeres MA, Paquette R, Fulp WJ, Sugimori C, Paleveda-Pena J, Maciejewski JP, List AF, Epling-Burnette PK. A phase II multicenter rabbit anti-thymocyte globulin trial in patients with myelodysplastic syndromes identifying a novel model for response prediction. Haematologica 2014; 99:1176-83. [PMID: 24488560 DOI: 10.3324/haematol.2012.083345] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
Immune dysregulation is a mechanism contributing to ineffective hematopoiesis in a subset of myelodysplastic syndrome patients. We report the first US multicenter non-randomized, phase II trial examining the efficacy of rabbit(r)-anti-thymocyte globulin using 2.5 mg/kg/day administered daily for 4 doses. The primary end point was hematologic response; secondary end points included duration of response, time to response, time to progression, and tolerance. Nine (33%;95% confidence interval=17%-54%) of the 27 patients treated experienced durable hematologic improvement in an intent-to-treat analysis with a median time to response and median response duration of 75 and 245 days, respectively. While younger age is the most significant factor favoring equine(e)-anti-thymocyte globulin response, treatment outcome on this study was independent of age (P=0.499). A shorter duration between diagnosis and treatment showed a positive trend (P=0.18), but International Prognostic Scoring System score (P=0.150), karyotype (P=0.319), and age-adjusted bone marrow cellularity (P=0.369) were not associated with response classification. Since activated T-lymphocytes are the primary cellular target of anti-thymocyte globulin, a T-cell expression profiling was conducted in a cohort of 38 patients consisting of rabbit and equine-antithymocyte globulin-treated patients. A model containing disease duration, CD8 terminal memory T cells and T-cell proliferation-associated-antigen expression predicted response with the greatest accuracy using a leave-one-out cross validation approach. This profile categorized patients independent of other covariates, including treatment type and age using a leave-one-out-cross-validation approach (75.7%). Therefore, rabbit-anti-thymocyte globulin has hematologic remitting activity in myelodysplastic syndrome and a T-cell activation profile has potential utility classifying those who are more likely to respond (NCT00466843 clinicaltrials.gov).
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Affiliation(s)
- Rami S Komrokji
- Malignant Hematology Division, H. Lee Moffitt Cancer Center, Tampa, FL, USA
| | - Adam W Mailloux
- Immunology Program, H. Lee Moffitt Cancer Center, Tampa, FL, USA
| | - Dung-Tsa Chen
- Biostatistics Program, H. Lee H. Lee Moffitt Cancer Center, Tampa, FL, USA
| | | | | | - William J Fulp
- Biostatistics Program, H. Lee H. Lee Moffitt Cancer Center, Tampa, FL, USA
| | - Chiharu Sugimori
- Ishikawa Prefectural Central Hospital, Kuratsukihigashi, Kanazawa, Japan
| | | | | | - Alan F List
- Malignant Hematology Division, H. Lee Moffitt Cancer Center, Tampa, FL, USA
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Garcia-Manero G. Myelodysplastic syndromes: 2014 update on diagnosis, risk-stratification, and management. Am J Hematol 2014; 89:97-108. [PMID: 24464505 DOI: 10.1002/ajh.23642] [Citation(s) in RCA: 97] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2013] [Indexed: 02/03/2023]
Abstract
DISEASE OVERVIEW The myelodysplastic (MDS) are a very heterogeneous group of myeloid disorders characterized by peripheral blood cytopenias and increased risk of transformation to acute myelogenous leukemia (AML). MDS occurs more frequently in older male and in individuals with prior exposure to cytotoxic therapy. DIAGNOSIS Diagnosis of MDS is based on morphological evidence of dysplasia upon visual examination of a bone marrow aspirate and biopsy. Information obtained from additional studies such as karyotype, flow cytometry or molecular genetics is complementary but not diagnostic. RISK-STRATIFICATION: Prognosis of patients with MDS can be calculated using a number of scoring systems. In general, all these scoring systems include analysis of peripheral cytopenias, percentage of blasts in the bone marrow and cytogenetic characteristics. The most commonly used system is the International Prognostic Scoring System (IPSS). IPSS is likely to be replaced by a new revised score (IPSS-R) and by the incorporation of new molecular markers recently described. RISK-ADAPTED THERAPY Therapy is selected based on risk, transfusion needs, percent of bone marrow blasts and more recently cytogenetic profile. Goals of therapy are different in lower risk patients than in higher risk. In lower risk, the goal is to decrease transfusion needs and transformation to higher risk disease or AML, as well as to improve survival. In higher risk, the goal is to prolong survival. Current available therapies include growth factor support, lenalidomide, hypomethylating agents, intensive chemotherapy, and allogeneic stem cell transplantation. The use of lenalidomide has significant clinical activity in patients with lower risk disease, anemia, and a chromosome 5 alteration. 5-Azacitidine and decitabine have activity in higher risk MDS. 5-Azacitidine has been shown to improve survival in higher risk MDS. A number of new molecular lesions have been described in MDS that may serve as new therapeutic targets or aid in the selection of currently available agents. Additional supportive care measures may include the use of prophylactic antibiotics and iron chelation. MANAGEMENT OF PROGRESSIVE OR REFRACTORY DISEASE There are no approved interventions for patients with progressive or refractory disease particularly after hypomethylating based therapy. Options include cytarabine based therapy, transplantation and participation on a clinical trial.
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Braun T, Fenaux P. Myelodysplastic Syndromes (MDS) and autoimmune disorders (AD): Cause or consequence? Best Pract Res Clin Haematol 2013; 26:327-36. [DOI: 10.1016/j.beha.2013.09.003] [Citation(s) in RCA: 60] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
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Long-term outcome of immunosuppressive therapy for Japanese patients with lower-risk myelodysplastic syndromes. Int J Hematol 2013; 98:687-93. [PMID: 24254637 DOI: 10.1007/s12185-013-1468-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2013] [Revised: 11/05/2013] [Accepted: 11/06/2013] [Indexed: 10/26/2022]
Abstract
To investigate the long-term usefulness of immunosuppressive therapy (IST) for Japanese patients with lower-risk myelodysplastic syndromes, we retrospectively analyzed 29 MDS patients who were treated with cyclosporine A alone or with anti-thymocyte globulin at a single institute in Japan. A total of 58.6 % of patients showed hematological response to IST. Overall survival of all patients was 74.5 % at 5 years and 48.3 % at 10 years. The major adverse event was the elevation of creatinine level (grade 1 and 2). Eleven patients were still on IST at the time of analysis with, at least, some clinical benefits. Pneumonia was the most frequent cause of death (eight of 12 deaths), followed by bleeding (three of 12); most of the patients who died were non-responders. The presence of paroxysmal nocturnal hemoglobinuria-type cells was significantly associated with both response to IST and long-term survival by univariate analysis. The 10-year overall survival of responders (72.2 %) was significantly superior to that of non-responders (15.6 %, P < 0.0001). These results suggest that IST using cyclosporine A provides long-term benefit for Japanese patients with lower-risk MDS.
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Heredia FF, de Sousa JC, Ribeiro Junior HL, Carvalho AF, Magalhaes SMM, Pinheiro RF. Proteins related to the spindle and checkpoint mitotic emphasize the different pathogenesis of hypoplastic MDS. Leuk Res 2013; 38:218-24. [PMID: 24314588 DOI: 10.1016/j.leukres.2013.11.003] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2013] [Revised: 10/21/2013] [Accepted: 11/02/2013] [Indexed: 10/26/2022]
Abstract
Some studies show that alterations in expression of proteins related to mitotic spindle (AURORAS KINASE A and B) and mitotic checkpoint (CDC20 and MAD2L1) are involved in chromosomal instability and tumor progression in various solid and hematologic malignancies. This study aimed to evaluate these genes in MDS patients. The cytogenetics analysis was carried out by G-banding, AURKA and AURKB amplification was performed using FISH, and AURKA, AURKB, CDC20 and MAD2L1 gene expression was performed by qRT-PCR in 61 samples of bone marrow from MDS patients. AURKA gene amplification was observed in 10% of the cases, which also showed higher expression levels than the control group (p=0.038). Patients with normo/hypercellular BM presented significantly higher expression levels than hypocellular BM patients, but normo and hypercellular BM groups did not differ. After logistic regression analysis, our results showed that HIGH expression levels were associated with increased risk of developing normo/hypercellular MDS. It also indicated that age is associated with AURKA, CDC20 and MAD2L1 HIGH expression levels. The distinct expression of hypocellular patients emphasizes the prognostic importance of cellularity to MDS. The amplification/high expression of AURKA suggests that the increased expression of this gene may be related to the pathogenesis of disease.
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Affiliation(s)
| | | | | | | | - Silvia Maria Meira Magalhaes
- Department of Clinical Medicine, Division of Hematology, Walter Cantidio Hospital, Federal University of Ceará, Brazil
| | - Ronald Feitosa Pinheiro
- Department of Clinical Medicine, Division of Hematology, Walter Cantidio Hospital, Federal University of Ceará, Brazil.
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