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Barnea I, Luria L, Girsault A, Dabah O, Dudaie M, Mirsky SK, Merkel D, Shaked NT. Analyzing Blood Cells of High-Risk Myelodysplastic Syndrome Patients Using Interferometric Phase Microscopy and Fluorescent Flow Cytometry. Bioengineering (Basel) 2024; 11:256. [PMID: 38534530 DOI: 10.3390/bioengineering11030256] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2024] [Revised: 02/28/2024] [Accepted: 03/03/2024] [Indexed: 03/28/2024] Open
Abstract
Myelodysplastic syndromes (MDSs) are a group of potentially deadly diseases that affect the morphology and function of neutrophils. Rapid diagnosis of MDS is crucial for the initiation of treatment that can vastly improve disease outcome. In this work, we present a new approach for detecting morphological differences between neutrophils isolated from blood samples of high-risk MDS patients and blood bank donors (BBDs). Using fluorescent flow cytometry, neutrophils were stained with 2',7'-dichlorofluorescin diacetate (DCF), which reacts with reactive oxygen species (ROS), and Hoechst, which binds to DNA. We observed that BBDs possessed two cell clusters (designated H and L), whereas MDS patients possessed a single cluster (L). Later, we used FACS to sort the H and the L cells and used interferometric phase microscopy (IPM) to image the cells without utilizing cell staining. IPM images showed that H cells are characterized by low optical path delay (OPD) in the nucleus relative to the cytoplasm, especially in cell vesicles containing ROS, whereas L cells are characterized by low OPD in the cytoplasm relative to the nucleus and no ROS-containing vesicles. Moreover, L cells present a higher average OPD and dry mass compared to H cells. When examining neutrophils from MDS patients and BBDs by IPM during flow, we identified ~20% of cells as H cells in BBDs in contrast to ~4% in MDS patients. These results indicate that IPM can be utilized for the diagnosis of complex hematological pathologies such as MDS.
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Affiliation(s)
- Itay Barnea
- Department of Biomedical Engineering, Tel Aviv University, Tel Aviv 6997801, Israel
| | - Lior Luria
- Department of Biomedical Engineering, Tel Aviv University, Tel Aviv 6997801, Israel
| | - Arik Girsault
- Department of Biomedical Engineering, Tel Aviv University, Tel Aviv 6997801, Israel
| | - Ofira Dabah
- Department of Biomedical Engineering, Tel Aviv University, Tel Aviv 6997801, Israel
| | - Matan Dudaie
- Department of Biomedical Engineering, Tel Aviv University, Tel Aviv 6997801, Israel
| | - Simcha K Mirsky
- Department of Biomedical Engineering, Tel Aviv University, Tel Aviv 6997801, Israel
| | - Drorit Merkel
- MDS Center, Sheba Medical Center, Ramat Gan 5266202, Israel
- Faculty of Medicine, Tel Aviv University, Tel Aviv 6997801, Israel
| | - Natan T Shaked
- Department of Biomedical Engineering, Tel Aviv University, Tel Aviv 6997801, Israel
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Oliva EN, Riva M, Niscola P, Santini V, Breccia M, Giai V, Poloni A, Patriarca A, Crisà E, Capodanno I, Salutari P, Reda G, Cascavilla N, Ferrero D, Guarini A, Tripepi G, Iannì G, Russo E, Castelli A, Fattizzo B, Beltrami G, Bocchia M, Molteni A, Fenaux P, Germing U, Ricco A, Palumbo GA, Impera S, Di Renzo N, Rivellini F, Buccisano F, Stamatoullas-Bastard A, Liberati AM, Candoni A, Delfino IM, Arcadi MT, Cufari P, Rizzo L, Bova I, D'Errigo MG, Zini G, Latagliata R. Eltrombopag for Low-Risk Myelodysplastic Syndromes With Thrombocytopenia: Interim Results of a Phase II, Randomized, Placebo-Controlled Clinical Trial (EQOL-MDS). J Clin Oncol 2023; 41:4486-4496. [PMID: 37294914 PMCID: PMC10552995 DOI: 10.1200/jco.22.02699] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2022] [Revised: 03/16/2023] [Accepted: 05/01/2023] [Indexed: 06/11/2023] Open
Abstract
PURPOSE In myelodysplastic syndromes (MDS), severe thrombocytopenia is associated with poor prognosis. This multicenter trial presents the second-part long-term efficacy and safety results of eltrombopag in patients with low-risk MDS and severe thrombocytopenia. METHODS In this single-blind, randomized, placebo-controlled, phase-II trial of adult patients with International Prognostic Scoring System low- or intermediate-1-risk MDS, patients with a stable platelet (PLT) count (<30 × 103/mm3) received eltrombopag or placebo until disease progression. Primary end points were duration of PLT response (PLT-R; calculated from the time of PLT-R to date of loss of PLT-R, defined as bleeding/PLT count <30 × 103/mm3 or last date in observation) and long-term safety and tolerability. Secondary end points included incidence and severity of bleeding, PLT transfusions, quality of life, leukemia-free survival, progression-free survival, overall survival and pharmacokinetics. RESULTS From 2011 to 2021, of 325 patients screened, 169 patients were randomly assigned oral eltrombopag (N = 112) or placebo (N = 57) at a starting dose of 50 mg once daily to maximum of 300 mg. PLT-R, with 25-week follow-up (IQR, 14-68) occurred in 47/111 (42.3%) eltrombopag patients versus 6/54 (11.1%) in placebo (odds ratio, 5.9; 95% CI, 2.3 to 14.9; P < .001). In eltrombopag patients, 12/47 (25.5%) lost the PLT-R, with cumulative thrombocytopenia relapse-free survival at 60 months of 63.6% (95% CI, 46.0 to 81.2). Clinically significant bleeding (WHO bleeding score ≥ 2) occurred less frequently in the eltrombopag arm than in the placebo group (incidence rate ratio, 0.54; 95% CI, 0.38 to 0.75; P = .0002). Although no difference in the frequency of grade 1-2 adverse events (AEs) was observed, a higher proportion of eltrombopag patients experienced grade 3-4 AEs (χ2 = 9.5, P = .002). AML evolution and/or disease progression occurred in 17% (for both) of eltrombopag and placebo patients with no difference in survival times. CONCLUSION Eltrombopag was effective and relatively safe in low-risk MDS with severe thrombocytopenia. This trial is registered with ClinicalTrials.gov identifier: NCT02912208 and EU Clinical Trials Register: EudraCT No. 2010-022890-33.
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Affiliation(s)
- Esther Natalie Oliva
- U.O.C. Ematologia, Grande Ospedale Metropolitano Bianchi Melacrino Morelli, Reggio di Calabria, Italy
| | - Marta Riva
- Dipartimento di Ematologia, Ospedale Niguarda Ca' Granda, Milano, Italy
| | | | - Valeria Santini
- U.O. di Ematologia, Azienda Ospedaliera Universitaria Careggi, Firenze, Italy
| | - Massimo Breccia
- Dipartimento di Ematologia Policlinico Umberto I, Università La Sapienza, Roma, Italy
| | - Valentina Giai
- S.C. a Direzione Universitaria di Ematologia A.O., SS. Antonio e Biagio e Cesare Arrigo Alessandria, Alessandria, Italy
| | - Antonella Poloni
- Clinica di Ematologia Azienda Ospedaliera Universitaria—Ospedali Riuniti di Ancona, Ancona, Italy
| | | | - Elena Crisà
- Candiolo Cancer Institute, FPO-IRCCS, Candiolo, Turin, Italy
| | - Isabella Capodanno
- U.O. di Ematologia, A.U.S.L.-IRCCS di Reggio Emilia, Reggio Emilia, Italy
| | - Prassede Salutari
- Dipartimento Oncologico-Ematologico, Ospedale Civile Spirito Santo, Pescara, Italy
| | - Gianluigi Reda
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Nicola Cascavilla
- U.O. Ematologia Ospedale Casa Sollievo della Sofferenza, San Giovanni Rotondo, Italy
| | - Dario Ferrero
- Dipartimento Biotecnologie Molecolari, Ematologia Universitaria A.O.U. Citta' della Salute e della Scienza di Torino, Turin, Italy
| | - Attilio Guarini
- U.O. Ematologia I.R.C.C.S. Istituto Tumori “Giovanni Paolo II”, Bari, Italy
| | - Giovanni Tripepi
- IFC-CNR Institute of Clinical Physiology, Reggio Calabria, Italy
| | | | - Emilio Russo
- Department of Pharmacology, University of Germaneto Catanzaro, Catanzaro, Italy
| | | | - Bruno Fattizzo
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
- Dipartimento di Oncologia ed Emato-Oncologia, Università degli Studi di Milano, Milan, Italy
| | - Germana Beltrami
- U.O. Ematologia e terapie cellulari, IRCCS Azienda Ospedaliera Universitaria San Martino, Genova, Italy
| | - Monica Bocchia
- UOC Ematologia, Università di Siena, Azienda Ospedaliera Universitaria Senese, Siena, Italy
| | | | - Pierre Fenaux
- Groupe Francais desmyélodysplasies (GFM), Paris, France
| | - Ulrich Germing
- Department of Hematology, Oncology, and Clinical Immunology, Heinrich-Heine-University Düsseldorf, Düsseldorf, Germany
| | - Alessandra Ricco
- U.O. Ematologia con Trapianto, Azienda Ospedale Policlinicodi Bari, Bari, Italy
| | - Giuseppe A. Palumbo
- Dipartimento di Scienze Mediche Chirurgiche e Tecnologie Avanzate “G.F. Ingrassia”, University of Catania, Catania, Italy
| | - Stefana Impera
- U.O. C. Ematologia, A. O.ad Alta Specializzazione Ospedale Garibaldi Nesima, Catania, Italy
| | | | - Flavia Rivellini
- Divisione Ematologia, P.O. A. Tortora di Pagani-ASL Salerno, Pagani, Italy
| | - Francesco Buccisano
- Divisione di Biopatologia e Diagnostica per Immagini, Policlinico Universitario Tor Vergata, Rome, Italy
| | | | - Anna Marina Liberati
- S.C. Oncoematologia, Università degli Studi di Perugia A.O. Santa Maria, Terni, Italy
| | - Anna Candoni
- Divisione Ematologia, P.O. Santa Maria della Misericordia, A.S.U.F.C di Udine, Udine, Italy
| | - Ilaria Maria Delfino
- U.O.C. Ematologia, Grande Ospedale Metropolitano Bianchi Melacrino Morelli, Reggio di Calabria, Italy
| | - Maria Teresa Arcadi
- U.O. Farmacia Grande Ospedale Metropolitano Bianchi Melacrino Morelli, Reggio di Calabria, Italy
| | - Patrizia Cufari
- U.O.C. Ematologia, Grande Ospedale Metropolitano Bianchi Melacrino Morelli, Reggio di Calabria, Italy
| | - Lorenzo Rizzo
- Dipartimento di Ematologia, Ospedale Niguarda Ca' Granda, Milan, Italy
| | - Irene Bova
- U.O.S. di Genetica Medica Grande Ospedale Metropolitano Bianchi Melacrino Morelli, Reggio di Calabria, Italy
| | - Maria Grazia D'Errigo
- U.O.S. di Genetica Medica Grande Ospedale Metropolitano Bianchi Melacrino Morelli, Reggio di Calabria, Italy
| | - Gina Zini
- Fondazione Policlinico, Universitario A. Gemelli IRCCS, Rome, Italy
- Università Cattolica del Sacro Cuore, Rome, Italy
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Montarello N, Leslie A, Chhetri R, Friel O, Singhal D, Ross D, Yeung D, Kok CH, Psaltis PJ, Hiwase DK. Personalized risk model for predicting risk of acute coronary syndrome in patients with myelodysplastic syndromes. Blood Adv 2023; 7:3032-3035. [PMID: 36884290 PMCID: PMC10331405 DOI: 10.1182/bloodadvances.2022009173] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2022] [Revised: 02/28/2023] [Accepted: 03/02/2023] [Indexed: 03/09/2023] Open
Affiliation(s)
- Natalie Montarello
- Department of Cardiology, Central Adelaide Local Health Network, Adelaide, SA, Australia
| | - Alasdair Leslie
- Adelaide Medical School, University of Adelaide, Adelaide, SA, Australia
| | - Rakchha Chhetri
- Department of Haematology, Royal Adelaide Hospital, Adelaide, SA, Australia
| | - Oisin Friel
- Department of Medicine, Beaumont Hospital, Dublin, Ireland
| | - Deepak Singhal
- Adelaide Medical School, University of Adelaide, Adelaide, SA, Australia
- Department of Haematology, Royal Adelaide Hospital, Adelaide, SA, Australia
| | - David Ross
- Adelaide Medical School, University of Adelaide, Adelaide, SA, Australia
- Department of Haematology, Royal Adelaide Hospital, Adelaide, SA, Australia
- Precision Medicine Theme, South Australian Health and Medical Research Institute, Adelaide, SA, Australia
| | - David Yeung
- Adelaide Medical School, University of Adelaide, Adelaide, SA, Australia
- Department of Haematology, Royal Adelaide Hospital, Adelaide, SA, Australia
- Precision Medicine Theme, South Australian Health and Medical Research Institute, Adelaide, SA, Australia
| | - Chung H. Kok
- Adelaide Medical School, University of Adelaide, Adelaide, SA, Australia
- Precision Medicine Theme, South Australian Health and Medical Research Institute, Adelaide, SA, Australia
| | - Peter J. Psaltis
- Adelaide Medical School, University of Adelaide, Adelaide, SA, Australia
- Department of Cardiology, Royal Adelaide Hospital, Central Adelaide Local Health Network, Adelaide, SA, Australia
- Vascular Research Centre, Lifelong Health Theme, South Australian Health and Medical Research Institute, Adelaide, SA, Australia
| | - Devendra K. Hiwase
- Adelaide Medical School, University of Adelaide, Adelaide, SA, Australia
- Department of Haematology, Royal Adelaide Hospital, Adelaide, SA, Australia
- Precision Medicine Theme, South Australian Health and Medical Research Institute, Adelaide, SA, Australia
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4
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Stempel JM, Podoltsev NA, Dosani T. Supportive Care for Patients With Myelodysplastic Syndromes. Cancer J 2023; 29:168-178. [PMID: 37195773 DOI: 10.1097/ppo.0000000000000661] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/18/2023]
Abstract
ABSTRACT Myelodysplastic syndromes are a heterogeneous group of bone marrow disorders characterized by ineffective hematopoiesis, progressive cytopenias, and an innate capability of progressing to acute myeloid leukemia. The most common causes of morbidity and mortality are complications related to myelodysplastic syndromes rather than progression to acute myeloid leukemia. Although supportive care measures are applicable to all patients with myelodysplastic syndromes, they are especially essential in patients with lower-risk disease who have a better prognosis compared with their higher-risk counterparts and require longer-term monitoring of disease and treatment-related complications. In this review, we will address the most frequent complications and supportive care interventions used in patients with myelodysplastic syndromes, including transfusion support, management of iron overload, antimicrobial prophylaxis, important considerations in the era of COVID-19 (coronavirus infectious disease 2019), role of routine immunizations, and palliative care in the myelodysplastic syndrome population.
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Marques FK, Sabino ADP. Myelodysplastic neoplasms: An overview on diagnosis, risk-stratification, molecular pathogenesis, and treatment. Biomed Pharmacother 2022; 156:113905. [DOI: 10.1016/j.biopha.2022.113905] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2022] [Revised: 10/10/2022] [Accepted: 10/19/2022] [Indexed: 11/02/2022] Open
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Abnormal platelet immunophenotypes and percentage of giant platelets in myelodysplastic syndrome: A pilot study. PLoS One 2022; 17:e0278040. [PMID: 36409726 PMCID: PMC9678267 DOI: 10.1371/journal.pone.0278040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2022] [Accepted: 11/08/2022] [Indexed: 11/22/2022] Open
Abstract
OBJECTIVES Myelodysplastic syndrome (MDS) is a heterogeneous hematopoietic stem cell disorder with thrombocytopenia. Flow cytometric immunophenotyping of blood cells has been instrumental in diagnosis as co-criteria, but the data regarding platelets remains lacking. This study aims to determine if there is a difference in surface antigen levels on platelets by comparing surface antigen levels in MDS patients and healthy control subjects. Concurrently, as flow cytometric gating can reveal the diameter of cells, this study will investigate differences in giant platelet percentage by comparing these percentages in high- and low-risk MDS patients. STUDY DESIGN Twenty newly diagnosed MDS patients were enrolled in this study. Platelet surface antigen levels were determined by measuring the binding capacity of antibodies with flow cytometry. RESULTS Platelets of MDS patients were shown to have a lower level of CD61 and higher levels of CD31 and CD36 than healthy controls. Judged by forward scatter (FSC), MDS patients' platelets appeared to be larger than those of healthy control subjects, whereas the MFI adjusted by diameter (MFI/FSC ratio) of CD31, CD41a, CD42a, CD42b and CD61 on platelets were lower in MDS patients than in healthy control subjects. There was a significant quantity of giant platelets found in MDS patients, and the high-risk MDS patients tended to have a higher percentage of giant platelets than low-risk patients. Conclusions: All the results indicate that MDS patients exhibit a lower antigen presentation (MFI) adjusted by diameter on platelets than healthy controls and the giant platelets detected by flow cytometry might correlate with the condition of MDS.
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7
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Okoye-Okafor UC, Javarappa KK, Tsallos D, Saad J, Yang D, Zhang C, Benard L, Thiruthuvanathan VJ, Cole S, Ruiz S, Tatiparthy M, Choudhary G, DeFronzo S, Bartholdy BA, Pallaud C, Ramos PM, Shastri A, Verma A, Heckman CA, Will B. Megakaryopoiesis impairment through acute innate immune signaling activation by azacitidine. J Exp Med 2022; 219:e20212228. [PMID: 36053753 PMCID: PMC9441716 DOI: 10.1084/jem.20212228] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2021] [Revised: 04/02/2022] [Accepted: 07/22/2022] [Indexed: 11/04/2022] Open
Abstract
Thrombocytopenia, prevalent in the majority of patients with myeloid malignancies, such as myelodysplastic syndrome (MDS) or acute myeloid leukemia (AML), is an independent adverse prognostic factor. Azacitidine (AZA), a mainstay therapeutic agent for stem cell transplant-ineligible patients with MDS/AML, often transiently induces or further aggravates disease-associated thrombocytopenia by an unknown mechanism. Here, we uncover the critical role of an acute type-I interferon (IFN-I) signaling activation in suppressing megakaryopoiesis in AZA-mediated thrombocytopenia. We demonstrate that megakaryocytic lineage-primed progenitors present IFN-I receptors and, upon AZA exposure, engage STAT1/SOCS1-dependent downstream signaling prematurely attenuating thrombopoietin receptor (TPO-R) signaling and constraining megakaryocytic progenitor cell growth and differentiation following TPO-R stimulation. Our findings directly implicate RNA demethylation and IFN-I signal activation as a root cause for AZA-mediated thrombocytopenia and suggest mitigation of TPO-R inhibitory innate immune signaling as a suitable therapeutic strategy to support platelet production, particularly during the early phases of AZA therapy.
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Affiliation(s)
- Ujunwa Cynthia Okoye-Okafor
- Albert Einstein College of Medicine/Montefiore Medical Center, Department of Cell Biology, Bronx, NY
- Albert Einstein College of Medicine/Montefiore Medical Center, Cancer Stem Cell Pharmacodynamics Unit, Bronx, NY
| | - Komal K. Javarappa
- Institute for Molecular Medicine Finland (FIMM), Helsinki Institute of Life Science, University of Helsinki, Helsinki, Finland
| | - Dimitrios Tsallos
- Institute for Molecular Medicine Finland (FIMM), Helsinki Institute of Life Science, University of Helsinki, Helsinki, Finland
| | - Joseph Saad
- Institute for Molecular Medicine Finland (FIMM), Helsinki Institute of Life Science, University of Helsinki, Helsinki, Finland
| | - Daozheng Yang
- Albert Einstein College of Medicine/Montefiore Medical Center, Department of Cell Biology, Bronx, NY
| | - Chi Zhang
- Albert Einstein College of Medicine/Montefiore Medical Center, Department of Cell Biology, Bronx, NY
| | - Lumie Benard
- Albert Einstein College of Medicine/Montefiore Medical Center, Department of Cell Biology, Bronx, NY
- Albert Einstein College of Medicine/Montefiore Medical Center, Cancer Stem Cell Pharmacodynamics Unit, Bronx, NY
| | - Victor J. Thiruthuvanathan
- Albert Einstein College of Medicine/Montefiore Medical Center, Department of Cell Biology, Bronx, NY
- Albert Einstein College of Medicine/Montefiore Medical Center, Cancer Stem Cell Pharmacodynamics Unit, Bronx, NY
| | - Sally Cole
- Albert Einstein College of Medicine/Montefiore Medical Center, Department of Cell Biology, Bronx, NY
- Albert Einstein College of Medicine/Montefiore Medical Center, Cancer Stem Cell Pharmacodynamics Unit, Bronx, NY
| | - Stephen Ruiz
- Albert Einstein College of Medicine/Montefiore Medical Center, Department of Cell Biology, Bronx, NY
- Albert Einstein College of Medicine/Montefiore Medical Center, Cancer Stem Cell Pharmacodynamics Unit, Bronx, NY
| | - Madhuri Tatiparthy
- Albert Einstein College of Medicine/Montefiore Medical Center, Department of Cell Biology, Bronx, NY
- Albert Einstein College of Medicine/Montefiore Medical Center, Cancer Stem Cell Pharmacodynamics Unit, Bronx, NY
| | - Gaurav Choudhary
- Albert Einstein College of Medicine/Montefiore Medical Center, Department of Medicine (Oncology), Bronx, NY
| | - Stefanie DeFronzo
- Albert Einstein College of Medicine/Montefiore Medical Center, Department of Cell Biology, Bronx, NY
| | - Boris A. Bartholdy
- Albert Einstein College of Medicine/Montefiore Medical Center, Department of Cell Biology, Bronx, NY
| | | | | | - Aditi Shastri
- Albert Einstein College of Medicine/Montefiore Medical Center, Department of Medicine (Oncology), Bronx, NY
| | - Amit Verma
- Albert Einstein College of Medicine/Montefiore Medical Center, Department of Medicine (Oncology), Bronx, NY
| | - Caroline A. Heckman
- Institute for Molecular Medicine Finland (FIMM), Helsinki Institute of Life Science, University of Helsinki, Helsinki, Finland
| | - Britta Will
- Albert Einstein College of Medicine/Montefiore Medical Center, Department of Cell Biology, Bronx, NY
- Albert Einstein College of Medicine/Montefiore Medical Center, Cancer Stem Cell Pharmacodynamics Unit, Bronx, NY
- Albert Einstein College of Medicine/Montefiore Medical Center, Department of Medicine (Oncology), Bronx, NY
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8
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Brings C, Fröbel J, Cadeddu P, Germing U, Haas R, Gattermann N. Impaired formation of neutrophil extracellular traps in patients with MDS. Blood Adv 2022; 6:129-137. [PMID: 34653237 PMCID: PMC8753191 DOI: 10.1182/bloodadvances.2021005721] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2021] [Accepted: 09/22/2021] [Indexed: 11/20/2022] Open
Abstract
Neutrophil extracellular traps (NETs) are networks of extracellular fibers primarily composed of DNA and histone proteins, which bind pathogens. We investigated NET formation in 12 patients with myelodysplastic syndrome (MDS) and 15 age-adjusted normal controls after stimulation with phorbol-12-myristate-13-acetate (PMA). Histones and neutrophil elastase were visualized by immunostaining. Since NET formation is triggered by reactive oxygen species (ROS), mainly produced by reduced NADP-oxidase and myeloperoxidase (MPO), ROS were analyzed by flow cytometry using hydroethidine, 3'-(p-aminophenyl) fluorescein, and 3'-(hydroxyphenyl) fluorescein. On fluorescence microscopy, PMA-stimulated MDS neutrophils generated fewer NETs than controls (stimulated increase from 17% to 67% vs 17% to 85%) (P = .02) and showed less cellular swelling (P = .04). The decrease in mean fluorescence intensity (MFI) of 4',6-diamidino-2-phenylindole, indicating chromatin decondensation, was significantly less in MDS neutrophils than controls (ΔMFI 3467 vs ΔMFI 4687, P = .03). In addition, the decrease in MFI for fluorescein isothiocyanate, indicating release of neutrophil elastase from cytoplasmic granules, was diminished in patients with MDS (P = .00002). On flow cytometry, less cell swelling after PMA (P = .02) and a smaller decrease in granularity after H2O2 stimulation (P = .002) were confirmed. PMA-stimulated ROS production and oxidative burst activity did not reveal significant differences between MDS and controls. However, inhibition of MPO activity was more easily achieved in patients with MDS (P = .01), corroborating the notion of a partial MPO defect. We conclude that NET formation is significantly impaired in MDS neutrophils. Although we found abnormalities of MPO-dependent generation of hypochloride, impaired ROS production may not be the only cause of deficient NETosis in MDS.
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Affiliation(s)
- Carolin Brings
- Department of Vascular and Endovascular Surgery, Heinrich Heine University, Düsseldorf, Germany
| | - Julia Fröbel
- Department of Immunology, Leibniz Institute on Aging - Fritz Lipmann Institute, Jena, Germany; and
| | - Patrick Cadeddu
- Department of Hematology, Oncology and Clinical Immunology, Heinrich Heine University, Düsseldorf, Germany
| | - Ulrich Germing
- Department of Hematology, Oncology and Clinical Immunology, Heinrich Heine University, Düsseldorf, Germany
| | - Rainer Haas
- Department of Hematology, Oncology and Clinical Immunology, Heinrich Heine University, Düsseldorf, Germany
| | - Norbert Gattermann
- Department of Hematology, Oncology and Clinical Immunology, Heinrich Heine University, Düsseldorf, Germany
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9
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Strapatsas J, Barbulescu EC, Lauseker M, Kaivers J, Hildebrandt B, Nachtkamp K, Strupp C, Rudelius M, Haas R, Germing U. Influence of platelet count at diagnosis and during the course of disease on prognosis in MDS patients. Ann Hematol 2021; 100:2575-2584. [PMID: 34324021 PMCID: PMC8440262 DOI: 10.1007/s00277-021-04608-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2021] [Accepted: 07/12/2021] [Indexed: 11/16/2022]
Abstract
Thrombocytopenia at diagnosis and platelet drop within the first 6 months have an adverse effect on prognosis of MDS patients. We therefore were interested in the association and impact on prognosis of morphologic findings of megakaryocytes and platelets with platelet count at diagnosis, bleeding complications, and the drop of platelets during the course of disease. This retrospective analysis was based on 334 MDS patients from the Duesseldorf MDS registry that were followed up for blood counts, bleeding, transfusion dependency, and AML evolution and correlated with morphology of the megakaryocytes and platelets. Thrombocytopenia was found more frequently in higher risk MDS and was associated with hypocellularity of the megakaryocytes in the bone marrow. Signs of bleeding were present at diagnosis in 14% and occurred during the disease in 48% of all MDS patients. Death due to bleeding was ranked third behind infections and AML. A decrement of platelets during the first 6 months was associated with an inferior overall survival of 21 vs. 49 months and with a higher cumulative 2-year AML rate of 22.2% vs. 8.3% (p = 0.001). In a multivariate analysis, besides bone marrow blasts and karyotype, decreasing platelets were also associated with an inferior outcome. Signs of bleeding are present in a relevant number of MDS patients and account for significant morbidity and mortality in MDS. We could demonstrate the prognostic importance of decreasing platelets during the course of disease in all MDS patients, identifying patients at higher risk for death or AML progression.
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Affiliation(s)
- Judith Strapatsas
- Department of Hematology, Oncology and Clinical Immunology, Heinrich-Heine University, Moorenstr. 5, 40225, Düsseldorf, Germany.
| | - Elena Calina Barbulescu
- Department of Hematology, Oncology and Clinical Immunology, Heinrich-Heine University, Moorenstr. 5, 40225, Düsseldorf, Germany
| | - Michael Lauseker
- Institute for Medical Information Sciences, Biometry and Epidemiology, Ludwig-Maximilians-University, Munich, Germany
| | - Jennifer Kaivers
- Department of Hematology, Oncology and Clinical Immunology, Heinrich-Heine University, Moorenstr. 5, 40225, Düsseldorf, Germany
| | - Barbara Hildebrandt
- Department of Human Genetics, Heinrich-Heine University, Duesseldorf, Germany
| | - Kathrin Nachtkamp
- Department of Hematology, Oncology and Clinical Immunology, Heinrich-Heine University, Moorenstr. 5, 40225, Düsseldorf, Germany
| | - Corinna Strupp
- Department of Oncology, Rheinland Klinikum, Dormagen, Germany
| | - Martina Rudelius
- Institute for Pathology, Ludwig-Maximilians-University, Munich, Germany
| | - Rainer Haas
- Department of Hematology, Oncology and Clinical Immunology, Heinrich-Heine University, Moorenstr. 5, 40225, Düsseldorf, Germany
| | - Ulrich Germing
- Department of Hematology, Oncology and Clinical Immunology, Heinrich-Heine University, Moorenstr. 5, 40225, Düsseldorf, Germany
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10
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Cheok KPL, Chhetri R, Wee LYA, Friel O, Pham A, Salvi A, McRae S, Bardy P, Singhal D, Roxby DJ, Wood EM, Hiwase DK. The burden of immune‐mediated refractoriness to platelet transfusions in myelodysplastic syndromes. Transfusion 2020; 60:2192-2198. [DOI: 10.1111/trf.16029] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2020] [Revised: 05/22/2020] [Accepted: 05/25/2020] [Indexed: 11/30/2022]
Affiliation(s)
- Kathleen P. L. Cheok
- Department of Haematology Royal Adelaide Hospital Adelaide South Australia Australia
| | - Rakchha Chhetri
- Department of Haematology Royal Adelaide Hospital Adelaide South Australia Australia
- Precision Medicine Theme South Australian Health and Medical Research Institute Adelaide South Australia Australia
- School of Public Health University of Adelaide Adelaide South Australia Australia
| | - Li Yan A. Wee
- Department of Haematology Royal Adelaide Hospital Adelaide South Australia Australia
- Precision Medicine Theme South Australian Health and Medical Research Institute Adelaide South Australia Australia
| | - Oisin Friel
- Department of Haematology Royal Adelaide Hospital Adelaide South Australia Australia
| | - Anh Pham
- Department of Haematology Blood Bank,Royal Adelaide Hospital Adelaide South Australia Australia
| | - Arabelle Salvi
- SA Pharmacy Royal Adelaide Hospital Adelaide South Australia Australia
| | - Simon McRae
- Department of Haematology Royal Adelaide Hospital Adelaide South Australia Australia
| | - Peter Bardy
- Department of Haematology Royal Adelaide Hospital Adelaide South Australia Australia
| | - Deepak Singhal
- Department of Haematology Royal Adelaide Hospital Adelaide South Australia Australia
- Precision Medicine Theme South Australian Health and Medical Research Institute Adelaide South Australia Australia
- School of Medicine University of Adelaide Adelaide South Australia Australia
| | - David J. Roxby
- College of Medicine and Public Health Flinders University Bedford Park South Australia Australia
| | - Erica M. Wood
- Transfusion Research Unit Monash University Melbourne Victoria Australia
- Monash Health Melbourne Victoria Australia
| | - Devendra K. Hiwase
- Department of Haematology Royal Adelaide Hospital Adelaide South Australia Australia
- Precision Medicine Theme South Australian Health and Medical Research Institute Adelaide South Australia Australia
- School of Medicine University of Adelaide Adelaide South Australia Australia
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11
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Adrianzen-Herrera D, Choudhary G, Gordon-Mitchell S, Ramachandra N, Bhagat T, Zhang H, Aluri S, Shastri A, Steidl U, Will B, Yang WL, Mahler M, Eichenbaum G, Guha C, Verma A. The thrombopoietin mimetic JNJ-26366821 increases megakaryopoiesis without affecting malignant myeloid proliferation. Leuk Lymphoma 2020; 61:2453-2465. [PMID: 32578476 DOI: 10.1080/10428194.2020.1775213] [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] [Indexed: 12/19/2022]
Abstract
Thrombocytopenia remains a challenge in myeloid malignancies, needing safer and more effective therapies. JNJ-26366821, a pegylated synthetic peptide thrombopoietin (TPO) mimetic not homologous to endogenous TPO, has an in-vitro EC50 of 0.2 ng/mL for the TPO receptor and dose dependently elevates platelets in volunteers. We demonstrate that JNJ-26366821 increases megakaryocytic differentiation and megakaryocytic colony formation in healthy controls and samples from myelodysplastic syndrome (MDS) and acute myeloid leukemia (AML). JNJ-26366821 had no effect on proliferation of malignant myeloid cell lines at doses up to 1000 ng/mL and malignant patient-derived mononuclear cells showed no increased cell growth or leukemic colony formation capacity at concentrations between 0.2 ng/mL and 10 ng/mL. Furthermore, JNJ-26366821 did not enhance in-vivo engraftment of leukemic cells in an AML xenotransplantation murine model. Our results show that JNJ-26366821 stimulates megakaryopoiesis without causing proliferation of the malignant myeloid clones in MDS/AML and provides the rationale for clinical testing of JNJ-26366821 in myeloid malignancies.
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Affiliation(s)
- Diego Adrianzen-Herrera
- Division of Hematology and Oncology, Larner College of Medicine at the University of Vermont, Burlington, VT, USA
| | - Gaurav Choudhary
- Department of Oncology, Albert Einstein College of Medicine - Montefiore Medical Center, Bronx, NY, USA
| | - Shanisha Gordon-Mitchell
- Department of Oncology, Albert Einstein College of Medicine - Montefiore Medical Center, Bronx, NY, USA
| | - Nandini Ramachandra
- Department of Oncology, Albert Einstein College of Medicine - Montefiore Medical Center, Bronx, NY, USA
| | - Tushar Bhagat
- Department of Oncology, Albert Einstein College of Medicine - Montefiore Medical Center, Bronx, NY, USA
| | - Hui Zhang
- Department of Oncology, Albert Einstein College of Medicine - Montefiore Medical Center, Bronx, NY, USA
| | - Srinivas Aluri
- Department of Oncology, Albert Einstein College of Medicine - Montefiore Medical Center, Bronx, NY, USA
| | - Aditi Shastri
- Department of Oncology, Albert Einstein College of Medicine - Montefiore Medical Center, Bronx, NY, USA
| | - Ulrich Steidl
- Department of Oncology, Albert Einstein College of Medicine - Montefiore Medical Center, Bronx, NY, USA
| | - Britta Will
- Department of Oncology, Albert Einstein College of Medicine - Montefiore Medical Center, Bronx, NY, USA
| | - Weng-Lang Yang
- Department of Radiation Oncology, Albert Einstein College of Medicine - Montefiore Medical Center, Bronx, NY, USA
| | - Michelle Mahler
- Department of the Chief Medical Officer, Johnson & Johnson Global Service, New Brunswick, NJ, USA
| | - Gary Eichenbaum
- Department of the Chief Medical Officer, Johnson & Johnson Global Service, New Brunswick, NJ, USA
| | - Chandan Guha
- Department of Radiation Oncology, Albert Einstein College of Medicine - Montefiore Medical Center, Bronx, NY, USA
| | - Amit Verma
- Department of Oncology, Albert Einstein College of Medicine - Montefiore Medical Center, Bronx, NY, USA
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12
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Newland A, Bentley R, Jakubowska A, Liebman H, Lorens J, Peck-Radosavljevic M, Taieb V, Takami A, Tateishi R, Younossi ZM. A systematic literature review on the use of platelet transfusions in patients with thrombocytopenia. ACTA ACUST UNITED AC 2020; 24:679-719. [PMID: 31581933 DOI: 10.1080/16078454.2019.1662200] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Objective: Investigate globally, current treatment patterns, benefit-risk assessments, humanistic, societal and economic burden of platelet transfusion (PT). Methods: Publications from 1998 to June 27, 2018 were identified, based on databases searches including MEDLINE®; Embase and Cochrane Database of Systematic Reviews. Data from studies meeting pre-specified criteria were extracted and validated by independent reviewers. Data were obtained for efficacy and safety from randomized controlled trials (RCTs); data for epidemiology, treatment patterns, effectiveness, safety, humanistic and societal burden from real-world evidence (RWE) studies; and economic data from both. Results: A total of 3425 abstracts, 194 publications (190 studies) were included. PT use varied widely, from 0%-100% of TCP patients; 1.7%-24.5% in large studies (>1000 patients). Most were used prophylactically rather than therapeutically. 5 of 43 RCTs compared prophylactic PT with no intervention, with mixed results. In RWE studies PT generally increased platelet count (PC). This increase varied by patient characteristics and hence did not always translate into a clinically significant reduction in bleeding risk. Safety concerns included infection risk, alloimmunization and refractoriness with associated cost burden. Discussion: In RCTs and RWE studies there was significant heterogeneity in study design and outcome measures. In RWE studies, patients receiving PT may have been at higher risk than those not receiving PT creating potential bias. There were limited data on humanistic and societal burden. Conclusion: Although PTs are used widely for increasing PC in TCP, it is important to understand the limitations of PTs, and to explore the use of alternative treatment options where available.
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Affiliation(s)
- Adrian Newland
- Barts Health National Health Service (NHS) Trust , London , UK
| | | | | | - Howard Liebman
- Jane Anne Nohl Division of Hematology, USC Norris Cancer Hospital , Los Angeles , CA , USA
| | | | - Markus Peck-Radosavljevic
- Department of Gastroenterology & Hepatology, Endocrinology and Nephrology, Klinikum Klagenfurt , Klagenfurt , Austria.,Division of Gastroenterology & Hepatology, Department of Internal Medicine III, Medical University of Vienna , Vienna , Austria
| | | | - Akiyoshi Takami
- Department of Internal Medicine, Division of Hematology, Aichi Medical University School of Medicine , Nagakute , Japan
| | - Ryosuke Tateishi
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo , Tokyo , Japan
| | - Zobair M Younossi
- Department of Medicine, Inova Fairfax Hospital , Falls Church , VA , USA
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13
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Liu J, Niu H, Yue L, Lv Q, Yang L, Liu C, Jiang H, Xing L, Shao Z, Wang H. Abnormal platelet phenotypes in patients with myelodysplastic syndromes. Int J Lab Hematol 2020; 42:371-379. [PMID: 32202052 DOI: 10.1111/ijlh.13191] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2019] [Revised: 02/24/2020] [Accepted: 02/26/2020] [Indexed: 11/29/2022]
Abstract
INTRODUCTION Hemorrhage and infection are two main causes of death in patients with myelodysplastic syndromes (MDS), and it is becoming increasingly clear that platelet dysfunction can also affect the process of hemostasis and anti-infection. The aim of this study was to evaluate activation function and immune-related function of platelets in MDS. METHODS We included 29 MDS patients and divided them into different subgroups (low-risk group and high-risk group; untreated group and treated group; pretransfusion group and post-transfusion group) according to IPSS-R score, hypomethylating agents (HMAs) therapy, and platelet transfusion history. Platelet light scatter properties, expression of CD41a, activation-associated phenotypes (CD62p and CD63), and immune-associated phenotypes (CD154 and TLR4) were detected by multiparameter flow cytometry. RESULTS Expression of CD41a was decreased (P < .05), and no difference was found in platelet light scatter properties between MDS patients and healthy subjects (P > .05). Significantly decreased expression frequency and intensity of activation phenotype CD63 were found in patients with MDS (P < .05). Low-risk MDS showed lower expression frequency while high-risk MDS showed reduced mean fluorescence intensity (MFI) of CD63. Decreased expression of CD154 and TLR4 was found in MDS patients (P < .05) which was significantly elevated after HMAs therapy (P < .05). Particularly, MFI of CD154 and TLR4 reduced in high-risk MDS patients (P < .05). CONCLUSION Myelodysplastic syndromes patients displayed defective expression of both activation- and immune-associated platelet phenotypes, with differential mechanisms between low-risk and high-risk groups regarding phenotype alterations. The findings confirmed impaired platelet phenotypes in MDS which may assist in the diagnosis and identification of MDS patients.
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Affiliation(s)
- Jiaxi Liu
- Department of Hematology, General Hospital, Tianjin Medical University, Tianjin, China
| | - Haiyue Niu
- Department of Hematology, General Hospital, Tianjin Medical University, Tianjin, China
| | - Lanzhu Yue
- Department of Hematology, General Hospital, Tianjin Medical University, Tianjin, China
| | - Qi Lv
- Department of Hematology, General Hospital, Tianjin Medical University, Tianjin, China
| | - Liyan Yang
- Department of Hematology, General Hospital, Tianjin Medical University, Tianjin, China
| | - Chunyan Liu
- Department of Hematology, General Hospital, Tianjin Medical University, Tianjin, China
| | - Huijuan Jiang
- Department of Hematology, General Hospital, Tianjin Medical University, Tianjin, China
| | - Limin Xing
- Department of Hematology, General Hospital, Tianjin Medical University, Tianjin, China
| | - Zonghong Shao
- Department of Hematology, General Hospital, Tianjin Medical University, Tianjin, China
| | - Huaquan Wang
- Department of Hematology, General Hospital, Tianjin Medical University, Tianjin, China
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14
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Germing U, Oliva EN, Hiwase D, Almeida A. Treatment of Anemia in Transfusion-Dependent and Non-Transfusion-Dependent Lower-Risk MDS: Current and Emerging Strategies. Hemasphere 2019; 3:e314. [PMID: 31976486 PMCID: PMC6924547 DOI: 10.1097/hs9.0000000000000314] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2019] [Revised: 10/10/2019] [Accepted: 10/21/2019] [Indexed: 12/17/2022] Open
Abstract
Myelodysplastic syndromes (MDS) are a heterogeneous group of bone marrow disorders with a highly diverse clinical course. For lower-risk MDS patients, therapeutic objectives aim to correct chronic anemia and improve/maintain health-related quality of life (HRQoL). However, disease burden is often insufficiently recognized, and although some patients do not respond/lose response to standard treatment, many are treated late. This is the case for non-transfusion-dependent patients with symptomatic anemia, in whom delayed treatment initiation may lead to unnecessary morbidity. Current active treatment options for lower-risk MDS are limited. Standard care for lower-risk 5q deletion [del(5q)] MDS patients with anemia remains supportive, consisting of red blood cell (RBC) transfusions, iron chelation therapy, and treatment with erythropoiesis-stimulating agents (ESAs) in the case of low serum erythropoietin levels. Response rates to ESAs range from 15% to 63%, whereas 56% to 67% of patients with del(5q) MDS achieve RBC transfusion independence with lenalidomide. Treatment options for patients’ refractory to ESAs and/or lenalidomide, however, are limited. Frequent transfusions are associated with profound clinical, HRQoL, and economic consequences for transfusion-dependent patients. This review focuses on the multiple unmet clinical needs that exist in the treatment of anemia associated with lower-risk MDS and the current and future treatment options that may improve disease management and patient outcomes.
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Affiliation(s)
- Ulrich Germing
- Department of Hematology, Oncology and Clinical Immunology, Universitätsklinikum Düsseldorf, Düsseldorf, Germany
| | - Ester N Oliva
- Department of Hematology, Grande Ospedale Metropolitano Bianchi Melacrino Morelli, Reggio Calabria, Italy
| | - Devendra Hiwase
- Hematology, Royal Adelaide Hospital, Adelaide, SA, Australia
| | - Antonio Almeida
- Clinical Hematology, Hospital da Luz Lisboa, Lisbon, Portugal
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15
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Bussel J, Kulasekararaj A, Cooper N, Verma A, Steidl U, Semple JW, Will B. Mechanisms and therapeutic prospects of thrombopoietin receptor agonists. Semin Hematol 2019; 56:262-278. [PMID: 31836033 DOI: 10.1053/j.seminhematol.2019.09.001] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2018] [Revised: 07/30/2019] [Accepted: 09/30/2019] [Indexed: 12/13/2022]
Abstract
The second-generation thrombopoietin (TPO) receptor agonists eltrombopag and romiplostim are potent activators of megakaryopoiesis and represent a growing treatment option for patients with thrombocytopenic hematological disorders. Both TPO receptor agonists have been approved worldwide for the treatment of children and adults with chronic immune thrombocytopenia. In the EU and USA, eltrombopag is approved for the treatment of patients with severe aplastic anemia who have had an insufficient response to immunosuppressive therapy and in the USA for the first-line treatment of severe aplastic anemia in combination with immunosuppressive therapy. Eltrombopag has also shown efficacy in several other disease settings, for example, chemotherapy-induced thrombocytopenia, selected inherited thrombocytopenias, and myelodysplastic syndromes. While both TPO receptor agonists stimulate TPO receptor signaling and enhance megakaryopoiesis, their vastly different biochemical structures bestow upon them markedly different molecular and functional properties. Here, we review and discuss results from preclinical and clinical studies on the functional and molecular mechanisms of action of this new class of drug.
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Affiliation(s)
- James Bussel
- Pediatric Hematology/Oncology, Weill Cornell Medicine, New York, NY.
| | | | | | - Amit Verma
- Albert Einstein College of Medicine, New York, NY
| | | | - John W Semple
- Division of Hematology and Transfusion Medicine, Lund University, Lund, Sweden
| | - Britta Will
- Albert Einstein College of Medicine, New York, NY.
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16
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Germing U, Schroeder T, Kaivers J, Kündgen A, Kobbe G, Gattermann N. Novel therapies in low- and high-risk myelodysplastic syndrome. Expert Rev Hematol 2019; 12:893-908. [PMID: 31353975 DOI: 10.1080/17474086.2019.1647778] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Introduction: Myelodysplastic syndromes (MDS) comprise a heterogeneous group of myeloid neoplasms with diverse clinical courses. The revised version of the international prognostic scoring system (IPSS-R) provides risk stratification into 5 different groups. Areas covered: For lower-risk patients, red blood cell transfusions and iron chelation are the backbone of supportive care. In addition, erythropoiesis-stimulating agents (ESA) are used to ameliorate anemia. Lenalidomide is approved for the treatment of lower-risk patients with del(5q) who are transfusion-dependent. Patients with higher-risk disease should be offered allogeneic stem cell transplantation whenever possible. If they are unfit for transplantation or an appropriate donor cannot be found, hypomethylating agents may be used. Expert opinion: New therapeutic options for lower-risk patients include thrombopoietin analogues, the TGF-beta family ligand trapping drug Luspatercept, and the telomerase inhibitor Imetelstat. Combinations of hypomethylating agents (HMA) with other compounds, and inhibitors of bcl2, such as venetoclax are being developed for higher-risk patients. Finally, hypomethylating agents in combination with donor lymphocytes may lead to long-term remission following molecular or hematological relapse after allogeneic SCT.
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Affiliation(s)
- Ulrich Germing
- Department of Hematology, Oncology and Clinical Immunology, University Hospital Düsseldorf , Düsseldorf , Germany
| | - Thomas Schroeder
- Department of Hematology, Oncology and Clinical Immunology, University Hospital Düsseldorf , Düsseldorf , Germany
| | - Jennifer Kaivers
- Department of Hematology, Oncology and Clinical Immunology, University Hospital Düsseldorf , Düsseldorf , Germany
| | - Andrea Kündgen
- Department of Hematology, Oncology and Clinical Immunology, University Hospital Düsseldorf , Düsseldorf , Germany
| | - Guido Kobbe
- Department of Hematology, Oncology and Clinical Immunology, University Hospital Düsseldorf , Düsseldorf , Germany
| | - Norbert Gattermann
- Department of Hematology, Oncology and Clinical Immunology, University Hospital Düsseldorf , Düsseldorf , Germany
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17
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Takami A, Matsushita T, Ogata M, Fujii N, Kubuki Y, Fujiwara S, Matsumoto M, Tomiyama Y. GUIDELINE FOR THE USE OF PLATELET TRANSFUSION CONCENTRATES BASED ON SCIENTIFIC EVIDENCE: UPDATE 2019. ACTA ACUST UNITED AC 2019. [DOI: 10.3925/jjtc.65.544] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Affiliation(s)
- Akiyoshi Takami
- Division of Hematology, Department of Internal Medicine, Aichi Medical University School of Medicine
- Subcommittee on the guideline for the use of platelet transfusion preparation of the Japan Society of Transfusion Medicine and Therapy
| | | | - Masao Ogata
- Blood Transfusion Center, Oita University Hospital
- Subcommittee on the guideline for the use of platelet transfusion preparation of the Japan Society of Transfusion Medicine and Therapy
| | - Nobuharu Fujii
- Division of Transfusion, Okayama University Hospital
- Subcommittee on the guideline for the use of platelet transfusion preparation of the Japan Society of Transfusion Medicine and Therapy
| | - Yoko Kubuki
- Department of Transfusion and Cell Therapy, University of Miyazaki Hospital
- Subcommittee on the guideline for the use of platelet transfusion preparation of the Japan Society of Transfusion Medicine and Therapy
| | - Shinichiro Fujiwara
- Division of Hematology, Department of Medicine, Jichi Medical University
- Subcommittee on the guideline for the use of platelet transfusion preparation of the Japan Society of Transfusion Medicine and Therapy
| | | | - Yoshiaki Tomiyama
- Department of Blood Transfusion, Osaka University Hospital
- Subcommittee on the guideline for the use of platelet transfusion preparation of the Japan Society of Transfusion Medicine and Therapy
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18
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Sanz-De Pedro M, Wang W, Kanagal-Shamanna R, Khoury JD. Myelodysplastic Syndromes: Laboratory Workup in the Context of New Concepts and Classification Criteria. Curr Hematol Malig Rep 2019; 13:467-476. [PMID: 30338456 DOI: 10.1007/s11899-018-0483-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
PURPOSE OF REVIEW This review provides a comprehensive update of myelodysplastic syndromes (MDS) and their diagnostic criteria, with emphasis on novel concepts and state-of-the-art laboratory workup, including multiparameter/multicolor flow cytometry, chromosome analysis, and mutation profiling. RECENT FINDINGS Recent advances in genetics and molecular technologies have provided unprecedented insights into the pathogenic mechanisms and genomic landscape of MDS and its precursor lesions. This has resulted in revised diagnostic criteria in the World Health Organization (WHO) classification and proposed new terminology for early lesions such as clonal hematopoiesis of indeterminate potential (CHIP). Against this landscape, a thorough understanding of the advantages and limitations of laboratory tests employed in the evaluation of patients with cytopenia has gained unprecedented importance. Healthcare providers involved in the care of patients with hematologic diseases should be aware of the intricacies of laboratory workup of such patients, particularly in view of the novel concepts and classification criteria of MDS.
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Affiliation(s)
- Maria Sanz-De Pedro
- Department of Laboratory Medicine, La Paz University Hospital, Madrid, Spain
| | - Wei Wang
- Department of Hematopathology, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Boulevard, MS-072, Houston, TX, 77030, USA
| | - Rashmi Kanagal-Shamanna
- Department of Hematopathology, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Boulevard, MS-072, Houston, TX, 77030, USA
| | - Joseph D Khoury
- Department of Hematopathology, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Boulevard, MS-072, Houston, TX, 77030, USA.
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19
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Tsagarakis NJ, Paterakis G, Papadhimitriou SI, Kritikou-Griva E, Goumakou E, Oudatzis G, Theodorakos I, Vasileiou P. "Bone marrow aspirate automated counts on hematology analyzers: formulating a scoring system based on hematology parameters, to discriminate reactive versus myelodysplastic syndrome-related bone marrows". Int J Lab Hematol 2019; 41:542-549. [PMID: 31102331 DOI: 10.1111/ijlh.13049] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2019] [Revised: 04/22/2019] [Accepted: 04/25/2019] [Indexed: 11/30/2022]
Abstract
INTRODUCTION Diagnosis of myelodysplastic syndromes (MDS) is usually challenging. In this context, we have attempted to employ data derived from automated analysis of bone marrow (BM) samples as an ancillary tool for the discrimination between reactive marrow and MDS. METHODS A total of 101 BM anticoagulated samples referred for flow cytometry (FCM) analysis on the clinical suspicion of MDS had been previously counted in a Mindray BC-6800 hematology analyzer (testing set). Among them, 22/101 randomly selected BM samples (comparison set) had been also simultaneously counted by an Advia 2120 and a CELL-DYN Sapphire hematology analyzer. Selected parameters obtained by Mindray BC-6800 were retrospectively evaluated with ROC and regression analysis in an attempt to formulate a discriminative scoring system (SS) for MDS. This system was further evaluated in the comparison set. RESULTS The diagnosis of MDS was established in 37/101 patients assessed ("MDS" group). Three patients were diagnosed with myelodysplastic/myeloproliferative neoplasm (MDS/MPN), while 61 revealed a "reactive" bone marrow ("RBM" group). Statistical analysis revealed significant differences in Hb, RDW-CV%, NRBC%, and RET% values between the "MDS" and the "RBM" group. Specific cutoff values were then indicated and employed for the formulation of a SS of high sensitivity (86.84%) and specificity (86.89%). The encouraging performance characteristics of the proposed SS were also confirmed in the BM comparison set. CONCLUSION Automated BM counts on hematology analyzers contributed to the formulation of a SS for the screening discrimination between reactive and MDS BM fluids, which seems to be applicable and informative, regardless of the analyzer used.
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Affiliation(s)
- Nikolaos J Tsagarakis
- Department of Laboratory Hematology, Athens Regional General Hospital "G. Gennimatas", Athens, Greece
| | - Georgios Paterakis
- Department of Immunology, Athens Regional General Hospital "G. Gennimatas", Athens, Greece
| | - Stefanos I Papadhimitriou
- Department of Laboratory Hematology, Athens Regional General Hospital "G. Gennimatas", Athens, Greece
| | - Elpiniki Kritikou-Griva
- Department of Laboratory Hematology, Athens Regional General Hospital "G. Gennimatas", Athens, Greece
| | - Eleni Goumakou
- Department of Laboratory Hematology, Athens Regional General Hospital "G. Gennimatas", Athens, Greece
| | | | - Ioannis Theodorakos
- Department of Immunology, Athens Regional General Hospital "G. Gennimatas", Athens, Greece
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20
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Early platelet count kinetics has prognostic value in lower-risk myelodysplastic syndromes. Blood Adv 2019; 2:2079-2089. [PMID: 30126931 DOI: 10.1182/bloodadvances.2018020495] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2018] [Accepted: 07/06/2018] [Indexed: 01/03/2023] Open
Abstract
Prognosis of lower-risk (International Prognostic Scoring System [IPSS] low/intermediate-1) myelodysplastic syndrome (MDS) is heterogeneous and relies on steady-state assessment of cytopenias. We analyzed relative drops in neutrophil and platelet counts during the first 6 months of follow-up of lower-risk MDS patients. We performed a landmark analysis of overall survival (OS) of lower-risk MDS patients prospectively included in the European LeukaemiaNet MDS registry having a visit at 6 ± 1 month from inclusion to assess the prognostic relevance of relative drops in neutrophils and platelets, defined as (count at landmark - count at inclusion)/count at inclusion. Of 2102 patients, 807 were eligible for the stringent 6-month landmark analysis. Median age was 73 years. Revised IPSS was very low, low, and intermediate/higher in 26%, 43%, and 31% of patients, respectively. A relative drop in platelets >25% at landmark predicted shorter OS (5-year OS, 21.9% vs 48.6% with platelet drop ≤25%, P < 10-4), regardless of baseline IPSS-revised or absolute platelet counts. Relative neutrophil drop >25% had no significant impact on OS. We built a classifier based on red blood cell transfusion dependence (RBC-TD) and relative platelet drop >25% at landmark. Patients with none (62%), either (27%), or both criteria (11%) had 5-year OS of 53.3%, 32.7%, and 9.0%, respectively (P < 10-4). This classifier was validated in an independent cohort of 335 patients. Combining relative platelet drop >25% and RBC-TD at 6 months from diagnosis provides an inexpensive and noninvasive way to predict outcome in lower-risk MDS. This study was registered at www.clinicaltrials.gov as #NCT00600860.
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21
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Vijenthira A, Premkumar D, Callum J, Lin Y, Wells RA, Chodirker L, Lenis M, Mamedov A, Buckstein R. The management and outcomes of patients with myelodysplastic syndrome with persistent severe thrombocytopenia: An observational single centre registry study. Leuk Res 2019; 76:76-81. [DOI: 10.1016/j.leukres.2018.12.002] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2018] [Revised: 12/07/2018] [Accepted: 12/10/2018] [Indexed: 10/27/2022]
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22
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Azacitidine with or without eltrombopag for first-line treatment of intermediate- or high-risk MDS with thrombocytopenia. Blood 2018; 132:2629-2638. [PMID: 30305280 DOI: 10.1182/blood-2018-06-855221] [Citation(s) in RCA: 67] [Impact Index Per Article: 11.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2018] [Accepted: 09/24/2018] [Indexed: 12/27/2022] Open
Abstract
Azacitidine treatment of myelodysplastic syndromes (MDSs) generally exacerbates thrombocytopenia during the first treatment cycles. A Study of Eltrombopag in Myelodysplastic Syndromes Receiving Azacitidine (SUPPORT), a phase 3, randomized, double-blind, placebo-controlled study, investigated the platelet supportive effects of eltrombopag given concomitantly with azacitidine. International Prognostic Scoring System intermediate-1, intermediate-2, or high-risk MDS patients with baseline platelets <75 × 109/L were randomized 1:1 to eltrombopag (start, 200 mg/d [East Asians, 100 mg/d], maximum, 300 mg/d [East Asians, 150 mg/d]) or placebo, plus azacitidine (75 mg/m2 subcutaneously once daily for 7 days every 28 days). The primary end point was the proportion of patients platelet transfusion-free during cycles 1 through 4 of azacitidine therapy. Based on planned interim analyses, an independent data monitoring committee recommended stopping the study prematurely because efficacy outcomes crossed the predefined futility threshold and for safety reasons. At termination, 28/179 (16%) eltrombopag and 55/177 (31%) placebo patients met the primary end point. Overall response (International Working Group criteria; complete, marrow, or partial response) occurred in 20% and 35% of eltrombopag and placebo patients, respectively, by investigator assessment. There was no difference in hematologic improvement in any cell lineage between the 2 arms. There was no improvement in overall or progression-free survival. Adverse events with ≥10% occurrence in the eltrombopag vs placebo arm were febrile neutropenia and diarrhea. Compared with azacitidine alone, eltrombopag plus azacitidine worsened platelet recovery, with lower response rates and a trend toward increased progression to acute myeloid leukemia. This trial was registered at www.clinicaltrials.gov as #NCT02158936.
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Garcia-Manero G, Scott BL, Cogle CR, Boyd TE, Kambhampati S, Hetzer J, Dong Q, Kumar K, Ukrainskyj SM, Beach CL, Skikne BS. CC-486 (oral azacitidine) in patients with myelodysplastic syndromes with pretreatment thrombocytopenia. Leuk Res 2018; 72:79-85. [PMID: 30114559 DOI: 10.1016/j.leukres.2018.08.001] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2018] [Revised: 07/18/2018] [Accepted: 08/02/2018] [Indexed: 11/24/2022]
Abstract
Thrombocytopenia is among the strongest predictors of decreased survival for patients with myelodysplastic syndromes (MDS) across all prognostic risk groups. The safety and efficacy of CC-486 (oral azacitidine) was investigated in early-phase studies; we assessed clinical outcomes among subgroups of MDS patients from these studies, defined by presence or lack of pretreatment thrombocytopenia (≤75 × 109/L platelet count). Patients received CC-486 300 mg once-daily for 14 or 21 days of repeated 28-day cycles. Overall, 81 patients with MDS, median age 72 years, comprised the Low Platelets (n = 45) and High Platelets (n = 36) cohorts. Pretreatment median platelet counts were 34 × 109/L and 198 × 109/L, respectively. Grade 3-4 bleeding events occurred in 2 patients in the Low Platelets and 1 patient in the High Platelets groups; events resolved without sequelae. Treatment-related mortality was reported for 7 patients, 5 of whom had pretreatment platelet values <25 × 109/L. Overall response rates were 38% and 46% in the Low Platelets and High Platelets groups, respectively. Five thrombocytopenic patients attained complete remission and 9 attained platelet hematologic improvement. In both cohorts, platelet counts dropped during the first CC-486 treatment cycle, then increased thereafter. Extended CC-486 dosing was generally well tolerated and induced hematologic responses in these patients regardless of pretreatment thrombocytopenia.
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Affiliation(s)
- Guillermo Garcia-Manero
- Department of Leukemia, University of Texas MD Anderson Cancer Center, Houston, TX, United States.
| | - Bart L Scott
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, WA, United States
| | - Christopher R Cogle
- Medicine/Hematology & Oncology, University of Florida, Gainesville, FL, United States
| | - Thomas E Boyd
- Willamette Valley Cancer Institute, Eugene, OR, United States
| | - Suman Kambhampati
- University of Kansas Medical Center, Kansas City, KS, United States; Sarah Cannon at Research Medical Center, Kansas City, MO, United States
| | - Joel Hetzer
- Celgene Corporation, Summit, NJ, United States
| | - Qian Dong
- Celgene Corporation, Summit, NJ, United States
| | | | | | - C L Beach
- Celgene Corporation, Summit, NJ, United States
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Lobectomy for lung cancer in a myelodysplastic syndrome patient with decreasing platelet aggregation: report of a case. J Cardiothorac Surg 2018; 13:89. [PMID: 30041670 PMCID: PMC6057011 DOI: 10.1186/s13019-018-0777-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2018] [Accepted: 07/11/2018] [Indexed: 11/10/2022] Open
Abstract
Background Myelodysplastic syndromes (MDS) are clonal stem cell disorders of the bone marrow. Most patients with MDS have a high risk of bleeding. Thrombocytopenia and defective platelet aggregation contribute to bleeding. We report a surgical case of a patient with lung cancer concomitant with MDS. Case presentation A 72-year-old man presented to our hospital because of an abnormal shadow on chest x-ray suggesting a primary lung cancer. A peripheral blood smear examination found giant platelets without thrombocytopenia. He was diagnosed with MDS by bone marrow biopsy, and showed defective platelet aggregation despite a normal bleeding time. The patient underwent left lower lobectomy and transfusion of platelets because of chest wall bleeding. Conclusions We demonstrated that ordering platelet preparations might be desirable for an MDS patient with defective platelet aggregation who will undergo surgery, even for a normal platelet count and bleeding time.
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Basood M, Oster HS, Mittelman M. Thrombocytopenia in Patients with Myelodysplastic Syndromes: Still an Unsolved Problem. Mediterr J Hematol Infect Dis 2018; 10:e2018046. [PMID: 30002802 PMCID: PMC6039085 DOI: 10.4084/mjhid.2018.046] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2018] [Accepted: 06/24/2018] [Indexed: 12/12/2022] Open
Abstract
The myelodysplastic syndromes (MDS) are a group of clonal bone marrow (BM) stem cell disorders, characterized by ineffective hematopoiesis, peripheral cytopenias, and hematologic cellular dysfunction, as well as potential transformation to acute leukemia. Thrombocytopenia is common in MDS and is associated with bleeding complications, occasionally life-threatening. Low platelet count (PLT), as well declining PLT also serves as a prognostic marker. Understanding thrombopoiesis led to the cloning of thrombopoietin, resulting in the development of platelet stimulating agents, thrombomimetics, romiplostim and eltrombopag. Both agents have been shown to increase PLT, decrease the need for platelet transfusions and reduce the number of bleeding episodes, with a reasonable tolerance. They are already approved for immune thrombocytopenia and thrombocytopenia related to liver disease. Romiplostim and eltrombopag have proven efficacy in lower- and higher-risk MDS with thrombocytopenia, as monotherapy, as well as a part of a combination, either with lenalidomide, and mainly combined with hypomethylating agents. However, safety concerns have been raised: while several trials have been completed with no evidence of disease progression, others have been early terminated due to an increased number of BM blasts and possible leukemic transformation in treated-patients. The jury is still out regarding this safety concern, although recent publications are more encouraging.
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Affiliation(s)
- May Basood
- Department of Medicine A, Tel Aviv Sourasky Medical Center, Sackler School of Medicine, Tel Aviv University, Tel Aviv, ISRAEL
| | - Howard S Oster
- Department of Medicine A, Tel Aviv Sourasky Medical Center, Sackler School of Medicine, Tel Aviv University, Tel Aviv, ISRAEL
| | - Moshe Mittelman
- Department of Medicine A, Tel Aviv Sourasky Medical Center, Sackler School of Medicine, Tel Aviv University, Tel Aviv, ISRAEL
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Mittelman M, Platzbecker U, Afanasyev B, Grosicki S, Wong RSM, Anagnostopoulos A, Brenner B, Denzlinger C, Rossi G, Nagler A, Garcia-Delgado R, Portella MSO, Zhu Z, Selleslag D. Eltrombopag for advanced myelodysplastic syndromes or acute myeloid leukaemia and severe thrombocytopenia (ASPIRE): a randomised, placebo-controlled, phase 2 trial. LANCET HAEMATOLOGY 2017; 5:e34-e43. [PMID: 29241762 DOI: 10.1016/s2352-3026(17)30228-4] [Citation(s) in RCA: 67] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/24/2017] [Revised: 11/09/2017] [Accepted: 11/10/2017] [Indexed: 12/26/2022]
Abstract
BACKGROUND Thrombocytopenia is a life-threatening complication in patients with advanced myelodysplastic syndromes (MDS) and acute myeloid leukaemia (AML). In this study (ASPIRE), we aimed to assess eltrombopag, an oral thrombopoietin receptor agonist, for thrombocytopenia (grade 4) treatment in adult patients with advanced MDS or AML. METHODS ASPIRE consisted of an open-label, double-blind phase for 8 weeks and a randomised, double-blind phase (parts 1 and 2, reported here) for 12 weeks, and an open-label extension (part 3). Eligible patients were men and women aged 18 years or older, with intermediate-2 or high-risk MDS or AML, with bone marrow blasts of 50% or less, and had either grade 4 thrombocytopenia due to bone marrow insufficiency (platelet counts <25 × 109 per L) or grade 4 thrombocytopenia before platelet transfusion, with 25 × 109 platelets per L or greater after transfusion. Additionally, eligible patients had at least one of the following within the screening period of 4 weeks: platelet transfusion, symptomatic bleeding, or platelet count of less than 10 × 109 per L. During part 1, patients received eltrombopag, and dose-escalation criteria for part 2 were determined. In part 2, we randomly allocated patients 2:1 using an interactive voice-response system to eltrombopag or placebo, stratified by baseline platelet count (<10 × 109 platelets per L vs ≥10 × 109 platelets per L) and disease (MDS vs AML). In parts 1 and 2, patients received supportive standard of care and initiated eltrombopag or placebo at 100 mg per day (50 mg per day for patients of east-Asian heritage) to a maximum of 300 mg per day (150 mg per day for patients of east-Asian heritage). The part 2 primary objective was assessed by a composite primary endpoint of clinically relevant thrombocytopenic events (CRTE) during weeks 5-12, defined as one of the following events, either alone or in combination: grade 3 or worse haemorrhagic adverse events; platelet counts of less than 10 × 109 per L; or platelet transfusions. Efficacy analyses were based on intention to treat; clinically meaningful efficacy was defined as 30% absolute difference between groups. This trial is registered with ClinicalTrials.gov, number NCT01440374. FINDINGS In part 1, 17 patients received eltrombopag and 11 patients completed treatment; four experienced significantly increased platelet counts, and ten had reduced platelet transfusion requirements. In part 2 we randomly allocated 145 patients to receive supportive care plus eltrombopag (n=98) or placebo (n=47); similar proportions had MDS (50 [51%] patients to eltrombopag, 22 (47%) patients to placebo) or AML (48 [49%] patients to eltrombopag, 25 [53%] patients to placebo). Average weekly CRTE proportions from weeks 5-12 were significantly lower with eltrombopag (54% [95% CI 43-64]) than with placebo (69% [57-80], odds ratio [OR] 0·20, 95% CI 0·05-0·87; p=0·032) although the difference between treatment groups was less than 30%. The most common grade 3 and grade 4 adverse events were fatigue (six [6%] in the eltrombopag group and one [2%] in the placebo group), hypokalaemia (six [6%] and two [4%]), pneumonia (five [5%] and five [11%]), and febrile neutropenia (five [5%] and six [13%]). Serious adverse events were reported in 56 (58%) eltrombopag-treated patients and 32 (68%) placebo-treated patients. Seven eltrombopag recipients and two placebo recipients had serious adverse events that were suspected to be study drug-related (eltrombopag: acute kidney injury, arterial thrombosis, bone pain, diarrhoea, myocardial infarction, pyrexia, retinal vein occlusion, n=1 each; placebo: vomiting, white blood cell count increased, n=1 each). Two eltrombopag recipients (arterial thrombosis n=1; myocardial infarction n=1) and no placebo recipients experienced fatal serious adverse events suspected to be study drug-related. INTERPRETATION No new safety concerns were noted with eltrombopag and the trial met the primary objective of a reduction in CRTEs; eltrombopag might be a treatment option for thrombocytopenic patients with AML or MDS who are ineligible for other treatment and who are not receiving disease-modifying treatment. FUNDING Novartis Pharma AG.
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Affiliation(s)
- Moshe Mittelman
- Tel Aviv Sourasky Medical Center, Sackler Medical Faculty, Tel Aviv University, Tel Aviv, Israel.
| | | | | | | | - Raymond S M Wong
- Sir YK Pao Centre for Cancer & Department of Medicine and Therapeutics, Prince of Wales Hospital, The Chinese University of Hong Kong, Shatin, NT, Hong Kong, China
| | | | - Benjamin Brenner
- Rambam Medical Center, Technion, Israel Institute of Technology, Haifa, Israel
| | | | | | - Arnon Nagler
- Sheba Medical Center, Tel Hashomer, Tel Aviv University, Tel Aviv, Israel
| | | | | | - Zewen Zhu
- Novartis Pharmaceuticals Corporation, East Hanover, NJ, USA
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Dodillet H, Kreuzer K, Monsef I, Skoetz N. Thrombopoietin mimetics for patients with myelodysplastic syndromes. Cochrane Database Syst Rev 2017; 9:CD009883. [PMID: 28962071 PMCID: PMC6483680 DOI: 10.1002/14651858.cd009883.pub2] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BACKGROUND Myelodysplastic syndrome (MDS) is one of the most frequent haematologic malignancies of the elderly population and characterised by progenitor cell dysplasia with ineffective haematopoiesis and a high rate of transformation to acute myeloid leukaemia (AML). Thrombocytopenia represents a common problem for patients with MDS. ranging from mild to serious bleeding events and death. To manage thrombocytopenia, the current standard treatment includes platelet transfusion, unfortunately leading to a range of side effects. Thrombopoietin (TPO) mimetics represent an alternative treatment option for MDS patients with thrombocytopenia. However, it remains unclear, whether TPO mimetics influence the increase of blast cells and therefore to premature progression to AML. OBJECTIVES To evaluate the efficacy and safety of thrombopoietin (TPO) mimetics for patients with MDS. SEARCH METHODS We searched for randomised controlled trials in the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE (January 2000 to August 2017), trials registries (ISRCTN, EU clinical trials register and clinicaltrials.gov) and conference proceedings. We did not apply any language restrictions. Two review authors independently screened search results, disagreements were solved by discussion. SELECTION CRITERIA We included randomised controlled trials comparing TPO mimetics with placebo, no further treatment or another TPO mimetic in patients with MDS of all risk groups, without gender, age or ethnicity restrictions. Additional chemotherapeutic treatment had to be equal in both arms. DATA COLLECTION AND ANALYSIS Two review authors independently extracted data and assessed the quality of trials, disagreements were resolved by discussion. Risk ratio (RR) was used to analyse mortality during study, transformation to AML, incidence of bleeding events, transfusion requirement, all adverse events, adverse events >= grade 3, serious adverse events and platelet response. Overall survival (OS) and progression-free survival (PFS) have been extracted as hazard ratios, but could not be pooled as results were reported in heterogenous ways. Health-related quality of life and duration of thrombocytopenia would have been analysed as standardised mean differences, but no trial reported these outcomes. MAIN RESULTS We did not identify any trial comparing one TPO mimetic versus another. We analysed six eligible trials involving 746 adult patients. All trials were reported as randomised and double-blind trials including male and female patients. Two trials compared TPO mimetics (romiplostim or eltrombopag) with placebo, one trial evaluated eltrombopag in addition to the hypomethylating agent azacitidine, two trials analysed romiplostim additionally to a hypomethylating agent (azacitidine or decitabine) and one trial evaluated romiplostim in addition to the immunomodulatory drug lenalidomide. There are more data on romiplostim (four included, completed, full-text trials) than on eltrombopag (two trials included: one full-text publication, one abstract publication). Due to small sample sizes and imbalances in baseline characteristics in three trials and premature termination of two studies, we judged the potential risk of bias of all included trials as high.Due to heterogenous reporting, we were not able to pool data for OS. Instead of that, we analysed mortality during study. There is little or no evidence for a difference in mortality during study for thrombopoietin mimetics compared to placebo (RR 0.97, 95% confidence interval (CI) 0.73 to 1.27, N = 6 trials, 746 patients, low-quality evidence). It is unclear whether the use of TPO mimetics induces an acceleration of transformation to AML (RR 1.02, 95% CI 0.59 to 1.77, N = 5 trials, 372 patients, very low-quality evidence).Thrombopoietin mimetics probably improve the incidence of all bleeding events (RR 0.92, 95% CI 0.86 to 0.99, N = 5 trials, 390 patients, moderate-quality evidence). This means that in the study population, 713 out of 1000 in the placebo arm will have a bleeding event, compared to 656 of 1000 (95% CI 613 to 699) in the TPO mimetics arm. There is little or no evidence for a difference that TPO mimetics significantly diminish the rate of transfusion requirement (RR 0.83, 95% CI 0.66 to 1.05, N = 4 trials, 358 patients, low-quality evidence). No studies were found that looked at quality of life or duration of thrombocytopenia.There is no evidence that patients given TPO mimetics suffer more all adverse events (RR 1.01, 95% CI 0.96 to 1.07, N = 5 trials, 390 patients, moderate-quality evidence). There is uncertainty whether the number of serious adverse events decrease under therapy with TPO mimetics (RR 0.89, 95% CI 0.54 to 1.46, N = 4 trials, 356 patients, very low-quality evidence).We identified one ongoing study and one study marked as completed (March 2015), but without publication of results for MDS patients (only results reported for AML and MDS patients together). Both studies evaluate MDS patients receiving eltrombopag in comparison to placebo. AUTHORS' CONCLUSIONS No trial evaluated one TPO mimetic versus another.Six trials including adult patients analysed one TPO mimetic versus placebo, sometimes combined with standard therapy in both arms. Given the uncertainty of the quality of evidence, meta-analyses show that there is little or no evidence for a difference in mortality during study and premature progress to AML. However, these assumptions have to be further explored. Treatment with TPO mimetics resulted in a lower number of MDS patients suffering from bleeding events.There is no evidence for a difference between study groups regarding transfusion requirement. Enlarged sample sizes and a longer follow-up of future trials should improve the estimate of safety and efficacy of TPO mimetics, moreover health-related quality of life should be evaluated. As two ongoing studies currently investigate eltrombopag (one already completed, but without published results), we are awaiting results for this drug.
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Affiliation(s)
- Helga Dodillet
- University Hospital of CologneDepartment I of Internal MedicineKerpener Str. 62CologneGermany50924
| | - Karl‐Anton Kreuzer
- University Hospital of CologneDepartment I of Internal MedicineKerpener Str. 62CologneGermany50924
| | - Ina Monsef
- University Hospital of CologneCochrane Haematological Malignancies Group, Department I of Internal MedicineKerpener Str. 62CologneGermany50924
| | - Nicole Skoetz
- University Hospital of CologneCochrane Haematological Malignancies Group, Department I of Internal MedicineKerpener Str. 62CologneGermany50924
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Uncovering Clinical Features of De Novo Philadelphia Positive Myelodysplasia. Case Rep Hematol 2017; 2017:5404131. [PMID: 28321349 PMCID: PMC5339529 DOI: 10.1155/2017/5404131] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2016] [Accepted: 01/24/2017] [Indexed: 11/25/2022] Open
Abstract
Myelodysplastic syndrome (MDS) is cytogenetically heterogeneous and retains variable risk for acute myeloid leukemia transformation. Though not yet fully understood, there is an association between genetic abnormalities and defects in gene expression. The functional role for infrequent cytogenetic alteration remains unclear. An uncommon chromosomic abnormality is the presence of the Philadelphia (Ph) chromosome. Here, we report a patient with Ph+ MDS treated with low dose Dasatinib who achieved hematologic response for 7 months. In addition, we also examined the English literature on all de novo Ph + MDS cases between 1996 and 2015 to gain insight into clinical features and outcome.
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Oliva EN, Alati C, Santini V, Poloni A, Molteni A, Niscola P, Salvi F, Sanpaolo G, Balleari E, Germing U, Fenaux P, Stamatoullas A, Palumbo GA, Salutari P, Impera S, Avanzini P, Cortelezzi A, Liberati AM, Carluccio P, Buccisano F, Voso MT, Mancini S, Kulasekararaj A, Morabito F, Bocchia M, Cufari P, Spiriti MAA, Santacaterina I, D'Errigo MG, Bova I, Zini G, Latagliata R. Eltrombopag versus placebo for low-risk myelodysplastic syndromes with thrombocytopenia (EQoL-MDS): phase 1 results of a single-blind, randomised, controlled, phase 2 superiority trial. LANCET HAEMATOLOGY 2017; 4:e127-e136. [DOI: 10.1016/s2352-3026(17)30012-1] [Citation(s) in RCA: 79] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/31/2016] [Revised: 12/30/2016] [Accepted: 01/02/2017] [Indexed: 12/28/2022]
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Feher A, Kampaktsis PN, Parameswaran R, Stein EM, Steingart R, Gupta D. Aspirin Is Associated with Improved Survival in Severely Thrombocytopenic Cancer Patients with Acute Myocardial Infarction. Oncologist 2017; 22:213-221. [PMID: 28159866 DOI: 10.1634/theoncologist.2016-0110] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2016] [Accepted: 10/06/2016] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND Patients with hematologic malignancies are at risk for severe thrombocytopenia (sTP). The risk and benefit of aspirin are not known in thrombocytopenic cancer patients experiencing acute myocardial infarction (AMI). MATERIALS AND METHODS Medical records of patients with hematologic malignancies diagnosed with AMI at Memorial Sloan Kettering Cancer Center during 2005-2014 were reviewed. sTP was defined as a platelet count <50,000 cells per µL within 7 days of AMI. RESULTS Of 118 patients with hematologic malignancies who had AMI, 58 (49%) had sTP. Twenty-five patients (43%) with sTP received aspirin as a treatment for AMI. Compared with patients without sTP with AMI, patients with sTP with AMI were less likely to receive aspirin (83% vs. 43%; p = .0001) and thienopyridine treatment (27% vs. 3%; p = .0005). During median follow-up of 3.7 years after AMI, survival was lower in patients with sTP than in those with no sTP (23% vs. 50% at 1 year; log rank p = .003). Patients with sTP who received aspirin for AMI had improved survival compared with those who did not (92% vs. 70% at 7 days, 72% vs. 33% at 30 days, and 32% vs. 13% at 1 year; log rank p = .008). In multivariate regression models, aspirin use was associated with improved 30-day survival both in the overall patient cohort and in sTP patients. No fatal bleeding events occurred. Major bleeding was not associated with sTP or aspirin use. CONCLUSION Treatment of AMI with aspirin in patients with hematologic malignancies and sTP is associated with improved survival without increase in major bleeding. The Oncologist 2017;22:213-221Implications for Practice: In patients with hematologic malignancies and acute myocardial infarction with severe thrombocytopenia (platelet count < 50,000 cells/µL), guideline-recommended medical therapy is often withheld because of the fear of major bleeding. In this study, aspirin therapy was associated with improved survival without an increase in major bleeding in this high-risk patient cohort.
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Affiliation(s)
- Attila Feher
- Department of Medicine, Weill Cornell Medical College, New York, New York, USA
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Polydoros N Kampaktsis
- Department of Medicine, Weill Cornell Medical College, New York, New York, USA
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Rekha Parameswaran
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Eytan M Stein
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Richard Steingart
- Department of Medicine, Weill Cornell Medical College, New York, New York, USA
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Dipti Gupta
- Department of Medicine, Weill Cornell Medical College, New York, New York, USA
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York, USA
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Allogeneic stem cell transplantation in myelodysplastic syndromes: does pretransplant clonal burden matter? Curr Opin Hematol 2016; 23:167-74. [PMID: 26717194 DOI: 10.1097/moh.0000000000000217] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
PURPOSE OF REVIEW Currently, the only potential curative therapy for myelodysplastic syndromes (MDS) is allogeneic hematopoietic stem cell transplantation (alloSCT). As alloSCT confers both a short-term mortality risk compared with conservative management, and a longer-term risk of chronic health burden from graft-versus-host disease and other complications, careful patient selection for alloSCT is essential. Here, we review data on disease burden and transplant outcomes in MDS, describing which patients stand to benefit most (and least) from alloSCT. Evidence for timing of alloSCT and modifying tumor burden prior to transplant is also discussed. RECENT FINDINGS Although patients who undergo alloSCT with excess blasts have poorer outcomes than those transplanted with fewer blasts, the effect of clone size in patients with MDS without increased blast proportion is poorly studied, and it is also not yet known whether posttransplant outcomes can be modified with pretransplant therapy such as intensive induction chemotherapy or hypomethylating agent treatment. Randomized data are lacking. Most hematopoietic cells in patients with MDS are clonal, even in cases without increased marrow blast proportion. Certain high-risk point mutations such as TP53 seem to be associated with a worse outcome even when subclonal. SUMMARY Patients with more than 10% blasts should be considered for cytoreductive therapy before transplant, especially if reduced intensity conditioning (alloSCT) is planned. Patients with less than 10% blasts who are appropriate candidates for transplant can proceed straight to transplant, though it appears better to delay transplant for those with lower-risk disease. Hypomethylating agent therapy may be useful as a bridge to transplant. Randomized data are eagerly awaited.
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Izquierdo I, García Á. Platelet proteomics applied to the search for novel antiplatelet therapeutic targets. Expert Rev Proteomics 2016; 13:993-1006. [DOI: 10.1080/14789450.2016.1246188] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
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Myelodysplastic Syndromes in the Elderly: Treatment Options and Personalized Management. Drugs Aging 2016; 32:891-905. [PMID: 26476843 DOI: 10.1007/s40266-015-0312-7] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Myelodysplastic syndromes (MDS) are typical diseases of the elderly, with a median age of 68-75 years at initial diagnosis. Demographic changes producing an increased proportion of elderly in our societies mean the incidence of MDS will rise dramatically. Considering the increasing number of treatment options, ranging from best supportive care to hematopoietic stem cell transplantation (HSCT), decision making is rather complex in this cohort of patients. Moreover, aspects of the aging process also have to be considered in therapy planning. Treatment of elderly MDS patients is dependent on the patient's individual risk and prognosis. Comorbidities play an essential role as predictors of survival and therapy tolerance. Age-adjusted models and the use of geriatric assessment scores are described as a basis for individualized treatment algorithms. Specific treatment recommendations for the different groups of patients are given. Currently available therapeutic agents, including supportive care, erythropoiesis-stimulating agents (ESAs), immune-modulating agents, hypomethylating agents, and HSCT are described in detail and discussed with a special focus on elderly MDS patients. The inclusion of elderly patients in clinical trials is of utmost importance to obtain data on efficacy and safety in this particular group of patients. Endpoints relevant for the elderly should be integrated, including maintenance of quality of life and functional activities as well as evaluation of use of healthcare resources.
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Nachtkamp K, Stark R, Strupp C, Kündgen A, Giagounidis A, Aul C, Hildebrandt B, Haas R, Gattermann N, Germing U. Causes of death in 2877 patients with myelodysplastic syndromes. Ann Hematol 2016; 95:937-44. [DOI: 10.1007/s00277-016-2649-3] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2015] [Accepted: 03/18/2016] [Indexed: 10/22/2022]
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Li W, Morrone K, Kambhampati S, Will B, Steidl U, Verma A. Thrombocytopenia in MDS: epidemiology, mechanisms, clinical consequences and novel therapeutic strategies. Leukemia 2015; 30:536-44. [PMID: 26500138 DOI: 10.1038/leu.2015.297] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2015] [Accepted: 08/03/2015] [Indexed: 12/14/2022]
Abstract
Thrombocytopenia is commonly seen in myelodysplastic syndrome (MDS) patients, and bleeding complications are a major cause of morbidity and mortality. Thrombocytopenia is an independent factor for decreased survival and has been incorporated in newer prognostic scoring systems. The mechanisms of thrombocytopenia are multifactorial and involve a differentiation block of megakaryocytic progenitor cells, leading to dysplastic, hypolobated and microscopic appearing megakaryocytes or increased apoptosis of megakaryocytes and their precursors. Dysregulated thrombopoietin (TPO) signaling and increased platelet destruction through immune or nonimmune mechanisms are frequently observed in MDS. The clinical management of patients with low platelet counts remains challenging and approved chemotherapeutic agents such as lenalidomide and azacytidine can also lead to a transient worsening of thrombocytopenia. Platelet transfusion is the only supportive treatment option currently available for clinically significant thrombocytopenia. The TPO receptor agonists romiplostim and eltrombopag have shown clinical activity in clinical trials in MDS. In addition to thrombopoietic effects, eltrombopag can inhibit leukemic cell proliferation via TPO receptor-independent effects. Other approaches such as treatment with cytokines, immunomodulating drugs and signal transduction inhibitors have shown limited activity in selected groups of MDS patients. Combination trials of approved agents with TPO agonists are ongoing and hold promise for this important clinical problem.
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Affiliation(s)
- W Li
- Department of Medicine, Albert Einstein College of Medicine/Jacobi Medical Center, Bronx, NY, USA
| | - K Morrone
- Department of Pediatrics, Albert Einstein College of Medicine/Montefiore Medical Center, Bronx, NY, USA
| | - S Kambhampati
- Department of Medicine, University of Kansas Medical Center, Kansas City, KS, USA
| | - B Will
- Division of Hemato-Oncology, Department of Oncology, Albert Einstein College of Medicine, Bronx, NY, USA
| | - U Steidl
- Division of Hemato-Oncology, Department of Oncology, Albert Einstein College of Medicine, Bronx, NY, USA
| | - A Verma
- Division of Hemato-Oncology, Department of Oncology, Albert Einstein College of Medicine, Bronx, NY, USA
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Platzbecker U, Wong RSM, Verma A, Abboud C, Araujo S, Chiou TJ, Feigert J, Yeh SP, Götze K, Gorin NC, Greenberg P, Kambhampati S, Kim YJ, Lee JH, Lyons R, Ruggeri M, Santini V, Cheng G, Jang JH, Chen CY, Johnson B, Bennett J, Mannino F, Kamel YM, Stone N, Dougherty S, Chan G, Giagounidis A. Safety and tolerability of eltrombopag versus placebo for treatment of thrombocytopenia in patients with advanced myelodysplastic syndromes or acute myeloid leukaemia: a multicentre, randomised, placebo-controlled, double-blind, phase 1/2 trial. LANCET HAEMATOLOGY 2015; 2:e417-26. [PMID: 26686043 DOI: 10.1016/s2352-3026(15)00149-0] [Citation(s) in RCA: 50] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/05/2015] [Revised: 08/06/2015] [Accepted: 08/07/2015] [Indexed: 10/23/2022]
Abstract
BACKGROUND Patients with myelodysplastic syndrome or acute myeloid leukaemia who are thrombocytopenic and unable to receive disease-modifying therapy have few treatment options. Platelet transfusions provide transient benefit and are limited by alloimmunisation. Eltrombopag, an oral thrombopoietin receptor agonist, increases platelet counts and has preclinical antileukaemic activity. We aimed to assess the safety and tolerability of eltrombopag for the treatment of thrombocytopenia in adult patients with advanced myelodysplastic syndrome, secondary acute myeloid leukaemia after myelodysplastic syndrome, or de-novo acute myeloid leukaemia. METHODS We did this multicentre, randomised, placebo-controlled, double-blind, phase 1/2 trial at 37 centres in ten countries in Europe, east Asia, and the Americas. Patients aged 18 years or older who had relapsed or refractory disease or were ineligible for standard treatments; had platelet counts of less than 30 × 10(9) platelets per L; had 10-50% bone-marrow blasts; or were platelet transfusion dependent were randomly assigned (2:1), via a telephone-based interactive voice-response system (GlaxoSmithKline Registration and Medication Ordering System) with a permuted-block randomisation schedule (block size of three), to receive once-daily eltrombopag or matching placebo dose adjusted from 50 mg to a maximum dose of 300 mg. Randomisation was stratified by presence of poor-prognosis (complex) karyotype (presence of at least three abnormalities, or chromosome 7 abnormalities, vs absence) and bone-marrow blast count (<20% vs ≥20%). Patients and study personnel were masked to treatment allocation. The primary endpoint was safety and tolerability, including adverse events, non-haematological laboratory grade 3-4 toxic effects, and changes in bone-marrow blast counts from baseline. Analysis was by intention to treat. This trial is registered at ClinicalTrials.gov, number NCT00903422. FINDINGS Between May 14, 2009, and May 9, 2013, we randomly assigned 98 patients to receive either eltrombopag (n=64) or placebo (n=34). 63 (98%) patients in the eltrombopag group and 32 (94%) patients in the placebo group had adverse events. The most common adverse events were pyrexia (27 [42%] vs 11 [32%]), nausea (20 [31%] vs 7 [21%]), diarrhoea (19 [30%] vs 6 [18%]), fatigue (16 [25%] vs 6 [18%]), decreased appetite (15 [23%] vs 5 [15%]), and pneumonia (14 [22%] vs 8 [24%]). Drug-related adverse events of grade 3 or higher were reported in six (9%) patients in the eltrombopag group and four (12%) patients in the placebo group. Increases in the proportion of peripheral blasts did not differ significantly between groups. Haemorrhage of grade 3 or higher was reported in ten (16%) patients given eltrombopag and nine (26%) patients given placebo. 21 (33%) patients receiving eltrombopag and 16 (47%) patients receiving placebo died while on treatment. No deaths in patients receiving eltrombopag and two deaths in patients receiving placebo were regarded as treatment related. Post-baseline bone-marrow examinations were done in 40 (63%) patients in the eltrombopag group and 17 (50%) patients in the placebo group. The most common reason for no examination was death before the scheduled 3 month assessment. There were no differences between median bone-marrow blast counts or proportions of peripheral blasts between groups. INTERPRETATION Eltrombopag doses up to 300 mg daily had an acceptable safety profile in patients with advanced myelodysplastic syndrome or acute myeloid leukaemia. The role of eltrombopag in these patients warrants further investigation. FUNDING GlaxoSmithKline.
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Affiliation(s)
- Uwe Platzbecker
- Department of Internal Medicine, University Hospital Carl Gustav Carus, Dresden, Germany.
| | - Raymond S M Wong
- Department of Medicine and Therapeutics, Prince of Wales Hospital, The Chinese University of Hong Kong, Shatin, NT, Hong Kong
| | - Amit Verma
- Division of Hematologic Malignancies, Albert Einstein College of Medicine, Montefiore Medical Center, Bronx, NY, USA
| | - Camille Abboud
- Division of Oncology, Bone Marrow Transplantation and Leukemia Section, Washington University Medical School, St Louis, MO, USA
| | - Sergio Araujo
- Hematology Unit, Hospital das Clínicas-UFMG, Belo Horizonte, Minas Gerais, Brazil
| | - Tzeon-Jye Chiou
- Division of Transfusion Medicine, Department of Medicine, Taipei Veterans General Hospital and National Yang-Ming University School of Medicine, Taipei, Taiwan
| | - John Feigert
- Georgetown University Department of Medicine, Virginia Cancer Specialists, Arlington, VA, USA
| | - Su-Peng Yeh
- Department of Medicine, China Medical University Hospital, Taichung, Taiwan
| | - Katharina Götze
- Department of Medicine, Technical University of Munich, Munich, Germany
| | | | - Peter Greenberg
- Hematology Division, Stanford University Cancer Center, Stanford, CA, USA
| | - Suman Kambhampati
- Department of Internal Medicine, Division of Hematology and Oncology, University of Kansas Medical Center, Kansas City, KS, USA
| | - Yoo-Jin Kim
- Division of Hematology, Department of Internal Medicine, Seoul St Mary's Hospital, Seocho-Gu, Seoul, South Korea
| | - Je-Hwan Lee
- Internal Medicine, Asan Medical Center, Songpa-Gu, Seoul, South Korea
| | - Roger Lyons
- Department of Hematology, Cancer Care Centers of South Texas-US Oncology Network, San Antonio, TX, USA
| | - Marco Ruggeri
- Hematology Department, San Bortolo Hospital, Vicenza, Italy
| | - Valeria Santini
- Department of Experimental and Clinical Medicine, Azienda Ospedaliero Universitaria Careggi, University of Florence, Florence, Italy
| | - Gregory Cheng
- Faculty of Health Science, Macau University of Science and Technology Hospital, Taipa, Macau, China
| | - Jun Ho Jang
- Division of Hematology Oncology, Samsung Medical Center, Seoul, South Korea
| | - Chien-Yuan Chen
- Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Brendan Johnson
- Clinical Pharmacology Modeling and Simulation, GlaxoSmithKline, Research Triangle Park, NC, USA
| | - John Bennett
- Department of Pathology and Laboratory Medicine, University of Rochester Medical Center, Rochester, NY, USA
| | - Frank Mannino
- Oncology R&D, Projects Clinical Platforms and Sciences, GlaxoSmithKline, Collegeville, PA, USA
| | | | - Nicole Stone
- Oncology R&D, Projects Clinical Platforms and Sciences, GlaxoSmithKline, Collegeville, PA, USA
| | - Souria Dougherty
- Oncology R&D, Projects Clinical Platforms and Sciences, GlaxoSmithKline, Collegeville, PA, USA
| | - Geoffrey Chan
- Oncology R&D, Projects Clinical Platforms and Sciences, GlaxoSmithKline, Collegeville, PA, USA
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Brierley CK, Steensma DP. Thrombopoiesis-stimulating agents and myelodysplastic syndromes. Br J Haematol 2015; 169:309-23. [DOI: 10.1111/bjh.13285] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Affiliation(s)
| | - David P. Steensma
- Division of Hematologic Malignancies; Dana-Farber Cancer Institute; Boston MA USA
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Díez Campelo M, Sánchez-Barba M, de Soria VGG, Martino R, Sanz G, Insunza A, Bernal T, Duarte R, Amigo M, Xicoy B, Tormo M, Iniesta F, Bailén A, Benlloch L, Córdoba I, López-Villar O, del Cañizo M. Results of allogeneic stem cell transplantation in the Spanish MDS registry: Prognostic factors for low risk patients. Leuk Res 2014; 38:1199-206. [DOI: 10.1016/j.leukres.2014.07.009] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2014] [Revised: 07/06/2014] [Accepted: 07/25/2014] [Indexed: 01/15/2023]
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Hellström-Lindberg E, van de Loosdrecht A. Erythropoiesis stimulating agents and other growth factors in low-risk MDS. Best Pract Res Clin Haematol 2013; 26:401-10. [PMID: 24507816 DOI: 10.1016/j.beha.2013.09.007] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Anemia and transfusion need constitute major problems for patients with myelodysplastic syndromes (MDS) and are associated with reduced quality of life, poorer survival and an increased risk for transformation to AML. Treatment with erythropoiesis-stimulating agents (ESAs) is first-line treatment for the anemia of most patients with MDS. Erythropoietin acts synergistically with G-CSF to inhibit erythroid apoptosis and promote erythrocyte production. The median duration of response is 2-3 years, with patients responding for more than a decade. Onset of a permanent transfusion need is delayed if treatment is introduced early after the onset of symptomatic anemia. A positive effect on long-term outcome has been suggested by several large epidemiological studies, with no difference in the rate of leukemic transformation between treated and untreated patients. Moreover, responding patients show improvement of quality of life and exercise capacity. Response to treatment can be predicted by combining serum erythropoietin, transfusion rate, and flow cytometry profiling.
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Affiliation(s)
- Eva Hellström-Lindberg
- Department of Medicine, Division of Hematology, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden.
| | - Arjan van de Loosdrecht
- Department of Hematology, Cancer Center Amsterdam, VU University Medical Center, Amsterdam, The Netherlands.
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41
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Özcan MA, Ilhan O, Ozcebe OI, Nalcaci M, Gülbas Z. Review of therapeutic options and the management of patients with myelodysplastic syndromes. Expert Rev Hematol 2013; 6:165-89. [PMID: 23547866 DOI: 10.1586/ehm.13.7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
Myelodysplastic syndromes (MDS) are a poorly understood group of disorders caused by one or more genetic aberrations in the bone marrow-derived cell line responsible for hematopoiesis. Recent advances in genetic medicine have offered new insights into the epigenesis as well as the prognosis of MDS, but have not resulted in new or improved curative treatment options. Bone marrow transplantation, introduced before the advent of genetic medicine, is still the only potential cure. Advances in other medical and pharmaceutical areas have broadened the scope of supportive care and disease-modifying therapies, and treating physicians now have a broad range of disease management options depending on a patient's likely prognosis. There is now clear evidence that appropriate supportive care and therapeutic intervention can improve progression-free and overall survival of MDS patients.
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Affiliation(s)
- Mehmet A Özcan
- Department of Hematology, Dokuz Eylül University, Izmir, Turkey.
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42
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Geyh S, Oz S, Cadeddu RP, Fröbel J, Brückner B, Kündgen A, Fenk R, Bruns I, Zilkens C, Hermsen D, Gattermann N, Kobbe G, Germing U, Lyko F, Haas R, Schroeder T. Insufficient stromal support in MDS results from molecular and functional deficits of mesenchymal stromal cells. Leukemia 2013; 27:1841-51. [PMID: 23797473 DOI: 10.1038/leu.2013.193] [Citation(s) in RCA: 169] [Impact Index Per Article: 15.4] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2013] [Revised: 06/03/2013] [Accepted: 06/19/2013] [Indexed: 01/09/2023]
Abstract
Ineffective hematopoiesis is a major characteristic of myelodysplastic syndromes (MDS) causing relevant morbidity and mortality. Mesenchymal stromal cells (MSC) have been shown to physiologically support hematopoiesis, but their contribution to the pathogenesis of MDS remains elusive. We show that MSC from patients across all MDS subtypes (n=106) exhibit significantly reduced growth and proliferative capacities accompanied by premature replicative senescence. Osteogenic differentiation was significantly reduced in MDS-derived MSC, indicated by cytochemical stainings and reduced expressions of Osterix and Osteocalcin. This was associated with specific methylation patterns that clearly separated MDS-MSC from healthy controls and showed a strong enrichment for biological processes associated with cellular phenotypes and transcriptional regulation. Furthermore, in MDS-MSC, we detected altered expression of key molecules involved in the interaction with hematopoietic stem and progenitor cells (HSPC), in particular Osteopontin, Jagged1, Kit-ligand and Angiopoietin as well as several chemokines. Functionally, this translated into a significantly diminished ability of MDS-derived MSC to support CD34+ HSPC in long-term culture-initiating cell assays associated with a reduced cell cycle activity. Taken together, our comprehensive analysis shows that MSC from all MDS subtypes are structurally, epigenetically and functionally altered, which leads to impaired stromal support and seems to contribute to deficient hematopoiesis in MDS.
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Affiliation(s)
- S Geyh
- Department of Hematology, University of Duesseldorf, Duesseldorf, Germany
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Fröbel J, Cadeddu RP, Hartwig S, Bruns I, Wilk CM, Kündgen A, Fischer JC, Schroeder T, Steidl UG, Germing U, Lehr S, Haas R, Czibere A. Platelet proteome analysis reveals integrin-dependent aggregation defects in patients with myelodysplastic syndromes. Mol Cell Proteomics 2013; 12:1272-80. [PMID: 23382103 DOI: 10.1074/mcp.m112.023168] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
Bleeding complications are a significant clinical problem in patients with myelodysplastic syndromes even at sufficient platelet counts (>50,000/μl). However, the underlying pathology of this hemorrhagic diathesis is still unknown. Here, we analyzed the platelet proteome of patients with myelodysplastic syndromes by quantitative two-dimensional difference gel electrophoresis followed by mass spectrometric protein identification. Proteins identified with lower concentrations, such as Talin-1, Vinculin, Myosin-9, Filmain-A, and Actin play critical roles in integrin αIIbβ3 signaling and thus platelet aggregation. Despite normal agonist receptor expression, calcium flux, and granule release upon activation, the activation capacity of integrin αIIbβ3 was diminished in myelodysplastic syndrome platelets. Förster resonance energy transfer analysis showed a reduced co-localization of Talin-1 to the integrin's β3-subunit, which is required for receptor activation and fibrinogen binding. In addition, platelet spreading on immobilized fibrinogen was incomplete, and platelet aggregation assays confirmed a general defect in integrin-dependent platelet aggregation in patients with myelodysplastic syndromes. Our data provide novel aspects on the molecular pathology of impaired platelet function in myelodysplastic syndromes and suggest a mechanism of defective integrin αIIbβ3 signaling that may contribute to the hemorrhagic diathesis observed in these patients.
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Affiliation(s)
- Julia Fröbel
- Department of Hematology, Heinrich-Heine-University, 40225 Düsseldorf, Germany
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Wang ES, Lyons RM, Larson RA, Gandhi S, Liu D, Matei C, Scott B, Hu K, Yang AS. A randomized, double-blind, placebo-controlled phase 2 study evaluating the efficacy and safety of romiplostim treatment of patients with low or intermediate-1 risk myelodysplastic syndrome receiving lenalidomide. J Hematol Oncol 2012. [PMID: 23190430 PMCID: PMC3520696 DOI: 10.1186/1756-8722-5-71] [Citation(s) in RCA: 53] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
Background Lenalidomide treatment in myelodysplastic syndrome (MDS) may lead to thrombocytopenia and dose reductions/delays. This study evaluated the safety and tolerability of the thrombopoietin mimetic romiplostim and its effects on the incidence of clinically significant thrombocytopenic events (CSTEs) in lower risk MDS patients receiving lenalidomide. Methods Patients were assigned to weekly placebo (n = 12) or romiplostim 500 μg (n = 14) or 750 μg (n = 13) for four 28-day lenalidomide cycles. Results The treatment groups were generally similar with respect to baseline disease characteristics. Del(5q) abnormalities were noted in 1 (8%) patient in the placebo group, 3 (21%) in the romiplostim 500 μg group, and two (15%) in the 750 μg group. CSTEs were noted in 8 (67%) patients in the placebo group, 4 (29%) in the romiplostim 500 μg group, and 8 (62%) in the romiplostim 750 μg group. Throughout the study, median platelet counts trended lower in placebo-treated than in romiplostim-treated patients. Thrombocytopenia-related adjustments in lenalidomide occurred in 6 (50%) patients in the placebo group, 5 (36%) in the romiplostim 500 μg group, and 2 (15%) in the 750 μg group. Although the percentages of patients who received platelet transfusions were similar across treatment groups, there was a trend toward lower numbers of transfusions in both romiplostim groups during each treatment cycle. There were two serious treatment-related adverse events during the treatment period (cerebrovascular accident, placebo; worsening thrombocytopenia, romiplostim 500 μg). Two patients (romiplostim 500 and 750 μg, respectively) had an increase in bone marrow blasts to >20% during treatment, but had no post-treatment biopsy to confirm or exclude the diagnosis of progression to AML. Conclusions These data suggest that romiplostim administered to MDS patients during lenalidomide treatment may decrease the frequency of dose reductions/delays due to thrombocytopenia. Additional study is needed to confirm the results of this preliminary trial. Trial registration ClinicalTrials.gov NCT00418665
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Affiliation(s)
- Eunice S Wang
- Leukemia Service, Department of Medicine, Roswell Park Cancer Institute, Elm and Carlton Streets, Buffalo, NY 14263, USA.
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Germing U, Kündgen A. Prognostic scoring systems in MDS. Leuk Res 2012; 36:1463-9. [PMID: 22980036 DOI: 10.1016/j.leukres.2012.08.005] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2012] [Revised: 07/30/2012] [Accepted: 08/06/2012] [Indexed: 10/27/2022]
Abstract
Prognostic scoring systems in myelodysplastic syndromes are useful tools in order to get in idea on the expected course of the disease and offer patients a risk adapted treatment. Several good scores have been developed, the international prognostic scoring system (IPSS) being the gold standard for 15 years, now validated and refined. As more and more patients receive therapy and drugs are approved, the major goal for future projects must be the identification of predictive parameters and scoring systems in order to predict the response and outcome after specific treatments.
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Affiliation(s)
- Ulrich Germing
- Department of Hematology, Oncology and Clinical Immunology, Heinrich-Heine-University of Duesseldorf, Duesseldorf, Germany.
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46
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Dodillet H, Skoetz N, Kreuzer KA, Monsef I, Engert A, Bauer K. Thrombopoietin mimetics for patients with myelodysplastic syndromes. Cochrane Database Syst Rev 2012. [DOI: 10.1002/14651858.cd009883] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
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47
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Cordoba I, Gonzalez-Porras J, Such E, Nomdedeu B, Luño E, de Paz R, Carbonell F, Vallespi T, Ardanaz M, Ramos F, Marco V, Bonanad S, Sanchez-Barba M, Costa D, Bernal T, Sanz G, Cañizo M. The degree of neutropenia has a prognostic impact in low risk myelodysplastic syndrome. Leuk Res 2012; 36:287-92. [DOI: 10.1016/j.leukres.2011.10.025] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2011] [Revised: 09/21/2011] [Accepted: 10/27/2011] [Indexed: 11/29/2022]
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48
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Sandes AF, Yamamoto M, Matarraz S, Chauffaille MDLLF, Quijano S, López A, Oguro T, Kimura EYS, Orfao A. Altered immunophenotypic features of peripheral blood platelets in myelodysplastic syndromes. Haematologica 2012; 97:895-902. [PMID: 22271903 DOI: 10.3324/haematol.2011.057158] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
BACKGROUND Multiparameter flow cytometric analysis of bone marrow and peripheral blood cells has proven to be of help in the diagnostic workup of myelodysplastic syndromes. However, the usefulness of flow cytometry for the detection of megakaryocytic and platelet dysplasia has not yet been investigated. The aim of this pilot study was to evaluate by flow cytometry the diagnostic and prognostic value of platelet dysplasia in myelodysplastic syndromes. DESIGN AND METHODS We investigated the pattern of expression of distinct surface glycoproteins on peripheral blood platelets from a series of 44 myelodysplastic syndrome patients, 20 healthy subjects and 19 patients with platelet alterations associated to disease conditions other than myelodysplastic syndromes. Quantitative expression of CD31, CD34, CD36, CD41a, CD41b, CD42a, CD42b and CD61 glycoproteins together with the PAC-1, CD62-P, fibrinogen and CD63 platelet activation-associated markers and platelet light scatter properties were systematically evaluated. RESULTS Overall, flow cytometry identified multiple immunophenotypic abnormalities on platelets of myelodysplastic syndrome patients, including altered light scatter characteristics, over-and under expression of specific platelet glycoproteins and asynchronous expression of CD34; decreased expression of CD36 (n = 5), CD42a (n = 1) and CD61 (n = 2), together with reactivity for CD34 (n = 1) were only observed among myelodysplastic syndrome cases, while other alterations were also found in other platelet disorders. Based on the overall platelet alterations detected for each patient, an immunophenotypic score was built which identified a subgroup of myelodysplastic syndrome patients with a high rate of moderate to severe alterations (score>1.5; n = 16) who more frequently showed thrombocytopenia, megakaryocytic dysplasia and high-risk disease, together with a shorter overall survival. CONCLUSIONS Our results show the presence of altered phenotypes by flow cytometry on platelets from around half of the myelodysplastic syndrome patients studied. If confirmed in larger series of patients, these findings may help refine the diagnostic and prognostic assessment of this group of disorders.
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Affiliation(s)
- Alex F Sandes
- Disciplina de Hematologia e Hemoterapia, Departamento de Oncologia Clínica, Universidade Federal de São Paulo, UNIFESP, R. Botucatu 740, V. Clementino, 04023-900, São Paulo, Brazil.
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49
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Germing U, Lauseker M, Hildebrandt B, Symeonidis A, Cermak J, Fenaux P, Kelaidi C, Pfeilstöcker M, Nösslinger T, Sekeres M, Maciejewski J, Haase D, Schanz J, Seymour J, Kenealy M, Weide R, Lübbert M, Platzbecker U, Valent P, Götze K, Stauder R, Blum S, Kreuzer KA, Schlenk R, Ganser A, Hofmann WK, Aul C, Krieger O, Kündgen A, Haas R, Hasford J, Giagounidis A. Survival, prognostic factors and rates of leukemic transformation in 381 untreated patients with MDS and del(5q): A multicenter study. Leukemia 2012; 26:1286-92. [PMID: 22289990 DOI: 10.1038/leu.2011.391] [Citation(s) in RCA: 96] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
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50
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Gonzalez-Porras JR, Cordoba I, Such E, Nomdedeu B, Vallespi T, Carbonell F, Luño E, Ardanaz M, Ramos F, Pedro C, Gomez V, de Paz R, Sanchez-Barba M, Sanz GF, Del Cañizo AC. Prognostic impact of severe thrombocytopenia in low-risk myelodysplastic syndrome. Cancer 2011; 117:5529-37. [PMID: 21638279 DOI: 10.1002/cncr.26173] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2011] [Revised: 02/23/2011] [Accepted: 03/08/2011] [Indexed: 01/18/2023]
Abstract
BACKGROUND Thrombocytopenia is very common in myelodysplastic syndrome (MDS); however, its clinical impact in low-risk patients remains controversial. METHODS The authors analyzed the incidence and prognostic significance of thrombocytopenia at diagnosis in 2565 de novo MDS patients included in the Spanish MDS Registry. RESULTS Thrombocytopenia (platelet count <100 × 10(9) /L) was identified in 842 patients (32.8%). Severe thrombocytopenia (platelet count <30 × 10(9) /L) was observed in 7.1% of patients and was significantly associated with a higher-risk World Health Organization subtype (P = .026) and intermediate-2/high-risk International Prognostic Scoring System (IPSS) score (P = .046). Severe thrombocytopenia was the most important prognostic factor and had negative effects on the low/intermediate-1 risk group. Median overall survival of patients with a platelet count <30 and ≥ 30 × 10(9) /L was 16 months and 71 months, respectively (hazard ratio, 4.66; 95% confidence interval, 2.74-7.90; P < .0001). The negative effect of severe thrombocytopenia in low/intermediate-1 risk patients was caused by increased risk of bleeding. CONCLUSIONS MDS patients with low/intermediate-1 IPSS risk score and severe thrombocytopenia should no longer be regarded as low risk, and must be considered for disease-altering approaches at diagnosis.
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