1
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Ali H, Bacigalupo A. 2024 update on allogeneic hematopoietic stem cell transplant for myelofibrosis: A review of current data and applications on risk stratification and management. Am J Hematol 2024; 99:938-945. [PMID: 38450790 DOI: 10.1002/ajh.27274] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2024] [Accepted: 02/06/2024] [Indexed: 03/08/2024]
Abstract
BACKGROUND Allogeneic hemopoietic stem cell transplantation (HSCT) currently remains the only curative treatment for patients with myelofibrosis (MF). Transplant related mortality (TRM) and relapse, remain two significant complications which need to be addressed. AIMS The aim of this manuscript is to review current available reports on changes which have recently occurred, to improve the outcome of MF patients undergoing an allogeneic HSCT. METHODS Published papers were used to analyze different aspects of allogeneic HSCT. RESULTS Changes and updates are provided on selection of patients, prognostic systems, managing splenomegaly, conditioning regimens, predicting transplant outcome, stem cell sources, stem cell donors, graft versus host disease (GvHD) prophylaxis, patients with blast phase, hematopoietic reconstitution, disease markers, donor chimerism, and treatment of relapse. CONCLUSIONS The review outlines new transplant platforms which are now available for patients with myelofibrosis, together with persisting problems, among which, older age combined with marrow fibrosis and an inflammatory disease. Relapse also requires aggressive monitoring of drivers mutations, and early cellular therapy.
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Affiliation(s)
- Haris Ali
- Divison of Leukemia, Department of Hematology and Hemopoietic Cell Transplantation, City of Hope, Duarte, California, USA
| | - Andrea Bacigalupo
- Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, Fondazione Policlinico Universitario A. Gemelli IRCCS, Roma, Italy
- Sezione di Ematologia, Dipartimento di Scienze Radiologiche ed Ematologiche, Università Cattolica del Sacro Cuore, Roma, Italy
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2
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Gagelmann N, Hobbs GS, Campodonico E, Helbig G, Novak P, Schroeder T, Schneider A, Rautenberg C, Reinhardt HC, Bosques L, Heuser M, Panagiota V, Thol F, Gurnari C, Maciejewski JP, Ciceri F, Rathje K, Robin M, Pagliuca S, Rubio MT, Rocha V, Funke V, Hamerschlak N, Salit R, Scott BL, Duarte F, Mitrus I, Czerw T, Greco R, Kröger N. Splenic irradiation for myelofibrosis prior to hematopoietic cell transplantation: A global collaborative analysis. Am J Hematol 2024; 99:844-853. [PMID: 38357714 DOI: 10.1002/ajh.27252] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2023] [Revised: 01/11/2024] [Accepted: 01/31/2024] [Indexed: 02/16/2024]
Abstract
Splenomegaly is the clinical hallmark of myelofibrosis. Splenomegaly at the time of allogeneic hematopoietic cell transplantation (HCT) is associated with graft failure and poor graft function. Strategies to reduce spleen size before HCT especially after failure to Janus kinase (JAK) inhibition represent unmet clinical needs in the field. Here, we leveraged a global collaboration to investigate the safety and efficacy of splenic irradiation as part of the HCT platform for patients with myelofibrosis. We included 59 patients, receiving irradiation within a median of 2 weeks (range, 0.9-12 weeks) before HCT. Overall, the median spleen size prior to irradiation was 23 cm (range, 14-35). Splenic irradiation resulted in a significant and rapid spleen size reduction in 97% of patients (57/59), with a median decrease of 5.0 cm (95% confidence interval, 4.1-6.3 cm). The most frequent adverse event was thrombocytopenia, with no correlation between irradiation dose and hematological toxicities. The 3-year overall survival was 62% (95% CI, 48%-76%) and 1-year non-relapse mortality was 26% (95% CI, 14%-38%). Independent predictors for survival were severe thrombocytopenia and anemia before irradiation, transplant-specific risk score, higher-intensity conditioning, and present portal vein thrombosis. When using a propensity score matching adjusted for common confounders, splenic irradiation was associated with significantly reduced relapse (p = .01), showing a 3-year incidence of 12% for splenic irradiation versus 29% for patients with immediate HCT and 38% for patients receiving splenectomy. In conclusion, splenic irradiation immediately before HCT is a reasonable approach in patients experiencing JAK inhibition failure and is associated with a low incidence of relapse.
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Affiliation(s)
- Nico Gagelmann
- Department of Stem Cell Transplantation, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Gabriela S Hobbs
- Department of Medical Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Edoardo Campodonico
- Hematology and Bone Marrow Transplantation Unit, IRCCS San Raffaele Hospital, University Vita-Salute San Raffaele, Milan, Italy
| | - Grzegorz Helbig
- Department of Hematology and Bone Marrow Transplantation, School of Medicine in Katowice, Medical University of Silesia, Katowice, Poland
| | - Polona Novak
- Department of Hematology, University Medical Center Ljubljana, Ljubljana, Slovenia
| | - Thomas Schroeder
- Department of Hematology and Stem Cell Transplantation, West German Cancer Center, University Hospital of Essen, Germany
| | - Artur Schneider
- Department of Hematology and Stem Cell Transplantation, West German Cancer Center, University Hospital of Essen, Germany
| | - Christina Rautenberg
- Department of Hematology and Stem Cell Transplantation, West German Cancer Center, University Hospital of Essen, Germany
| | - Hans Christian Reinhardt
- Department of Hematology and Stem Cell Transplantation, West German Cancer Center, University Hospital of Essen, Germany
| | - Linette Bosques
- Department of Medical Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Michael Heuser
- Department of Hematology, Hemostasis, Oncology and Stem Cell Transplantation, Hannover Medical School, Hannover, Germany
| | - Victoria Panagiota
- Department of Hematology, Hemostasis, Oncology and Stem Cell Transplantation, Hannover Medical School, Hannover, Germany
| | - Felicitas Thol
- Department of Hematology, Hemostasis, Oncology and Stem Cell Transplantation, Hannover Medical School, Hannover, Germany
| | - Carmelo Gurnari
- Translational Hematology and Oncology Research Department, Taussig Cancer Center, Cleveland Clinic, Cleveland, Ohio, USA
- Department of Biomedicine and Prevention, Tor Vergata University of Rome, Rome, Italy
| | - Jaroslaw P Maciejewski
- Translational Hematology and Oncology Research Department, Taussig Cancer Center, Cleveland Clinic, Cleveland, Ohio, USA
- Leukemia Program, Department of Hematology and Medical Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Fabio Ciceri
- Hematology and Bone Marrow Transplantation Unit, IRCCS San Raffaele Hospital, University Vita-Salute San Raffaele, Milan, Italy
| | - Kristin Rathje
- Department of Stem Cell Transplantation, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Marie Robin
- Service d'Hématologie-Greffe, Hôpital Saint-Louis, Assistance Publique Hôpitaux de Paris, Paris, France
| | - Simona Pagliuca
- Department of Hematology, Brabois Hospital, Centre Hospitalier Régional Universitaire (CHRU), Nancy, France
| | - Marie-Thérèse Rubio
- Department of Hematology, Brabois Hospital, Centre Hospitalier Régional Universitaire (CHRU), Nancy, France
| | - Vanderson Rocha
- Hospital de Clinicas, Hematology, Transfusion and Cell Therapy Service, University of São Paulo, Sao Paulo, Brazil
| | - Vaneuza Funke
- Blood and Marrow Transplantation Programme, Hospital de Clínicas, Federal University of Parana, Curitiba, Paraná, Brazil; Hospital Nossa Senhora das Graças, Curitiba, Brazil
| | | | - Rachel Salit
- Fred Hutchinson Cancer Research Center, Seattle, USA
| | - Bart L Scott
- Fred Hutchinson Cancer Research Center, Seattle, USA
| | - Fernando Duarte
- Hospital Universitario Walter Cantídio, Universidade Federal do Ceara, Fortaleza, Brazil
| | - Iwona Mitrus
- Hematology Department, Maria Skłodowska-Curie National Research Institute of Oncology, Gliwice, Poland
| | - Tomasz Czerw
- Hematology Department, Maria Skłodowska-Curie National Research Institute of Oncology, Gliwice, Poland
| | - Raffaella Greco
- Hematology and Bone Marrow Transplantation Unit, IRCCS San Raffaele Hospital, University Vita-Salute San Raffaele, Milan, Italy
| | - Nicolaus Kröger
- Department of Stem Cell Transplantation, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
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3
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Tefferi A, Vannucchi AM. Risk models in myelofibrosis-the past, present, and future. Am J Hematol 2024; 99:519-522. [PMID: 38400565 DOI: 10.1002/ajh.27270] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2024] [Accepted: 02/14/2024] [Indexed: 02/25/2024]
Abstract
Risk models in myelofibrosis (MYSEC-PM) or primary myelofibrosis (IPSS, DIPSS, DIPSS+, MIPSS70, MIPSS70+, MIPSSv2, GIPSS).
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Affiliation(s)
- Ayalew Tefferi
- Division of Hematology, Department of Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Alessandro M Vannucchi
- CRIMM, Center Research and Innovation of Myeloproliferative Neoplasms, University of Florence, AOU Careggi, Florence, Italy
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4
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Maze D, Arcasoy MO, Henrie R, Cerquozzi S, Kamble R, Al-Hadidi S, Yacoub A, Singh AK, Elsawy M, Sirhan S, Smith E, Marcoux C, Viswabandya A, Daly A, Sibai H, McNamara C, Shi Y, Xu W, Lajkosz K, Foltz L, Gupta V. Upfront allogeneic transplantation versus JAK inhibitor therapy for patients with myelofibrosis: a North American collaborative study. Bone Marrow Transplant 2024; 59:196-202. [PMID: 37938736 PMCID: PMC10849956 DOI: 10.1038/s41409-023-02146-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2023] [Revised: 10/19/2023] [Accepted: 10/30/2023] [Indexed: 11/09/2023]
Abstract
Allogeneic hematopoietic cell transplantation (HCT) is the only curative therapy for myelofibrosis (MF) and is recommended for patients with higher risk disease. However, there is a risk of early mortality, and optimal timing is unknown. JAK inhibitor (JAKi) therapy may offer durable improvement in symptoms, splenomegaly and quality of life. The aim of this multicentre, retrospective observational study was to compare outcomes of patients aged 70 years or below with MF in chronic phase who received upfront JAKi therapy vs. upfront HCT in dynamic international prognostic scoring system (DIPSS)-stratified categories. For the whole study cohort, median overall survival (OS) was longer for patients who received a JAKi vs. upfront HCT, 69 (95% CI 57-89) vs. 42 (95% CI 20-not reached, NR) months, respectively (p = 0.01). In patients with intermediate-2 and high-risk disease, median OS was 55 (95% CI 36-73) months with JAKi vs. 36 (95% CI 20-NR) months for HCT (p = 0.27). An upfront HCT strategy was associated with early mortality and difference in median OS was not observed in any risk group by 5 years of follow-up. Within the limitations of a retrospective observational study, we did not observe any benefit of a universal upfront HCT approach for higher-risk MF.
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Affiliation(s)
- Dawn Maze
- The Princess Margaret Cancer Centre, University of Toronto, Toronto, ON, Canada.
| | - Murat O Arcasoy
- Duke Cancer Institute, Duke University School of Medicine, Durham, NC, USA
| | - Ryan Henrie
- Division of Hematology, St. Paul's Hospital, University of British Columbia, Vancouver, BC, Canada
| | - Sonia Cerquozzi
- Tom Baker Cancer Centre, Alberta Health Service Calgary Zone, University of Calgary, Calgary, AB, Canada
| | - Rammurti Kamble
- Center for Cell and Gene Therapy, Baylor College of Medicine and Houston Methodist Hospital, Houston, TX, USA
| | - Samer Al-Hadidi
- Myeloma Section, Winthrop P. Rockefeller Cancer Institute, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Abdulraheem Yacoub
- Division of Hematology and Oncology, University of Kansas Medical Center, Kansas City, KS, USA
| | - Anurag K Singh
- Division of Hematology and Oncology, University of Kansas Medical Center, Kansas City, KS, USA
| | - Mahmoud Elsawy
- Division of Hematology, Dalhousie University, Halifax, NS, Canada
| | - Shireen Sirhan
- Jewish General Hospital, McGill University, Montreal, QC, Canada
| | - Elliot Smith
- The Princess Margaret Cancer Centre, University of Toronto, Toronto, ON, Canada
| | - Curtis Marcoux
- Division of Hematology, Dalhousie University, Halifax, NS, Canada
| | - Auro Viswabandya
- The Princess Margaret Cancer Centre, University of Toronto, Toronto, ON, Canada
| | - Andrew Daly
- Tom Baker Cancer Centre, Alberta Health Service Calgary Zone, University of Calgary, Calgary, AB, Canada
| | - Hassan Sibai
- The Princess Margaret Cancer Centre, University of Toronto, Toronto, ON, Canada
| | - Caroline McNamara
- The Princess Margaret Cancer Centre, University of Toronto, Toronto, ON, Canada
| | - Yuliang Shi
- Department of Biostatistics, Princess Margaret Cancer Centre, University Health Network, Toronto, ON, Canada
- Department of Statistics and Actuarial Science, University of Waterloo, Waterloo, ON, Canada
| | - Wei Xu
- Department of Biostatistics, Princess Margaret Cancer Centre, University Health Network, Toronto, ON, Canada
- Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
| | - Katherine Lajkosz
- Department of Biostatistics, Princess Margaret Cancer Centre, University Health Network, Toronto, ON, Canada
- Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
| | - Lynda Foltz
- Division of Hematology, St. Paul's Hospital, University of British Columbia, Vancouver, BC, Canada
| | - Vikas Gupta
- The Princess Margaret Cancer Centre, University of Toronto, Toronto, ON, Canada
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5
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Tefferi A, Pardanani A, Gangat N. Momelotinib expands the therapeutic armamentarium for myelofibrosis: Impact on hierarchy of treatment choices. Am J Hematol 2024; 99:300-308. [PMID: 38164985 DOI: 10.1002/ajh.27163] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2023] [Accepted: 11/05/2023] [Indexed: 01/03/2024]
Abstract
The primary objective of treatment in myelofibrosis (MF) is prolongation of life, which is currently accomplished only by allogeneic hematopoietic stem cell transplantation (AHSCT). Determination of optimal timing for AHSCT is facilitated by molecular risk stratification. Non-transplant treatment options in MF are palliative in scope and include Janus kinase 2 (JAK2) inhibitors (JAKi): momelotinib (FDA approved on September 15, 2023), ruxolitinib (November 16, 2011), fedratinib (August 16, 2019), and pacritinib (February 28, 2022); all four JAKi are effective in reducing spleen size and alleviating symptoms, considered a drug class effect and attributed to their canonical JAK-STAT inhibitory mechanism of action. In addition, momelotinib exhibits erythropoietic effect, attributed to alleviation of ineffective erythropoiesis through inhibition of activin A receptor type-I (ACVR1). In transplant-ineligible or deferred patients, the order of treatment preference is based on specific symptoms and individual assessment of risk tolerance. Because of drug-induced immunosuppression and other toxicities attributed to JAKi, we prefer non-JAKi drugs as initial treatment for MF-associated anemia that is not accompanied by treatment-requiring splenomegaly or constitutional symptoms. Otherwise, it is reasonable to consider momelotinib as the first-line JAKi treatment of choice, in order to target the triad of quality-of-life offenders in MF: anemia, splenomegaly, and constitutional symptoms/cachexia. For second-line therapy, we favor ruxolitinib, over fedratinib, based on toxicity profile. Pacritinib and fedratinib provide alternative options in the presence of severe thrombocytopenia or ruxolitinib-resistance/intolerance, respectively. Splenectomy remains a viable option for drug-resistant symptomatic splenomegaly and cytopenia.
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Affiliation(s)
- Ayalew Tefferi
- Division of Hematology, Department of Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Animesh Pardanani
- Division of Hematology, Department of Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Naseema Gangat
- Division of Hematology, Department of Medicine, Mayo Clinic, Rochester, Minnesota, USA
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6
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Tefferi A, Vannucchi AM. CALR mutations possess unique prognostic relevance in myelofibrosis-before and after transplant. Bone Marrow Transplant 2024; 59:1-3. [PMID: 37821534 DOI: 10.1038/s41409-023-02112-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2023] [Revised: 08/30/2023] [Accepted: 09/19/2023] [Indexed: 10/13/2023]
Affiliation(s)
- Ayalew Tefferi
- Division of Hematology, Department of Medicine, Mayo Clinic, Rochester, MN, USA.
| | - Alessandro M Vannucchi
- CRIMM, Center Research and Innovation of Myeloproliferative Neoplasms, University of Florence, AOU Careggi, Florence, Italy
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7
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Gupta V. Evidence creation for myelofibrosis: Challenges and opportunities. Br J Haematol 2024; 204:19-21. [PMID: 38083995 DOI: 10.1111/bjh.19257] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2023] [Accepted: 11/29/2023] [Indexed: 01/11/2024]
Abstract
Evidence-based guidelines for rare diseases, such as myelofibrosis (MF), continue to prove challenging to develop, and decision-making for MF is complex. The British Society for Haematology (BSH) has created a pragmatic symptom-guided risk-adapted framework on all aspects of management of MF and shared best practices on the use of JAK inhibitors, transplantation and other conventional therapies in the management of myelofibrosis. Commentary on: McLornan et al. The management of myelofibrosis: A British Society for Haematology Guideline. Br J Haematol 2024;204:136-150.
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Affiliation(s)
- Vikas Gupta
- Medical Oncology and Hematology, Princess Margaret Cancer Centre, University of Toronto, Toronto, Ontario, Canada
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8
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Kröger N, Bacigalupo A, Barbui T, Ditschkowski M, Gagelmann N, Griesshammer M, Gupta V, Hamad N, Harrison C, Hernandez-Boluda JC, Koschmieder S, Jain T, Mascarenhas J, Mesa R, Popat UR, Passamonti F, Polverelli N, Rambaldi A, Robin M, Salit RB, Schroeder T, Scott BL, Tamari R, Tefferi A, Vannucchi AM, McLornan DP, Barosi G. Indication and management of allogeneic haematopoietic stem-cell transplantation in myelofibrosis: updated recommendations by the EBMT/ELN International Working Group. Lancet Haematol 2024; 11:e62-e74. [PMID: 38061384 DOI: 10.1016/s2352-3026(23)00305-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2023] [Revised: 09/26/2023] [Accepted: 10/03/2023] [Indexed: 12/24/2023]
Abstract
New options for medical therapy and risk scoring systems containing molecular data are leading to increased complexity in the management of patients with myelofibrosis. To inform patients' optimal care, we updated the 2015 guidelines on indications for and management of allogeneic haematopoietic stem-cell transplantation (HSCT) with the support of the European Society for Blood and Marrow Transplantation (EBMT) and European LeukemiaNet (ELN). New recommendations were produced using a consensus-building methodology after a comprehensive review of articles released from January, 2015 to December, 2022. Seven domains and 18 key questions were selected through a series of questionnaires using a Delphi process. Key recommendations in this update include: patients with primary myelofibrosis and an intermediate-2 or high-risk Dynamic International Prognostic Scoring System score, or a high-risk Mutation-Enhanced International Prognostic Score Systems (MIPSS70 or MIPSS70-plus) score, or a low-risk or intermediate-risk Myelofibrosis Transplant Scoring System score should be considered candidates for allogeneic HSCT. All patients who are candidates for allogeneic HSCT with splenomegaly greater than 5 cm below the left costal margin or splenomegaly-related symptoms should receive a spleen-directed treatment, ideally with a JAK-inhibitor; HLA-matched sibling donors remain the preferred donor source to date. Reduced intensity conditioning and myeloablative conditioning are both valid options for patients with myelofibrosis. Regular post-transplantation driver mutation monitoring is recommended to detect and treat early relapse with donor lymphocyte infusion. In a disease where evidence-based guidance is scarce, these recommendations might help clinicians and patients in shared decision making.
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Affiliation(s)
- Nicolaus Kröger
- Department of Stem Cell Transplantation, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.
| | - Andrea Bacigalupo
- Department of Hematology, Fondazione Policlinico Universitario Gemelli IRCCS, Universita' Cattolica del Sacro Cuore, Rome, Italy
| | - Tiziano Barbui
- FROM Research Foundation, Papa Giovanni XXIII Hospital, Bergamo, Italy
| | - Markus Ditschkowski
- Department of Hematology and Stem Cell Transplantation, West German Cancer Center, University Hospital of Essen, Essen, Germany
| | - Nico Gagelmann
- Department of Stem Cell Transplantation, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Martin Griesshammer
- University Clinic for Hematology, Oncology, Haemostaseology and Palliative Care, Johannes Wesling Medical Center Minden, University of Bochum, Bochum, Germany
| | - Vikas Gupta
- Princess Margaret Cancer Centre, Toronto, ON, Canada
| | - Nada Hamad
- School of Clinical Medicine, Faculty of Medicine and Health, UNSW Sydney, Sydney, NSW, Australia; Department of Haematology, St Vincent's Hospital, Sydney, NSW, Australia; School of Medicine, University of Notre Dame, Sydney, NSW, Australia
| | | | | | - Steffen Koschmieder
- Center for Integrated Oncology Aachen Bonn Cologne Düsseldorf, Aachen, Germany; Department of Hematology, Oncology, Hemostaseology, and Stem Cell Transplantation, Faculty of Medicine, RWTH Aachen University, Aachen, Germany
| | - Tania Jain
- Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University, Baltimore, MD, USA
| | - John Mascarenhas
- Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Ruben Mesa
- Atrium Health Wake Forest Baptist Comprehensive Cancer Center, Winston-Salem, NC, USA
| | - Uday R Popat
- The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Francesco Passamonti
- Università degli Studi di Milano; Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Nicola Polverelli
- Division of Hematology, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Alessandro Rambaldi
- Department of Oncology and Hemato-Oncology, University of Milan, Milan, Italy; Azienda Socio-Sanitaria Territoriale Papa Giovanni XXIII, Bergamo, Italy
| | - Marie Robin
- Department of Hematology, University Hospital of Saint Louis, Paris, France
| | | | - Thomas Schroeder
- Department of Hematology and Stem Cell Transplantation, West German Cancer Center, University Hospital of Essen, Essen, Germany
| | | | - Roni Tamari
- Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Ayalew Tefferi
- Division of Hematology, Department of Medicine, Mayo Clinic, Rochester, MN, USA
| | - Alessandro M Vannucchi
- Centro Ricerca e Innovazione delle Malattie Mieloproliferative, Azienda Ospedaliera-Universitaria Careggi, Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
| | - Donal P McLornan
- Department of Haematology and Stem Cell Transplantation, University College London Hospitals NHS Trust, London, UK
| | - Giovanni Barosi
- Center for the Study of Myelofibrosis, IRCCS Policlinico S Matteo, Pavia, Italy
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9
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Rafati M, Brown DW, Zhou W, Jones K, Luo W, St. Martin A, Wang Y, He M, Spellman SR, Wang T, Deeg HJ, Gupta V, Lee SJ, Bolon YT, Chanock SJ, Machiela MJ, Saber W, Gadalla SM. JAK2 V617F mutation and associated chromosomal alterations in primary and secondary myelofibrosis and post-HCT outcomes. Blood Adv 2023; 7:7506-7515. [PMID: 38011490 PMCID: PMC10758737 DOI: 10.1182/bloodadvances.2023010882] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2023] [Revised: 10/02/2023] [Accepted: 10/02/2023] [Indexed: 11/29/2023] Open
Abstract
JAK2 V617F is the most common driver mutation in primary or secondary myelofibrosis for which allogeneic hematopoietic cell transplantation (HCT) is the only curative treatment. Knowledge of the prognostic utility of JAK2 alterations in the HCT setting is limited. We identified all patients with MF who received HCT between 2000 and 2016 and had a pre-HCT blood sample (N = 973) available at the Center of International Blood and Marrow Transplant Research biorepository. PacBio sequencing and single nucleotide polymorphism-array genotyping were used to identify JAK2V617F mutation and associated mosaic chromosomal alterations (mCAs), respectively. Cox proportional hazard models were used for HCT outcome analyses. Genomic testing was complete for 924 patients with MF (634 primary MF [PMF], 135 postpolycythemia vera [PPV-MF], and 155 postessential thrombocytopenia [PET-MF]). JAK2V617F affected 562 patients (57.6% of PMF, 97% of PPV-MF, and 42.6% of PET-MF). Almost all patients with mCAs involving the JAK2 region (97.9%) were JAK2V617-positive. In PMF, JAK2V617F mutation status, allele burden, or identified mCAs were not associated with disease progression/relapse, nonrelapse mortality (NRM), or overall survival. Almost all PPV-MF were JAK2V617F-positive (97%), with no association between HCT outcomes and mutation allele burden or mCAs. In PET-MF, JAK2V617F high mutation allele burden (≥60%) was associated with excess risk of NRM, restricted to transplants received in the era of JAK inhibitors (2013-2016; hazard ratio = 7.65; 95% confidence interval = 2.10-27.82; P = .002). However, allele burden was not associated with post-HCT disease progression/relapse or survival. Our findings support the concept that HCT can mitigate the known negative effect of JAK2V617F in patients with MF, particularly for PMF and PPV-MF.
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Affiliation(s)
- Maryam Rafati
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, National Institutes of Health, Bethesda, MD
| | - Derek W. Brown
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, National Institutes of Health, Bethesda, MD
| | - Weiyin Zhou
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, National Institutes of Health, Bethesda, MD
- Leidos Biomedical Research, Inc, Frederick National Laboratory for Cancer Research, Frederick, MD
| | - Kristine Jones
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, National Institutes of Health, Bethesda, MD
- Leidos Biomedical Research, Inc, Frederick National Laboratory for Cancer Research, Frederick, MD
| | - Wen Luo
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, National Institutes of Health, Bethesda, MD
- Leidos Biomedical Research, Inc, Frederick National Laboratory for Cancer Research, Frederick, MD
| | - Andrew St. Martin
- Center for International Blood and Marrow Transplant Research, Minneapolis, MN
| | - Youjin Wang
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, National Institutes of Health, Bethesda, MD
| | - Meilun He
- Center for International Blood and Marrow Transplant Research, Minneapolis, MN
| | - Stephen R. Spellman
- Center for International Blood and Marrow Transplant Research, Minneapolis, MN
| | - Tao Wang
- Center for International Blood and Marrow Transplant Research, Milwaukee, WI
- Division of Biostatistics, Medical College of Wisconsin, Milwaukee, WI
| | - H. Joachim Deeg
- Clinical Research Division, Fred Hutchinson Cancer Center, Seattle, WA
| | - Vikas Gupta
- MPN Program, Princess Margaret Cancer Centre, University of Toronto, Toronto, ON, Canada
| | - Stephanie J. Lee
- Center for International Blood and Marrow Transplant Research, Milwaukee, WI
- Clinical Research Division, Fred Hutchinson Cancer Center, Seattle, WA
| | - Yung-Tsi Bolon
- Center for International Blood and Marrow Transplant Research, Minneapolis, MN
| | - Stephen J. Chanock
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, National Institutes of Health, Bethesda, MD
| | - Mitchell J. Machiela
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, National Institutes of Health, Bethesda, MD
| | - Wael Saber
- Center for International Blood and Marrow Transplant Research, Milwaukee, WI
| | - Shahinaz M. Gadalla
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, National Institutes of Health, Bethesda, MD
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10
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Palmer J. Are transplant indications changing for myelofibrosis? HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2023; 2023:676-681. [PMID: 38066916 PMCID: PMC10727025 DOI: 10.1182/hematology.2023000453] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/18/2023]
Abstract
Myelofibrosis is a devastating myeloid malignancy characterized by dysregulation of the JAK-STAT pathway, resulting in splenomegaly, constitutional symptoms, anemia, thrombocytopenia, leukocytosis, and an increased likelihood of progression to acute leukemia. The only curative option is allogeneic stem cell transplantation. The numbers of transplants have been increasing every year, and although there have been improvements in survival, there remain many unanswered questions. In this review, we will evaluate patient selection and appropriate timing for transplantation. We will cover the current prognostic scoring systems, which can aid in the decision of when to move forward with transplant. We will also review the different donor options, as well as the conditioning regimens. The peritransplant management of splenomegaly will be reviewed. We will discuss management of posttransplant complications such as loss of donor chimerism or disease relapse. Finally, we will review what is known about the outlook of patients who have undergone allogeneic stem cell transplant with regards to quality of life and long-term survival.
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Affiliation(s)
- Jeanne Palmer
- Division of Hematology/Medical Oncology, Mayo Clinic, Phoenix, AZ
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11
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Chen J, Wang K, Xiao Z, Xu Z. Efficacy and safety of combination therapies vs monotherapy of hypomethylating agents in accelerated or blast phase of Philadelphia negative myeloproliferative neoplasms: a systematic review and meta-analysis. Ann Med 2023; 55:348-360. [PMID: 36644935 PMCID: PMC9848335 DOI: 10.1080/07853890.2022.2164611] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/17/2023] Open
Abstract
BACKGROUND There is a lack of evidence regarding whether combination therapy of hypomethylating agents (HMAs) has better outcomes than HMA monotherapy in patients with Philadelphia chromosome-negative accelerated or blast phase myeloproliferative neoplasms (MPN-AP/BP). MATERIALS AND METHODS Pubmed, Embase, Web of Science and Cochrane library databases were searched for studies from inception of each database until 31 December 2021. Data extraction and synthesis were conducted following the PRISMA reporting guideline. RESULTS It was found that HMAs plus venetoclax therapy yielded a higher CR/CRi rate than HMAs alone [36% vs 19%, p = .0204] and a higher CR rate than HMAs plus ruxolitinib [22% vs 8%, p = .0313]. HMAs plus ruxolitinib combination showed a higher ORR than HMA monotherapy [45% vs 30%, p = .0395], but there was no improvement in CR/CRi. The one-year and two-year OS rate for patients treated with HMAs plus venetoclx/ruxolitinib demonstrated a trend towards prolonged survival than HMAs alone [HMAs plus venetoclax: 24% vs 11%, p = .1295 and 12% vs 3%, p = .2357; HMAs plus ruxolitinib: 25% vs 11%, p = .0774 and 33% vs 3%, p = .051]. CONCLUSION It was confirmed that HMA in combination with venetoclax is an effective and well-tolerated option in MPN-AP/BP patients in pre- as well as post-haematopoietic stem cell transplantation settings. HMA plus ruxolitinib therapy was revealed to be effective in patients with MPN-AP.Key MessagesCombination therapy with HMAs and venetoclax/ruxolitinib was associated with improved outcomes than HMAs alone in MPN-AP/BP patients.Further large-scale randomized controlled trials are needed to confirm regarding to the optimal treatment for this patient population.
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Affiliation(s)
- Jia Chen
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Institute of Hematology and Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin, China.,Tianjin Institutes of Health Science, Tianjin, China.,MDS and MPN Centre, Institute of Hematology and Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin, China
| | - Kefei Wang
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Institute of Hematology and Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin, China.,Tianjin Institutes of Health Science, Tianjin, China
| | - Zhijian Xiao
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Institute of Hematology and Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin, China.,Tianjin Institutes of Health Science, Tianjin, China.,MDS and MPN Centre, Institute of Hematology and Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin, China
| | - Zefeng Xu
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Institute of Hematology and Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin, China.,Tianjin Institutes of Health Science, Tianjin, China.,MDS and MPN Centre, Institute of Hematology and Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin, China
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12
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Tefferi A, Pardanani A, Gangat N. Momelotinib (JAK1/JAK2/ACVR1 inhibitor): mechanism of action, clinical trial reports, and therapeutic prospects beyond myelofibrosis. Haematologica 2023; 108:2919-2932. [PMID: 36861402 PMCID: PMC10620561 DOI: 10.3324/haematol.2022.282612] [Citation(s) in RCA: 11] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2023] [Accepted: 02/20/2023] [Indexed: 03/03/2023] Open
Abstract
Janus kinase (JAK) 2 inhibitors are now part of the therapeutic armamentarium for primary and secondary myelofibrosis (MF). Patients with MF endure shortened survival and poor quality of life. Allogeneic stem cell transplantation (ASCT) is currently the only treatment modality in MF with the potential to cure the disease or prolong survival. By contrast, current drug therapy in MF targets quality of life and does not modify the natural history of the disease. The discovery of JAK2 and other JAK-STAT activating mutations (i.e., CALR and MPL) in myeloproliferative neoplasms, including MF, has facilitated the development of several JAK inhibitors that are not necessarily specific to the oncogenic mutations themselves but have proven effective in countering JAK-STAT signaling, resulting in suppression of inflammatory cytokines and myeloproliferation. This non-specific activity resulted in clinically favorable effects on constitutional symptoms and splenomegaly and, consequently, approval by the Food and Drug Administration (FDA) of three small molecule JAK inhibitors: ruxolitinib, fedratinib, and pacritinib. A fourth JAK inhibitor, momelotinib, is poised for FDA approval soon and has been shown to provide additional benefit in alleviating transfusion-dependent anemia in MF. The salutary effect of momelotinib on anemia has been attributed to inhibition of activin A receptor, type 1 (ACVR1) and recent information suggests a similar effect from pacritinib. ACRV1 mediates SMAD2/3 signaling which contributes to upregulation of hepcidin production and iron-restricted erythropoiesis. Targeting ACRV1 raises therapeutic prospects in other myeloid neoplasms associated with ineffective erythropoiesis, such as myelodysplastic syndromes with ring sideroblasts or SF3B1 mutation, especially those with co-expression of a JAK2 mutation and thrombocytosis.
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Affiliation(s)
- Ayalew Tefferi
- Division of Hematology, Department of Medicine, Mayo Clinic, Rochester, MN.
| | - Animesh Pardanani
- Division of Hematology, Department of Medicine, Mayo Clinic, Rochester, MN
| | - Naseema Gangat
- Division of Hematology, Department of Medicine, Mayo Clinic, Rochester, MN
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13
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Bastin DJ, Mount G, Hsia CC, Jarrar M, McCann K, Xenocostas A, Teriaky A, Deotare U. The tale of two organs: allogeneic hematopoietic stem cell transplantation following liver transplantation in a myelofibrosis patient. Hematol Transfus Cell Ther 2023; 45:502-504. [PMID: 34955451 PMCID: PMC10627999 DOI: 10.1016/j.htct.2021.11.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2021] [Revised: 07/06/2021] [Accepted: 11/02/2021] [Indexed: 11/13/2022] Open
Affiliation(s)
| | | | | | | | - Kit McCann
- Western University, London, ON, Canada; Windsor Regional Hospital, Windsor, ON, Canada
| | - Anargyros Xenocostas
- Western University, London, ON, Canada; Blood and Marrow Transplant Program, London Health Sciences Centre, London, ON, Canada
| | | | - Uday Deotare
- Western University, London, ON, Canada; Blood and Marrow Transplant Program, London Health Sciences Centre, London, ON, Canada; The Centre for Quality, Innovation and Safety, Department of Medicine, Western University, London, ON, Canada.
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14
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Jungius S, Adam FC, Grosheintz K, Medinger M, Buser A, Passweg JR, Halter JP, Meyer SC. Characterization of engraftment dynamics in myelofibrosis after allogeneic hematopoietic cell transplantation including novel conditioning schemes. Front Oncol 2023; 13:1205387. [PMID: 37637037 PMCID: PMC10449533 DOI: 10.3389/fonc.2023.1205387] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2023] [Accepted: 07/24/2023] [Indexed: 08/29/2023] Open
Abstract
Introduction Myelofibrosis (MF) is a rare hematopoietic stem cell disorder progressing to bone marrow (BM) failure or blast phase. Allogeneic hematopoietic cell transplantation (HCT) represents a potentially curative therapy for a limited subset of patients with advanced MF, who are eligible, but engraftment in MF vs. AML is delayed which promotes complications. As determinants of engraftment in MF are incompletely characterized, we studied engraftment dynamics at our center. Methods A longitudinal cohort of 71 allogeneic HCT performed 2000-2019 with >50% after 2015 was evaluated. Results Median time to neutrophil engraftment ≥0.5x109/l was +20 days post-transplant and associated with BM fibrosis, splenomegaly and infused CD34+ cell number. Engraftment dynamics were similar in primary vs. secondary MF and were independent of MF driver mutations in JAK2, CALR and MPL. Neutrophil engraftment occurred later upon haploidentical HCT with thiotepa-busulfan-fludarabine conditioning, post-transplant cyclophosphamide and G-CSF (TBF-PTCy/G-CSF) administered to 9.9% and 15.6% of patients in 2000-2019 and after 2015, respectively. Engraftment of platelets was similarly delayed, while reconstitution of reticulocytes was not affected. Conclusions Since MF is a rare hematologic malignancy, this data from a large number of HCT for MF is essential to substantiate that later neutrophil and platelet engraftment in MF relates both to host and treatment-related factors. Observations from this longitudinal cohort support that novel conditioning schemes administered also to rare entities such as MF, require detailed evaluation in larger, multi-center cohorts to assess also indicators of long-term graft function and overall outcome in patients with this infrequent hematopoietic neoplasm undergoing allogeneic transplantation.
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Affiliation(s)
- Sarah Jungius
- Department of Biomedicine, University Hospital Basel and University of Basel, Basel, Switzerland
- Department of Biomedical Research, University of Bern, Bern, Switzerland
| | - Franziska C. Adam
- Division of Hematology, University Hospital Basel, Basel, Switzerland
| | | | - Michael Medinger
- Division of Hematology, University Hospital Basel, Basel, Switzerland
| | - Andreas Buser
- Division of Hematology, University Hospital Basel, Basel, Switzerland
| | - Jakob R. Passweg
- Division of Hematology, University Hospital Basel, Basel, Switzerland
| | - Jörg P. Halter
- Division of Hematology, University Hospital Basel, Basel, Switzerland
| | - Sara C. Meyer
- Department of Biomedicine, University Hospital Basel and University of Basel, Basel, Switzerland
- Department of Biomedical Research, University of Bern, Bern, Switzerland
- Division of Hematology, University Hospital Basel, Basel, Switzerland
- Department of Hematology and Central Hematology Laboratory, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
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15
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Tamari R, McLornan DP, Ahn KW, Estrada-Merly N, Hernández-Boluda JC, Giralt S, Palmer J, Gale RP, DeFilipp Z, Marks DI, van der Poel M, Verdonck LF, Battiwalla M, Diaz MA, Gupta V, Ali H, Litzow MR, Lazarus HM, Gergis U, Bashey A, Liesveld J, Hashmi S, Pu JJ, Beitinjaneh A, Bredeson C, Rizzieri D, Savani BN, Abid MB, Ganguly S, Agrawal V, Ulrike Bacher V, Wirk B, Jain T, Cutler C, Aljurf M, Kindwall-Keller T, Kharfan-Dabaja MA, Hildebrandt GC, Pawarode A, Solh MM, Yared JA, Grunwald MR, Nathan S, Nishihori T, Seo S, Scott BL, Nakamura R, Oran B, Czerw T, Yakoub-Agha I, Saber W. A simple prognostic system in patients with myelofibrosis undergoing allogeneic stem cell transplantation: a CIBMTR/EBMT analysis. Blood Adv 2023; 7:3993-4002. [PMID: 37134306 PMCID: PMC10410129 DOI: 10.1182/bloodadvances.2023009886] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2023] [Revised: 04/17/2023] [Accepted: 04/17/2023] [Indexed: 05/05/2023] Open
Abstract
To develop a prognostic model for patients undergoing allogeneic hematopoietic cell transplantation (allo-HCT) for myelofibrosis (MF), we examined the data of 623 patients undergoing allo-HCT between 2000 and 2016 in the United States (the Center for International Blood and Marrow Transplant Research [CIBMTR] cohort). A Cox multivariable model was used to identify factors prognostic of mortality. A weighted score using these factors was assigned to patients who received transplantation in Europe (the European Bone Marrow Transplant [EBMT] cohort; n = 623). Patient age >50 years (hazard ratio [HR], 1.39; 95% confidence interval [CI], 0.98-1.96), and HLA-matched unrelated donor (HR, 1.29; 95% CI, 0.98-1.7) were associated with an increased hazard of death and were assigned 1 point. Hemoglobin levels <100 g/L at time of transplantation (HR, 1.63; 95% CI, 1.2-2.19) and a mismatched unrelated donor (HR, 1.78; 95% CI, 1.25-2.52) were assigned 2 points. The 3-year overall survival (OS) in patients with a low (1-2 points), intermediate (3-4 points), and high score (5 points) were 69% (95% CI, 61-76), 51% (95% CI, 46-56.4), and 34% (95% CI, 21-49), respectively (P < .001). Increasing score was predictive of increased transplant-related mortality (TRM; P = .0017) but not of relapse (P = .12). The derived score was predictive of OS (P < .001) and TRM (P = .002) but not of relapse (P = .17) in the EBMT cohort as well. The proposed system was prognostic of survival in 2 large cohorts, CIBMTR and EBMT, and can easily be applied by clinicians consulting patients with MF about the transplantation outcomes.
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Affiliation(s)
- Roni Tamari
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Donal P. McLornan
- Department of Medicine, University College Hospital, London, United Kingdom
| | - Kwang Woo Ahn
- Division of Biostatistics, Institute for Health and Equity, Medical College of Wisconsin, Milwaukee, WI
- Department of Medicine, Center for International Blood and Marrow Transplant Research, Medical College of Wisconsin, Milwaukee, WI
| | - Noel Estrada-Merly
- Department of Medicine, Center for International Blood and Marrow Transplant Research, Medical College of Wisconsin, Milwaukee, WI
| | | | - Sergio Giralt
- Department of Internal Medicine, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Jeanne Palmer
- Department of Medicine, Mayo Clinic Arizona and Phoenix Children’s Hospital, Phoenix, AZ
| | - Robert Peter Gale
- Department of Immunology and Inflammation, Haematology Centre, Imperial College London, London, United Kingdom
| | - Zachariah DeFilipp
- Department of Medicine, Hematopoietic Cell Transplant and Cellular Therapy Program, Massachusetts General Hospital, Boston, MA
| | - David I. Marks
- Adult Bone Marrow Transplant, University Hospitals Bristol NHS Trust, Bristol, United Kingdom
| | - Marjolein van der Poel
- Division of Hematology, Department of Internal Medicine, GROW School for Oncology and Developmental Biology, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Leo F. Verdonck
- Department of Hematology/Oncology, Isala Clinic, Zwolle, The Netherlands
| | - Minoo Battiwalla
- Outcomes Research, Sarah Cannon Blood Cancer Network, Nashville, TN
| | - Miguel Angel Diaz
- Department of Hematology/Oncology, Hospital Infantil Universitario Niño Jesus, Madrid, Spain
| | - Vikas Gupta
- Department of Internal Medicine, Princess Margaret Cancer Centre, University of Toronto, Toronto, Canada
| | - Haris Ali
- Department of Hematology & Hematopoietic Cell Transplantation, City of Hope, Duarte, CA
| | - Mark Robert Litzow
- Division of Hematology and Transplant Center, Mayo Clinic, Rochester, MN
| | - Hillard M. Lazarus
- Department of Hematology and Internal Medicine, University Hospitals Cleveland Medical Center, Case Western Reserve University, Cleveland, OH
| | - Usama Gergis
- Division of Hematological Malignancies, Department of Medicine Oncology, Thomas Jefferson University, Philadelphia, PA
| | - Asad Bashey
- Department of Medicine, Blood and Marrow Transplant Program at Northside Hospital, Atlanta, GA
| | - Jane Liesveld
- Department of Medicine, University of Rochester Medical Center, Rochester, NY
| | - Shahrukh Hashmi
- Department of Internal Medicine, Mayo Clinic, Rochester, MN
- Department of Medicine, Sheikh Shakhbout Medical City, Abu Dhabi, United Arab Emirates
| | - Jeffrey J. Pu
- Department of Medicine, Banner University Medical Center Tucson, Syracuse, NY
| | - Amer Beitinjaneh
- Divison of Transplantation and Cellular Therapy, University of Miami Hospital and Clinics, Sylvester Comprehensive Cancer Center, Miami, FL
| | - Christopher Bredeson
- Department of Medicine, The Ottawa Hospital Transplant & Cellular Therapy Program, Ottawa, ON, Canada
| | | | - Bipin N. Savani
- Division of Hematology/Oncology, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN
| | - Muhammad Bilal Abid
- Divisions of Hematology/Oncology & Infectious Diseases, Department of Medicine, Medical College of Wisconsin, Milwaukee, WI
| | - Siddhartha Ganguly
- Department of Medicine, Houston Methodist Hospital and Cancer Center, Houston, TX
| | - Vaibhav Agrawal
- Division of Leukemia, Department of Hematology & Hematopoietic Cell Transplantation, City of Hope National Medical Center, Duarte, CA
| | - Vera Ulrike Bacher
- Department of Hematology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Baldeep Wirk
- Department of Medicine, Bone Marrow Transplant Program, Penn State Cancer Institute, Hershey, PA
| | - Tania Jain
- Division of Hematological Malignancies and Bone Marrow Transplantation, Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University, Baltimore, MD
| | - Corey Cutler
- Stem Cell Transplantation and Cellular Therapy, Dana-Farber Cancer Institute, Boston, MA
| | - Mahmoud Aljurf
- Department of Oncology, King Faisal Specialist Hospital Center & Research, Riyadh, Saudi Arabia
| | - Tamila Kindwall-Keller
- Division of Hematology/Oncology, University of Virginia Health System, Charlottesville, VA
| | - Mohamed A. Kharfan-Dabaja
- Division of Hematology-Oncology, Blood and Marrow Transplantation Program, Mayo Clinic, Jacksonville, FL
| | | | - Attaphol Pawarode
- Division of Hematology/Oncology, Department of Internal Medicine, Blood and Marrow Transplantation Program, University of Michigan Medical School, Ann Arbor, MI
| | - Melhem M. Solh
- The Blood and Marrow Transplant Program, Northside Hospital Cancer Institute, Atlanta, GA
| | - Jean A. Yared
- Division of Hematology/Oncology, Department of Medicine, Transplantation & Cellular Therapy Program, Greenebaum Comprehensive Cancer Center, University of Maryland, Baltimore, MD
| | - Michael R. Grunwald
- Department of Hematologic Oncology and Blood Disorders, Levine Cancer Institute, Atrium Health, Charlotte, NC
| | - Sunita Nathan
- Department of Internal Medicine, Section of Bone Marrow Transplant and Cell Therapy, Rush University Medical Center, Chicago, IL
| | - Taiga Nishihori
- Department of Blood & Marrow Transplant and Cellular Immunotherapy, Moffitt Cancer Center, Tampa, FL
| | - Sachiko Seo
- Department of Hematology and Oncology, Dokkyo Medical University, Tochigi, Japan
| | - Bart L. Scott
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, WA
| | - Ryotaro Nakamura
- Department of Hematology & Hematopoietic Cell Transplantation, City of Hope, Duarte, CA
| | - Betul Oran
- Division of Cancer Medicine, Department of Stem Cell Transplantation, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Tomasz Czerw
- Department of Haematology and BMT, Maria Skłodowska-Curie National Research Institute of Oncology, Gliwice, Poland
| | | | - Wael Saber
- Department of Medicine, Center for International Blood and Marrow Transplant Research, Medical College of Wisconsin, Milwaukee, WI
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16
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Murthy GSG, Kim S, Estrada-Merly N, Abid MB, Aljurf M, Assal A, Badar T, Badawy SM, Ballen K, Beitinjaneh A, Cerny J, Chhabra S, DeFilipp Z, Dholaria B, Perez MAD, Farhan S, Freytes CO, Gale RP, Ganguly S, Gupta V, Grunwald MR, Hamad N, Hildebrandt GC, Inamoto Y, Jain T, Jamy O, Juckett M, Kalaycio M, Krem MM, Lazarus HM, Litzow M, Munker R, Murthy HS, Nathan S, Nishihori T, Ortí G, Patel SS, Van der Poel M, Rizzieri DA, Savani BN, Seo S, Solh M, Verdonck LF, Wirk B, Yared JA, Nakamura R, Oran B, Scott B, Saber W. Association between the choice of the conditioning regimen and outcomes of allogeneic hematopoietic cell transplantation for myelofibrosis. Haematologica 2023; 108:1900-1908. [PMID: 36779595 PMCID: PMC10316233 DOI: 10.3324/haematol.2022.281958] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2020] [Accepted: 02/01/2023] [Indexed: 02/11/2023] Open
Abstract
Allogeneic hematopoietic cell transplantation (allo-HCT) remains the only curative treatment for myelofibrosis. However, the optimal conditioning regimen either with reduced-intensity conditioning (RIC) or myeloablative conditioning (MAC) is not well known. Using the Center for International Blood and Marrow Transplant Research database, we identified adults aged ≥18 years with myelofibrosis undergoing allo-HCT between 2008-2019 and analyzed the outcomes separately in the RIC and MAC cohorts based on the conditioning regimens used. Among 872 eligible patients, 493 underwent allo-HCT using RIC (fludarabine/ busulfan n=166, fludarabine/melphalan n=327) and 379 using MAC (fludarabine/busulfan n=247, busulfan/cyclophosphamide n=132). In multivariable analysis with RIC, fludarabine/melphalan was associated with inferior overall survival (hazard ratio [HR]=1.80; 95% confidenec interval [CI]: 1.15-2.81; P=0.009), higher early non-relapse mortality (HR=1.81; 95% CI: 1.12-2.91; P=0.01) and higher acute graft-versus-host disease (GvHD) (grade 2-4 HR=1.45; 95% CI: 1.03-2.03; P=0.03; grade 3-4 HR=2.21; 95%CI: 1.28-3.83; P=0.004) compared to fludarabine/busulfan. In the MAC setting, busulfan/cyclophosphamide was associated with a higher acute GvHD (grade 2-4 HR=2.33; 95% CI: 1.67-3.25; P<0.001; grade 3-4 HR=2.31; 95% CI: 1.52-3.52; P<0.001) and inferior GvHD-free relapse-free survival (GRFS) (HR=1.94; 95% CI: 1.49-2.53; P<0.001) as compared to fludarabine/busulfan. Hence, our study suggests that fludarabine/busulfan is associated with better outcomes in RIC (better overall survival, lower early non-relapse mortality, lower acute GvHD) and MAC (lower acute GvHD and better GRFS) in myelofibrosis.
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Affiliation(s)
| | - Soyoung Kim
- Division of Biostatistics, Institute for Health and Equity, Medical College of Wisconsin, Milwaukee, WI; CIBMTR® (Center for International Blood and Marrow Transplant Research), Department of Medicine, Medical College of Wisconsin, Milwaukee
| | - Noel Estrada-Merly
- CIBMTR® (Center for International Blood and Marrow Transplant Research), Department of Medicine, Medical College of Wisconsin, Milwaukee
| | - Muhammad Bilal Abid
- Divisions of Hematology/Oncology, and Infectious Diseases, Department of Medicine, Medical College of Wisconsin, Milwaukee
| | - Mahmoud Aljurf
- Department of Oncology, King Faisal Specialist Hospital Center and Research, Riyadh
| | - Amer Assal
- Columbia University Irving Medical Center, Department of Medicine, Bone Marrow Transplant and Cell Therapy Program
| | | | - Sherif M Badawy
- Division of Hematology, Oncology and Stem Cell Transplantation, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, IL; Department of Pediatrics, Northwestern University Feinberg School of Medicine
| | - Karen Ballen
- Division of Hematology/Oncology, University of Virginia Health System, Charlottesville, VA
| | - Amer Beitinjaneh
- Division of Transplantation and Cellular Therapy, University of Miami Hospital and Clinics, Slyvester Comprehensive Cancer Center, Miami, FL
| | - Jan Cerny
- Division of Hematology/Oncology, Department of Medicine, University of Massachusetts Medical Center, Worcester, MA
| | - Saurabh Chhabra
- CIBMTR® (Center for International Blood and Marrow Transplant Research), Department of Medicine, Medical College of Wisconsin, Milwaukee
| | - Zachariah DeFilipp
- Hematopoietic Cell Transplant and Cellular Therapy Program, Massachusetts General Hospital
| | | | | | - Shatha Farhan
- Henry Ford Health System Stem Cell Transplant and Cellular Therapy Program, Detroit, MI
| | - Cesar O Freytes
- University of Texas Health Science Center at San Antonio, San Antonio, TX
| | - Robert Peter Gale
- Haematology Research Centre, Department of Immunology and Inflammation, Imperial College London, London
| | - Siddhartha Ganguly
- Division of Hematological Malignancy and Cellular Therapeutics, University of Kansas Health System, Kansas City, KS
| | - Vikas Gupta
- MPN Program, Princess Margaret Cancer Centre, University of Toronto, Toronto, ON
| | - Michael R Grunwald
- Department of Hematologic Oncology and Blood Disorders, Levine Cancer Institute, Atrium Health, Charlotte, NC
| | | | | | - Yoshihiro Inamoto
- Division of Hematopoietic Stem Cell Transplantation, National Cancer Center, Tokyo
| | - Tania Jain
- John Hopkins University School of Medicine, Baltimore, MD
| | - Omer Jamy
- University of Alabama at Birmingham, Birmingham, AL
| | - Mark Juckett
- University of Minnesota Blood and Marrow Transplant Program - Adults
| | - Matt Kalaycio
- Cleveland Clinic Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH
| | | | - Hillard M Lazarus
- University Hospitals Cleveland Medical Center, Case Western Reserve University, Cleveland, OH
| | - Mark Litzow
- Division of Hematology and Transplant Center, Mayo Clinic Rochester, Rochester, MN
| | | | - Hemant S Murthy
- Division of Hematology-Oncology, Blood and Marrow Transplantation Program, Mayo Clinic, Jacksonville, FL
| | - Sunita Nathan
- Section of Bone Marrow Transplant and Cell Therapy, Rush University Medical Center
| | - Taiga Nishihori
- Department of Blood and Marrow Transplant and Cellular Immunotherapy (BMT CI), Moffitt Cancer Center, Tampa, FL
| | | | - Sagar S Patel
- Blood and Marrow Transplant Program, Huntsman Cancer Institute, University of Utah, Salt Lake City, UT
| | - Marjolein Van der Poel
- Department of Internal Medicine, Division of Hematology, GROW School for Oncology and Developmental Biology, Masstricht University Medical Center, Maastricht
| | - David A Rizzieri
- Division of Hematologic Malignancies and Cellular Therapy, Duke University, Durham, NC
| | - Bipin N Savani
- Division of Hematology/Oncology, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN
| | - Sachiko Seo
- Department of Hematology and Oncology, Dokkyo Medical University, Tochigo
| | - Melhem Solh
- The Blood and Marrow Transplant Group of Georgia, Northside Hospital, Atlanta, GA
| | - Leo F Verdonck
- Department of Hematology/Oncology, Isala, Clinic, Zwolle
| | - Baldeep Wirk
- Bone Marrow Transplant Program, Penn State Cancer Institute, Hershey, Pennsylvania
| | - Jean A Yared
- Transplantation and Cellular Therapy Program, Division of Hematology/Oncology, Department of Medicine, Greenebaum Comprehensive Cancer Center, University of Maryland, Baltimore, MD
| | - Ryotaro Nakamura
- Department of Hematology and Hematopoietic Cell Transplantation, City of Hope, Duarte, CA
| | - Betul Oran
- Department of Stem Cell Transplantation, Division of Cancer Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Bart Scott
- Fred Hutchinson Cancer Research Center, Seattle, WA
| | - Wael Saber
- CIBMTR® (Center for International Blood and Marrow Transplant Research), Department of Medicine, Medical College of Wisconsin, Milwaukee
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17
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Díaz-González Á, Mora E, Avetisyan G, Furió S, De la Puerta R, Gil JV, Liquori A, Villamón E, García-Hernández C, Santiago M, García-Ruiz C, Llop M, Ferrer-Lores B, Barragán E, García-Palomares S, Mayordomo E, Luna I, Vicente A, Cordón L, Senent L, Álvarez-Larrán A, Cervera J, De la Rubia J, Hernández-Boluda JC, Such E. Cytogenetic Assessment and Risk Stratification in Myelofibrosis with Optical Genome Mapping. Cancers (Basel) 2023; 15:cancers15113039. [PMID: 37297002 DOI: 10.3390/cancers15113039] [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: 04/15/2023] [Revised: 05/09/2023] [Accepted: 06/01/2023] [Indexed: 06/12/2023] Open
Abstract
Cytogenetic assessment in myelofibrosis is essential for risk stratification and patient management. However, an informative karyotype is unavailable in a significant proportion of patients. Optical genome mapping (OGM) is a promising technique that allows for a high-resolution assessment of chromosomal aberrations (structural variants, copy number variants, and loss of heterozygosity) in a single workflow. In this study, peripheral blood samples from a series of 21 myelofibrosis patients were analyzed via OGM. We assessed the clinical impact of the application of OGM for disease risk stratification using the DIPSS-plus, GIPSS, and MIPSS70+v2 prognostic scores compared with the standard-of-care approach. OGM, in combination with NGS, allowed for risk classification in all cases, compared to only 52% when conventional techniques were used. Cases with unsuccessful karyotypes (n = 10) using conventional techniques were fully characterized using OGM. In total, 19 additional cryptic aberrations were identified in 9 out of 21 patients (43%). No alterations were found via OGM in 4/21 patients with previously normal karyotypes. OGM upgraded the risk category for three patients with available karyotypes. This is the first study using OGM in myelofibrosis. Our data support that OGM is a valuable tool that can greatly contribute to improve disease risk stratification in myelofibrosis patients.
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Affiliation(s)
- Álvaro Díaz-González
- Hematology Research Group, Instituto de Investigación Sanitaria La Fe, 46026 Valencia, Spain
| | - Elvira Mora
- Hematology Research Group, Instituto de Investigación Sanitaria La Fe, 46026 Valencia, Spain
- Department of Hematology, Hospital Universitario y Politécnico La Fe, 46026 Valencia, Spain
| | - Gayane Avetisyan
- Hematology Research Group, Instituto de Investigación Sanitaria La Fe, 46026 Valencia, Spain
| | - Santiago Furió
- Hematology Research Group, Instituto de Investigación Sanitaria La Fe, 46026 Valencia, Spain
- Department of Hematology, Hospital Universitario y Politécnico La Fe, 46026 Valencia, Spain
| | | | - José Vicente Gil
- Hematology Research Group, Instituto de Investigación Sanitaria La Fe, 46026 Valencia, Spain
| | - Alessandro Liquori
- Hematology Research Group, Instituto de Investigación Sanitaria La Fe, 46026 Valencia, Spain
- Centro de Investigación Biomédica en Red de Cáncer (CIBERONC), 28029 Madrid, Spain
| | - Eva Villamón
- Department of Hematology, Hospital Clínico Universitario-INCLIVA, 46010 Valencia, Spain
| | | | - Marta Santiago
- Hematology Research Group, Instituto de Investigación Sanitaria La Fe, 46026 Valencia, Spain
- Department of Hematology, Hospital Universitario y Politécnico La Fe, 46026 Valencia, Spain
| | - Cristian García-Ruiz
- Hematology Research Group, Instituto de Investigación Sanitaria La Fe, 46026 Valencia, Spain
| | - Marta Llop
- Centro de Investigación Biomédica en Red de Cáncer (CIBERONC), 28029 Madrid, Spain
- Molecular Biology Unit, Clinical Analysis Service, Hospital Universitario y Politécnico La Fe, 46026 Valencia, Spain
| | - Blanca Ferrer-Lores
- Department of Hematology, Hospital Clínico Universitario-INCLIVA, 46010 Valencia, Spain
| | - Eva Barragán
- Centro de Investigación Biomédica en Red de Cáncer (CIBERONC), 28029 Madrid, Spain
- Molecular Biology Unit, Clinical Analysis Service, Hospital Universitario y Politécnico La Fe, 46026 Valencia, Spain
| | - Silvia García-Palomares
- Hematology Research Group, Instituto de Investigación Sanitaria La Fe, 46026 Valencia, Spain
| | - Empar Mayordomo
- Pathology Department, Hospital Universitario y Politécnico La Fe, 46026 Valencia, Spain
| | - Irene Luna
- Hematology Research Group, Instituto de Investigación Sanitaria La Fe, 46026 Valencia, Spain
- Department of Hematology, Hospital Universitario y Politécnico La Fe, 46026 Valencia, Spain
| | - Ana Vicente
- Hematology Research Group, Instituto de Investigación Sanitaria La Fe, 46026 Valencia, Spain
- Department of Hematology, Hospital Universitario y Politécnico La Fe, 46026 Valencia, Spain
| | - Lourdes Cordón
- Hematology Research Group, Instituto de Investigación Sanitaria La Fe, 46026 Valencia, Spain
- Centro de Investigación Biomédica en Red de Cáncer (CIBERONC), 28029 Madrid, Spain
| | - Leonor Senent
- Hematology Research Group, Instituto de Investigación Sanitaria La Fe, 46026 Valencia, Spain
- Department of Hematology, Hospital Universitario y Politécnico La Fe, 46026 Valencia, Spain
- Centro de Investigación Biomédica en Red de Cáncer (CIBERONC), 28029 Madrid, Spain
| | | | - José Cervera
- Hematology Research Group, Instituto de Investigación Sanitaria La Fe, 46026 Valencia, Spain
- Department of Hematology, Hospital Universitario y Politécnico La Fe, 46026 Valencia, Spain
- Centro de Investigación Biomédica en Red de Cáncer (CIBERONC), 28029 Madrid, Spain
- Genetics Department, Hospital Universitario y Politécnico La Fe, 46026 Valencia, Spain
| | - Javier De la Rubia
- Hematology Research Group, Instituto de Investigación Sanitaria La Fe, 46026 Valencia, Spain
- Department of Hematology, Hospital Universitario y Politécnico La Fe, 46026 Valencia, Spain
- Centro de Investigación Biomédica en Red de Cáncer (CIBERONC), 28029 Madrid, Spain
- School of Medicine and Dentistry, Catholic University of Valencia, 46001 Valencia, Spain
| | | | - Esperanza Such
- Hematology Research Group, Instituto de Investigación Sanitaria La Fe, 46026 Valencia, Spain
- Department of Hematology, Hospital Universitario y Politécnico La Fe, 46026 Valencia, Spain
- Centro de Investigación Biomédica en Red de Cáncer (CIBERONC), 28029 Madrid, Spain
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18
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García-Cadenas I, Redondo S, Esquirol A, Portos JM, Novelli S, Saavedra S, Moreno C, Garrido A, Oñate G, López J, Ana-Carolina C, Miqueleiz S, Arguello-Tomas M, Briones J, Sierra J, Martino R. Successful Outcome in Patients with Myelofibrosis Undergoing Allogeneic Donor Hematopoietic Cell Transplantation Using Reduced-Doses of Post-Transplant Cyclophosphamide: challenges and review of the literature. Transplant Cell Ther 2023:S2666-6367(23)01239-3. [PMID: 37086849 DOI: 10.1016/j.jtct.2023.04.008] [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: 02/27/2023] [Revised: 04/05/2023] [Accepted: 04/10/2023] [Indexed: 04/24/2023]
Abstract
BACKGROUND Engraftment and non-relapse mortality (NRM) greatly depend upon the transplant platform in patients with Myelofibrosis (MF). OBJECTIVE We report outcomes of 14 consecutive MF patients who received reduced doses of post-transplant Cyclophosphamide (PTCy) (60 mg/kg total dose) and tacrolimus as graft versus host disease (GVHD) prophylaxis as part of a new standardized allogeneic hematopoietic-cell transplantation (allo-HCT) protocol. STUDY DESIGN Median age at HCT was 59 years (range: 41-67), and median interval from diagnosis to HCT was 19 months (range: 2-114). All cases received ruxolitinib before HCT and 71% had no response. Most patients (78%) had symptomatic splenomegaly at HCT. Eighty-six percent received reduced-intensity conditioning (RIC) and most of them (64%) from an unrelated donor. RESULTS There were not graft failures and neutrophil and platelet recovery occurred at a median of 21 and 31 days. The cumulative incidence of grade II-IV and III-IV acute GVHD was 28.6% and 7%. The 2-year incidence of overall and moderate-severe chronic GVHD was 36% and 14%. Only 1 patient relapsed after transplant, and NRM at 100 days and 2-years was 7% and 14%. GVHD-free/relapse-free and immunosuppression free incidence at 1 year was 41%. With a median follow-up for survivors of 28 months (range:8-55), the 2-year overall survival and progression-free survival are 86% and 69%. CONCLUSION Reduced doses of PTCy as GVHD prophylaxis for high risk MF patients shows promising results by reducing GVHD incidence without cases of graft failure.
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Affiliation(s)
- Irene García-Cadenas
- Hematology Department, Hospital de la Santa Creu i Sant Pau. IIB-Sant Pau and José Carreras Leukemia Research Institutes. Departamento de Medicina, Universidad Autónoma de Barcelona, Spain
| | - Sara Redondo
- Hematology Department, Hospital de la Santa Creu i Sant Pau. IIB-Sant Pau and José Carreras Leukemia Research Institutes. Departamento de Medicina, Universidad Autónoma de Barcelona, Spain..
| | - Albert Esquirol
- Hematology Department, Hospital de la Santa Creu i Sant Pau. IIB-Sant Pau and José Carreras Leukemia Research Institutes. Departamento de Medicina, Universidad Autónoma de Barcelona, Spain
| | - J M Portos
- Hematology Department, Hospital de la Santa Creu i Sant Pau. IIB-Sant Pau and José Carreras Leukemia Research Institutes. Departamento de Medicina, Universidad Autónoma de Barcelona, Spain
| | - Silvana Novelli
- Hematology Department, Hospital de la Santa Creu i Sant Pau. IIB-Sant Pau and José Carreras Leukemia Research Institutes. Departamento de Medicina, Universidad Autónoma de Barcelona, Spain
| | - Silvana Saavedra
- Hematology Department, Hospital de la Santa Creu i Sant Pau. IIB-Sant Pau and José Carreras Leukemia Research Institutes. Departamento de Medicina, Universidad Autónoma de Barcelona, Spain
| | - Carol Moreno
- Hematology Department, Hospital de la Santa Creu i Sant Pau. IIB-Sant Pau and José Carreras Leukemia Research Institutes. Departamento de Medicina, Universidad Autónoma de Barcelona, Spain
| | - Ana Garrido
- Hematology Department, Hospital de la Santa Creu i Sant Pau. IIB-Sant Pau and José Carreras Leukemia Research Institutes. Departamento de Medicina, Universidad Autónoma de Barcelona, Spain
| | - Guadalupe Oñate
- Hematology Department, Hospital de la Santa Creu i Sant Pau. IIB-Sant Pau and José Carreras Leukemia Research Institutes. Departamento de Medicina, Universidad Autónoma de Barcelona, Spain
| | - Jordi López
- Hematology Department, Hospital de la Santa Creu i Sant Pau. IIB-Sant Pau and José Carreras Leukemia Research Institutes. Departamento de Medicina, Universidad Autónoma de Barcelona, Spain
| | - Caballero Ana-Carolina
- Hematology Department, Hospital de la Santa Creu i Sant Pau. IIB-Sant Pau and José Carreras Leukemia Research Institutes. Departamento de Medicina, Universidad Autónoma de Barcelona, Spain
| | - Sara Miqueleiz
- Hematology Department, Hospital de la Santa Creu i Sant Pau. IIB-Sant Pau and José Carreras Leukemia Research Institutes. Departamento de Medicina, Universidad Autónoma de Barcelona, Spain
| | - Miguel Arguello-Tomas
- Hematology Department, Hospital de la Santa Creu i Sant Pau. IIB-Sant Pau and José Carreras Leukemia Research Institutes. Departamento de Medicina, Universidad Autónoma de Barcelona, Spain
| | - Javier Briones
- Hematology Department, Hospital de la Santa Creu i Sant Pau. IIB-Sant Pau and José Carreras Leukemia Research Institutes. Departamento de Medicina, Universidad Autónoma de Barcelona, Spain
| | - Jorge Sierra
- Hematology Department, Hospital de la Santa Creu i Sant Pau. IIB-Sant Pau and José Carreras Leukemia Research Institutes. Departamento de Medicina, Universidad Autónoma de Barcelona, Spain
| | - Rodrigo Martino
- Hematology Department, Hospital de la Santa Creu i Sant Pau. IIB-Sant Pau and José Carreras Leukemia Research Institutes. Departamento de Medicina, Universidad Autónoma de Barcelona, Spain
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19
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Passamonti F, Mora B. Myelofibrosis. Blood 2023; 141:1954-1970. [PMID: 36416738 PMCID: PMC10646775 DOI: 10.1182/blood.2022017423] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2022] [Revised: 11/15/2022] [Accepted: 11/18/2022] [Indexed: 11/24/2022] Open
Abstract
The clinical phenotype of primary and post-polycythemia vera and postessential thrombocythemia myelofibrosis (MF) is dominated by splenomegaly, symptomatology, a variety of blood cell alterations, and a tendency to develop vascular complications and blast phase. Diagnosis requires assessing complete cell blood counts, bone marrow morphology, deep genetic evaluations, and disease history. Driver molecular events consist of JAK2V617F, CALR, and MPL mutations, whereas about 8% to 10% of MF are "triple-negative." Additional myeloid-gene variants are described in roughly 80% of patients. Currently available clinical-based and integrated clinical/molecular-based scoring systems predict the survival of patients with MF and are applied for conventional treatment decision-making, indication to stem cell transplant (SCT) and allocation in clinical trials. Standard treatment consists of anemia-oriented therapies, hydroxyurea, and JAK inhibitors such as ruxolitinib, fedratinib, and pacritinib. Overall, spleen volume reduction of 35% or greater at week 24 can be achieved by 42% of ruxolitinib-, 47% of fedratinib-, 19% of pacritinib-, and 27% of momelotinib-treated patients. Now, it is time to move towards new paradigms for evaluating efficacy like disease modification, that we intend as a robust and unequivocal effect on disease biology and/or on patient survival. The growing number of clinical trials potentially pave the way for new strategies in patients with MF. Translational studies of some molecules showed an early effect on bone marrow fibrosis and on variant allele frequencies of myeloid genes. SCT is still the only curative option, however, it is associated with relevant challenges. This review focuses on the diagnosis, prognostication, and treatment of MF.
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Affiliation(s)
- Francesco Passamonti
- Department of Medicine and Surgery, University of Insubria, Varese, Italy
- Department of Oncology, ASST Sette Laghi, Ospedale di Circolo, Varese, Italy
| | - Barbara Mora
- Department of Oncology, ASST Sette Laghi, Ospedale di Circolo, Varese, Italy
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20
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Acosta-Medina AA, Baranwal A, Johnson IM, Kharfan-Dabaja MA, Murthy H, Palmer JM, Sproat L, Mangaonkar A, Shah MV, Hogan WJ, Litzow MR, Tefferi A, Alkhateeb HB. Comparison of Pretransplantation Prediction Models for Nonrelapse Mortality in Patients with Myelofibrosis Undergoing Allogeneic Stem Cell Transplantation. Transplant Cell Ther 2023:S2666-6367(23)01069-2. [PMID: 36773650 DOI: 10.1016/j.jtct.2023.02.002] [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: 12/14/2022] [Revised: 02/01/2023] [Accepted: 02/01/2023] [Indexed: 02/11/2023]
Abstract
Allogeneic stem cell transplantation (alloSCT) is the only known curative treatment for myelofibrosis (MF). Risk assessment remains important for patient counseling and predicting survival outcomes for relapse and nonrelapse mortality (NRM). Outcome-prediction tools can guide decision-making. Their use in MF has relied on their extrapolation from other malignancies. The primary objective of this study was to assess the performance of the Hematopoietic cell Transplantation Comorbidity Index (HCT-CI), the augmented HCT-CI (aHCT-CI), and the Endothelial Activation and Stress Index (EASIX) in predicting NRM in patients with MF undergoing alloSCT. We retrospectively reviewed patients with MF undergoing alloSCT between 2012 and 2020 at the Mayo Clinic. Data were abstracted from the electronic medical record. EASIX score was calculated before starting conditioning therapy and analyzed based on log2- transformed values. We evaluated the log2-EASIX scores by quartiles to assess the effect of increasing values on NRM. NRM was evaluated using competing risk analyses. We used the Kaplan-Meier and log-rank methods to evaluate OS. The Fine-Gray model was used to determine risk factors for NRM. The performance of HCT-CI and aHCT-CI was compared by evaluation of model concordance given the high correlation between HCT-CI and aHCT-CI (r = .75). A total of 87 patients were evaluated. The median duration of follow-up after alloSCT was 5 years (95% confidence interval [CI], 4.4 to 6.31 years). Patients with a high HCT-CI score had significantly increased cumulative incidence of NRM at 3 years (35.5% versus 11.6%; P = .011) after alloSCT. A progressively increasing 3-year NRM was observed with increasing aHCT-CI risk category, and patients with a high or very high aHCT-CI score had significantly higher 3-year NRM compared to those with intermediate-risk or low-risk aHCT-CI scores at 3 years post-alloSCT (31.9% versus 6.52%; P = .004). An increasing log2-EASIX score quartile was not associated with 3-year NRM (19.0% versus 10.1% versus 25% versus 14.3%; P = .59), and the EASIX score was not found to be a predictor of post-transplantation NRM. A high HCT-CI was associated with significantly worse 3-year overall survival (OS) (hazard ratio [HR], 4.41; 95% CI, 1.97 to 9.87; P < .001). A high or very high aHCT-CI was significantly associated with poor 3-year OS (HR, 3.99; 95% CI, 1.56 to 10.22; P = .004). An increasing log2-EASIX score quartile group was not associated with 3-year OS (3-year OS rate, 66.7% versus 80.4% versus 64.6% versus 76.2%; P = .57). The EASIX score should not be used routinely in patients with MF. Both the HCT-CI and the aHCT-CI are accurate in predicting long-term survival outcomes in this patient population. Further studies are important to validate our findings of the role of EASIX in predicting NRM in patients with MF or other myeloproliferative neoplasms undergoing alloSCT. © 2023 American Society for Transplantation and Cellular Therapy. Published by Elsevier Inc.
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Affiliation(s)
| | - Anmol Baranwal
- Division of Hematology, Mayo Clinic, Rochester, Minnesota
| | | | | | - Hemant Murthy
- Division of Hematology, Mayo Clinic, Jacksonville, Florida
| | | | - Lisa Sproat
- Division of Hematology, Mayo Clinic, Phoenix, Arizona
| | | | - Mithun V Shah
- Division of Hematology, Mayo Clinic, Rochester, Minnesota
| | | | - Mark R Litzow
- Division of Hematology, Mayo Clinic, Rochester, Minnesota
| | - Ayalew Tefferi
- Division of Hematology, Mayo Clinic, Rochester, Minnesota
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21
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Bales JR, Kim HT, Portillo R, Patel C, McAfee S, Dey B, Spitzer T, Chen YB, El-Jawahri A, DeFilipp Z, Hobbs GS. Splenic irradiation prior to allogeneic hematopoietic cell transplantation for patients with myelofibrosis. Bone Marrow Transplant 2023; 58:459-461. [PMID: 36624162 DOI: 10.1038/s41409-023-01913-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2022] [Revised: 01/02/2023] [Accepted: 01/05/2023] [Indexed: 01/11/2023]
Affiliation(s)
- John R Bales
- Department of Medical Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Haesook T Kim
- Department of Data Science, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Roxana Portillo
- Department of Medical Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Chirayu Patel
- Department of Radiation Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Steven McAfee
- Hematopoietic Cell Transplant and Cellular Therapy Program, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Bimalangshu Dey
- Hematopoietic Cell Transplant and Cellular Therapy Program, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Thomas Spitzer
- Hematopoietic Cell Transplant and Cellular Therapy Program, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Yi-Bin Chen
- Hematopoietic Cell Transplant and Cellular Therapy Program, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Areej El-Jawahri
- Hematopoietic Cell Transplant and Cellular Therapy Program, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Zachariah DeFilipp
- Hematopoietic Cell Transplant and Cellular Therapy Program, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Gabriela S Hobbs
- Department of Medical Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA.
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22
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Puglianini OC, Peker D, Zhang L, Papadantonakis N. Essential Thrombocythemia and Post-Essential Thrombocythemia Myelofibrosis: Updates on Diagnosis, Clinical Aspects, and Management. Lab Med 2023; 54:13-22. [PMID: 35960786 DOI: 10.1093/labmed/lmac074] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
Abstract
Although several decades have passed since the description of myeloproliferative neoplasms (MPN), many aspects of their pathophysiology have not been elucidated. In this review, we discuss the mutational landscape of patients with essential thrombocythemia (ET), prognostic scores and salient pathology, and clinical points. We discuss also the diagnostic challenges of differentiating ET from prefibrotic MF. We then focus on post-essential thrombocythemia myelofibrosis (post-ET MF), a rare subset of MPN that is usually studied in conjunction with post-polycythemia vera MF. The transition of ET to post-ET MF is not well studied on a molecular level, and we present available data. Patients with secondary MF could benefit from allogenic hematopoietic stem cell transplantation, and we present available data focusing on post-ET MF.
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Affiliation(s)
- Omar Castaneda Puglianini
- H. Lee Moffitt Cancer Center & Research Institute, Department of Blood & Marrow Transplant & Cellular Immunotherapy, Tampa, FL, USA
- Department of Oncologic Sciences, University of South Florida Morsani College of Medicine, Tampa, FL, USA
| | - Deniz Peker
- Department of Pathology and Laboratory Medicine, Emory University School of Medicine, Atlanta, GA, USA
| | - Linsheng Zhang
- Department of Pathology and Laboratory Medicine, Emory University School of Medicine, Atlanta, GA, USA
| | - Nikolaos Papadantonakis
- Winship Cancer Institute of Emory University, Department of Hematology and Medical Oncology, Atlanta, GA, USA
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23
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Haploidentical Hematopoietic Cell Transplantation for Myelofibrosis in the Ruxolitinib Era. Transplant Cell Ther 2023; 29:49.e1-49.e7. [PMID: 36288760 DOI: 10.1016/j.jtct.2022.10.015] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2022] [Revised: 10/17/2022] [Accepted: 10/19/2022] [Indexed: 11/05/2022]
Abstract
Haploidentical stem cell transplantation is a viable strategy in the absence of an HLA-identical donor, but in myelofibrosis (MF), concerns may rise due to the risk of graft failure. Considering that engraftment is a major issue in MF, we sought to highlight its impact on survival outcomes. In addition, we explored the impact of pretransplantation ruxolitinib administration as an independent variable on outcomes. Here we report the results of a retrospective, monocentric experience with T cell-replete haploidentical bone marrow transplantation with post-transplantation cyclophosphamide as graft-versus-host disease (GVHD) prophylaxis in 51 consecutive MF-affected patients. The median duration of follow-up was 47 months. All 51 patients received a double-alkylating conditioning regimen, and 21 patients (41%) received pretransplantation ruxolitinib. Thirty-seven of 49 evaluable patients (76%) achieved full donor chimerism with neutrophil engraftment, 8 of 49 (16%) experienced graft rejection, and 4 of 49 (8%) had primary poor graft function. Splenectomy was more frequent among patients who engrafted (P = .06). Graft rejection was the sole factor negatively impacting overall survival (hazard ratio [HR], 4.19; 95% confidence interval [CI], 1.37 to 12.80; P = .01) and the major determinant for nonrelapse mortality (HR, 10.31; 95% CI, 2.54 to 41.82; P = .001). The 24-month incidence of relapse was 19% and was negatively impacted by splenectomy (HR, 5.84; 95% CI, 1.28 to 26.72; P = .02). The cumulative incidence of grade II-IV acute GVHD was 27% (95% CI, 20% to 33%), and that of grade III-IV acute GVHD was 8% (95% CI, 4% to 12%). The 24-month cumulative incidence of all-grade chronic GVHD was 28% (95% CI, 21% to 35%). Our data show that T cell-replete haploidentical bone marrow transplantation following double-alkylating conditioning in patients with MF is associated with favorable rates of GVHD and an acceptable relapse risk; nevertheless, rejection is not negligible and is associated with significant mortality. Splenectomy, which favors engraftment, is predictive of a higher risk of relapse.
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24
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Abbou N, Piazzola P, Gabert J, Ernest V, Arcani R, Couderc AL, Tichadou A, Roche P, Farnault L, Colle J, Ouafik L, Morange P, Costello R, Venton G. Impact of Molecular Biology in Diagnosis, Prognosis, and Therapeutic Management of BCR::ABL1-Negative Myeloproliferative Neoplasm. Cells 2022; 12:cells12010105. [PMID: 36611899 PMCID: PMC9818322 DOI: 10.3390/cells12010105] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2022] [Revised: 12/16/2022] [Accepted: 12/23/2022] [Indexed: 12/28/2022] Open
Abstract
BCR::ABL1-negative myeloproliferative neoplasms (MPNs) include three major subgroups-polycythemia vera (PV), essential thrombocythemia (ET), and primary myelofibrosis (PMF)-which are characterized by aberrant hematopoietic proliferation with an increased risk of leukemic transformation. Besides the driver mutations, which are JAK2, CALR, and MPL, more than twenty additional mutations have been identified through the use of next-generation sequencing (NGS), which can be involved with pathways that regulate epigenetic modifications, RNA splicing, or DNA repair. The aim of this short review is to highlight the impact of molecular biology on the diagnosis, prognosis, and therapeutic management of patients with PV, ET, and PMF.
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Affiliation(s)
- Norman Abbou
- Molecular Biology Laboratory, North University Hospital, 13015 Marseille, France
- INSERM, INRAE, C2VN, Aix-Marseille University, 13005 Marseille, France
| | - Pauline Piazzola
- Hematology and Cellular Therapy Department, Conception University Hospital, 13005 Marseille, France
| | - Jean Gabert
- Molecular Biology Laboratory, North University Hospital, 13015 Marseille, France
- INSERM, INRAE, C2VN, Aix-Marseille University, 13005 Marseille, France
| | - Vincent Ernest
- Hematology Laboratory, Timone University Hospital, 13005 Marseille, France
| | - Robin Arcani
- INSERM, INRAE, C2VN, Aix-Marseille University, 13005 Marseille, France
- Department of Internal Medicine, Timone University Hospital, 13005 Marseille, France
| | - Anne-Laure Couderc
- Department of Geriatrics, South University Hospital, 13005 Marseille, France
| | - Antoine Tichadou
- Hematology and Cellular Therapy Department, Conception University Hospital, 13005 Marseille, France
| | - Pauline Roche
- Hematology and Cellular Therapy Department, Conception University Hospital, 13005 Marseille, France
| | - Laure Farnault
- Hematology and Cellular Therapy Department, Conception University Hospital, 13005 Marseille, France
| | - Julien Colle
- INSERM, INRAE, C2VN, Aix-Marseille University, 13005 Marseille, France
- Hematology and Cellular Therapy Department, Conception University Hospital, 13005 Marseille, France
| | - L’houcine Ouafik
- CNRS, INP, Institute of Neurophysiopathol, Aix-Marseille Université, 13005 Marseille, France
- APHM, CHU Nord, Service d’Onco-Biologie, Aix-Marseille Université, 13005 Marseille, France
| | - Pierre Morange
- INSERM, INRAE, C2VN, Aix-Marseille University, 13005 Marseille, France
- Hematology Laboratory, Timone University Hospital, 13005 Marseille, France
| | - Régis Costello
- INSERM, INRAE, C2VN, Aix-Marseille University, 13005 Marseille, France
- Hematology and Cellular Therapy Department, Conception University Hospital, 13005 Marseille, France
- TAGC, INSERM, UMR1090, Aix-Marseille University, 13005 Marseille, France
| | - Geoffroy Venton
- INSERM, INRAE, C2VN, Aix-Marseille University, 13005 Marseille, France
- Hematology and Cellular Therapy Department, Conception University Hospital, 13005 Marseille, France
- TAGC, INSERM, UMR1090, Aix-Marseille University, 13005 Marseille, France
- Correspondence: ; Tel.: +33-4-91-38-41-52
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Perram J, Ross DM, McLornan D, Gowin K, Kröger N, Gupta V, Lewis C, Gagelmann N, Hamad N. Innovative strategies to improve hematopoietic stem cell transplant outcomes in myelofibrosis. Am J Hematol 2022; 97:1464-1477. [PMID: 35802782 PMCID: PMC9796730 DOI: 10.1002/ajh.26654] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2022] [Revised: 06/28/2022] [Accepted: 07/05/2022] [Indexed: 01/28/2023]
Abstract
Myelofibrosis (MF) is a clonal myeloproliferative neoplasm characterized by inflammation, marrow fibrosis, and an inherent risk of blastic transformation. Hematopoietic allogeneic stem cell transplant is the only potentially curative therapy for this disease, however, survival gains observed for other transplant indications over the past two decades have not been realized for MF. The role of transplantation may also evolve with the use of novel targeted agents. The chronic inflammatory state associated with MF necessitates pretransplantation assessment of end-organ function. Applying the transplant methodology employed for other myeloid disorders to patients with MF fails to acknowledge differences in the underlying disease pathophysiology. Limited understanding of the causes of poor transplant outcomes in this cohort has prevented refinement of transplant eligibility criteria in MF. There is increasing evidence of heterogeneity in molecular disease grade, beyond the clinical manifestations which have traditionally guided transplant timing. Exploring the physiological consequences of disease chronicity unique to MF, acknowledging the heterogeneity in disease grade, and using advanced prognostic models, molecular diagnostics and other organ function diagnostic tools, we present an innovative review of strategies with the potential to improve transplant outcomes in this disease. Larger, prospective studies which consider the impact of molecular-based disease grade are needed for MF transplantation.
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Affiliation(s)
- Jacinta Perram
- Department of Bone Marrow Transplantation and HaematologySt Vincent's HospitalDarlinghurstNew South WalesAustralia,School of Clinical Medicine, UNSW Medicine & HealthKensingtonNew South WalesAustralia
| | - David M. Ross
- Department of Haematology and Bone Marrow TransplantationRoyal Adelaide HospitalAdelaideSouth AustraliaAustralia,Centre for Cancer BiologySA Pathology and University of South AustraliaAdelaideSouth AustraliaAustralia
| | - Donal McLornan
- Department of Haematology and Stem Cell TransplantationUniversity College London Hospitals NHSLondonUK
| | - Krisstina Gowin
- Department of Hematology and OncologyBone Marrow Transplant and Cellular Therapy, University of ArizonaTucsonArizonaUSA
| | - Nicolas Kröger
- Department of Stem Cell TransplantationUniversity Medical Center Hamburg‐EppendorfHamburgGermany
| | - Vikas Gupta
- Medical Oncology and HaematologyPrincess Margaret Cancer CentreTorontoOntarioCanada
| | - Clinton Lewis
- Department of HaematologyAuckland City HospitalAucklandNew Zealand
| | - Nico Gagelmann
- Department of Stem Cell TransplantationUniversity Medical Center Hamburg‐EppendorfHamburgGermany
| | - Nada Hamad
- Department of Bone Marrow Transplantation and HaematologySt Vincent's HospitalDarlinghurstNew South WalesAustralia,School of Clinical Medicine, UNSW Medicine & HealthKensingtonNew South WalesAustralia,School of MedicineUniversity of Notre Dame AustraliaFremantleWestern AustraliaAustralia
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Gerds AT, Gotlib J, Ali H, Bose P, Dunbar A, Elshoury A, George TI, Gundabolu K, Hexner E, Hobbs GS, Jain T, Jamieson C, Kaesberg PR, Kuykendall AT, Madanat Y, McMahon B, Mohan SR, Nadiminti KV, Oh S, Pardanani A, Podoltsev N, Rein L, Salit R, Stein BL, Talpaz M, Vachhani P, Wadleigh M, Wall S, Ward DC, Bergman MA, Hochstetler C. Myeloproliferative Neoplasms, Version 3.2022, NCCN Clinical Practice Guidelines in Oncology. J Natl Compr Canc Netw 2022; 20:1033-1062. [PMID: 36075392 DOI: 10.6004/jnccn.2022.0046] [Citation(s) in RCA: 27] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
The classic Philadelphia chromosome-negative myeloproliferative neoplasms (MPN) consist of myelofibrosis, polycythemia vera, and essential thrombocythemia and are a heterogeneous group of clonal blood disorders characterized by an overproduction of blood cells. The NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines) for MPN were developed as a result of meetings convened by a multidisciplinary panel with expertise in MPN, with the goal of providing recommendations for the management of MPN in adults. The Guidelines include recommendations for the diagnostic workup, risk stratification, treatment, and supportive care strategies for the management of myelofibrosis, polycythemia vera, and essential thrombocythemia. Assessment of symptoms at baseline and monitoring of symptom status during the course of treatment is recommended for all patients. This article focuses on the recommendations as outlined in the NCCN Guidelines for the diagnosis of MPN and the risk stratification, management, and supportive care relevant to MF.
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Affiliation(s)
- Aaron T Gerds
- Case Comprehensive Cancer Center/University Hospitals Seidman Cancer Center and Cleveland Clinic Taussig Cancer Institute
| | | | - Haris Ali
- City of Hope National Medical Center
| | | | | | | | | | | | | | | | - Tania Jain
- The Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins
| | | | | | | | | | | | | | | | - Stephen Oh
- Siteman Cancer Center at Barnes-Jewish Hospital and Washington University School of Medicine
| | | | | | | | - Rachel Salit
- Fred Hutchinson Cancer Research Center/Seattle Cancer Care Alliance
| | - Brady L Stein
- Robert H. Lurie Comprehensive Cancer Center of Northwestern University
| | | | | | | | - Sarah Wall
- The Ohio State University Comprehensive Cancer Center - James Cancer Hospital and Solove Research Institute
| | - Dawn C Ward
- UCLA Jonsson Comprehensive Cancer Center; and
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Hernández-Boluda JC, Czerw T. Transplantation algorithm for myelofibrosis in 2022 and beyond. Best Pract Res Clin Haematol 2022; 35:101369. [DOI: 10.1016/j.beha.2022.101369] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2022] [Accepted: 07/27/2022] [Indexed: 11/16/2022]
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Gerds AT, Lyons RM, Colucci P, Kalafut P, Paranagama D, Verstovsek S. Disease and Clinical Characteristics of Patients With a Clinical Diagnosis of Myelofibrosis Enrolled in the MOST Study. CLINICAL LYMPHOMA, MYELOMA & LEUKEMIA 2022; 22:e532-e540. [PMID: 35256316 DOI: 10.1016/j.clml.2022.02.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/08/2021] [Revised: 01/28/2022] [Accepted: 02/03/2022] [Indexed: 06/14/2023]
Abstract
BACKGROUND Clinical characteristics and treatment patterns of patients with lower-risk myelofibrosis (MF) are not well described. This analysis from the MOST (NCT02953704) assessed the demographic and clinical characteristics and treatment patterns of patients with the clinical diagnosis of lower-risk MF at enrollment. PATIENTS AND METHODS MOST is an ongoing, prospective, observational study in patients with clinical diagnoses of MF or essential thrombocythemia enrolled at clinical practices throughout the United States. Patients included in the MF cohort (≥18 years of age) had low-risk MF by the Dynamic International Prognostic Scoring System or intermediate-1 (INT-1) risk MF (by age >65 years only) at enrollment. Patient data were entered into an electronic case report form during usual-care visits over a planned 36 month observation period. RESULTS Two hundred five patients were eligible for this analysis (low risk, n = 85; INT-1 risk, n = 120; median age, 68 years [range, 35-88]); 166 patients (81.0%) had mutation testing results available. The median time from MF diagnosis to enrollment was 1.8 years. Hemoglobin and hematocrit levels were below the normal range in 50.5% and 48.7% of patients, respectively. Nearly all (98.0%) patients had comorbid conditions, most commonly hypertension (49.8%). Fatigue was the most common physician-reported MF symptom (30.7%). At enrollment, 55.6% of patients were receiving MF-directed monotherapy, most frequently hydroxyurea (46.5%) or ruxolitinib (40.4%). CONCLUSION Future longitudinal analyses of data from MOST will help identify unmet needs and characterize how patients with lower-risk MF are managed throughout the disease course.
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Affiliation(s)
- Aaron T Gerds
- Cleveland Clinic Taussig Cancer Institute, Cleveland, OH.
| | - Roger M Lyons
- Texas Oncology and US Oncology Research, San Antonio, TX
| | | | | | | | - Srdan Verstovsek
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX
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CD34+ -selected hematopoietic stem cell transplant conditioned with a myeloablative regimen in patients with advanced myelofibrosis. Bone Marrow Transplant 2022; 57:1101-1107. [PMID: 35484207 PMCID: PMC10015419 DOI: 10.1038/s41409-022-01684-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2021] [Revised: 03/23/2022] [Accepted: 04/06/2022] [Indexed: 11/09/2022]
Abstract
Allogeneic hematopoietic stem cell transplantation (Allo-HCT) remains the only curative treatment for myelofibrosis (MF). Transplantation in patients with MF is mostly done using a reduced intensity conditioning regimen with calcineurin inhibitors for graft versus host disease (GVHD) prophylaxis. Here we sought to evaluate outcomes of patients who underwent an ex vivo CD34+ -selected allo-HCT using myeloablative conditioning (MAC). Twenty-seven patients were included in this retrospective analysis. All patients were conditioned with busulfan, melphalan and fludarabine and antithymocyte globulin to prevent graft rejection. G-CSF mobilized peripheral blood stem cell grafts were depleted of T-cells using immunomagnetic CD34+ selection by CliniMACS device. Median follow-up among survivors was 50.6 months. The estimated 3-year overall survival, relapse free survival and the combined endpoint of GVHD/relapse free survival were 88% (95% CI, 75-100%), 80% (95% CI, 66-98%) and 74% (95% CI, 59-93%), respectively. The cumulative incidence of grade II-IV acute GVHD at day 100 was 33.3% (95% CI 16.4-51.3%), and two patients suffered chronic GVHD. There were no cases of primary graft failure. However, delayed graft failure occurred in two patients. We conclude that CD34+ selected allo-HCT with a MAC resulted in high survival rates in this cohort of patients with MF.
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Castillo Tokumori F, Al Ali N, Chan O, Sallman D, Yun S, Sweet K, Padron E, Lancet J, Komrokji R, Kuykendall AT. Comparison of Different Treatment Strategies for Blast-Phase Myeloproliferative Neoplasms. CLINICAL LYMPHOMA, MYELOMA & LEUKEMIA 2022; 22:e521-e525. [PMID: 35241387 PMCID: PMC10766145 DOI: 10.1016/j.clml.2022.01.015] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/04/2022] [Revised: 01/26/2022] [Accepted: 01/28/2022] [Indexed: 01/08/2023]
Abstract
INTRODUCTION Up to 20% of patients with myeloproliferative neoplasms (MPN) will progress to blast phase (MPN-BP). Outcomes are dismal, with intensive chemotherapy providing little benefit. Low-intensity therapy is preferred due to better tolerability, but the prognosis remains poor. Allogeneic stem cell transplant (AHSCT) is still the only potential for long term survival. PATIENTS AND METHODS To better evaluate the initial treatment approach in MPN-BP, we performed a single-institution retrospective analysis of 75 patients with MPN-BP treated at Moffitt Cancer Center between 2001 and 2021. Patients were stratified by initial treatment: best supportive care (BSC), hypomethylating agent (HMA)-based therapy or intensive chemotherapy (IC). RESULTS Median overall survival (mOS) for the entire cohort was 4.8 months (BSC 0.8 months, HMA 4.7 months, and IC 11.4 months). Among IC patients, improved survival was evident in those that received AHSCT (mOS 40.8 months vs. 4.9 months, p < .01). Most patients that underwent AHSCT were initially treated with IC (p < .01). All patients that underwent AHSCT had achieved complete response (CR) or CR with incomplete hematological recovery (CRi). On multivariate analysis, factors associated with improved survival were receipt of therapy (HMA or IC) (P = .017), CR/CRi (P = .037) and receipt of AHSCT (p < .001). CONCLUSION We show that active treatment with IC improves survival, but it is mostly tied to receipt of AHSCT. IC is a reasonable approach in appropriate patients as it can provide an effective bridge to AHSCT. Other treatment strategies such as molecularly targeted therapy and novel agents are desperately needed.
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Affiliation(s)
- Franco Castillo Tokumori
- University of South Florida, Morsani College of Medicine, Department of Internal Medicine. Tampa, FL; H. Lee Moffitt Cancer Center & Research Institute, Department of Malignant Hematology. Tampa, FL.
| | - Najla Al Ali
- H. Lee Moffitt Cancer Center & Research Institute, Department of Malignant Hematology. Tampa, FL
| | - Onyee Chan
- H. Lee Moffitt Cancer Center & Research Institute, Department of Malignant Hematology. Tampa, FL
| | - David Sallman
- H. Lee Moffitt Cancer Center & Research Institute, Department of Malignant Hematology. Tampa, FL
| | - Seongseok Yun
- H. Lee Moffitt Cancer Center & Research Institute, Department of Malignant Hematology. Tampa, FL
| | - Kendra Sweet
- H. Lee Moffitt Cancer Center & Research Institute, Department of Malignant Hematology. Tampa, FL
| | - Eric Padron
- H. Lee Moffitt Cancer Center & Research Institute, Department of Malignant Hematology. Tampa, FL
| | - Jeffrey Lancet
- H. Lee Moffitt Cancer Center & Research Institute, Department of Malignant Hematology. Tampa, FL
| | - Rami Komrokji
- H. Lee Moffitt Cancer Center & Research Institute, Department of Malignant Hematology. Tampa, FL
| | - Andrew T Kuykendall
- H. Lee Moffitt Cancer Center & Research Institute, Department of Malignant Hematology. Tampa, FL
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Gerds AT, Bartalucci N, Assad A, Yacoub A. Targeting the PI3K pathway in myeloproliferative neoplasms. Expert Rev Anticancer Ther 2022; 22:835-843. [PMID: 35763287 DOI: 10.1080/14737140.2022.2093192] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
INTRODUCTION Decreasing efficacy over time and initial suboptimal response to Janus kinase (JAK) inhibitors such as ruxolitinib in a subset of patients are critical clinical challenges associated with myeloproliferative neoplasms (MPNs), primarily myelofibrosis. AREAS COVERED The role of phosphatidylinositol-3 kinase (PI3K) in MPN disease progression and treatment resistance and as a potential therapeutic target in patients who experience loss of response to JAK inhibition is discussed. Understanding the complex signaling networks involved in the pathogenesis of MPNs has identified potentially novel therapeutic targets and treatment strategies, such as inhibiting other signaling pathways in addition to the JAK/signal transducer and activator of transcription (STAT) pathway. PI3K plays a crucial role downstream of JAK signaling in rescuing tumor cell proliferation, with PI3Kδ being particularly important in hematologic malignancies. Concurrent targeting of both PI3K and JAK/STAT pathways may offer an innovative therapeutic strategy to maximize efficacy. EXPERT OPINION Based on our understanding of the underlying mechanisms and the role of PI3K pathway signaling in the loss of response or resistance to JAK inhibitor treatment and initial results from clinical studies, the combination of parsaclisib (PI3Kδ inhibitor) and ruxolitinib holds great clinical potential. If confirmed in larger clinical trials, parsaclisib may provide more treatment options and improve clinical outcomes for patients with MPNs.
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Affiliation(s)
- Aaron T Gerds
- Cleveland Clinic Taussig Cancer Institute Cleveland, Cleveland, OH, USA
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Gowin K. TIMING IS EVERYTHING: When IS the Time Right for Transplant in Myelofibrosis Therapy? Transplant Cell Ther 2022; 28:177-178. [PMID: 35365335 DOI: 10.1016/j.jtct.2022.03.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Affiliation(s)
- Krisstina Gowin
- Department of Hematology Oncology, Bone Marrow Transplant and Cellular Therapy, University of Arizona, Tucson, United States.
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Posttransplantation Cyclophosphamide-based Graft versus Host Disease Prophylaxis with Non-myeloablative Conditioning for Blood or Marrow Transplantation for Myelofibrosis. Transplant Cell Ther 2022; 28:259.e1-259.e11. [PMID: 35158092 PMCID: PMC9081210 DOI: 10.1016/j.jtct.2022.02.004] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2021] [Revised: 02/01/2022] [Accepted: 02/03/2022] [Indexed: 11/20/2022]
Abstract
We describe outcomes with posttransplantation cyclophosphamide and non-myeloablative conditioning based allogeneic blood or marrow transplantation for myelofibrosis using matched or mismatched, family or unrelated donors. The conditioning regimen consisted of fludarabine, cyclophosphamide and total body irradiation. Forty-two patients, with a median age of 63 years, were included, of whom 19% had intermediate-1, 60% had intermediate-2, and 21% had high-risk DIPSS-plus disease, and 60% had atleast one high-risk somatic mutation. Over 90% patients engrafted neutrophils at a median of 19.5 days and 7% had graft failure. At 1 and 3-years, respectively, the overall survival was 65% and 60%, relapse-free survival was 65% and 31%, relapse was 5% and 40%, and non-relapse mortality was 30% and 30%. Acute graft versus host disease grade 3-4 was noted in 17% at 1 year and chronic graft versus host disease requiring systemic therapy in 12% patients. Spleen size ≥ 17 cm or prior splenectomy was associated with inferior relapse-free survival (HR 3.50, 95% CI 1.18-10.37, P=0.02) and higher relapse rate (SDHR not calculable, P=0.01). Age > 60 years (SDHR 0.26, 95% CI: 0.08-0.80, P=0.02) and peripheral blood graft (SDHR 0.34, 95% CI 0.11-0.99, P=0.05) was associated with lower risk of relapse. In our limited sample, the presence of a high-risk mutation was not statistically significantly associated with an inferior outcome although ASXL1 was suggestive of inferior survival (SDHR 2.36. 95% CI 0.85-6.6, P=0.09). Overall, this approach shows comparable outcomes as previously reported and underscores the importance of spleen size in evaluation of transplant candidates.
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How We Manage Myelofibrosis Candidates for Allogeneic Stem Cell Transplantation. Cells 2022; 11:cells11030553. [PMID: 35159362 PMCID: PMC8834299 DOI: 10.3390/cells11030553] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/25/2021] [Revised: 01/31/2022] [Accepted: 02/03/2022] [Indexed: 02/01/2023] Open
Abstract
Moving from indication to transplantation is a critical process in myelofibrosis. Most of guidelines specifically focus on either myelofibrosis disease or transplant procedure, and, currently, no distinct indication for the management of MF candidates to transplant is available. Nevertheless, this period of time is crucial for the transplant outcome because engraftment, non-relapse mortality, and relapse incidence are greatly dependent upon the pre-transplant management. Based on these premises, in this review, we will go through the path of identification of the MF patients suitable for a transplant, by using disease-specific prognostic scores, and the evaluation of eligibility for a transplant, based on performance, comorbidity, and other combined tools. Then, we will focus on the process of donor and conditioning regimens’ choice. The pre-transplant management of splenomegaly and constitutional symptoms, cytopenias, iron overload and transplant timing will be comprehensively discussed. The principal aim of this review is, therefore, to give a practical guidance for managing MF patients who are potential candidates for allo-HCT.
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Chifotides HT, Bose P, Verstovsek S. Momelotinib: an emerging treatment for myelofibrosis patients with anemia. J Hematol Oncol 2022; 15:7. [PMID: 35045875 PMCID: PMC8772195 DOI: 10.1186/s13045-021-01157-4] [Citation(s) in RCA: 33] [Impact Index Per Article: 16.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2021] [Accepted: 08/30/2021] [Indexed: 12/11/2022] Open
Abstract
The suite of marked anemia benefits that momelotinib has consistently conferred on myelofibrosis (MF) patients stem from its unique inhibitory activity on the BMP6/ACVR1/SMAD and IL-6/JAK/STAT3 pathways, resulting in decreased hepcidin (master iron regulator) expression, higher serum iron and hemoglobin levels, and restored erythropoiesis. Clinical data on momelotinib from the phase 2 and the two phase 3 SIMPLIFY trials consistently demonstrated high rates of sustained transfusion-independence. In a recent phase 2 translational study, 41% of the patients achieved transfusion independence for ≥ 12 weeks. In the phase 3 trials SIMPLIFY-1 and SIMPLIFY-2, 17% more JAK inhibitor-naïve patients and two-fold more JAK inhibitor-treated patients achieved or maintained transfusion independence with momelotinib versus ruxolitinib and best available therapy (89% ruxolitinib), respectively. Anemia is present in approximately a third of MF patients at diagnosis, eventually developing in nearly all patients. The need for red blood cell transfusions is an independent adverse risk factor for both overall survival and leukemic transformation. Presently, FDA-approved medications to address anemia are lacking. Momelotinib is one of the prime candidates to durably address the critical unmet needs of MF patients with moderate/severe anemia. Importantly, momelotinib may have overall survival benefits in frontline and second-line MF patients. MOMENTUM is an international registration-track phase 3 trial further assessing momelotinib’s unique constellation of anemia and other benefits in second-line MF patients; the results of the MOMENTUM trial are keenly awaited and may lead to regulatory approval of momelotinib.
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Cipkar C, Kumar S, Thavorn K, Kekre N. The optimal timing of allogeneic stem cell transplantation for primary myelofibrosis. Transplant Cell Ther 2022; 28:189-194. [DOI: 10.1016/j.jtct.2022.01.018] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2021] [Revised: 01/17/2022] [Accepted: 01/18/2022] [Indexed: 11/15/2022]
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England J, Gupta V. Novel therapies vs hematopoietic cell transplantation in myelofibrosis: who, when, how? HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2021; 2021:453-462. [PMID: 34889421 PMCID: PMC8791173 DOI: 10.1182/hematology.2021000279] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/05/2023]
Abstract
Myelofibrosis is one of the classical Philadelphia chromosome-negative myeloproliferative neoplasms characterized by progressive marrow failure and chronic inflammation. Discovery of the JAK2 mutation paved the way for development of small molecular inhibitors and further facilitated the research in understanding of molecular biology of the disease. Development of novel medications and synergistic combinations with standard JAK inhibitor (JAKi) therapy may have the potential to improve depth and duration of disease control and symptomatic benefit, whereas advancements in allogeneic hematopoietic stem cell transplantation (HCT) have improved tolerability and donor availability, allowing for more patients to pursue this potentially curative therapy. The increase in options for medical therapy and changing risk profile of HCT is leading to increased complexity in counseling patients on choice of management strategy. In this case-based review, we summarize our approach to symptom-directed medical therapy, including the use of novel drugs and combination therapies currently under study in advanced clinical trials. We outline our recommendations for optimal timing of HCT, including risk-adapted selection for early HCT as opposed to delayed HCT after upfront JAKi therapy, as well as the use of pretransplant JAKi and alternative donor sources.
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Affiliation(s)
- James England
- Princess Margaret Cancer Centre, University of Toronto, Toronto, Ontario, Canada
| | - Vikas Gupta
- Princess Margaret Cancer Centre, University of Toronto, Toronto, Ontario, Canada
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38
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Tremblay D, Hoffman R. Emerging drugs for the treatment of myelofibrosis: phase II & III clinical trials. Expert Opin Emerg Drugs 2021; 26:351-362. [PMID: 34875179 DOI: 10.1080/14728214.2021.2015320] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
INTRODUCTION Myelofibrosis is a clonal hematologic malignancy with clinical manifestations that include cytopenias, debilitating constitutional symptoms, splenomegaly, bone marrow fibrosis and a propensity toward leukemic progression. While allogeneic hematopoietic stem cell transplantation can be curative, this therapy is not available for the majority of patients. Ruxolitinib and fedratinib are approved JAK2 inhibitors that have produced meaningful benefits in terms of spleen reduction and symptom improvement, but there remain several unmet needs. AREAS COVERED We discuss novel therapies based upon published data from phase II or III clinical trials. Specifically, we cover novel JAK inhibitors (momelotinib and pacritinib), and agents that target bromodomain and extra-terminal domain (pelabresib), the antiapoptotic proteins BCL-2/BCL-xL (navitoclax), MDM2 (navtemadlin), phosphatidylinositol 3-kinase (parsaclisib), or telomerase (imetelstat). EXPERT OPINION Patients with disease related cytopenias are ineligible for currently approved JAK2 inhibitors. However, momelotinib and pacritinib may be able to fill this void. Novel therapies are being evaluated in the upfront setting to improve the depth and duration of responses with ruxolitinib. Future evaluation of agents must be judged on their potential to modify disease progression, which current JAK2 inhibitors lack. Combination therapy, possibly with an immunotherapeutic agent might serve as key components of future myelofibrosis treatment options.
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Affiliation(s)
- Douglas Tremblay
- Division of Hematology and Medical Oncology, Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA10029
| | - Ronald Hoffman
- Division of Hematology and Medical Oncology, Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA10029
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Allogeneic blood or marrow transplantation with haploidentical donor and post-transplantation cyclophosphamide in patients with myelofibrosis: a multicenter study. Leukemia 2021; 36:856-864. [PMID: 34663912 PMCID: PMC10084790 DOI: 10.1038/s41375-021-01449-1] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2021] [Revised: 09/29/2021] [Accepted: 10/04/2021] [Indexed: 11/08/2022]
Abstract
We report the results from a multicenter retrospective study of 69 adult patients who underwent haploidentical blood or marrow transplantation (haplo-BMT) with post-transplantation cyclophosphamide (PTCy) for chronic phase myelofibrosis. The median age at BMT was 63 years (range, 41-74). Conditioning regimens were reduced intensity in 54% and nonmyeloablative in 39%. Peripheral blood grafts were used in 86%. The median follow-up was 23.1 months (range, 1.6-75.7). At 3 years, the overall survival, relapse-free survival (RFS), and graft-versus-host-disease (GVHD)-free-RFS were 72% (95% CI 59-81), 44% (95% CI 29-59), and 30% (95% CI 17-43). Cumulative incidences of non-relapse mortality and relapse were 23% (95% CI 14-34) and 31% (95% CI 17-47) at 3 years. Spleen size ≥22 cm or prior splenectomy (HR 6.37, 95% CI 2.02-20.1, P = 0.002), and bone marrow grafts (HR 4.92, 95% CI 1.68-14.4, P = 0.004) were associated with increased incidence of relapse. Cumulative incidence of acute GVHD grade 3-4 was 10% at 3 months and extensive chronic GVHD was 8%. Neutrophil engraftment was reported in 94% patients, at a median of 20 days (range, 14-70). In conclusion, haplo-BMT with PTCy is feasible in patients with myelofibrosis. Splenomegaly ≥22 cm and bone marrow grafts were associated with a higher incidence of relapse in this study.
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Bewersdorf JP, Sheth AH, Vetsa S, Grimshaw A, Giri S, Podoltsev NA, Gowda L, Tamari R, Tallman MS, Rampal RK, Zeidan AM, Stahl M. Outcomes of Allogeneic Hematopoietic Cell Transplantation in Patients With Myelofibrosis-A Systematic Review and Meta-Analysis. Transplant Cell Ther 2021; 27:873.e1-873.e13. [PMID: 34052505 PMCID: PMC8478722 DOI: 10.1016/j.jtct.2021.05.016] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2021] [Revised: 05/18/2021] [Accepted: 05/20/2021] [Indexed: 01/14/2023]
Abstract
Allogeneic hematopoietic cell transplant (allo-HCT) remains the only potentially curative therapeutic modality for patients with primary or secondary myelofibrosis (MF). However, many patients are considered ineligible for allo-HCT, and transplant-related mortality can be substantial. Data on the efficacy and safety of allo-HCT are mixed and largely derived from retrospective studies. We aimed to synthesize the available evidence on the safety and efficacy of allo-HCT in MF and to identify patient, disease, and transplant characteristics with prognostic impact on outcomes of patients with MF undergoing allo-HCT. For this systematic review and meta-analysis, Cochrane Library, Google Scholar, Ovid Medline, Ovid Embase, PubMed, Scopus, and Web of Science Core Collection were searched from inception to October 11, 2020, for studies on allo-HCT in MF. Random-effects models were used to pool response rates for the co-primary outcomes of 1-year, 2-year, and 5-year overall survival (OS). Rates of non-relapse mortality and acute and chronic graft-versus-host-disease (GVHD) were studied as secondary endpoints. Subgroup analyses on the effect of conditioning regimen intensity, baseline dynamic international prognostic scoring system (DIPSS) score, and patient age were performed. The study protocol has been registered on PROSPERO (CRD42020188706). Forty-three studies with 8739 patients were identified and included in this meta-analysis. Rates of 1-year, 2-year, and 5-year OS were 66.7% (95% confidence interval [CI], 63.5%-69.8%), 64.4% (95% CI, 57.6%-70.6%), and 55.0% (95% CI, 51.8%-58.3%), respectively. Rates of 1-year, 2-year, and 5-year nonrelapse mortality were 25.9% (95% CI, 23.3%-28.7%), 29.7% (95% CI, 24.5%-35.4%), and 30.5% (95% CI, 25.9%-35.5%), respectively. The combined rate of graft failure was 10.6% (95% CI, 8.9%-12.5%) with primary and secondary graft failure occurring in 7.3% (95% CI, 5.7%-9.4%) and 5.9% (95% CI, 4.3%-8.0%) of patients, respectively. Rates of acute and chronic graft-versus-host disease were 44.0% (95% CI, 39.6%-48.4%; grade III/IV: 15.2%) and 46.5% (95% CI, 42.2%-50.8%; extensive or moderate/severe: 26.1%), respectively. Subgroup analyses did not show any significant difference between conditioning regimen intensity (myeloablative versus reduced-intensity), median patient age, and proportion of DIPSS-intermediate-2/high patients. The quality of the evidence is limited by the absence of randomized clinical trials in the field and the heterogeneity of patient and transplant characteristics across included studies. Given the poor prognosis of patients not receiving transplants and in the absence of curative nontransplantation therapies, our results support consideration of allo-HCT for eligible patients with MF.
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Affiliation(s)
- Jan Philipp Bewersdorf
- Department of Internal Medicine, Section of Hematology, Yale School of Medicine, New Haven, Connecticut
| | | | - Shaurey Vetsa
- Yale School of Medicine, Department of Neurosurgery, New Haven, Connecticut
| | - Alyssa Grimshaw
- Harvey Cushing/John Hay Whitney Medical Library, Yale University, New Haven, Connecticut
| | - Smith Giri
- Division of Hematology and Oncology, University of Alabama School of Medicine
| | - Nikolai A Podoltsev
- Department of Internal Medicine, Section of Hematology, Yale School of Medicine, New Haven, Connecticut; Cancer Outcomes, Public Policy, and Effectiveness Research (COPPER) Center, Yale University, New Haven, Connecticut
| | - Lohith Gowda
- Department of Internal Medicine, Section of Hematology, Yale School of Medicine, New Haven, Connecticut
| | - Roni Tamari
- Bone Marrow Transplant Service, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Martin S Tallman
- Leukemia Service, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Raajit K Rampal
- Leukemia Service, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Amer M Zeidan
- Department of Internal Medicine, Section of Hematology, Yale School of Medicine, New Haven, Connecticut; Cancer Outcomes, Public Policy, and Effectiveness Research (COPPER) Center, Yale University, New Haven, Connecticut
| | - Maximilian Stahl
- Department of Medical Oncology, Adult Leukemia Program, Dana-Farber Cancer Institute, Boston, Massachusetts.
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Hernández‐Boluda J, Pereira A, Kröger N, Cornelissen JJ, Finke J, Beelen D, Witte M, Wilson K, Platzbecker U, Sengeloev H, Blaise D, Einsele H, Sockel K, Krüger W, Lenhoff S, Salaroli A, Martin H, García‐Gutiérrez V, Pavone V, Alvarez‐Larrán A, Raya J, Zinger N, Gras L, Hayden P, Czerw T, P. McLornan D, Yakoub‐Agha I. Allogeneic hematopoietic cell transplantation in older myelofibrosis patients: A study of the chronic malignancies working party of EBMT and the Spanish Myelofibrosis Registry. Am J Hematol 2021; 96:1186-1194. [PMID: 34152630 DOI: 10.1002/ajh.26279] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2021] [Revised: 06/11/2021] [Accepted: 06/17/2021] [Indexed: 01/13/2023]
Abstract
Allogeneic hematopoietic cell transplantation (allo-HCT) is increasingly used in older myelofibrosis (MF) patients, but its risk/benefit ratio compared to non-transplant approaches has not been evaluated in this population. We analyzed the outcomes of allo-HCT in 556 MF patients aged ≥65 years from the EBMT registry, and determined the excess mortality over the matched general population of MF patients ≥65 years managed with allo-HCT (n = 556) or conventional drug treatment (n = 176). The non-transplant cohort included patients with intermediate-2 or high risk DIPSS from the Spanish Myelofibrosis Registry. After a median follow-up of 3.4 years, the estimated 5-year survival rate, non-relapse mortality (NRM), and relapse incidence after transplantation was 40%, 37%, and 25%, respectively. Busulfan-based conditioning was associated with decreased mortality (HR: 0.7, 95% CI: 0.5-0.9) whereas the recipient CMV+/donor CMV- combination (HR: 1.7, 95% CI: 1.2-2.4) and the JAK2 mutated genotype (HR: 1.9, 95% CI: 1.1-3.5) predicted higher mortality. Busulfan-based conditioning correlated with improved survival due to less NRM, despite its higher relapse rate when compared with melphalan-based regimens. Excess mortality was higher in transplanted patients than in the non-HCT cohort in the first year of follow-up (ratio: 1.93, 95% CI: 1.13-2.80), whereas the opposite occurred between the fourth and eighth follow-up years (ratio: 0.31, 95% CI: 0.18-0.53). Comparing the excess mortality of the two treatments, male patients seemed to benefit more than females from allo-HCT, mainly due to their worse prognosis with non-transplant approaches. These findings could potentially enhance counseling and treatment decision-making in elderly transplant-eligible MF patients.
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Affiliation(s)
| | - Arturo Pereira
- Department of Hemotherapy and Hemostasis Hospital Clínic Barcelona Spain
| | - Nicolaus Kröger
- Hematology Department University Medical Center Hamburg‐Eppendorf Hamburg Germany
| | - Jan J. Cornelissen
- Erasmus MC Cancer Center University Medical Center Rotterdam the Netherlands
| | - Jürgen Finke
- Medical Center University of Freiburg, Faculty of Medicine Freiburg Germany
| | | | - Moniek Witte
- Hematology Department University Medical Center Utrecht the Netherlands
| | - Keith Wilson
- Hematology Department University Hospital of Wales Cardiff UK
| | - Uwe Platzbecker
- Hematology Department University Hospital Leipzig Leipzig Germany
| | | | - Didier Blaise
- Hematology Department Institut Paoli Calmettes Marseille France
| | - Hermann Einsele
- Hematology Department Universitaetsklinikum Würzburg Wuerzburg Germany
| | - Katja Sockel
- Hematology Department University Hospital Dresden, TU Dresden Dresden Germany
| | - William Krüger
- Hematology Department Universitaetsklinikum Greifswald Greifswald Germany
| | - Stig Lenhoff
- Hematology Department Skanes University Hospital Lund Sweden
| | | | - Hans Martin
- Hematology Department Universitaetsklinikum Frankfurt Frankfurt Germany
| | | | | | | | - José‐María Raya
- Hematology Department Hospital Universitario de Canarias Tenerife Spain
| | | | - Luuk Gras
- EBMT Statistical Unit Leiden The Netherlands
| | - Patrick Hayden
- Hematology Department Trinity College Dublin, St. James's Hospital Dublin Ireland
| | - Tomasz Czerw
- Hematology Department Maria Skłodowska‐Curie National Research Institute of Oncology, Gliwice Branch Gliwice Poland
| | - Donal P. McLornan
- Hematology Department Guys' and St. Thomas' NHS Foundation Trust and University College London Hospitals London UK
| | - Ibrahim Yakoub‐Agha
- Hematology Department CHU de Lille, Université de Lille, INSERM U1286 Lille France
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Abstract
This is the first report demonstrating the safety and lack of efficacy of pembrolizumab treatment in patients with advanced MPNs. Pembrolizumab was associated with changes in the immune milieu that could potentially support antitumor immunity in patients with advanced MPNs.
Myelofibrosis (MF) is a clonal stem cell neoplasm characterized by abnormal JAK-STAT signaling, chronic inflammation, cytopenias, and risk of transformation to acute leukemia. Despite improvements in the therapeutic options for patients with MF, allogeneic hematopoietic stem cell transplantation remains the only curative treatment. We previously demonstrated multiple immunosuppressive mechanisms in patients with MF, including increased expression of programmed cell death protein 1 (PD-1) on T cells compared with healthy controls. Therefore, we conducted a multicenter, open-label, phase 2, single-arm study of pembrolizumab in patients with Dynamic International Prognostic Scoring System category of intermediate-2 or greater primary, post-essential thrombocythemia or post-polycythemia vera myelofibrosis that were ineligible for or were previously treated with ruxolitinib. The study followed a Simon 2-stage design and enrolled a total of 10 patients, 5 of whom had JAK2V617mutation, 2 had CALR mutation, and 6 had additional mutations. Most patients were previously treated with ruxolitinib. Pembrolizumab treatment was well tolerated, but there were no objective clinical responses, so the study closed after the first stage was completed. However, immune profiling by flow cytometry, T-cell receptor sequencing, and plasma proteomics demonstrated changes in the immune milieu of patients, which suggested improved T-cell responses that can potentially favor antitumor immunity. The fact that these changes were not reflected in a clinical response strongly suggests that combination immunotherapeutic approaches rather than monotherapy may be necessary to reverse the multifactorial mechanisms of immune suppression in myeloproliferative neoplasms. This trial was registered at www.clinicaltrials.gov as #NCT03065400.
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Peritransplant Ruxolitinib Administration is Safe and Effective in Patients with Myelofibrosis: a Pilot Open-Label Study. Blood Adv 2021; 6:1444-1453. [PMID: 34581764 PMCID: PMC8905711 DOI: 10.1182/bloodadvances.2021005035] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2021] [Accepted: 07/14/2021] [Indexed: 11/20/2022] Open
Abstract
Peritransplantation ruxolitinib was safe and well tolerated in patients with myelofibrosis, with MTD determined as 10 mg twice daily.
We report results of our prospective pilot trial evaluating safety/feasibility of peritransplantation ruxolitinib for myelofibrosis treatment. Primary objectives were to determine safety and maximum tolerated dose (MTD) of ruxolitinib. Ruxolitinib was administered at 2 dose levels (DLs) of 5 and 10 mg twice daily, with fludarabine/melphalan conditioning regimen and tacrolimus/sirolimus graft-versus-host disease (GVHD) prophylaxis. We enrolled 6 and 12 patients at DL1 and DL2, respectively. Median age at transplantation was 65 years (range, 25-73). Per Dynamic International Prognostic Scoring System, 4 patients were high and 14 intermediate risk. Peripheral blood stem cells were graft source from matched sibling (n = 5) or unrelated (n = 13) donor. At each DL, 1 patient developed dose-limiting toxicities (DLTs): grade 3 cardiac and gastrointestinal with grade 4 pulmonary DLTs in DL1, and grade 3 kidney injury in DL2. All patients achieved engraftment. Grade 2 to 4 and 3 to 4 acute GVHD cumulative incidence was 17% (95% confidence interval [CI], 6-47) and 11% (95% CI, 3-41), respectively. Cumulative incidence of 1-year chronic GVHD was 42% (95% CI, 24-74). With 22.6-month (range, 6.2-25.8) median follow-up in surviving patients, 1-year overall and progression-free survival were 77% (95% CI, 50-91) and 71% (95% CI, 44-87), respectively. Causes of death (n = 4) were cardiac arrest, GVHD, respiratory failure, and refractory GVHD of liver. Our results show peritransplantation ruxolitinib is safe and well tolerated at MTD of 10 mg twice daily and associated with dose-dependent pharmacokinetic and cytokine profile. Early efficacy data are highly promising in high-risk older patients with myelofibrosis. This trial was registered at www.clinicaltrials.gov as #NCT02917096.
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Myelofibrosis: let's go high! Bone Marrow Transplant 2021; 56:2864-2865. [PMID: 34446854 DOI: 10.1038/s41409-021-01438-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2021] [Revised: 08/03/2021] [Accepted: 08/13/2021] [Indexed: 11/09/2022]
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Battipaglia G, Mauff K, Wendel L, Angelucci E, Mohty M, Arcese W, Santarone S, Rubio MT, Kroger N, Fox ML, Blaise D, Iori AP, Fanin R, Chalandon Y, Pioltelli P, Marotta G, Chiusolo P, Sever M, Solano C, Contentin N, de Wreede LC, Czerw T, Hernandez-Boluda JC, Hayden P, McLornan D, Yakoub-Agha I. Thiotepa-busulfan-fludarabine (TBF) conditioning regimen in patients undergoing allogeneic hematopoietic cell transplantation for myelofibrosis: an outcome analysis from the Chronic Malignancies Working Party of the EBMT. Bone Marrow Transplant 2021; 56:1593-1602. [PMID: 33526919 DOI: 10.1038/s41409-021-01222-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2020] [Revised: 12/20/2020] [Accepted: 01/11/2021] [Indexed: 01/31/2023]
Abstract
Allogeneic hematopoietic cell transplantation (allo-HCT) remains the only curative option in MF. There is no consensus on the optimal conditioning regimen. We report outcomes of 187 patients with MF transplanted between 2010 and 2017 conditioned with TBF. Median age was 58 years. Median interval from diagnosis to allo-HCT was 44 months. Donors were haploidentical (41%), unrelated (36%) or HLA-identical siblings (23%). Stem cell source was PB in 60%. Conditioning was myeloablative in 48% of cases. Antithymocyte globulin (ATG) was used in 41% of patients. At 100 days, neutrophil and platelet engraftment were 91% and 63% after a median of 21 and 34 days, respectively. Grade II-IV and III-IV acute GVHD occurred in 24% and 12%, while at 3 years, all grade chronic GVHD and chronic extensive GVHD had been diagnosed in 38% and 11%. At 3 years, OS, RFS and GRFS were 55%, 49% and 43%, respectively. RI and NRM were 17% and 33%. On multivariate analysis, poor KPS and the use of unrelated donors were associated with worse GRFS and a higher grade II-IV acute GVHD, respectively. Neither donor type nor intensity of the conditioning regimen influenced survival outcomes. TBF is a feasible conditioning regimen in allo-HCT for MF in all donor settings although longer term outcomes are required.
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Affiliation(s)
- Giorgia Battipaglia
- Department of Clinical Medicine and Surgery, Federico II University of Naples, Naples, Italy.
| | | | | | | | - Mohamad Mohty
- Department of Clinical Hematology and Cellular Therapy, Saint-Antoine Hospital, AP-HP, Sorbonne University, Paris, France
| | - William Arcese
- Hematology, Stem Cell Transplant Unit, University Tor Vergata, Rome, Italy
| | - Stella Santarone
- Ospedale Civile Dipartimento di Ematologia, Medicina Trasfusionale e Biotecnologie, Pescara, Italy
| | - Marie Therese Rubio
- Department of Hematology, Hôpital Brabois, CHRU Nancy and CNRS UMR 7365, Biopole del'Université del Lorraine, Vendoeuvre les Nancy, France
| | - Nicolaus Kroger
- Department of Stem Cell Transplantation, Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Maria Laura Fox
- Department of Hematology, Vall d'Hebron Institute of Oncology (VHIO), University Hospital Vall d'Hebron, Barcelona, Spain
| | - Didier Blaise
- Department of Hematology, Institut Paoli Calmettes, Marseille, France
| | - Anna Paola Iori
- Hematology, Department of Translational and Precision Medicine, University Sapienza, Rome, Italy
| | - Renato Fanin
- Division of Hematology and Stem Cell Transplantation, Azienda Sanitaria Universitaria Integrata di Udine, Udine, Italy
| | - Yves Chalandon
- Division of Hematology, University of Geneva Hospitals, Geneva, Switzerland
| | - Pietro Pioltelli
- Hematology Division and Bone Marrow Transplantation Unit, San Gerardo Hospital, Monza, Italy
| | - Giuseppe Marotta
- Department of Oncology, UOSA Transplant and Cellular Therapy Center, Azienda Ospedaliera Universitaria Senese, Siena, Italy
| | - Patrizia Chiusolo
- Fondazione Policlinico A. Gemelli IRCCS, Roma, Italy.,Istituto di Ematologia, Università Cattolica del Sacro Cuore, Roma, Italy
| | - Matjaz Sever
- Department of Hematology, University Medical Centre Ljubljana, Ljubljana, Slovenia.,Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
| | - Carlos Solano
- Hematology Service, Hospital Clínico Universitario, INCLIVA Research Institute, Valencia, Spain
| | | | - Liesbeth C de Wreede
- Department of Biomedical Data Sciences, Leiden University Medical Center, Leiden, The Netherlands
| | - Tomasz Czerw
- Department of Bone Marrow Transplantation and Onco-Hematology, Maria Sklodowska-Curie National Research Institute of Oncology, Gliwice Branch, Poland
| | | | - Patrick Hayden
- Department of Haematology, Trinity College Dublin, St. James's Hospital, Dublin, Ireland
| | - Donal McLornan
- Department of Haematology, Guy's and St. Thomas' NHS Foundation Trust, London, UK.
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Shahin OA, Chifotides HT, Bose P, Masarova L, Verstovsek S. Accelerated Phase of Myeloproliferative Neoplasms. Acta Haematol 2021; 144:484-499. [PMID: 33882481 DOI: 10.1159/000512929] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2020] [Accepted: 11/09/2020] [Indexed: 12/27/2022]
Abstract
BACKGROUND Myeloproliferative neoplasms (MPNs) can transform into blast phase MPN (leukemic transformation; MPN-BP), typically via accelerated phase MPN (MPN-AP), in ∼20-25% of the cases. MPN-AP and MPN-BP are characterized by 10-19% and ≥20% blasts, respectively. MPN-AP/BP portend a dismal prognosis with no established conventional treatment. Allogeneic hematopoietic stem cell transplantation (allo-HSCT) is the sole modality associated with long-term survival. SUMMARY MPN-AP/BP has a markedly different mutational profile from de novo acute myeloid leukemia (AML). In MPN-AP/BP, TP53 and IDH1/2 are more frequent, whereas FLT3 and DNMT3A are rare. Higher incidence of leukemic transformation has been associated with the most aggressive MPN subtype, myelofibrosis (MF); other risk factors for leukemic transformation include rising blast counts above 3-5%, advanced age, severe anemia, thrombocytopenia, leukocytosis, increasing bone marrow fibrosis, type 1 CALR-unmutated status, lack of driver mutations (negative for JAK2, CALR, or MPL genes), adverse cytogenetics, and acquisition of ≥2 high-molecular risk mutations (ASXL1, EZH2, IDH1/2, SRSF2, and U2AF1Q157). The aforementioned factors have been incorporated in several novel prognostic scoring systems for MF. Currently, elderly/unfit patients with MPN-AP/BP are treated with hypomethylating agents with/without ruxolitinib; these regimens appear to confer comparable benefit to intensive chemotherapy but with lower toxicity. Retrospective studies in patients who acquired actionable mutations during MPN-AP/BP showed positive outcomes with targeted AML treatments, such as IDH1/2 inhibitors, and require further evaluation in clinical trials. Key Messages: Therapy for MPN-AP patients represents an unmet medical need. MF patients, in particular, should be appropriately stratified regarding their prognosis and the risk for transformation. Higher-risk patients should be monitored regularly and treated prior to progression to MPN-BP. MPN-AP patients may be treated with hypomethylating agents alone or in combination with ruxolitinib; also, patients can be provided with the option to enroll in rationally designed clinical trials exploring combination regimens, including novel targeted drugs, with an ultimate goal to transition to transplant.
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Affiliation(s)
- Omar A Shahin
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Helen T Chifotides
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Prithviraj Bose
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Lucia Masarova
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Srdan Verstovsek
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
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47
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Savani M, Dulery R, Bazarbachi AH, Mohty R, Brissot E, Malard F, Bazarbachi A, Nagler A, Mohty M. Allogeneic haematopoietic cell transplantation for myelofibrosis: a real-life perspective. Br J Haematol 2021; 195:495-506. [PMID: 33881169 DOI: 10.1111/bjh.17469] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2021] [Accepted: 03/19/2021] [Indexed: 01/12/2023]
Abstract
Myelofibrosis (MF) is a clonal stem cell neoplasm with heterogeneous clinical phenotypes and well-established molecular drivers. Allogeneic haematopoietic stem cell transplantation (HSCT) offers an important curative treatment option for primary MF and post-essential thrombocythaemia/polycythaemia vera MF or secondary MF. With a disease course that varies from indolent to highly progressive, we are now able to stratify risk of mortality through various tools including patient-related clinical characteristics as well as molecular genetic profile. Owing to the high risk of mortality and morbidity associated with HSCT for patients with myelofibrosis, it is important to improve patient selection for transplant. Our primary goal is to comprehensively define our understanding of current practices including the role of Janus Kinase (JAK) inhibitors, to present the data behind transplantation before and after leukaemic transformation, and to introduce novel personalization of MF treatment with a proposed clinical-molecular prognostic model to help elucidate a timepoint optimal for consideration of HSCT.
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Affiliation(s)
- Malvi Savani
- Division of Hematology and Oncology, University of Arizona Cancer Center, Tucson, AZ, USA
| | - Rémy Dulery
- Service d'Hématologie Clinique et Thérapie Cellulaire, Hôpital Saint-Antoine, Sorbonne Université, INSERM UMRs 938, Paris, France
| | - Abdul Hamid Bazarbachi
- Service d'Hématologie Clinique et Thérapie Cellulaire, Hôpital Saint-Antoine, Sorbonne Université, INSERM UMRs 938, Paris, France.,Department of Internal Medicine, Jacobi Medical Center, Albert Einstein College of Medicine, New York, New York, USA
| | - Razan Mohty
- Service d'Hématologie Clinique et Thérapie Cellulaire, Hôpital Saint-Antoine, Sorbonne Université, INSERM UMRs 938, Paris, France.,Department of Internal Medicine, Bone Marrow Transplantation Program, American University of Beirut Medical Center, Beirut, Lebanon
| | - Eolia Brissot
- Service d'Hématologie Clinique et Thérapie Cellulaire, Hôpital Saint-Antoine, Sorbonne Université, INSERM UMRs 938, Paris, France
| | - Florent Malard
- Service d'Hématologie Clinique et Thérapie Cellulaire, Hôpital Saint-Antoine, Sorbonne Université, INSERM UMRs 938, Paris, France
| | - Ali Bazarbachi
- Department of Internal Medicine, Bone Marrow Transplantation Program, American University of Beirut Medical Center, Beirut, Lebanon
| | - Arnon Nagler
- Hematology Division, Chaim Sheba Medical Center, Tel-Hashomer, Ramat Gan, Israel
| | - Mohamad Mohty
- Service d'Hématologie Clinique et Thérapie Cellulaire, Hôpital Saint-Antoine, Sorbonne Université, INSERM UMRs 938, Paris, France
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48
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Smith E, Huang J, Viswabandya A, Maze D, Malik S, Cheung V, Siddiq N, Claudio J, Arruda A, Kennedy J, Bankar A, Law AD, Lam W, Michelis FV, Kim D, Lipton J, Kumar R, Mattsson J, McNamara C, Sibai H, Xu W, Gupta V. Association of Factors Influencing Selection of Upfront Hematopoietic Cell Transplantation versus Nontransplantation Therapies in Myelofibrosis. Transplant Cell Ther 2021; 27:600.e1-600.e8. [PMID: 33798769 DOI: 10.1016/j.jtct.2021.03.027] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2021] [Revised: 03/11/2021] [Accepted: 03/22/2021] [Indexed: 11/29/2022]
Abstract
Despite the curative potential of allogeneic hematopoietic cell transplantation (HCT) for myelofibrosis (MF), a significant number of patients with MF do not undergo HCT. Factors influencing treatment preferences in these patients have not been well studied. This study was conducted to identify patient-, disease-, and donor-related factors influencing the decision regarding HCT in patients with MF. A secondary objective was to compare survival between patients who elected upfront HCT and those who opted for nontransplantation therapy. We conducted a retrospective chart review amongst patients meeting criteria for transplant indication, evaluating clinical characteristics, treatment preferences, and outcomes. Of the 183 study eligible patients age <70 years, 129 (70%) developed an HCT indication. Age >60 years was significantly associated with higher rates of HLA-typing refusal (13 of 72 versus 1 of 44; P = .02). Caucasian ethnicity was significantly associated with an increased rate of identifying well-matched donors compared with non-Caucasian ethnicity (75% versus 48%; P = .02). Of the 69 patients with well-matched donors, 34 (49%) preferred to not pursue upfront HCT despite an indication for transplantation. Patient preference for nontransplantation therapies was the most common reason for declining HCT. We did not find any difference in survival between patients pursuing upfront HCT and those opting for nontransplantation therapies, although more patients in the HCT arm were in remission at the last follow-up. Patients of Caucasian ethnicity were significantly more likely than non-Caucasian patients to identify a well-matched donor. Despite availability of a well-matched donor, a significant proportion of MF patients with an indication for transplantation do not pursue HCT. Patient age, donor type, and patient preference play major roles in the selection of upfront HCT. Although a survival difference was not observed between upfront HCT versus non-transplant therapy, more patients in the HCT arm were in remission at the last follow-up.
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Affiliation(s)
- Elliot Smith
- Medical Oncology and Hematology, Princess Margaret Cancer Centre, University of Toronto, Toronto, Ontario, Canada
| | - Jingyue Huang
- Department of Biostatistics, Princess Margaret Cancer Centre, University of Toronto, Toronto, Ontario, Canada
| | - Auro Viswabandya
- Medical Oncology and Hematology, Princess Margaret Cancer Centre, University of Toronto, Toronto, Ontario, Canada
| | - Dawn Maze
- Medical Oncology and Hematology, Princess Margaret Cancer Centre, University of Toronto, Toronto, Ontario, Canada
| | - Sarah Malik
- Medical Oncology and Hematology, Princess Margaret Cancer Centre, University of Toronto, Toronto, Ontario, Canada
| | - Verna Cheung
- Medical Oncology and Hematology, Princess Margaret Cancer Centre, University of Toronto, Toronto, Ontario, Canada
| | - Nancy Siddiq
- Medical Oncology and Hematology, Princess Margaret Cancer Centre, University of Toronto, Toronto, Ontario, Canada
| | - Jaime Claudio
- Medical Oncology and Hematology, Princess Margaret Cancer Centre, University of Toronto, Toronto, Ontario, Canada
| | - Andrea Arruda
- Medical Oncology and Hematology, Princess Margaret Cancer Centre, University of Toronto, Toronto, Ontario, Canada
| | - James Kennedy
- Medical Oncology and Hematology, Princess Margaret Cancer Centre, University of Toronto, Toronto, Ontario, Canada
| | - Aniket Bankar
- Medical Oncology and Hematology, Princess Margaret Cancer Centre, University of Toronto, Toronto, Ontario, Canada
| | - Arjun Datt Law
- Medical Oncology and Hematology, Princess Margaret Cancer Centre, University of Toronto, Toronto, Ontario, Canada
| | - Wilson Lam
- Medical Oncology and Hematology, Princess Margaret Cancer Centre, University of Toronto, Toronto, Ontario, Canada
| | - Fotios V Michelis
- Medical Oncology and Hematology, Princess Margaret Cancer Centre, University of Toronto, Toronto, Ontario, Canada
| | - Dennis Kim
- Medical Oncology and Hematology, Princess Margaret Cancer Centre, University of Toronto, Toronto, Ontario, Canada
| | - Jeffrey Lipton
- Medical Oncology and Hematology, Princess Margaret Cancer Centre, University of Toronto, Toronto, Ontario, Canada
| | - Rajat Kumar
- Medical Oncology and Hematology, Princess Margaret Cancer Centre, University of Toronto, Toronto, Ontario, Canada
| | - Jonas Mattsson
- Medical Oncology and Hematology, Princess Margaret Cancer Centre, University of Toronto, Toronto, Ontario, Canada
| | - Caroline McNamara
- Medical Oncology and Hematology, Princess Margaret Cancer Centre, University of Toronto, Toronto, Ontario, Canada
| | - Hassan Sibai
- Medical Oncology and Hematology, Princess Margaret Cancer Centre, University of Toronto, Toronto, Ontario, Canada
| | - Wei Xu
- Department of Biostatistics, Princess Margaret Cancer Centre, University of Toronto, Toronto, Ontario, Canada
| | - Vikas Gupta
- Medical Oncology and Hematology, Princess Margaret Cancer Centre, University of Toronto, Toronto, Ontario, Canada.
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49
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Ross DM, Thomson C, Hamad N, Lane SW, Manos K, Grigg AP, Guo B, Erber WN, Scott A, Viiala N, Chee L, Latimer M, Tate C, Grove C, Perkins AC, Blombery P. Myeloid somatic mutation panel testing in myeloproliferative neoplasms. Pathology 2021; 53:339-348. [PMID: 33674147 DOI: 10.1016/j.pathol.2021.01.003] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2020] [Revised: 01/14/2021] [Accepted: 01/17/2021] [Indexed: 12/22/2022]
Abstract
Myeloproliferative neoplasms are characterised by somatic mutations in pathways that regulate cell proliferation, epigenetic modifications, RNA splicing or DNA repair. Assessment of the mutational profile assists diagnosis and classification, but also aids assessment of prognosis, and may guide the use of emerging targeted therapies. The most practical way to provide information on numerous genetic variants is by using massively parallel sequencing, commonly in the form of disease specific next generation sequencing (NGS) panels. This review summarises the diagnostic and prognostic value of somatic mutation testing in Philadelphia-negative myeloproliferative neoplasms: polycythaemia vera, essential thrombocythaemia, primary myelofibrosis, chronic neutrophilic leukaemia, systemic mastocytosis, and chronic eosinophilic leukaemia. NGS panel testing is increasing in routine practice and promises to improve the accuracy and efficiency of pathological diagnosis and prognosis.
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Affiliation(s)
- David M Ross
- Myeloproliferative Neoplasms Working Party, Australasian Leukaemia and Lymphoma Group, Melbourne, Vic, Australia; Department of Haematology and Bone Marrow Transplantation, Royal Adelaide Hospital, University of Adelaide, Adelaide, SA, Australia; Centre for Cancer Biology, SA Pathology and University of South Australia, Adelaide, SA, Australia; Department of Haematology and Genetic Pathology, Flinders University and Medical Centre, Adelaide, SA, Australia.
| | - Candice Thomson
- Myeloproliferative Neoplasms Working Party, Australasian Leukaemia and Lymphoma Group, Melbourne, Vic, Australia; Department of Haematology and Bone Marrow Transplantation, Royal Adelaide Hospital, University of Adelaide, Adelaide, SA, Australia
| | - Nada Hamad
- Myeloproliferative Neoplasms Working Party, Australasian Leukaemia and Lymphoma Group, Melbourne, Vic, Australia; Haematology Department, St Vincent's Hospital, Faculty of Medicine, University of New South Wales, Sydney, NSW, Australia
| | - Steven W Lane
- Myeloproliferative Neoplasms Working Party, Australasian Leukaemia and Lymphoma Group, Melbourne, Vic, Australia; Department of Haematology and Bone Marrow Transplantation, Royal Brisbane and Women's Hospital, Brisbane, Qld, Australia; QIMR Berghofer Medical Research Institute, University of Queensland, Brisbane, Qld, Australia
| | - Kate Manos
- Myeloproliferative Neoplasms Working Party, Australasian Leukaemia and Lymphoma Group, Melbourne, Vic, Australia; Department of Clinical Haematology, Austin Health, Heidelberg, Vic, Australia
| | - Andrew P Grigg
- Myeloproliferative Neoplasms Working Party, Australasian Leukaemia and Lymphoma Group, Melbourne, Vic, Australia; Department of Clinical Haematology, Austin Health, Heidelberg, Vic, Australia
| | - Belinda Guo
- Myeloproliferative Neoplasms Working Party, Australasian Leukaemia and Lymphoma Group, Melbourne, Vic, Australia; School of Biomedical Sciences, University of Western Australia, Perth, WA, Australia
| | - Wendy N Erber
- Myeloproliferative Neoplasms Working Party, Australasian Leukaemia and Lymphoma Group, Melbourne, Vic, Australia; School of Biomedical Sciences, University of Western Australia, Perth, WA, Australia; Haematology Department, PathWest Laboratory Medicine, Perth, WA, Australia
| | - Ashleigh Scott
- Myeloproliferative Neoplasms Working Party, Australasian Leukaemia and Lymphoma Group, Melbourne, Vic, Australia; Department of Haematology and Bone Marrow Transplantation, Royal Brisbane and Women's Hospital, Brisbane, Qld, Australia
| | - Nick Viiala
- Myeloproliferative Neoplasms Working Party, Australasian Leukaemia and Lymphoma Group, Melbourne, Vic, Australia; Department of Haematology, Liverpool Hospital, University of New South Wales, Sydney, NSW, Australia
| | - Lynette Chee
- Myeloproliferative Neoplasms Working Party, Australasian Leukaemia and Lymphoma Group, Melbourne, Vic, Australia; Department of Clinical Haematology, Royal Melbourne Hospital, Peter MacCallum Cancer Centre, Department of Medicine, The University of Melbourne, Melbourne, Vic, Australia
| | - Maya Latimer
- Myeloproliferative Neoplasms Working Party, Australasian Leukaemia and Lymphoma Group, Melbourne, Vic, Australia; ACT Pathology and Canberra Hospital, Australian National University, Canberra, ACT, Australia
| | - Courtney Tate
- Myeloproliferative Neoplasms Working Party, Australasian Leukaemia and Lymphoma Group, Melbourne, Vic, Australia; Haematology Department, Gold Coast University Hospital, University of Queensland, Southport, Qld, Australia
| | - Carolyn Grove
- Myeloproliferative Neoplasms Working Party, Australasian Leukaemia and Lymphoma Group, Melbourne, Vic, Australia; School of Biomedical Sciences, University of Western Australia, Perth, WA, Australia; Haematology Department, PathWest Laboratory Medicine, Perth, WA, Australia; Haematology Department, Sir Charles Gairdner Hospital, Perth, WA, Australia
| | - Andrew C Perkins
- Myeloproliferative Neoplasms Working Party, Australasian Leukaemia and Lymphoma Group, Melbourne, Vic, Australia; Department of Haematology, Alfred Hospital, Monash University, Melbourne, Vic, Australia
| | - Piers Blombery
- Myeloproliferative Neoplasms Working Party, Australasian Leukaemia and Lymphoma Group, Melbourne, Vic, Australia; Department of Clinical Haematology, Royal Melbourne Hospital, Peter MacCallum Cancer Centre, Department of Medicine, The University of Melbourne, Melbourne, Vic, Australia
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50
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Abstract
Myelofibrosis (MF) belongs to a group of clonal stem cell disorders known as the BCR-ABL-negative myeloproliferative neoplasms. Allogeneic hematopoietic stem cell transplantation (HCT) is currently the only curative treatment option for MF. Because HCT can be associated with significant morbidity and mortality, patients need to be carefully selected based on disease-risk, fitness, and transplant factors. Furthermore, in the era of JAK inhibitors, the timing of transplantation has become a challenging question. Here the authors review recent developments in HCT for MF, focusing on risk stratification and optimal timing.
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Affiliation(s)
- Marta B Davidson
- Division of Medical Oncology and Hematology, University Health Network, Princess Margaret Cancer Centre, 700 University 6W091, Toronto, Ontario M5G 1Z5, Canada
| | - Vikas Gupta
- Department of Medicine, Princess Margaret Cancer Centre, Suite 5-303C, 610-University Avenue, University of Toronto, Toronto, Ontario M5G 2M9, Canada.
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