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Palma AM, Hanes MR, Marshall JS. Mast Cell Modulation of B Cell Responses: An Under-Appreciated Partnership in Host Defence. Front Immunol 2021; 12:718499. [PMID: 34566974 PMCID: PMC8460918 DOI: 10.3389/fimmu.2021.718499] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2021] [Accepted: 08/23/2021] [Indexed: 12/17/2022] Open
Abstract
Mast cells are well known to be activated via cross-linking of immunoglobulins bound to surface receptors. They are also recognized as key initiators and regulators of both innate and adaptive immune responses against pathogens, especially in the skin and mucosal surfaces. Substantial attention has been given to the role of mast cells in regulating T cell function either directly or indirectly through actions on dendritic cells. In contrast, the ability of mast cells to modify B cell responses has been less explored. Several lines of evidence suggest that mast cells can greatly modify B cell generation and activities. Mast cells co-localise with B cells in many tissue settings and produce substantial amounts of cytokines, such as IL-6, with profound impacts on B cell development, class-switch recombination events, and subsequent antibody production. Mast cells have also been suggested to modulate the development and functions of regulatory B cells. In this review, we discuss the critical impacts of mast cells on B cells using information from both clinical and laboratory studies and consider the implications of these findings on the host response to infections.
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Affiliation(s)
- Alejandro M Palma
- IWK Health Centre and Department of Pediatrics, Dalhousie University, Halifax, NS, Canada
| | - Mark R Hanes
- Department of Pathology, Dalhousie University, Halifax, NS, Canada.,Beatrice Hunter Cancer Research Institute, Halifax, NS, Canada
| | - Jean S Marshall
- Department of Pathology, Dalhousie University, Halifax, NS, Canada.,Beatrice Hunter Cancer Research Institute, Halifax, NS, Canada.,Department of Microbiology and Immunology, Dalhousie University, Halifax, NS, Canada
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Zimmermann N, Abonia JP, Dreskin SC, Akin C, Bolton S, Happel CS, Geller M, Larenas-Linnemann D, Nanda A, Peterson K, Wasan A, Wechsler J, Zhang S, Bernstein JA. Developing a standardized approach for assessing mast cells and eosinophils on tissue biopsies: A Work Group Report of the AAAAI Allergic Skin Diseases Committee. J Allergy Clin Immunol 2021; 148:964-983. [PMID: 34384610 DOI: 10.1016/j.jaci.2021.06.030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2021] [Revised: 06/29/2021] [Accepted: 06/30/2021] [Indexed: 10/20/2022]
Abstract
Mast cells and eosinophils are commonly found, expectedly or unexpectedly, in human tissue biopsies. Although the clinical significance of their presence, absence, quantity, and quality continues to be investigated in homeostasis and disease, there are currently gaps in knowledge related to what constitutes quantitatively relevant increases in mast cell and eosinophil number in tissue specimens for several clinical conditions. Diagnostically relevant thresholds of mast cell and eosinophil numbers have been proposed and generally accepted by the medical community for a few conditions, such as systemic mastocytosis and eosinophilic esophagitis. However, for other mast cell- and eosinophil-associated disorders, broad discrepancies remain regarding diagnostic thresholds and how samples are processed, routinely and/or specially stained, and interpreted and/or reported by pathologists. These discrepancies can obfuscate or delay a patient's correct diagnosis. Therefore, a work group was assembled to review the literature and develop a standardized consensus for assessing the presence of mast cells and eosinophils for a spectrum of clinical conditions, including systemic mastocytosis and cutaneous mastocytosis, mast cell activation syndrome, eosinophilic esophagitis, eosinophilic gastritis/enteritis, and hypereosinophilia/hypereosinophilic syndrome. The intent of this work group is to build a consensus among pathology, allergy, dermatology, hematology/oncology, and gastroenterology stakeholders for qualitatively and quantitatively assessing mast cells and eosinophils in skin, gastrointestinal, and bone marrow pathologic specimens for the benefit of clinical practice and patients.
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Affiliation(s)
- Nives Zimmermann
- Department of Pathology and Laboratory Medicine, University of Cincinnati, Cincinnati, Ohio; Division of Allergy and Immunology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - J Pablo Abonia
- Department of Pathology and Laboratory Medicine, University of Cincinnati, Cincinnati, Ohio; Department of Pediatrics, University of Cincinnati, Cincinnati, Ohio
| | - Stephen C Dreskin
- Division of Allergy and Immunology, Department of Internal Medicine, University of Colorado, Aurora, Colo
| | - Cem Akin
- Division of Allergy and Immunology, Department of Internal Medicine, University of Michigan, Ann Arbor, Mich
| | - Scott Bolton
- Department of Pediatrics, University of Cincinnati, Cincinnati, Ohio; Division of Gastroenterology, Hepatology and Nutrition, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Corinne S Happel
- Division of Allergy and Immunology, Department of Internal Medicine, John Hopkins School of Medicine, Baltimore, Md
| | - Mario Geller
- Department of Medicine, the Academy of Medicine of Rio de Janeiro, Rio de Janeiro, Brazil
| | | | - Anil Nanda
- Asthma and Allergy Center, Lewisville, Tex; Asthma and Allergy Center, Flower Mound, Tex; Division of Allergy and Immunology, University of Texas Southwestern Medical Center, Dallas, Tex
| | - Kathryn Peterson
- Division of Gastroenterology, Department of Medicine, University of Utah Health Sciences Center, Salt Lake City, Utah
| | - Anita Wasan
- Division of Gastroenterology, Hepatology, and Nutrition, Allergy and Asthma Center, McLean, Va
| | - Joshua Wechsler
- Division of Allergy and Immunology, Department of Pediatrics, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, Ill
| | - Simin Zhang
- Allergy Section, Division of Immunology, Department of Internal Medicine, College of Medicine, University of Cincinnati, Cincinnati, Ohio
| | - Jonathan A Bernstein
- Allergy Section, Division of Immunology, Department of Internal Medicine, College of Medicine, University of Cincinnati, Cincinnati, Ohio.
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CD52-targeted depletion by Alemtuzumab ameliorates allergic airway hyperreactivity and lung inflammation. Mucosal Immunol 2021; 14:899-911. [PMID: 33731828 PMCID: PMC8225558 DOI: 10.1038/s41385-021-00388-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2020] [Revised: 02/03/2021] [Accepted: 02/07/2021] [Indexed: 02/04/2023]
Abstract
Allergic asthma is a chronic inflammatory disorder associated with airway hyperreactivity (AHR) whose global prevalence is increasing at an alarming rate. Group 2 innate lymphoid cells (ILC2s) and T helper 2 (TH2) cells are producers of type 2 cytokines, which may contribute to development of AHR. In this study, we explore the potential of CD52-targeted depletion of type 2 immune cells for treating allergic AHR. Here we show that anti-CD52 therapy can prevent and remarkably reverse established IL-33-induced AHR by reducing airway resistance and alleviating lung inflammation. We further show that CD52 depletion prevents and treats allergic AHR induced by clinically relevant allergens such as Alternaria alternata and house dust mite. Importantly, we leverage various humanized mice models of AHR to show new therapeutic applications for Alemtuzumab, an anti-CD52 depleting antibody that is currently FDA approved for treatment of multiple sclerosis. Our results demonstrate that CD52 depletion is a viable therapeutic option for reduction of pulmonary inflammation, abrogation of eosinophilia, improvement of lung function, and thus treatment of allergic AHR. Taken together, our data suggest that anti-CD52 depleting monoclonal antibodies, such as Alemtuzumab, can serve as viable therapeutic drugs for amelioration of TH2- and ILC2-dependent AHR.
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Ahn A, Park CJ, Cho YU, Jang S, Seo EJ, Lee JH, Yoon DH, Suh C. Clinical, Laboratory, and Bone Marrow Findings of 31 Patients With Waldenström Macroglobulinemia. Ann Lab Med 2020; 40:193-200. [PMID: 31858758 PMCID: PMC6933056 DOI: 10.3343/alm.2020.40.3.193] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2019] [Revised: 05/29/2019] [Accepted: 10/24/2019] [Indexed: 01/27/2023] Open
Abstract
Background Waldenström macroglobulinemia (WM) is a subset of lymphoplasmacytic lymphoma (LPL) with bone marrow (BM) involvement and an IgM monoclonal gammopathy of any level. We aimed to identify the clinical, laboratory, and BM findings of patients with WM and to evaluate the usefulness of CD154 for the diagnosis and prognosis of WM. Methods We reviewed the medical records and BM studies and/or flow cytometric immunotyping of 31 patients with untreated WM. Semiquantitative immunohistochemistry (CD20, CD138, tryptase, and CD154) of BM was performed. Results Only six patients presented with symptoms of hyperviscosity syndrome. Eleven patients had solid cancer and/or another hematologic malignancy. Mast cells (MC) increased in all samples, with some in close contact with tumor cells. Tryptase-positive MC (17.1/ high-power fields [HPF], 1.2–72.0/HPF) and CD154-positive MC (8.6/HPF, 0.1–31.1/HPF) were observed. The high CD154-positive MC (≥8.6/HPF) group showed a lower overall five-year survival rate than the low CD154-positive MC (<8.6/HPF) group (71.9% vs. 100.0%; P=0.012). Flow cytometric immunophenotyping of BM aspirates showed increased B lymphocytes and plasma cells with a normal phenotype (CD138+/CD38+/CD19+/CD45+/CD56−). Conclusions Approximately one third of WM patients showed other malignancies and all patients had increased MC. Immunohistochemistry and flow cytometric immunophenotyping are useful for diagnosing WM, and increased CD154-positive MC can indicate poor prognosis.
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Affiliation(s)
- Ari Ahn
- Department of Laboratory Medicine, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Chan Jeoung Park
- Department of Laboratory Medicine, University of Ulsan College of Medicine and Asan Medical Center, Seoul, Korea.
| | - Young Uk Cho
- Department of Laboratory Medicine, University of Ulsan College of Medicine and Asan Medical Center, Seoul, Korea
| | - Seongsoo Jang
- Department of Laboratory Medicine, University of Ulsan College of Medicine and Asan Medical Center, Seoul, Korea
| | - Eul Ju Seo
- Department of Laboratory Medicine, University of Ulsan College of Medicine and Asan Medical Center, Seoul, Korea
| | - Jung Hee Lee
- Department of Internal Medicine, University of Ulsan College of Medicine and Asan Medical Center, Seoul, Korea
| | - Dok Hyun Yoon
- Department of Internal Medicine, University of Ulsan College of Medicine and Asan Medical Center, Seoul, Korea
| | - Cheolwon Suh
- Department of Internal Medicine, University of Ulsan College of Medicine and Asan Medical Center, Seoul, Korea
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Dominguez A, Kastritis E, Castillo JJ. Monoclonal Antibodies for Waldenström Macroglobulinemia. Hematol Oncol Clin North Am 2018; 32:841-852. [PMID: 30190022 DOI: 10.1016/j.hoc.2018.05.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
For the last 2 decades, anti-CD20 monoclonal antibodies have revolutionized the treatment of patients with B-cell lymphomas. These agents have shown efficacy when used as single agents and also have improved response and survival rates when added to chemotherapy. Monoclonal antibodies are safe and effective as well in patients with Waldenström macroglobulinemia (WM). The purpose of this article is to review the mechanism of action of monoclonal antibodies and to discuss current clinical data supporting their use in patients with WM. This review focuses on retrospective and prospective studies and clinical trials on anti-CD20 antibodies, anti-CD38 antibody, and anti-CXCR4 antibody.
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Affiliation(s)
- Andres Dominguez
- Department of Internal Medicine, Fundación Valle del Lili, CES University, Cali, Colombia
| | - Efstathios Kastritis
- Department of Clinical Therapeutics, National and Kapodistrian University, Athens, Greece
| | - Jorge J Castillo
- Bing Center for Waldenstrom Macroglobulinemia, Dana-Farber Cancer Institute, Harvard Medical School, 450 Brookline Avenue, Mayer 221, Boston, MA 02215, USA.
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García-Sanz R, Jiménez C, González De La Calle V, Sarasquete ME. A safety profile of medications used to treat Waldenström's macroglobulinemia. Expert Opin Drug Saf 2018; 17:609-621. [PMID: 29768934 DOI: 10.1080/14740338.2018.1477936] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
INTRODUCTION Waldenström's macroglobulinemia (WM) is a B-cell lymphoproliferative disease with serum IgM monoclonal component and bone marrow infiltration by lymphoplasmacytic lymphoma. Traditional therapy was based on that regimens used for closely related entities, such as chronic lymphocytic leukemia or multiple myeloma. This resulted in a lack of drugs specifically approved for WM, until the discovery of the Bruton Tyrosine Kinase (BTK) inhibitors. AREAS COVERED Two main therapeutic attitudes are possible: (1) conventional therapies based on combinations with alkylating agents or proteasome inhibitors with steroids and anti-CD20 monoclonal antibodies or (2) new approaches with BTK inhibitors, usually alone. Other possibilities such as BCL2 inhibitors, PI3K/AKT inhibitors, and others are currently under evaluation, but we will focus the review on the most consolidated approaches that are available for patients with WM at different stages of the disease. PubMed, Web of Science, and clinicaltrials.gov were queried for the keywords 'Waldenstrom macroglobulinemia' and the different drugs here evaluated through 1 February 2018. EXPERT OPINION Although WM has no many specific drugs, there are many possible therapies, including Ibrutinib, the first formally approved drug for this disorder.
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Affiliation(s)
- Ramón García-Sanz
- a Servicio de Hematología, Hospital Universitario de Salamanca , Instituto de Investigación Biomédica de Salamanca (IBSAL), Centro de Investigación del Cáncer de Salamanca, CIBERONC , Salamanca , Spain
| | - Cristina Jiménez
- a Servicio de Hematología, Hospital Universitario de Salamanca , Instituto de Investigación Biomédica de Salamanca (IBSAL), Centro de Investigación del Cáncer de Salamanca, CIBERONC , Salamanca , Spain
| | - Verónica González De La Calle
- a Servicio de Hematología, Hospital Universitario de Salamanca , Instituto de Investigación Biomédica de Salamanca (IBSAL), Centro de Investigación del Cáncer de Salamanca, CIBERONC , Salamanca , Spain
| | - María Eugenia Sarasquete
- a Servicio de Hematología, Hospital Universitario de Salamanca , Instituto de Investigación Biomédica de Salamanca (IBSAL), Centro de Investigación del Cáncer de Salamanca, CIBERONC , Salamanca , Spain
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Mastocytosis: 2016 updated WHO classification and novel emerging treatment concepts. Blood 2016; 129:1420-1427. [PMID: 28031180 DOI: 10.1182/blood-2016-09-731893] [Citation(s) in RCA: 419] [Impact Index Per Article: 52.4] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2016] [Accepted: 12/17/2016] [Indexed: 12/13/2022] Open
Abstract
Over the past few years, substantial advances have been made in understanding the pathogenesis, evolution, and complexity of mast cell neoplasms. New diagnostic and prognostic parameters and novel therapeutic targets with demonstrable clinical impact have been identified. Several of these new markers, molecular targets, and therapeutic approaches have been validated and translated into clinical practice. At the same time, the classification of mastocytosis and related diagnostic criteria have been refined and updated by the consensus group and the World Health Organization (WHO). As a result, more specific therapies tailored toward prognostic subgroups of patients have been developed. Emerging treatment concepts use drugs directed against KIT and other relevant targets in neoplastic mast cells and will hopefully receive recognition by health authorities in the near future. This article provides an overview of recent developments in the field, with emphasis on the updated WHO classification, refined criteria, additional prognostic parameters, and novel therapeutic approaches. Based on these emerging concepts, the prognosis, quality of life, and survival of patients with advanced mastocytosis are expected to improve in the coming years.
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Mekori YA, Hershko AY, Frossi B, Mion F, Pucillo CE. Integrating innate and adaptive immune cells: Mast cells as crossroads between regulatory and effector B and T cells. Eur J Pharmacol 2016; 778:84-9. [DOI: 10.1016/j.ejphar.2015.03.087] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2015] [Revised: 02/26/2015] [Accepted: 03/25/2015] [Indexed: 12/12/2022]
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9
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Ribatti D. Mast cells as therapeutic target in cancer. Eur J Pharmacol 2016; 778:152-7. [DOI: 10.1016/j.ejphar.2015.02.056] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2014] [Revised: 02/06/2015] [Accepted: 02/17/2015] [Indexed: 02/07/2023]
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10
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Gotlib J. Tyrosine Kinase Inhibitors and Therapeutic Antibodies in Advanced Eosinophilic Disorders and Systemic Mastocytosis. Curr Hematol Malig Rep 2015; 10:351-61. [DOI: 10.1007/s11899-015-0280-3] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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Hoermann G, Blatt K, Greiner G, Putz EM, Berger A, Herrmann H, Cerny-Reiterer S, Gleixner KV, Walz C, Hoetzenecker K, Müllauer L, Reiter A, Sotlar K, Sexl V, Valent P, Mayerhofer M. CD52 is a molecular target in advanced systemic mastocytosis. FASEB J 2014; 28:3540-51. [PMID: 24760752 DOI: 10.1096/fj.14-250894] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Advanced systemic mastocytosis (SM) is an aggressive hematopoietic neoplasm with poor prognosis and short survival times. So far, no curative therapy is available for affected patients. We have identified the cell surface antigen CD52 (CAMPATH-1) as a molecular target expressed abundantly on the surface of primary neoplastic mast cells (MCs) in patients with advanced SM. In contrast, neoplastic MCs of patients with indolent SM and normal MCs expressed only low levels or did not express CD52. To study the mechanisms of CD52 expression and the value of this antigen as a potential therapeutic target, we generated a human MC cell line, designated MCPV-1, by lentiviral immortalization of cord blood-derived MC progenitor cells. Functional studies revealed that activated RAS profoundly promotes surface expression of CD52. The CD52-targeting antibody alemtuzumab induced cell death in CD52(+) primary neoplastic MCs obtained from patients with SM as well as in MCPV-1 cells. NSG mice xenotransplanted with MCPV-1 cells survived significantly longer after treatment with alemtuzumab (median survival: 31 d untreated vs. 46 d treated; P=0.0012). We conclude that CD52 is a novel marker and potential therapeutic target in neoplastic MCs in patients with advanced SM.
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Affiliation(s)
| | - Katharina Blatt
- Department of Internal Medicine I, Division of Hematology and Hemostaseology
| | | | - Eva Maria Putz
- Institute of Pharmacology and Toxicology, University of Veterinary Medicine Vienna, Vienna, Austria
| | - Angelika Berger
- Institute of Pharmacology and Toxicology, University of Veterinary Medicine Vienna, Vienna, Austria
| | | | - Sabine Cerny-Reiterer
- Department of Internal Medicine I, Division of Hematology and Hemostaseology, Ludwig Boltzmann Cluster Oncology, Vienna, Austria
| | - Karoline V Gleixner
- Department of Internal Medicine I, Division of Hematology and Hemostaseology
| | - Christoph Walz
- Institute of Pathology, Ludwig Maximilians University Munich, Munich, Germany
| | | | - Leonhard Müllauer
- Department of Pathology, Medical University of Vienna, Vienna, Austria
| | - Andreas Reiter
- Medizinische Universitätsklinik, Universitätsmedizin Mannheim, Mannheim, Germany; and
| | - Karl Sotlar
- Institute of Pathology, Ludwig Maximilians University Munich, Munich, Germany
| | - Veronika Sexl
- Institute of Pharmacology and Toxicology, University of Veterinary Medicine Vienna, Vienna, Austria
| | - Peter Valent
- Department of Internal Medicine I, Division of Hematology and Hemostaseology, Ludwig Boltzmann Cluster Oncology, Vienna, Austria
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Transcription factor GATA1 is dispensable for mast cell differentiation in adult mice. Mol Cell Biol 2014; 34:1812-26. [PMID: 24615013 DOI: 10.1128/mcb.01524-13] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Abstract
Although previous studies have shown that GATA1 is required for mast cell differentiation, the effects of the complete ablation of GATA1 in mast cells have not been examined. Using conditional Gata1 knockout mice (Gata1(-/y)), we demonstrate here that the complete ablation of GATA1 has a minimal effect on the number and distribution of peripheral tissue mast cells in adult mice. The Gata1(-/y) bone marrow cells were capable of differentiating into mast cells ex vivo. Microarray analyses showed that the repression of GATA1 in bone marrow mast cells (BMMCs) has a small impact on the mast cell-specific gene expression in most cases. Interestingly, however, the expression levels of mast cell tryptases in the mouse chromosome 17A3.3 were uniformly reduced in the GATA1 knockdown cells, and GATA1 was found to bind to a 500-bp region at the 5' end of this locus. Revealing a sharp contrast to that observed in the Gata1-null BMMCs, GATA2 deficiency resulted in a significant loss of the c-Kit(+) FcεRIα(+) mast cell fraction and a reduced expression of several mast cell-specific genes. Collectively, GATA2 plays a more important role than GATA1 in the regulation of most mast cell-specific genes, while GATA1 might play specific roles in mast cell functions.
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García-Sanz R, Ocio EM. Novel treatment regimens for Waldenström’s macroglobulinemia. Expert Rev Hematol 2014; 3:339-50. [DOI: 10.1586/ehm.10.19] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
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14
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Ghobrial IM, Maiso P, Azab A, Liu Y, Zhang Y, Issa G, Azab F, Sacco A, Quang P, Ngo H, Roccaro A. The bone marrow microenvironment in waldenstrom macroglobulinemia. Ther Adv Hematol 2013; 2:267-72. [PMID: 23556094 DOI: 10.1177/2040620711410096] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
Waldenstrom macroglobulinemia (WM) is a low-grade B-cell lymphoproliferative disorder characterized primarily by specific homing and growth of tumor cells within the bone marrow niches. The progressive growth of tumor cells throughout the bone marrow indicates that the tumor cells are capable of homing and adhering to specific niches that allow growth, survival and drug resistance. In this review we highlight the interaction of the tumor cells in WM and the bone marrow microenvironment including bone marrow stromal cells, endothelial cells and mast cells. Migration, adhesion and downstream activation of signaling pathways leads to cell trafficking and cell dissemination in WM. Future therapeutic agents need to target not only the tumor clone, but also its close interaction with the bone marrow microenvironment.
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van den Hoogen MWF, Hoitsma AJ, Hilbrands LB. Anti-T-cell antibodies for the treatment of acute rejection after renal transplantation. Expert Opin Biol Ther 2012; 12:1031-42. [DOI: 10.1517/14712598.2012.689278] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
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16
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Treon SP, Soumerai JD, Hunter ZR, Patterson CJ, Ioakimidis L, Kahl B, Boxer M. Long-term follow-up of symptomatic patients with lymphoplasmacytic lymphoma/Waldenström macroglobulinemia treated with the anti-CD52 monoclonal antibody alemtuzumab. Blood 2011; 118:276-81. [PMID: 21566092 PMCID: PMC3138682 DOI: 10.1182/blood-2011-02-338558] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2011] [Accepted: 04/25/2011] [Indexed: 11/20/2022] Open
Abstract
CD52 is expressed on malignant cells in lymphoplasmacytic lymphoma (LPL), including IgM-secreting Waldenström macroglobulinemia (WM). We examined the activity of alemtuzumab in 28 symptomatic LPL (27 IgM and 1 IgA) patients. The median prior number of therapies for these patients was 2 (range, 0-5) and 43% had refractory disease. Patients received alemtuzumab at 30 mg IV 3 times weekly for up to 12 weeks after test dosing, and also received hydrocortisone, acyclovir, and Bactrim or equivalent prophylaxis. Patients had a complete response (n = 1), a partial response (n = 9), or a MR (n = 11) for an overall and major response rate of 75% and 36%, respectively. Median serum Ig decreased from 3510 to 1460 mg/dL (P < .001 at best response). With a median follow-up of 64 months, the median time to progression was 14.5 months. Hematologic and infectious complications, including CMV reactivation, were more common in previously treated patients and were indirectly associated with 3 deaths. Long-term follow-up revealed late-onset autoimmune thrombocytopenia (AITP) in 4 patients at a median of 13.6 months after therapy, which contributed to 1 death. Alemtuzumab is an active therapy in patients with LPL, but short- and long-term toxicities need to be carefully weighed against other available treatment options. Late AITP is a newly recognized complication of alemtuzumab in this patient population. This study is registered at www.clinicaltrials.gov as NCT00142181.
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Affiliation(s)
- Steven P Treon
- Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA 02115, USA.
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Kastritis E, Terpos E, Dimopoulos MA. Emerging drugs for Waldenström's macroglobulinemia. Expert Opin Emerg Drugs 2011; 16:45-57. [PMID: 21352069 DOI: 10.1517/14728214.2011.523418] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
INTRODUCTION Waldenström's macroglobulinemia (WM) is a rare but distinct B-cell lymphoproliferative disorder characterized by lymphoplasmacytic bone marrow infiltration and IgM monoclonal paraproteinemia. Alkylators or nucleosides analogs, often in combination with rituximab, are the most commonly used drugs, but WM will relapse and even salvage treatments may fail. AREAS COVERED We present recent advances on the treatment of WM, focusing on drugs that are under clinical investigation and for which data indicate promising activity and positive future prospects. Bortezomib is a proteasome inhibitor that eventually becomes a major treatment option for WM. Everolimus and perifosine which target mTOR (mammalian target of rapamycin) and Akt, respectively, of the PI3K/AKT/mTOR pathway showed some activity. Bendamustine, a novel alkylating agent is active, especially in combination with rituximab. Immunomodulatory drugs can act synergistically with rituximab but are toxic. Targeting surface antigens of the lymphoplasmatic cells have shown promising results. EXPERT OPINION Combinations of novel drugs with established agents are feasible and increase response rates but whether there will be an increase in the survival of patients with WM needs further investigation. The toxicity profile is an important determinant for the feasibility of these drugs in patients with WM.
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Affiliation(s)
- Efstathios Kastritis
- University of Athens School of Medicine, Department of Clinical Therapeutics, 80 Vas. Sofias Ave, 115 28, Athens, Greece
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Ghobrial IM, Zhang Y, Liu Y, Ngo H, Azab F, Sacco A, Azab A, Maiso P, Morgan B, Quang P, Issa G, Roccaro A. The bone marrow niche in Waldenström's macroglobulinemia. CLINICAL LYMPHOMA MYELOMA & LEUKEMIA 2011; 11:118-20. [PMID: 21454209 DOI: 10.3816/clml.2011.n.025] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
The widespread involvement of the bone marrow with tumor cells indicates that there is continuous cell trafficking of WM cells in and out of the bone marrow leading to cell dissemination in the bone marrow and in the lymph nodes in many patients with WM. The interaction of the WM cells with the bone marrow is critical for the regulation of cell proliferation, cell cycle, drug resistance as well as cell dissemination and trafficking. Advances in understanding the interaction of the tumor clone with the BM microenvironment have led to the development of therapeutic agents that not only target the tumor clone but also regulate the bone marrow microenvironment. Here, we review the role of the cellular and liquid bone marrow compartments in the regulation of cell proliferation and dissemination in WM.
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Issa GC, Ghobrial IM, Roccaro AM. Novel agents in Waldenström macroglobulinemia. CLINICAL INVESTIGATION 2011; 1:815-824. [PMID: 22034589 PMCID: PMC3199976 DOI: 10.4155/cli.11.60] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Waldenström macroglobulinemia (WM) is a B-cell disorder characterized by the infiltration of the bone marrow with lymphoplasmacytic cells and the detection of an IgM monoclonal gammopathy in the serum. WM is considered an incurable disease, with a median overall survival of 87 months. The success of targeted therapy in multiple myeloma has led to the development and investigation of more than 30 new compounds in this disease and in other plasma cell dyscrasias, including WM, both in the preclinical settings and as part of clinical trials. Among therapeutic options, first-line therapies have been based on single-agent or combination regimens with alkylator agents, nucleoside analogues and the monoclonal antibody anti-CD20. Based on the understanding of the complex interaction between WM tumor cells and the bone marrow microenvironment, and the signaling pathways that are deregulated in WM pathogenesis, a number of novel therapeutic agents are now available and have demonstrated significant efficacy in WM. The range of the overall response rate for these novel agents is between 25 and 96%. Ongoing and planned future clinical trials include those using protein kinase C inhibitors such as enzastaurin, new proteasome inhibitors such as carfilzomib, histone deacetylase inhibitors such as LBH589, humanized CD20 antibodies such as ofatumumab and additional alkylating agents such as bendamustine. These agents, when compared with traditional chemotherapeutic agents, may lead in the future to higher responses, longer remissions and better quality of life for patients with WM. This article will mainly focus on those novel agents that have entered clinical trials for the treatment of WM.
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Affiliation(s)
- Ghayas C Issa
- Department of Medical Oncology, Dana Farber Cancer Institute, Harvard Medical School, 450 Brookline Avenue, Boston, MA 02115, USA
| | - Irene M Ghobrial
- Department of Medical Oncology, Dana Farber Cancer Institute, Harvard Medical School, 450 Brookline Avenue, Boston, MA 02115, USA
| | - Aldo M Roccaro
- Department of Medical Oncology, Dana Farber Cancer Institute, Harvard Medical School, 450 Brookline Avenue, Boston, MA 02115, USA
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Aldinucci D, Gloghini A, Pinto A, De Filippi R, Carbone A. The classical Hodgkin's lymphoma microenvironment and its role in promoting tumour growth and immune escape. J Pathol 2010; 221:248-63. [DOI: 10.1002/path.2711] [Citation(s) in RCA: 196] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
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Abstract
AbstractWaldenström macroglobulinemia (WM) is a distinct B-cell disorder resulting from the accumulation, predominantly in the bone marrow, of clonally related IgM-secreting lymphoplasmacytic cells. Genetic factors play an important role, with 20% of patients demonstrating a familial predisposition. Asymptomatic patients should be observed. Patients with a disease-related hemoglobin level less than 10 g/L, platelet count less than 100 × 109/L, bulky adenopathy or organomegaly, symptomatic hyperviscosity, peripheral neuropathy, amyloidosis, cryoglobulinemia, cold-agglutinin disease, or evidence of disease transformation should be considered for therapy. Plasmapheresis should be considered for symptomatic hyperviscosity and for prophylaxis in patients in whom rituximab therapy is contemplated. The use of rituximab as monotherapy or in combination with cyclophosphamide, nucleoside analog, bortezomib, or thalidomide-based regimens can be considered for the first-line therapy of WM and should take into account specific treatment goals, future autologous stem cell transplantation eligibility, and long-term risks of secondary malignancies. In the salvage setting, the reuse or use of an alternative frontline regimen can be considered as well as bortezomib, alemtuzumab, and stem cell transplantation. Newer agents, such as bendamustine and everolimus, can also be considered in the treatment of WM.
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22
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Analysis of the antibody repertoire of patients with mantle cell lymphoma directed against mantle cell lymphoma-associated antigens. Ann Hematol 2009; 88:999-1003. [DOI: 10.1007/s00277-009-0711-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2008] [Accepted: 01/28/2009] [Indexed: 12/01/2022]
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Leleu X, Gay J, Roccaro AM, Moreau AS, Poulain S, Dulery R, Champs BBD, Robu D, Ghobrial IM. Update on therapeutic options in Waldenström macroglobulinemia. Eur J Haematol 2009; 82:1-12. [PMID: 19087134 PMCID: PMC3133624 DOI: 10.1111/j.1600-0609.2008.01171.x] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
Waldenström macroglobulinemia (WM) is a B-cell disorder characterized primarily by bone marrow infiltration with lymphoplasmacytic cells (LPCs), along with demonstration of an IgM monoclonal gammopathy in the blood. WM remains incurable, with 5-6 yr median overall survival for patients with symptomatic WM. The main therapeutic options include alkylating agents, nucleoside analogues, and rituximab, either in monotherapy or in combination. Studies involving combination chemotherapy are ongoing, and preliminary results are encouraging. However, there are several limitations to these approaches. The complete response rate is low and the treatment free survival are short in many patients, no specific agent or regimen has been shown to be superior to another, and no treatment has been specifically approved for WM. As such, novel therapeutic agents are needed for the treatment of WM. In ongoing efforts, we and others have sought to exploit advances made in the understanding of the biology of WM so as to develop new targeted therapeutics for this malignancy. These efforts have led to the development of proteasome inhibitors, of them bortezomib, several Akt/mTor inhibitors, such as perifosine and Rad001, and immunomodulatory agents such as thalidomide and lenalidomide. Many agents and monoclonal antibodies are currently being tested in clinical trials and seem promising. This report provides an update of the current preclinical studies and clinical efforts for the development of novel agents in the treatment of WM.
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Affiliation(s)
- Xavier Leleu
- Kirsch Laboratory for Waldenström macroglobulinemia, Department of Medical Oncology, Dana-Farber Cancer Institute (DFCI) and Harvard Medical School, Boston, MA, USA.
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Leleu X, Roccaro AM, Moreau AS, Dupire S, Robu D, Gay J, Hatjiharissi E, Burwik N, Ghobrial IM. Waldenstrom macroglobulinemia. Cancer Lett 2008; 270:95-107. [PMID: 18555588 PMCID: PMC3133633 DOI: 10.1016/j.canlet.2008.04.040] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2008] [Revised: 02/09/2008] [Accepted: 04/28/2008] [Indexed: 12/30/2022]
Abstract
In the past years, new developments have occurred both in the understanding of the biology of Waldenstrom Macroglobulinemia (WM) and in therapeutic options for WM. WM is a B-cell disorder characterized primarily by bone marrow infiltration with lymphoplasmacytic cells, along with demonstration of an IgM monoclonal gammopathy. Despite advances in therapy, WM remains incurable, with 5-6 years median overall survival of patients in symptomatic WM. Therapy is postponed for asymptomatic patients, and progressive anemia is the most common indication for initiation of treatment. The main therapeutic options include alkylating agents, nucleoside analogues, and rituximab. Studies involving combination chemotherapy are ongoing, and preliminary results are encouraging. No specific agent or regimen has been shown to be superior to another for treatment of WM. As such, novel therapeutic agents are needed for the treatment of WM. In ongoing efforts, we and others have sought to exploit advances made in the understanding of the biology of WM so as to better target therapeutics for this malignancy. These efforts have led to the development of several novel agents including the proteasome inhibitor bortezomib, and several Akt/mTor inhibitors, perifosine and Rad001, and immunomodulatory agents such as thalidomide and lenalidomide. Studies with monoclonal antibodies are ongoing and promising including the use of alemtuzumab, SGN-70, and the APRIL/BLYS blocking protein TACI-Ig atacicept. Other agents currently being tested in clinical trials include the PKC inhibitor enzastaurin, the natural product resveratrol, as well as the statin simvastatin. This report provides an update of the current preclinical studies and clinical efforts for the development of novel agents in the treatment of WM.
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Affiliation(s)
- Xavier Leleu
- Department of Medical Oncology, Dana-Farber Cancer Institute and Harvard Medical School, 44 Binney Street, Boston, MA 02115, USA
- Service des Maladies du Sang, Hopital Huriez, CHRU, Lille, France
| | - Aldo M. Roccaro
- Department of Medical Oncology, Dana-Farber Cancer Institute and Harvard Medical School, 44 Binney Street, Boston, MA 02115, USA
- Department of Internal Medicine and Oncology, University of Bari Medical School, Bari, Italy
| | - Anne-Sophie Moreau
- Department of Medical Oncology, Dana-Farber Cancer Institute and Harvard Medical School, 44 Binney Street, Boston, MA 02115, USA
- Service des Maladies du Sang, Hopital Huriez, CHRU, Lille, France
| | - Sophie Dupire
- Service des Maladies du Sang, Hopital Huriez, CHRU, Lille, France
| | - Daniela Robu
- Service des Maladies du Sang, Hopital Huriez, CHRU, Lille, France
| | - Julie Gay
- Service des Maladies du Sang, Hopital Huriez, CHRU, Lille, France
| | - Evdoxia Hatjiharissi
- Department of Medical Oncology, Dana-Farber Cancer Institute and Harvard Medical School, 44 Binney Street, Boston, MA 02115, USA
| | - Nicholas Burwik
- Department of Medical Oncology, Dana-Farber Cancer Institute and Harvard Medical School, 44 Binney Street, Boston, MA 02115, USA
| | - Irene M. Ghobrial
- Department of Medical Oncology, Dana-Farber Cancer Institute and Harvard Medical School, 44 Binney Street, Boston, MA 02115, USA
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Moreau AS, Jia X, Patterson CJ, Roccaro AM, Xu L, Sacco A, O'Connor K, Soumerai J, Ngo HT, Hatjiharissi E, Hunter ZR, Ciccarelli B, Manning R, Ghobrial IM, Leleu X, Treon SP. The HMG-CoA inhibitor, simvastatin, triggers in vitro anti-tumour effect and decreases IgM secretion in Waldenstrom macroglobulinaemia. Br J Haematol 2008; 142:775-85. [PMID: 18537966 DOI: 10.1111/j.1365-2141.2008.07257.x] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Waldenstrom macroglobulinaemia (WM) is an incurable lymphoplasmacytic lymphoma with secretion of serum monoclonal immunoglobulin M (IgM). We previously showed that patients receiving cholesterol-lowering statins, had the lowest IgM value in a large cohort of patients with WM. Simvastatin, a 3-hydroxy-3-methyl-glutaryl-CoA reductase inhibitor, induced inhibition of proliferation, cytotoxic effect and apoptosis in IgM secreting cell lines as well as in primary CD19(+) WM cells. Interestingly, those effects were reversed by addition of mevalonate and geranylgeranylpyrophosphate, demonstrating that simvastatin inhibited cell growth, survival and IgM secretion on BCWM.1 WM cells by inhibition of geranylgeranylated proteins. Furthermore, simvastatin overcame tumour cell growth induced by co-culture of WM cells with bone-marrow stromal cells. Simvastatin also decreased IgM secretion by BCWM.1 cells at an early time-point that had not affected cell survival. Simvastatin-induced cytotoxicity was preceded by a decrease in Akt (protein kinase B, PKB) and extracellular signal-regulated kinase (ERK) mitogen-activated protein kinase (MAPK) pathways at 18 h. In addition, simvastatin induced an increase in stress-activated protein kinase/c-Jun N-terminal kinase (SAPK/JNK) MAPK followed by caspase-8, -9, -3 and poly(ADP-ribose) polymerase (PARP) cleavages at 18 h, leading to apoptosis. Furthermore, simvastatin enhanced the cytotoxicity induced by bortezomib, fludarabine and dexamethasone. Our studies therefore support our earlier observation of statin-mediated anti-WM activity and provide the framework for future clinical trials testing simvastatin in WM.
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Affiliation(s)
- Anne-Sophie Moreau
- Bing Center for Waldenstrom's Macroglobulinemia, Dana-Farber Cancer Institute, Boston, MA, USA
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Galinsky DST, Nechushtan H. Mast cells and cancer--no longer just basic science. Crit Rev Oncol Hematol 2008; 68:115-30. [PMID: 18632284 DOI: 10.1016/j.critrevonc.2008.06.001] [Citation(s) in RCA: 56] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2007] [Revised: 03/27/2008] [Accepted: 06/04/2008] [Indexed: 02/06/2023] Open
Abstract
The incorporation of new anti-cancer kinase inhibitors within cancer management is rapidly increasing. Mast cells are sensitive to several of these new anti-cancer agents most notably to c-Kit inhibitors. As a result, studies investigating the role of mast cells in tumors may have direct clinical relevance and consequently, important clinical implications. Here we review some of the basic attributes of mast cells, especially those related to the new "targeted" drugs. Mast cell roles such as modulators of regulatory T-cells, inducers of angiogenesis and promoters of clot formation are discussed. We also review recent mouse tumor models and human pathological data which implicate mast cells as having both pro- and anti-tumor growth properties. These studies expose a complex, emerging picture of mast cell involvement in tumor biology. It seems that mast cell modulator drugs may improve the efficacy of anti-tumor therapy under certain circumstances, whilst under others, may negatively affect drug efficacy.
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Abstract
Waldenström macroglobulinemia (WM) is a B-cell malignancy characterized by an IgM monoclonal gammopathy and bone marrow (BM) infiltration with lymphoplasmacytic cells (LPCs). Excess mast cells (MCs) are commonly present in WM, and provide growth and survival signals to LPCs through several TNF family ligands (CD40L, a proliferation-inducing ligand [APRIL], and B-lymphocyte stimulator factor [BLYS]). As part of these studies, we demonstrated that WM LPCs secrete soluble CD27 (sCD27), which is elevated in patients with WM (P < .001 vs healthy donors), and serves as a faithful marker of disease. Importantly, sCD27 stimulated expression of CD40L on 10 of 10 BM MC samples and APRIL on 4 of 10 BM MC samples obtained from patients with WM as well as on LAD2 MCs. Moreover, the SGN-70 humanized monoclonal antibody, which binds to CD70 (the receptor-ligand partner of CD27), abrogated sCD27 mediated up-regulation of CD40L and APRIL on WM MCs. Last, treatment of severe combined immunodeficiency-human (SCID-hu) mice with established WM using the SGN-70 antibody blocked disease progression in 12 of 12 mice, whereas disease progressed in all 5 untreated mice. The results of these studies demonstrate a functional role for sCD27 in WM pathogenesis, along with its utility as a surrogate marker of disease and a target in the treatment of WM.
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Ault P, Lynn A, Tam CS, Medeiros LJ, Keating MJ. Systemic mastocytosis in association with chronic lymphocytic leukemia: A rare diagnosis. Leuk Res 2007; 31:1755-8. [PMID: 17521719 DOI: 10.1016/j.leukres.2007.04.002] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2007] [Revised: 03/31/2007] [Accepted: 04/02/2007] [Indexed: 11/23/2022]
Abstract
Systemic mastocytosis may be primary or be associated with other hematological malignancies, most commonly myeloid neoplasms. In contrast, the association of systemic mastocytosis with lymphoid neoplasms is comparatively rare, and in the absence of appropriate clinical vigilance the diagnosis may be missed. We report a case of aggressive systemic mastocytosis associated with chronic lymphocytic leukemia (SM-CLL), placing particular emphasis on the investigational algorithm used in establishing this diagnosis, and discussing key clinical considerations in the initiation of therapy.
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Affiliation(s)
- Patricia Ault
- Leukemia Department, University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd, Houston, TX 77030 USA
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Orfao A, Garcia-Montero AC, Sanchez L, Escribano L. Recent advances in the understanding of mastocytosis: the role of KIT mutations. Br J Haematol 2007; 138:12-30. [PMID: 17555444 DOI: 10.1111/j.1365-2141.2007.06619.x] [Citation(s) in RCA: 173] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Mastocytosis is a heterogeneous disorder characterised by the expansion and accumulation of mast cells in different organs and tissues. Mast cell physiology is closely dependent on activation of the stem cell factor/Kit signalling pathways and accumulating evidences confirm the physiopathological key role of activating KIT mutations (typically D816V) in mastocytosis and their relationship with the clinical manifestations of the disease. This paper reviews the most recent advances in the understanding of the molecular mechanisms associated with KIT mutations in mastocytosis, including recent data about the use of new therapies targeting the Kit molecule and its associated downstream signalling pathways.
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Affiliation(s)
- Alberto Orfao
- Centro de Investigación del Cáncer/IBMCC, Departamento de Medicina and Servicio General de Citometría, University of Salamanca, Salamanca, Spain.
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