101
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Daghia G, Zabelina T, Zeck G, von Pein U, Christopeit M, Wolschke C, Ayuk F, Kröger N. Allogeneic stem cell transplantation for myelofibrosis patients aged ≥65 years. Eur J Haematol 2019; 103:370-378. [DOI: 10.1111/ejh.13294] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2019] [Revised: 06/28/2019] [Accepted: 06/29/2019] [Indexed: 12/13/2022]
Affiliation(s)
- Giulia Daghia
- Department of Stem Cell Transplantation University Medical Center Hamburg‐Eppendorf Hamburg Germany
- Ospedale SM delle Croci, Sezione di Ematologia e Unità Trapianto Cellule Staminali Azienda Ospedaliera della Romagna Ravenna Italy
| | - Tatjana Zabelina
- Department of Stem Cell Transplantation University Medical Center Hamburg‐Eppendorf Hamburg Germany
| | - Gaby Zeck
- Department of Stem Cell Transplantation University Medical Center Hamburg‐Eppendorf Hamburg Germany
| | - Ute‐Marie von Pein
- Department of Stem Cell Transplantation University Medical Center Hamburg‐Eppendorf Hamburg Germany
| | - Maximilian Christopeit
- Department of Stem Cell Transplantation University Medical Center Hamburg‐Eppendorf Hamburg Germany
| | - Christine Wolschke
- Department of Stem Cell Transplantation University Medical Center Hamburg‐Eppendorf Hamburg Germany
| | - Francis Ayuk
- Department of Stem Cell Transplantation University Medical Center Hamburg‐Eppendorf Hamburg Germany
| | - Nicolaus Kröger
- Department of Stem Cell Transplantation University Medical Center Hamburg‐Eppendorf Hamburg Germany
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102
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Mannina D, Zabelina T, Wolschke C, Heinzelmann M, Triviai I, Christopeit M, Badbaran A, Bonmann S, von Pein UM, Janson D, Ayuk F, Kröger N. Reduced intensity allogeneic stem cell transplantation for younger patients with myelofibrosis. Br J Haematol 2019; 186:484-489. [PMID: 31090920 DOI: 10.1111/bjh.15952] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2019] [Accepted: 03/03/2019] [Indexed: 11/29/2022]
Abstract
Allogeneic stem cell transplantation (alloSCT) is a curative procedure for myelofibrosis. Elderly people are mainly affected, limiting the feasibility of myeloablative regimens. The introduction of reduced-intensity conditioning (RIC) made alloSCT feasible for older patients. Nevertheless, the incidence of myelofibrosis is not negligible in young patients, who are theoretically able to tolerate high-intensity therapy. Very few data are available about the efficacy of RIC-alloSCT in younger myelofibrosis patients. This study included 56 transplanted patients aged <55 years. Only 30% had a human leucocyte antigen (HLA)-matched sibling donor, the others were transplanted from a fully-matched (36%) or partially-matched (34%) unrelated donor. All transplants were conditioned according the European Society for Blood and Marrow Transplantation protocol: busulfan-fludarabine + anti-thymocyte globulin, followed by ciclosporin and mycophenolate. One patient experienced primary graft failure. Incidence of graft-versus-host disease grade II-IV was 44% (grade III/IV 23%). One-year non-relapse mortality was 7% and the 5-year cumulative incidence of relapse was 19%. After a median follow-up of 8·6 years, the estimated 5-year progression-free survival and overall survival (OS) was 68% and 82%, respectively. Patients with fully-matched donor had a 5-year OS of 92%, in contrast to 68% for those with a mismatched donor (P = 0·03). The most important outcome-determining factor is donor HLA-matching. In conclusion, RIC-alloSCT ensures optimal engraftment and low relapse rate in younger myelofibrosis patients, enabling the possibility of cure in this group.
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Affiliation(s)
- Daniele Mannina
- Department of Stem Cell Transplantation, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany.,Department of Haematology, Vita-Salute San Raffaele University Milano, Milano, Italy
| | - Tatjana Zabelina
- Department of Stem Cell Transplantation, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany
| | - Christine Wolschke
- Department of Stem Cell Transplantation, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany
| | - Marion Heinzelmann
- Department of Stem Cell Transplantation, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany
| | - Ioanna Triviai
- Department of Stem Cell Transplantation, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany
| | - Maximilian Christopeit
- Department of Stem Cell Transplantation, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany
| | - Anita Badbaran
- Department of Stem Cell Transplantation, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany
| | - Stefan Bonmann
- Department of Stem Cell Transplantation, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany
| | - Ute-Marie von Pein
- Department of Stem Cell Transplantation, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany
| | - Dietlinde Janson
- Department of Stem Cell Transplantation, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany
| | - Francis Ayuk
- Department of Stem Cell Transplantation, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany
| | - Nicolaus Kröger
- Department of Stem Cell Transplantation, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany
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103
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Tavares RS, Nonino A, Pagnano KBB, Nascimento ACKVD, Conchon M, Fogliatto LM, Funke VAM, Bendit I, Clementino NCD, Chauffaille MDLLF, Bernardo WM, Santos FPDS. Guideline on myeloproliferative neoplasms: Associacão Brasileira de Hematologia, Hemoterapia e Terapia Cellular: Project guidelines: Associação Médica Brasileira - 2019. Hematol Transfus Cell Ther 2019; 41 Suppl 1:1-73. [PMID: 31248788 PMCID: PMC6630088 DOI: 10.1016/j.htct.2019.03.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2019] [Accepted: 03/20/2019] [Indexed: 12/22/2022] Open
Affiliation(s)
| | - Alexandre Nonino
- Instituto Hospital de Base do Distrito Federal (IHBDF), Brasília, DF, Brazil
| | | | | | | | | | | | - Israel Bendit
- Hospital Das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), São Paulo, SP, Brazil
| | | | | | - Wanderley Marques Bernardo
- Hospital Das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), São Paulo, SP, Brazil; Associação Médica Brasileira (AMB), São Paulo, SP, Brazil
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104
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Short C, Lim HK, Tan J, O'Neill HC. Targeting the Spleen as an Alternative Site for Hematopoiesis. Bioessays 2019; 41:e1800234. [PMID: 30970171 DOI: 10.1002/bies.201800234] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2018] [Revised: 02/25/2019] [Indexed: 12/21/2022]
Abstract
Bone marrow is the main site for hematopoiesis in adults. It acts as a niche for hematopoietic stem cells (HSCs) and contains non-hematopoietic cells that contribute to stem cell dormancy, quiescence, self-renewal, and differentiation. HSC also exist in resting spleen of several species, although their contribution to hematopoiesis under steady-state conditions is unknown. The spleen can however undergo extramedullary hematopoiesis (EMH) triggered by physiological stress or disease. With the loss of bone marrow niches in aging and disease, the spleen as an alternative tissue site for hematopoiesis is an important consideration for future therapy, particularly during HSC transplantation. In terms of harnessing the spleen as a site for hematopoiesis, here the remarkable regenerative capacity of the spleen is considered with a view to forming additional or ectopic spleen tissue through cell engraftment. Studies in mice indicate the potential for such grafts to support the influx of hematopoietic cells leading to the development of normal spleen architecture. An important goal will be the formation of functional ectopic spleen tissue as an aid to hematopoietic recovery following clinical treatments that impact bone marrow. For example, expansion or replacement of niches could be considered where myeloablation ahead of HSC transplantation compromises treatment outcomes.
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Affiliation(s)
- Christie Short
- Clem Jones Centre for Regenerative Medicine, Bond University, Gold Coast, QLD, 4229, Australia
| | - Hong K Lim
- Clem Jones Centre for Regenerative Medicine, Bond University, Gold Coast, QLD, 4229, Australia
| | - Jonathan Tan
- Clem Jones Centre for Regenerative Medicine, Bond University, Gold Coast, QLD, 4229, Australia
| | - Helen C O'Neill
- Clem Jones Centre for Regenerative Medicine, Bond University, Gold Coast, QLD, 4229, Australia
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105
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Duarte RF, Labopin M, Bader P, Basak GW, Bonini C, Chabannon C, Corbacioglu S, Dreger P, Dufour C, Gennery AR, Kuball J, Lankester AC, Lanza F, Montoto S, Nagler A, Peffault de Latour R, Snowden JA, Styczynski J, Yakoub-Agha I, Kröger N, Mohty M. Indications for haematopoietic stem cell transplantation for haematological diseases, solid tumours and immune disorders: current practice in Europe, 2019. Bone Marrow Transplant 2019; 54:1525-1552. [PMID: 30953028 DOI: 10.1038/s41409-019-0516-2] [Citation(s) in RCA: 176] [Impact Index Per Article: 35.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2019] [Revised: 03/05/2019] [Accepted: 03/07/2019] [Indexed: 12/20/2022]
Abstract
This is the seventh special EBMT report on the indications for haematopoietic stem cell transplantation for haematological diseases, solid tumours and immune disorders. Our aim is to provide general guidance on transplant indications according to prevailing clinical practice in EBMT countries and centres. In order to inform patient decisions, these recommendations must be considered together with the risk of the disease, the risk of the transplant procedure and the results of non-transplant strategies. In over two decades since the first report, the EBMT indications manuscripts have incorporated changes in transplant practice coming from scientific and technical developments in the field. In this same period, the establishment of JACIE accreditation has promoted high quality and led to improved outcomes of patient and donor care and laboratory performance in transplantation and cellular therapy. An updated report with operating definitions, revised indications and an additional set of data with overall survival at 1 year and non-relapse mortality at day 100 after transplant in the commonest standard-of-care indications is presented. Additional efforts are currently underway to enable EBMT member centres to benchmark their risk-adapted outcomes as part of the Registry upgrade Project 2020 against national and/or international outcome data.
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Affiliation(s)
- Rafael F Duarte
- Hospital Universitario Puerta de Hierro Majadahonda - Universidad Autónoma de Madrid, Madrid, Spain.
| | - Myriam Labopin
- EBMT Paris Study Office, Hopital Saint Antoine, Paris, France
| | - Peter Bader
- Goethe University Hospital, Frankfurt/Main, Germany
| | | | - Chiara Bonini
- Vita-Salute San Raffaele University & Ospedale San Raffaele Scientific Institute, Milan, Italy
| | - Christian Chabannon
- Institut Paoli Calmettes & Centre d'Investigations Cliniques en Biothérapies, Marseille, France
| | | | - Peter Dreger
- Medizinische Klinik V, Universität Heidelberg, Heidelberg, Germany
| | - Carlo Dufour
- Giannina Gaslini Children's Hospital, Genoa, Italy
| | | | - Jürgen Kuball
- University Medical Center Utrecht, Utrecht, The Netherlands
| | - Arjan C Lankester
- Willem-Alexander Children's Hospital, Leiden University Medical Center, Leiden, The Netherlands
| | | | | | - Arnon Nagler
- Chaim Sheva Medical Center, Tel-Hashomer, Israel
| | | | - John A Snowden
- Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, United Kingdom
| | - Jan Styczynski
- Collegium Medicum, Nicolaus Copernicus University, Bydgoszcz, Poland
| | | | | | - Mohamad Mohty
- Hopital Saint Antoine, Sorbonne Université, Paris, France
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106
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McLornan DP, Yakoub-Agha I, Robin M, Chalandon Y, Harrison CN, Kroger N. State-of-the-art review: allogeneic stem cell transplantation for myelofibrosis in 2019. Haematologica 2019; 104:659-668. [PMID: 30872371 PMCID: PMC6442950 DOI: 10.3324/haematol.2018.206151] [Citation(s) in RCA: 45] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2018] [Accepted: 11/16/2018] [Indexed: 12/14/2022] Open
Abstract
Advances in understanding the pathogenesis and molecular landscape of myelofibrosis have occurred over the last decade. Treating physicians now have access to an ever-evolving armamentarium of novel agents to treat patients, although allogeneic hematopoietic stem cell transplantation remains the only curative approach. Improvements in donor selection, conditioning regimens, disease monitoring and supportive care have led to augmented survival after transplantation. Nowadays, there are comprehensive guidelines concerning allogeneic hematopoietic stem cell transplantation for patients with myelofibrosis. However, it commonly remains difficult for both physicians and patients alike to weigh up the risk-benefit ratio of transplantation given the inherent heterogeneity regarding both clinical course and therapeutic response. In this timely review, we provide an up-to-date synopsis of current transplantation recommendations, discuss usage of JAK inhibitors before and after transplantation, examine donor selection and compare conditioning platforms. Moreover, we discuss emerging data concerning the impact of the myelofibrosis mutational landscape on transplantation outcome, peritransplant management of splenomegaly, poor graft function and prevention/management of relapse.
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Affiliation(s)
- Donal P McLornan
- Guy's and St. Thomas' NHS Foundation Trust, Department of Haematology, Guy's Tower, Great Maze Pond, London, UK
- Comprehensive Cancer Centre, King's College, London, UK
| | | | - Marie Robin
- Hôpital Saint-Louis, Service d'Hématologie-Greffe, Assistance Publique Hôpitaux de Paris, University Paris 7, INSERM 1131, France
| | - Yves Chalandon
- Geneva University Hospitals, Division of Hematology, Rue Gabrielle-Perret-Gentil 4 and Faculty of Medicine, University of Geneva, Switzerland
| | - Claire N Harrison
- Guy's and St. Thomas' NHS Foundation Trust, Department of Haematology, Guy's Tower, Great Maze Pond, London, UK
- Comprehensive Cancer Centre, King's College, London, UK
| | - Nicolaus Kroger
- University Hospital Eppendorf, Hematology Department, Hamburg, Germany
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107
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Murata M, Takenaka K, Uchida N, Ozawa Y, Ohashi K, Kim SW, Ikegame K, Kanda Y, Kobayashi H, Ishikawa J, Ago H, Hirokawa M, Fukuda T, Atsuta Y, Kondo T. Comparison of Outcomes of Allogeneic Transplantation for Primary Myelofibrosis among Hematopoietic Stem Cell Source Groups. Biol Blood Marrow Transplant 2019; 25:1536-1543. [PMID: 30826464 DOI: 10.1016/j.bbmt.2019.02.019] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2018] [Accepted: 02/19/2019] [Indexed: 12/15/2022]
Abstract
The choice of alternative donor is a major issue in allogeneic hematopoietic stem cell transplantation (HSCT) for patients with primary myelofibrosis (PMF) without an HLA-matched related donor. We conducted this retrospective study using the Japanese national registry data for 224 PMF patients to compare the outcomes of first allogeneic HSCT from HLA-matched related donor bone marrow (Rtd-BM), HLA-matched related donor peripheral blood stem cells (Rtd-PB), HLA-matched unrelated donor bone marrow (UR-BM), unrelated umbilical cord blood (UR-UCB), and other hematopoietic stem cell grafts. Nonrelapse mortality (NRM) rates at 1 year after Rtd-BM, Rtd-PB, UR-BM, UR-UCB, and other transplantations were 16%, 36%, 30%, 41%, and 48%, respectively. Multivariate analysis identified UR-UCB transplantation, other transplantation, frequent RBC transfusion before transplantation, and frequent platelet (PLT) transfusion before transplantation as predictive of higher NRM. Relapse rates at 1 year after Rtd-BM, Rtd-PB, UR-BM, UR-UCB, and other transplantation were 14%, 17%, 11%, 14%, and 15%, respectively. No specific factor was associated with the incidence of relapse. Overall survival (OS) at 1 and 4 years after Rtd-BM, Rtd-PB, UR-BM, UR-UCB, and other transplantation were 81% and 71%, 58% and 52%, 61% and 46%, 48% and 27%, and 48% and 41%, respectively. Multivariate analysis identified older patient age, frequent RBC transfusion before transplantation, and frequent PLT transfusion before transplantation as predictive of lower OS. In conclusion, UR-UCB transplantation, as well as UR-BM transplantation, can be selected for PMF patients without an HLA-identical related donor. However, careful management is required for patients after UR-UCB transplantation because of the high NRM. Further studies including more patients after HLA-haploidentical related donor and HLA-mismatched unrelated donor transplantation would provide more valuable information for patients with PMF when making decisions regarding the choice of alternative donor.
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Affiliation(s)
- Makoto Murata
- Department of Hematology and Oncology, Nagoya University Graduate School of Medicine, Nagoya, Japan.
| | - Katsuto Takenaka
- Department of Hematology, Clinical Immunology and Infectious Diseases, Ehime University Graduate School of Medicine, Toon, Japan
| | - Naoyuki Uchida
- Department of Hematology, Toranomon Hospital, Tokyo, Japan
| | - Yukiyasu Ozawa
- Department of Hematology, Japanese Red Cross Nagoya First Hospital, Nagoya, Aichi, Japan
| | - Kazuteru Ohashi
- Hematology Division, Tokyo Metropolitan Cancer and Infectious Diseases Center, Komagome Hospital, Tokyo, Japan
| | - Sung-Won Kim
- Department of Hematopoietic Stem Cell Transplantation, National Cancer Center Hospital, Tokyo, Japan
| | - Kazuhiro Ikegame
- Division of Hematology, Department of Internal Medicine, Hyogo College of Medicine, Nishinomiya, Japan
| | - Yoshinobu Kanda
- Division of Hematology, Saitama Medical Center, Jichi Medical University, Saitama, Japan
| | - Hikaru Kobayashi
- Department of Hematology, Nagano Red Cross Hospital, Nagano, Japan
| | - Jun Ishikawa
- Department of Hematology, Osaka International Cancer Institute, Osaka, Japan
| | - Hiroatsu Ago
- Department of Hematology and Oncology, Shimane Prefectural Central Hospital, Izumo, Japan
| | - Makoto Hirokawa
- Department of General Internal Medicine and Clinical Laboratory Medicine, Akita University Graduate School of Medicine, Akita, Japan
| | - Takahiro Fukuda
- Department of Hematopoietic Stem Cell Transplantation, National Cancer Center Hospital, Tokyo, Japan
| | - Yoshiko Atsuta
- Japanese Data Center for Hematopoietic Cell Transplantation, Nagoya, Japan; Department of Healthcare Administration, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Takeshi Kondo
- Department of Hematology, Aiiku Hospital, Sapporo, Japan
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108
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Utilization and Outcomes of Fertility Preservation Techniques in Women Undergoing Allogeneic Hematopoietic Cell Transplant. Biol Blood Marrow Transplant 2019; 25:1232-1239. [PMID: 30772513 DOI: 10.1016/j.bbmt.2019.02.013] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2018] [Accepted: 02/09/2019] [Indexed: 12/24/2022]
Abstract
Iatrogenic menopause with consequent infertility is a major complication in reproductive-age women undergoing hematopoietic cell transplantation (HCT). Recent guidelines recommend a discussion of the possibility of infertility and the options for fertility preservation as part of informed consent before initiation of any cancer-directed therapy, including HCT. Women age 15 to 49 years at the time of allogeneic HCT, between the years 2001 and 2017, were identified from the Mayo Clinic Rochester institutional HCT database. One hundred seventy-seven women were eligible, of whom 49 (28%) were excluded due to documented postmenopausal state or prior hysterectomy. The median age of the cohort was 31 years (range, 15 to 49 years) with median gravidity and parity being G1P1 (range, G0 to G8, P0 to P6). Fifty-four (42%) women were nulligravid at the time of HCT. Eighty-two percent underwent myeloablative conditioning (MAC), whereas 18% underwent reduced-intensity conditioning (RIC). Only 34 women (27%) had documented fertility counseling within 72 hours of diagnosis, and a total of 61 (48%) received fertility counseling prior to HCT. Thirty-eight women (30%) were referred to a reproductive endocrinologist, of whom 13 (10%) underwent assisted reproductive technologies (ART; nine oocyte cryopreservation, four embryo cryopreservation). Of these, nine procedures yielded successful cryopreserved tissue (two completed at outside institutions). The median time to completion of the seven successful ART procedures at Mayo Clinic was 13 days (range, 9 to 15 days). The remainder of women referred to reproductive endocrinology did not undergo ART due to disease severity (68%), financial barriers (20%), and/or low antral follicle count (12%). Ninety-three women (73%) received leuprolide for ovarian suppression prior to conditioning. Three (4%) of 75 women who underwent MAC and were alive >365 days after HCT had spontaneous menstrual recovery after HCT (median time, 14 months; range, 6 to 21 months), in comparison to 10 (50%) of 20 women who underwent RIC and were alive >365 days after HCT (P < .01) (median, 21.5 months; range, 5 to 83 months). In the latter cohort, there were two spontaneous pregnancies, occurring at 71 and 72 months after HCT, respectively. Oncofertility is an emerging field due to an increasing number of young cancer survivors. Herein, we document that even at a large tertiary HCT center, the rate of documented fertility counseling and reproductive endocrinology referrals was low and the rate of ART was even lower. Spontaneous menstrual recovery was rare but more likely in the setting of nonmalignant disease and RIC HCT. A concerted multidisciplinary effort is needed to understand parenthood goals and to explore the impact of HCT on decision making about fertility preservation and parenthood. These efforts could improve oncofertility referral, ART utilization, and reproductive outcomes.
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109
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Kaushansky K, Zhan H. The marrow stem cell niche in normal and malignant hematopoiesis. Ann N Y Acad Sci 2019; 1466:17-23. [PMID: 30767234 DOI: 10.1111/nyas.14028] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2018] [Revised: 01/09/2019] [Accepted: 01/23/2019] [Indexed: 02/06/2023]
Abstract
The hematopoietic niche is composed of endothelial cells, mesenchymal stromal cells of several types, and megakaryocytes, and functions to support the survival, proliferation, and differentiation of normal hematopoietic stem cells (HSCs). An abundance of evidence from a range of hematological malignancies supports the concept that the niche also participates in the pathogenesis of malignant hematopoiesis, differentially supporting malignant stem or progenitor cells over that of normal blood cell development. In 2005, patients with myeloproliferative neoplasms were reported to harbor an acquired, activating, missense V617F mutation of the cytokine-signaling Janus kinase (JAK)-2, JAK2V617F , present in virtually all patients with polycythemia vera and half of patients with essential thrombocythemia and primary myelofibrosis. Using both in vitro and in vivo methods, several investigators have shown that in addition to driving cytokine-independent proliferation in HSCs, JAK2V617F contributes to these neoplasms by altering the hematopoietic niche. The role of both endothelial cells and megakaryocytes bearing JAK2V617F will be presented, which involves altering cytokine production within the niche, resulting in their differential support of mutant kinase-bearing stem cells over their normal counterparts, and imparting relative radiation resistance to stem cells. The clinical correlates of these findings will be discussed, as will their therapeutic implications.
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Affiliation(s)
| | - Huichun Zhan
- Stony Brook University School of Medicine, Stony Brook, New York
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110
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Comprehensive clinical-molecular transplant scoring system for myelofibrosis undergoing stem cell transplantation. Blood 2019; 133:2233-2242. [PMID: 30760453 DOI: 10.1182/blood-2018-12-890889] [Citation(s) in RCA: 116] [Impact Index Per Article: 23.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2018] [Accepted: 02/08/2019] [Indexed: 01/02/2023] Open
Abstract
Allogeneic hematopoietic stem cell transplantation is curative in myelofibrosis, and current prognostic scoring systems aim to select patients for transplantation. Here, we aimed to develop a prognostic score to determine prognosis after transplantation itself, using clinical, molecular, and transplant-specific information from a total of 361 patients with myelofibrosis. Of these, 205 patients were used as a training cohort to create a clinical-molecular myelofibrosis transplant scoring system (MTSS), which was then externally validated in a cohort of 156 patients. Multivariable analysis on survival identified age at least 57 years, Karnofsky performance status lower than 90%, platelet count lower than 150 × 109/L, leukocyte count higher than 25 × 109/L before transplantation, HLA-mismatched unrelated donor, ASXL1 mutation, and non-CALR/MPL driver mutation genotype being independent predictors of outcome. The uncorrected concordance index for the final survival model was 0.723, and bias-corrected indices were similar. Risk factors were incorporated into a 4-level MTSS: low (score, 0-2), intermediate (score, 3-4), high (score, 5), and very high (score, >5). The 5-year survival according to risk groups in the validation cohort was 83% (95% confidence interval [CI], 71%-95%), 64% (95% CI, 53%-75%), 37% (95% CI, 17%-57%), and 22% (95% CI, 4%-39%), respectively (P < .001). Increasing score was predictive of nonrelapse mortality (P < .001) and remained applicable to primary (0.718) and post-essential thrombocythemia (ET)/polycythemia vera (PV) myelofibrosis (0.701) improving prognostic ability in comparison with all currently available disease-specific systems. In conclusion, this MTSS predicts outcome of patients with primary and post-ET/PV myelofibrosis undergoing allogeneic stem cell transplantation.
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111
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Robin M, de Wreede LC, Wolschke C, Schetelig J, Eikema DJ, Van Lint MT, Knelange NS, Beelen D, Brecht A, Niederwieser D, Vitek A, Bethge W, Arnold R, Finke J, Volin L, Yakoub-Agha I, Nagler A, Poiré X, Einsele H, Chevallier P, Holler E, Ljungman P, Robinson S, Radujkovic A, McLornan D, Chalandon Y, Kröger N. Long-term outcome after allogeneic hematopoietic cell transplantation for myelofibrosis. Haematologica 2019; 104:1782-1788. [PMID: 30733269 PMCID: PMC6717573 DOI: 10.3324/haematol.2018.205211] [Citation(s) in RCA: 41] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2018] [Accepted: 01/31/2019] [Indexed: 12/25/2022] Open
Abstract
Allogeneic hematopoietic stem cell transplant remains the only curative treatment for myelofibrosis. Most post-transplantation events occur during the first two years and hence we aimed to analyze the outcome of 2-year disease-free survivors. A total of 1055 patients with myelofibrosis transplanted between 1995 and 2014 and registered in the registry of the European Society for Blood and Marrow Transplantation were included. Survival was compared to the matched general population to determine excess mortality and the risk factors that are associated. In the 2-year survivors, disease-free survival was 64% (60-68%) and overall survival was 74% (71-78%) at ten years; results were better in younger individuals and in women. Excess mortality was 14% (8-21%) in patients aged <45 years and 33% (13-53%) in patients aged ≥65 years. The main cause of death was relapse of the primary disease. Graft-versus-host disease (GvHD) before two years decreased the risk of relapse. Multivariable analysis of excess mortality showed that age, male sex recipient, secondary myelofibrosis and no GvHD disease prior to the 2-year landmark increased the risk of excess mortality. This is the largest study to date analyzing long-term outcome in patients with myelofibrosis undergoing transplant. Overall it shows a good survival in patients alive and in remission at two years. However, the occurrence of late complications, including late relapses, infectious complications and secondary malignancies, highlights the importance of screening and monitoring of long-term survivors.
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Affiliation(s)
- Marie Robin
- Hôpital Saint-Louis, APHP, Université Paris 7, Paris, France
| | - Liesbeth C de Wreede
- Department of Biomedical Data Sciences, LUMC, Leiden, the Netherlands and DKMS CTU, Dresden, Germany
| | | | - Johannes Schetelig
- Medizinische Klinik und Poliklinik I, Universitätsklinikum Dresden, Dresden, Germany
| | | | | | | | | | | | | | - Antonin Vitek
- Institute of Hematology and Blood Transfusion, Prague, Czech Republic
| | | | | | - Jürgen Finke
- Division of Medicine I, Hematology, Oncology and Stem Cell Transplantation, University of Freiburg, Freiburg, Germany
| | - Liisa Volin
- HUCH Comprehensive Cancer Center, Helsinki, Finland
| | | | - Arnon Nagler
- Chaim Sheba Medical Center, Tel-Hashomer, Israel
| | - Xavier Poiré
- Cliniques Universitaires St. Luc, Brussels, Belgium
| | - Hermann Einsele
- Department of Internal Medicine II, University Hospital Würzburg, Würzburg, Germany
| | | | | | - Per Ljungman
- Karolinska University Hospital, Stockholm, Sweden
| | | | | | - Donal McLornan
- Comprehensive Cancer Centre, Department of Haematology, Kings College, London, UK
| | - Yves Chalandon
- Hôpitaux Universitaires de Genève and Faculty of Medicine, University of Geneva, Geneva, Switzerland
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112
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Gupta V, Kosiorek HE, Mead A, Klisovic RB, Galvin JP, Berenzon D, Yacoub A, Viswabandya A, Mesa RA, Goldberg J, Price L, Salama ME, Weinberg RS, Rampal R, Farnoud N, Dueck AC, Mascarenhas JO, Hoffman R. Ruxolitinib Therapy Followed by Reduced-Intensity Conditioning for Hematopoietic Cell Transplantation for Myelofibrosis: Myeloproliferative Disorders Research Consortium 114 Study. Biol Blood Marrow Transplant 2019; 25:256-264. [PMID: 30205231 PMCID: PMC6339828 DOI: 10.1016/j.bbmt.2018.09.001] [Citation(s) in RCA: 41] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2018] [Accepted: 09/03/2018] [Indexed: 11/15/2022]
Abstract
We evaluated the feasibility of ruxolitinib therapy followed by a reduced-intensity conditioning (RIC) regimen for patients with myelofibrosis (MF) undergoing transplantation in a 2-stage Simon phase II trial. The aims were to decrease the incidence of graft failure (GF) and nonrelapse mortality (NRM) compared with data from the previous Myeloproliferative Disorders Research Consortium 101 Study. The plan was to enroll 11 patients each in related donor (RD) and unrelated donor (URD) arms, with trial termination if ≥3 failures (GF or death by day +100 post-transplant) occurred in the RD arm or ≥6 failures occurred in the URD. A total of 21 patients were enrolled, including 7 in the RD arm and 14 in the URD arm. The RD arm did not meet the predetermined criteria for proceeding to stage II. Although the URD arm met the criteria for stage II, the study was terminated owing to poor accrual and a significant number of failures. In all 19 transplant recipients, ruxolitinib was tapered successfully without significant side effects, and 9 patients (47%) had a significant decrease in symptom burden. The cumulative incidences of GF, NRM, acute graft-versus-host disease (GVHD), and chronic GVHD at 24 months were 16%, 28%, 64%, and 76%, respectively. On an intention-to-treat basis, the 2-year overall survival was 61% for the RD arm and 70% for the URD arm. Ruxolitinib can be integrated as pretransplantation treatment for patients with MF, and a tapering strategy before transplantation is safe, allowing patients to commence conditioning therapy with a reduced symptom burden. However, GF and NRM remain significant.
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Affiliation(s)
- Vikas Gupta
- MPN Program, Princess Margaret Cancer Centre, University of Toronto, Toronto, Ontario, Canada.
| | | | - Adam Mead
- MRC Molecular Hematology Unit, MRC Weatherall Institute of Molecular Medicine, BRC Biomedical Research Centre, University of Oxford, Oxford, United Kingdom
| | - Rebecca B Klisovic
- Division of Hematology, Department of Internal Medicine, The Ohio State University, Columbus, Ohio
| | - John P Galvin
- Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Dmitriy Berenzon
- Comprehensive Cancer Center, Wake Forest School of Medicine, Winston Salem, North Carolina
| | | | - Auro Viswabandya
- MPN Program, Princess Margaret Cancer Centre, University of Toronto, Toronto, Ontario, Canada
| | | | | | - Leah Price
- New York University School of Medicine, New York, New York
| | - Mohamed E Salama
- Department of Pathology, University of Utah, Salt Lake City, Utah
| | | | - Raajit Rampal
- Memorial Sloan-Kettering Cancer Center, New York, New York
| | | | | | - John O Mascarenhas
- Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Ronald Hoffman
- Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, New York
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113
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Robin M, Chevret S, Koster L, Wolschke C, Yakoub-Agha I, Bourhis JH, Chevallier P, Cornelissen JJ, Reményi P, Maertens J, Poiré X, Craddock C, Socié G, Itälä-Remes M, Schouten HC, Marchand T, Passweg J, Blaise D, Damaj G, Ozkurt ZN, Zuckerman T, Cluzeau T, Labussière-Wallet H, Cammenga J, McLornan D, Chalandon Y, Kröger N. Antilymphocyte globulin for matched sibling donor transplantation in patients with myelofibrosis. Haematologica 2019; 104:1230-1236. [PMID: 30655365 PMCID: PMC6545844 DOI: 10.3324/haematol.2018.201400] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2018] [Accepted: 01/09/2019] [Indexed: 12/20/2022] Open
Abstract
The use of antihuman T-lymphocyte immunoglobulin in the setting of transplantation from an HLA-matched related donor is still much debated. Acute and chronic graft-versus-host disease are the main causes of morbidity and mortality after allogeneic hematopoietic stem cell transplantation in patients with myelofibrosis. The aim of this study was to evaluate the effect of antihuman T-lymphocyte immunoglobulin in a large cohort of patients with myelofibrosis (n=287). The cumulative incidences of grade II-IV acute graft-versus-host disease among patients who were or were not given antihuman T-lymphocyte immunoglobulin were 26% and 41%, respectively. The corresponding incidences of chronic graft-versus-host disease were 52% and 55%, respectively. Non-adjusted overall survival, disease-free survival and non-relapse mortality rates were 55% versus 53%, 49% versus 45%, and 32% versus 31%, respectively, among the patients who were or were not given antihuman T-lymphocyte immunoglobulin. An adjusted model confirmed that the risk of acute graft-versus-host disease was lower following antihuman T-lymphocyte immunoglobulin (hazard ratio, 0.54; P=0.010) while it did not decrease the risk of chronic graft-versus-host disease. The hazard ratios for overall survival and non-relapse mortality were 0.66 and 0.64, with P-values of 0.05 and 0.09, respectively. Antihuman T-lymphocyte immunoglobulin did not influence disease-free survival, graft-versus-host disease, relapse-free survival or relapse risk. In conclusion, in the setting of matched related transplantation in myelofibrosis patients, this study demonstrates that antihuman T-lymphocyte immunoglobulin decreases the risk of acute graft-versus-host disease without increasing the risk of relapse.
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Affiliation(s)
- Marie Robin
- Hôpital Saint-Louis, APHP, INSERM 1131, Paris, France
| | - Sylvie Chevret
- Service de Biostatistique, Hôpital Saint-Louis, APHP, ESCTRA Team, INSERM UMR1153, Université Paris 7, France
| | | | | | | | - Jean Henri Bourhis
- Institut Gustave Roussy, INSERM U1186, Université Paris Saclay, Villejuif, France
| | | | - Jan J Cornelissen
- Department of Hematology, Erasmus University Medical Center, Rotterdam, the Netherlands
| | | | | | - Xavier Poiré
- Cliniques Universitaires St. Luc, Brussels, Belgium
| | - Charles Craddock
- Centre for Clinical Haematology, Queen Elizabeth Hospital, Birmingham, UK
| | - Gérard Socié
- Hôpital Saint-Louis, APHP, INSERM 1131, Paris, France
| | | | | | | | | | - Didier Blaise
- Aix-Marseille University, Inserm, CNRS, Institut Paoli-Calmettes, CRCM, Marseille, France
| | | | | | | | | | | | | | - Donal McLornan
- Comprehensive Cancer Centre, Department of Haematology, King's College, London, UK
| | - Yves Chalandon
- Hôpitaux Universitaires de Genève and Faculty of Medicine, University of Geneva, Switzerland
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114
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Helbig G, Wieczorkiewicz-Kabut A, Markiewicz M, Krzemień H, Wójciak M, Białas K, Kopera M, Rzenno E, Woźniczka K, Kopińska A, Grygoruk-Wiśniowska I, Koclęga A. Splenic irradiation before allogeneic stem cell transplantation for myelofibrosis. Med Oncol 2019; 36:16. [PMID: 30617767 PMCID: PMC6326000 DOI: 10.1007/s12032-019-1245-5] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2018] [Accepted: 01/02/2019] [Indexed: 11/29/2022]
Abstract
Splenectomy before allogeneic stem cell transplantation (ASCT) for patients with myelofibrosis (MF) remains a matter of debate, and conflicting results have been reported to date. The procedure seems to fasten post-transplant hematological recovery, but it does not have an impact on survival. The role of pre-transplant splenic irradiation (SI) is much more difficult to evaluate. Forty-four patients (25 males and 19 females) with MF at median age of 49 years at diagnosis (range 14-67) underwent ASCT. The post-transplant outcome was compared between irradiated and non-irradiated patients. Eleven patients received irradiation before transplantation. Median dose of radiation was 1000 cGy (range 600-2400). There was no difference in median time to engraftment between patients with and without previous radiotherapy. Acute and chronic graft versus host disease (GVHD) occurred in 47% and 36% of patients, respectively. There was no difference in GVHD incidence between groups. Eight patients relapsed/progressed in irradiated group versus 17 in non-irradiated (70% vs. 51%; p = 0.3). Transformation to acute myeloid leukemia was observed in 3 patients: 2 in irradiated and 1 in non-irradiated group. In total, 22 patients died with no statistical difference in death rate between irradiated and non-irradiated subjects. The probability of overall survival after transplant for the entire cohort at 2 years was 54% (72% for irradiated and 48% for non-irradiated patients; p = 0.25). Splenic irradiation prior to ASCT for myelofibrosis has not beneficial effect on post-transplant outcome.
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Affiliation(s)
- Grzegorz Helbig
- Department of Hematology and Bone Marrow Transplantation, School of Medicine in Katowice, Medical University of Silesia, Dąbrowski Street 25, 40-032, Katowice, Poland.
| | - Agata Wieczorkiewicz-Kabut
- Department of Hematology and Bone Marrow Transplantation, School of Medicine in Katowice, Medical University of Silesia, Dąbrowski Street 25, 40-032, Katowice, Poland
| | - Mirosław Markiewicz
- Department of Hematology and Bone Marrow Transplantation, School of Medicine in Katowice, Medical University of Silesia, Dąbrowski Street 25, 40-032, Katowice, Poland
| | - Helena Krzemień
- Department of Hematology and Bone Marrow Transplantation, School of Medicine in Katowice, Medical University of Silesia, Dąbrowski Street 25, 40-032, Katowice, Poland
| | - Michał Wójciak
- Students' Research Group, Medical University of Warsaw, Warsaw, Poland
| | - Krzysztof Białas
- Department of Hematology and Bone Marrow Transplantation, School of Medicine in Katowice, Medical University of Silesia, Dąbrowski Street 25, 40-032, Katowice, Poland
| | - Małgorzata Kopera
- Department of Hematology and Bone Marrow Transplantation, School of Medicine in Katowice, Medical University of Silesia, Dąbrowski Street 25, 40-032, Katowice, Poland
| | - Ewa Rzenno
- Department of Hematology and Bone Marrow Transplantation, School of Medicine in Katowice, Medical University of Silesia, Dąbrowski Street 25, 40-032, Katowice, Poland
| | - Krzysztof Woźniczka
- Department of Hematology and Bone Marrow Transplantation, School of Medicine in Katowice, Medical University of Silesia, Dąbrowski Street 25, 40-032, Katowice, Poland
| | - Anna Kopińska
- Department of Hematology and Bone Marrow Transplantation, School of Medicine in Katowice, Medical University of Silesia, Dąbrowski Street 25, 40-032, Katowice, Poland
| | - Iwona Grygoruk-Wiśniowska
- Department of Hematology and Bone Marrow Transplantation, School of Medicine in Katowice, Medical University of Silesia, Dąbrowski Street 25, 40-032, Katowice, Poland
| | - Anna Koclęga
- Department of Hematology and Bone Marrow Transplantation, School of Medicine in Katowice, Medical University of Silesia, Dąbrowski Street 25, 40-032, Katowice, Poland
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115
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Tamari R, Rapaport F, Zhang N, McNamara C, Kuykendall A, Sallman DA, Komrokji R, Arruda A, Najfeld V, Sandy L, Medina J, Litvin R, Famulare CA, Patel MA, Maloy M, Castro-Malaspina H, Giralt SA, Weinberg RS, Mascarenhas JO, Mesa R, Rondelli D, Dueck AC, Levine RL, Gupta V, Hoffman R, Rampal RK. Impact of High-Molecular-Risk Mutations on Transplantation Outcomes in Patients with Myelofibrosis. Biol Blood Marrow Transplant 2019; 25:1142-1151. [PMID: 30625392 DOI: 10.1016/j.bbmt.2019.01.002] [Citation(s) in RCA: 42] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2018] [Accepted: 01/01/2019] [Indexed: 12/22/2022]
Abstract
Mutational profiling has demonstrated utility in predicting the likelihood of disease progression in patients with myelofibrosis (MF). However, there is limited data regarding the prognostic utility of genetic profiling in MF patients undergoing allogeneic hematopoietic stem cell transplantation (allo-HCT). We performed high-throughput sequencing of 585 genes on pre-transplant samples from 101 patients with MF who underwent allo-HCT and evaluated the association of mutations and clinical variables with transplantation outcomes. Overall survival (OS) at 5 years post-transplantation was 52%, and relapse-free survival (RFS) was 51.1 % for this cohort. Nonrelapse mortality (NRM) accounted for most deaths. Patient's age, donor's age, donor type, and Dynamic International Prognostic Scoring System score at diagnosis did not predict for outcomes. Mutations known to be associated with increased risk of disease progression, such as ASXL1, SRSF2, IDH1/2, EZH2, and TP53, did not impact OS or RFS. The presence of U2AF1 (P = .007) or DNMT3A (P = .034) mutations was associated with worse OS. A Mutation-Enhanced International Prognostic Scoring System 70 score was available for 80 patients (79%), and there were no differences in outcomes between patients with high risk scores and those with intermediate and low risk scores. Collectively, these data identify mutational predictors of outcome in MF patients undergoing allo-HCT. These genetic biomarkers in conjunction with clinical variables may have important utility in guiding transplantation decision making.
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Affiliation(s)
- Roni Tamari
- Memorial Sloan Kettering Cancer Center, New York, New York
| | - Franck Rapaport
- Center for Clinical and Translational Science, Rockefeller University, New York, New York
| | | | | | | | | | | | - Andrea Arruda
- Princess Margaret Hospital Cancer Center, Toronto, Ontario, Canada
| | | | | | - Juan Medina
- Memorial Sloan Kettering Cancer Center, New York, New York
| | - Rivka Litvin
- Memorial Sloan Kettering Cancer Center, New York, New York
| | | | - Minal A Patel
- Memorial Sloan Kettering Cancer Center, New York, New York
| | - Molly Maloy
- Memorial Sloan Kettering Cancer Center, New York, New York
| | | | | | | | | | | | - Damiano Rondelli
- University of Illinois Hospital & Health Sciences System and University of Illinois Cancer Center, Chicago, Illinois
| | | | - Ross L Levine
- Memorial Sloan Kettering Cancer Center, New York, New York
| | - Vikas Gupta
- Princess Margaret Hospital Cancer Center, Toronto, Ontario, Canada
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116
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Patriarca F, Masciulli A, Bacigalupo A, Bregante S, Pavoni C, Finazzi MC, Bosi A, Russo D, Narni F, Messina G, Alessandrino EP, Carella AM, Milone G, Bruno B, Mammoliti S, Bruno B, Fanin R, Bonifazi F, Rambaldi A. Busulfan- or Thiotepa-Based Conditioning in Myelofibrosis: A Phase II Multicenter Randomized Study from the GITMO Group. Biol Blood Marrow Transplant 2018; 25:932-940. [PMID: 30579966 DOI: 10.1016/j.bbmt.2018.12.064] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2018] [Accepted: 12/06/2018] [Indexed: 01/28/2023]
Abstract
We report a randomized study comparing fludarabine in combination with busulfan (FB) or thiotepa (FT), as conditioning regimen for hematopoietic stem cell transplantation (HSCT) in patients with myelofibrosis. The primary study endpoint was progression-free survival (PFS). Sixty patients were enrolled with a median age of 56 years and an intermediate-2 or high-risk score in 65%, according to the Dynamic International Prognostic Staging System (DIPSS). Donors were HLA-identical sibling (n = 25), matched unrelated (n = 25) or single allele mismatched unrelated (n = 10). With a median follow-up of 22 months (range, 1 to 68 months), outcomes at 2 years after HSCT in the FB arm versus the FT arm were as follows: PFS, 43% versus 55% (P = .28); overall survival (OS), 54% versus 70% (P = .17); relapse/progression, 36% versus 24% (P = .24); nonrelapse mortality (NRM), 21% in both arms (P = .99); and graft failure, 14% versus 10% (P = .96). A better PFS was observed in patients with intermediate-1 DIPSS score (P = .03). Both neutrophil engraftment and platelet engraftment were significantly influenced by previous splenectomy (hazard ratio [HR], 2.28; 95% confidence interval [CI], 1.16 to 4.51; P = .02) and splenomegaly at transplantation (HR, 0.51; 95% CI, 0.27 to 0.94; P = .03). In conclusion, the clinical outcome after HSCT was comparable when using either a busulfan or thiotepa based conditioning regimen.
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Affiliation(s)
| | | | | | | | | | | | - Alberto Bosi
- Hematology, University of Florence, Florence, Italy
| | - Domenico Russo
- ASST Hospital of Brescia, DSCS, Brescia University, Brescia, Italy
| | | | | | | | | | | | - Benedetto Bruno
- "Citta' della Salute e della Scienza" University Hospital, DBMSS, University of Torino, Torino, Italy
| | - Sonia Mammoliti
- Trial Clinical Office, Gruppo Italiano Trapianto Midollo Osseo (GITMO), Genoa, Italy
| | - Barbara Bruno
- Trial Clinical Office, Gruppo Italiano Trapianto Midollo Osseo (GITMO), Genoa, Italy
| | - Renato Fanin
- Udine University Hospital, DAME, University of Udine, Udine, Italy
| | - Francesca Bonifazi
- Institute of Hematology "Seragnoli", University Hospital "S. Orsola Malpighi", Bologna, Italy
| | - Alessandro Rambaldi
- "Papa Giovanni XXIII" Hospital, Bergamo, Italy; Department of Hematology-Oncology, University of Milano, Milan, Italy
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117
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Tefferi A. Primary myelofibrosis: 2019 update on diagnosis, risk-stratification and management. Am J Hematol 2018; 93:1551-1560. [PMID: 30039550 DOI: 10.1002/ajh.25230] [Citation(s) in RCA: 106] [Impact Index Per Article: 17.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2018] [Accepted: 07/18/2018] [Indexed: 12/12/2022]
Abstract
DISEASE OVERVIEW Primary myelofibrosis (PMF) is a myeloproliferative neoplasm (MPN) characterized by stem cell-derived clonal myeloproliferation that is often but not always accompanied by JAK2, CALR, or MPL mutations; additional disease features include bone marrow stromal reaction including reticulin fibrosis, abnormal cytokine expression, anemia, hepatosplenomegaly, extramedullary hematopoiesis (EMH), constitutional symptoms, cachexia, leukemic progression, and shortened survival. DIAGNOSIS Diagnosis of PMF is based on bone marrow morphology. Presence of JAK2, CALR, or MPL mutation, expected in ∼ 90% of the patients, is supportive but not essential for diagnosis. The revised 2016 World Health Organization (WHO) classification system distinguishes "prefibrotic" from "overtly fibrotic" PMF; the former might mimic ET in its presentation and it is prognostically relevant to distinguish the two. RISK STRATIFICATION Two new prognostic systems for PMF have recently been introduced: GIPSS (genetically inspired prognostic scoring system) and MIPSS70+ version 2.0 (mutation- and karyotype-enhanced international prognostic scoring system). GIPSS is based exclusively on mutations and karyotype. MIPSS70+ version 2.0 utilizes both genetic and clinical risk factors. GIPSS features four and MIPSS70+ version 2.0 five risk categories. MIPSS70+ version 2.0 requires an online score calculator (http://www.mipss70score.it) while GIPPS offers a lower complexity prognostic tool. RISK-ADAPTED THERAPY Observation alone is advised for MIPSS70+ version 2.0 "low" and "very low" risk disease (estimated 10-year survival 56%-92%); allogeneic stem cell transplant is the preferred treatment of choice for "very high" and "high" risk disease (estimated 10-year survival 0-13%); treatment-requiring patients with intermediate-risk disease (estimated 10-year survival 30%) are best served by participating in clinical trials. All other treatment approaches, including the use of JAK2 inhibitors, are mostly palliative and should not be used in the absence of clear treatment indications. Conventional treatment for anemia includes androgens, prednisone, thalidomide and danazol, for symptomatic splenomegaly hydroxyurea and ruxolitinib and for constitutional symptoms ruxolitinib. Splenectomy is considered for drug-refractory splenomegaly and involved field radiotherapy for nonhepatosplenic EMH and extremity bone pain.
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Affiliation(s)
- Ayalew Tefferi
- Division of Hematology, Department of Medicine; Mayo Clinic; Rochester Minnesota
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118
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Raj K, Eikema DJ, McLornan DP, Olavarria E, Blok HJ, Bregante S, Ciceri F, Passweg J, Ljungman P, Schaap N, Carlson K, Zuckerman T, de Wreede LC, Volin L, Koc Y, Diez-Martin JL, Brossart P, Wolf D, Blaise D, Bartolomeo PD, Vitek A, Robin M, Yakoub-Agha I, Chalandon Y, Kroger N. Family Mismatched Allogeneic Stem Cell Transplantation for Myelofibrosis: Report from the Chronic Malignancies Working Party of European Society for Blood and Marrow Transplantation. Biol Blood Marrow Transplant 2018; 25:522-528. [PMID: 30408564 DOI: 10.1016/j.bbmt.2018.10.017] [Citation(s) in RCA: 42] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2017] [Accepted: 10/19/2018] [Indexed: 12/19/2022]
Abstract
This analysis included 56 myelofibrosis (MF) patients transplanted from family mismatched donor between 2009 and 2015 enrolled in the European Society for Blood and Marrow Transplantation database. The median age was 57years (range, 38 to 72); 75% had primary MF and 25% had secondary MF. JAK2 V617F was mutated in 61%. Donors were HLA mismatched at 2 or more loci. Stem cells were sourced from bone marrow in 66% and peripheral blood in 34%. The median CD34+ cell dose was 4.8 × 106/kg (range, 1.7 to 22.9; n = 43). Conditioning was predominantly myeloablative in 70% and reduced intensity in the remainder. Regimens were heterogeneous with thiotepa, busulfan, fludarabine, and post-transplant cyclophosphamide used in 59%. The incidence of neutrophil engraftment by 28days was 82% (range, 70% to 93%), at a median of 21days (range, 19 to 23). At 2years the cumulative incidence of primary graft failure was 9% (95% CI 1% to 16%) and secondary graft failure was 13% (95% CI 4% to 22%). The cumulative incidence of acute graft-versus-host disease (GVHD) grades II to IV and III to IV was 28% (95% CI 16% to 40%) and 9% (95% CI 2% to 17%) at 100days. The cumulative incidence of chronic GVHD at 1 year was 45% (95% CI 32% to 58%), but the cumulative incidence of death without chronic GVHD by 1 year was 20% (95% CI 10% to 31%). With a median follow-up of 32 months, the 1- and 2-year overall survival was 61% (95% CI 48% to 74%) and 56% (95% CI 41% to 70%), respectively. The 1- and 2- year progression-free survival was 58% (95% CI 45% to 71%) and 43% (95% CI 28% to 58%), respectively, with a 2-year cumulative incidence of relapse of 19% (95% CI 7% to 31%). The 2-year nonrelapse mortality was 38% (95% CI 24% to 51%). This retrospective study of MF allo-SCT using family mismatched donors demonstrated feasibility of the approach, timely neutrophil engraftment in over 80% of cases, and acceptable overall and progression-free survival rates with relapse rates not dissimilar to the unrelated donor setting. However, strategies to minimize the risk of graft failure and the relatively high nonrelapse mortality need to be used, ideally in a multicenter prospective fashion.
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Affiliation(s)
- Kavita Raj
- Department of Haematological Medicine,Guy's and St. Thomas' NHS Foundation Trust, London, United Kingdom.
| | - Diderik-Jan Eikema
- Department of Medical Statistics & Bioinformatics, EBMT Statistical Unit, Leiden, The Netherlands
| | - Donal P McLornan
- Department of Haematological Medicine,Guy's and St. Thomas' NHS Foundation Trust, London, United Kingdom
| | - Eduardo Olavarria
- Department of Haematological Medicine, Hammersmith Hospital, London, United Kingdom
| | - Henric-Jan Blok
- Department of Medical Statistics & Bioinformatics, EBMT Statistical Unit, Leiden, The Netherlands
| | | | - Fabio Ciceri
- Department of Hematology and Hematopoietic Stem Cell Transplantation Instituto Di Ricovero e Cura a Carattere Scientificio San Raffaele Scientific Institute, Milano, Italy
| | - Jakob Passweg
- Department of Internal Medicine, University Hospital, Basel, Switzerland
| | - Per Ljungman
- Division of Hematology, Karolinska University Hospital, Stockholm, Sweden
| | - Nicolaas Schaap
- Department of Hematology, Radboud University, Medical Centre, Nijmegen, The Netherlands
| | - Kristina Carlson
- Internal Medicine/Hematology, University Hospital, Uppsala, Sweden
| | - Tsila Zuckerman
- Depatment of Hematology and Bone marrow Transplantation,Rambam Medical Center, Haifa, Israel
| | - Liesbeth C de Wreede
- Department of Medical Statistics & Bioinformatics, EBMT Statistical Unit, Leiden, The Netherlands; Deutsche Knochenmarkspenderdatei Clinical Trials Unit, Dresden, Germany
| | - Liisa Volin
- Department of Medicine, Helsinki University Central Hospital Comprehensive Cancer Center, Helsinki, Finland
| | - Yener Koc
- Department of Oncology, Stem cell transplant unit, Medical Park Hospitals, Antalya, Turkey
| | - Jose Luis Diez-Martin
- Department of Hematology, Instituto de investigación sanitaria Gregorio Marañon, Universidad Complutense Medicina, Madrid, Spain
| | - Peter Brossart
- Departmetn of Immuno-oncolgy and Rheumatology, Universitat Bonn, Bonn, Germany
| | - Dominik Wolf
- Departmetn of Immuno-oncolgy and Rheumatology, Universitat Bonn, Bonn, Germany
| | - Didier Blaise
- Department of Onco-Hematology, Transplantation and cell therapy unit, Institut Paoli Calmettes, Marseille, France
| | - Paolo Di Bartolomeo
- Department of Hematology, Transfusion Medicine and Biotechnology, Ospedale Civile, Pescara, Italy
| | - Antonin Vitek
- Institute of Hematology and Blood Transfusion, Prague, Czech Rep
| | - Marie Robin
- Department of Hematology and Bone marrow transplantation, Hopital St. Louis, Paris, France
| | - Ibrahim Yakoub-Agha
- Department of Hematology, Lille University hospital INSERM U995, Universite de Lille, France
| | - Yves Chalandon
- Hôpitaux Universitaires de Genève, Hematology Division and Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | - Nicolaus Kroger
- Department of Stem Cell Transplantation, University Hospital Eppendorf, Hamburg, Germany
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119
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Zimran E, Keyzner A, Iancu-Rubin C, Hoffman R, Kremyanskaya M. Novel treatments to tackle myelofibrosis. Expert Rev Hematol 2018; 11:889-902. [PMID: 30324817 DOI: 10.1080/17474086.2018.1536538] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
INTRODUCTION Despite the dramatic progress made in the treatment of patients with myelofibrosis since the introduction of the JAK1/2 inhibitor ruxolitinib, a therapeutic option that can modify the natural history of the disease and prevent evolution to blast-phase is still lacking. Recent investigational treatments including immunomodulatory drugs and histone deacetylase inhibitors benefit some patients but these effects have proven modest at best. Several novel agents do show promising activity in preclinical studies and early-phase clinical trials. We will illustrate a snapshot view of where the management of myelofibrosis is evolving, in an era of personalized medicine and advanced molecular diagnostics. Areas covered: A literature search using MEDLINE and recent meeting abstracts was performed using the keywords below. It focused on therapies in active phases of development based on their scientific and preclinical rationale with the intent to highlight agents that have novel biological effects. Expert commentary: The most mature advances in treatment of myelofibrosis are the development of second-generation JAK1/2 inhibitors and improvements in expanding access to donors for transplantation. In addition, there are efforts to identify drugs that target pathways other than JAK/STAT signaling that might improve the survival of myelofibrosis patients, and limit the need for stem-cell transplantation.
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Affiliation(s)
- Eran Zimran
- a Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai , Myeloproliferative Neoplasms Research Program , New York , NY , USA
| | - Alla Keyzner
- a Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai , Myeloproliferative Neoplasms Research Program , New York , NY , USA
| | - Camelia Iancu-Rubin
- a Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai , Myeloproliferative Neoplasms Research Program , New York , NY , USA
| | - Ronald Hoffman
- a Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai , Myeloproliferative Neoplasms Research Program , New York , NY , USA
| | - Marina Kremyanskaya
- a Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai , Myeloproliferative Neoplasms Research Program , New York , NY , USA
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Palmer J, Scherber R, Girardo M, Geyer H, Kosiorek H, Dueck A, Jain T, Mesa R. Patient Perspectives Regarding Allogeneic Bone Marrow Transplantation in Myelofibrosis. Biol Blood Marrow Transplant 2018; 25:398-402. [PMID: 30292010 DOI: 10.1016/j.bbmt.2018.09.033] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2018] [Accepted: 09/27/2018] [Indexed: 11/29/2022]
Abstract
Hematopoietic stem cell transplantation (HCT) is a curative treatment for patients with myelofibrosis (MF); however, many HCT-eligible patients decline this potentially life-saving procedure. The reasons behind this decision are not clear. We sought to survey patients with MF to understand their perspective on HCT. A 63-question survey was posted on myeloproliferative neoplasm patient advocacy websites. A total of 129 patients with MF responded to the survey. Among these patients, 49 (41%) were referred for HCT, and 41(32%) attended the transplantation consult. Of the patients who attended the transplantation consult, 24 (59%) did not plan on going on to HCT, and 16 (41%) intended to proceed with HCT. Reasons for the decision to not undergo transplantation included the desire to not be ill, desire to not spend time in the hospital, and concerns about overall quality of life. Specifically, concerns related to financial impact and the risk of graft-versus-host disease (GVHD) were expressed. Patients who decided to proceed with HCT felt that this would extend their survival and allow them to be around family for longer. This is the first survey to investigate patient perceptions regarding HCT for MF. Less than one-half of the patients were referred for HCT, and of those, less than one-half planned on proceeding with the transplantation, suggesting that many patients do not receive this life-saving procedure. Further exploration of the basis of patients' reluctance to proceed with HCT is warranted.
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Affiliation(s)
- Jeanne Palmer
- Division of Hematology and Medical Oncology, Department of Medicine, Mayo Clinic, Phoenix Arizona.
| | - Robyn Scherber
- Department of Hematology/Oncology, Oregon Health Sciences University, Portland, Oregon; Department of Hematology/Oncology, University of Texas Health Science Center at San Antonio, San Antonio, Texas
| | - Marlene Girardo
- Division of Biostatistics, Department of Health Sciences Research, Mayo Clinic, Scottsdale, Arizona
| | - Holly Geyer
- Department of Internal Medicine, Mayo Clinic, Phoenix, Arizona
| | - Heidi Kosiorek
- Division of Biostatistics, Department of Health Sciences Research, Mayo Clinic, Scottsdale, Arizona
| | - Amylou Dueck
- Division of Biostatistics, Department of Health Sciences Research, Mayo Clinic, Scottsdale, Arizona
| | - Tania Jain
- Division of Hematology and Medical Oncology, Department of Medicine, Mayo Clinic, Phoenix Arizona
| | - Ruben Mesa
- Department of Hematology/Oncology, University of Texas Health Science Center at San Antonio, San Antonio, Texas
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Shahnaz Syed Abd Kadir S, Christopeit M, Wulf G, Wagner E, Bornhauser M, Schroeder T, Crysandt M, Mayer K, Jonas J, Stelljes M, Badbaran A, Ayuketang Ayuk F, Triviai I, Wolf D, Wolschke C, Kröger N. Impact of ruxolitinib pretreatment on outcomes after allogeneic stem cell transplantation in patients with myelofibrosis. Eur J Haematol 2018; 101:305-317. [PMID: 29791053 DOI: 10.1111/ejh.13099] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/11/2018] [Indexed: 12/19/2022]
Abstract
INTRODUCTION Ruxolitinib is the first approved drug for treatment of myelofibrosis, but its impact of outcome after allogeneic stem cell transplantation (ASCT) is unknown. PATIENTS AND METHODS We reported on 159 myelofibrosis patients (pts) with a median age of 59 years (r: 28-74) who received reduced intensity ASCT between 2000 and 2015 in eight German centers from related (n = 23), matched (n = 86) or mismatched (n = 50) unrelated donors. Forty-six (29%) patients received ruxolitinib at any time point prior to ASCT. The median daily dose of ruxolitinib was 30 mg (range 10-40 mg) and the median duration of treatment was 4.9 months (range 0.4-39.1 months). RESULTS Primary graft failure was seen in 2 pts (4%) in the ruxolitinib and 3 (2%) in the non-ruxolitinib group. Engraftment and incidence of acute GVHD grade II to IV and III/IV did not differ between groups (37% vs 39% and 19% vs 28%, respectively), nor did the non-relapse mortality at 2 years (23% vs 23%). A trend for lower risk of relapse was seen in the ruxolitinib group (9% vs 17%, P = .2), resulting in a similar 2 year DFS and OS (68% vs 60% and 73% vs 70%, respectively). No difference in any outcome variable could be seen between ruxolitinib responders and those who failed or lost response to ruxolitinib. CONCLUSIONS These results suggest that ruxolitinib pretreatment in myelofibrosis patient does not negatively influence outcome after allogeneic stem cell transplantation.
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Affiliation(s)
- Sharifah Shahnaz Syed Abd Kadir
- Department of Stem Cell Transplantation, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.,Department of Haematology, Ampang Hospital, Selangor, Malaysia
| | - Maximilian Christopeit
- Department of Stem Cell Transplantation, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Gerald Wulf
- Department of Hematology/Oncology, University Hospital Göttingen, Göttingen, Germany
| | - Eva Wagner
- Department for Hematology and Oncology, University Hospital Mainz, Mainz, Germany
| | - Martin Bornhauser
- Department for Hematology and Oncology, University Hospital Dresden, Dresden, Germany
| | - Thomas Schroeder
- Department for Hematology, Oncology and Clinical Immunology, University Hospital Duesseldorf, Düsseldorf, Germany
| | - Martina Crysandt
- Department of Hematology, Oncology, Hemostaseology, and Stem Cell Transplantation, Faculty of Medicine, RWTH Aachen University, Aachen, Germany
| | - Karin Mayer
- Medical Clinic 3, Oncology, Hematology, Immunoncology and Rheumatology, University Clinic Bonn (UKB), Bonn, Germany
| | - Julia Jonas
- Medical Clinic 3, Oncology, Hematology, Immunoncology and Rheumatology, University Clinic Bonn (UKB), Bonn, Germany
| | - Matthias Stelljes
- Department of Medicine A, Hematology and Oncology, University of Muenster, Muenster, Germany
| | - Anita Badbaran
- Department of Stem Cell Transplantation, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Francis Ayuketang Ayuk
- Department of Stem Cell Transplantation, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Ioanna Triviai
- Department of Stem Cell Transplantation, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Dominik Wolf
- Medical Clinic 3, Oncology, Hematology, Immunoncology and Rheumatology, University Clinic Bonn (UKB), Bonn, Germany
| | - Christine Wolschke
- Department of Stem Cell Transplantation, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Nicolaus Kröger
- Department of Stem Cell Transplantation, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
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Takenaka K, Shimoda K, Akashi K. Recent advances in the diagnosis and management of primary myelofibrosis. Korean J Intern Med 2018; 33:679-690. [PMID: 29665657 PMCID: PMC6030412 DOI: 10.3904/kjim.2018.033] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2018] [Accepted: 03/07/2018] [Indexed: 12/13/2022] Open
Abstract
Primary myelofibrosis (PMF) is a myeloproliferative neoplasm (MPN) in which dysregulation of the Janus kinase/signal transducers and activators of transcription (JAK/STAT) signaling pathways is the major pathogenic mechanism. Most patients with PMF carry a driver mutation in the JAK2, MPL (myeloproliferative leukemia), or CALR (calreticulin) genes. Mutations in epigenetic regulators and RNA splicing genes may also occur, and play critical roles in PMF disease progression. Based on revised World Health Organization diagnostic criteria for MPNs, both screening for driver mutations and bone marrow biopsy are required for a specific diagnosis. Clinical trials of JAK2 inhibitors for PMF have revealed significant efficacy for improving splenomegaly and constitutional symptoms. However, the currently available drug therapies for PMF do not improve survival. Although allogeneic stem cell transplantation is potentially curative, it is associated with substantial treatment-related morbidity and mortality. PMF is a heterogeneous disorder and decisions regarding treatments are often complicated, necessitating the use of prognostic models to determine the management of treatments for individual patients. This review focuses on the clinical aspects and outcomes of a cohort of Japanese patients with PMF, including discussion of recent advances in the management of PMF.
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Affiliation(s)
- Katsuto Takenaka
- Department of Medicine and Biosystemic Science, Kyushu University Graduate School of Medical Sciences, Fukuoka, Japan
- Correspondence to Katsuto Takenaka, M.D. Division of Hematology, Oncology & Cardiovascular Medicine, Kyushu University Hospital, 3-1-1 Maidashi, Higashi-ku, Fukuoka 812-8582, Japan Tel: +81-92-642-5230 Fax: +81-92-642-5247 E-mail:
| | - Kazuya Shimoda
- Department of Gastroenterology and Hematology, University of Miyazaki Faculty of Medicine, Miyazaki, Japan
| | - Koichi Akashi
- Department of Medicine and Biosystemic Science, Kyushu University Graduate School of Medical Sciences, Fukuoka, Japan
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Kaushansky K, Zhan H. The regulation of normal and neoplastic hematopoiesis is dependent on microenvironmental cells. Adv Biol Regul 2018; 69:11-15. [PMID: 29970351 DOI: 10.1016/j.jbior.2018.06.003] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2018] [Revised: 06/20/2018] [Accepted: 06/26/2018] [Indexed: 01/10/2023]
Abstract
Each day the adult human produces 4 × 1011 red blood cells, 1 × 1011 white blood cells and 1 × 1011 platelets, levels of production which can increase 10-20 fold in times of heightened demand. Hematopoiesis, or the formation of the ten different types of blood and marrow cells, is a complex process involving hematopoietic stem cells (HSCs), cytokine growth factors and cell surface adhesion molecules, and both specific and ubiquitous transcription factors. The marrow micro-environmental niche is defined as the site at which HSCs reside and are nurtured, receiving the signals that lead to their survival, replication and/or differentiation. Using microscopic, biochemical and molecular methods many different cells and the signals responsible for niche function have been identified. Early studies suggested two distinct anatomical sites for the niche, perivascular and periosteal, but the preponderance of evidence now favors the former. Within the "vascular niche" much evidence exists for important contributions by vascular endothelial cells (ECs), CXCL12-abundant reticular (CAR) cells and mesenchymal stromal cells, through their elaboration of chemokines, cytokines and cell surface adhesion molecules. In a series of studies we have found, and will present the evidence that megakaryocytes (MKs), the precursors of blood platelets, must be added to this list. In addition to normal blood cell development, numerous studies have implicated the perivascular niche as contributing to the pathogenesis of a variety of hematological malignancies. Our laboratory focuses on the Ph (Crane et al., 2017)-negative myeloproliferative neoplasms (MPNs), polycythemia vera (PV), essential thrombocythemia (ET) and primary myelofibrosis (PMF). These diseases are characterized by clonal expansion of HSCs and one or more mature blood cell types, hypermetabolism, a propensity to disorders of hemostasis (thrombosis > bleeding) and in some, evolution to acute leukemia. While a variety of therapies can control the abnormal expansion of the progeny of the malignant HSC, the only curative therapy is myeloablation with conditioning therapy or immunological means, followed by allogeneic stem cell transplantation (SCT), a procedure that is often inadequate due to relapse of the malignant clone. While the three disorders were postulated by Dameshek in the 1950s to be related to one another, proof came in 2005 when an acquired mutation in the signaling kinase Janus kinase 2 (Jak2V617F) was identified in virtually all patients with PV, and ∼50% of patients with ET and PMF. Since that time a number of other mutations have been identified that account for the "Jak2V617F negative" MPNs, including the thrombopoietin receptor, c-MPL, other mutations of Jak2, calreticulin and a variety of epigenetic modifier genes (e.g. TET2). Using a cell-specific Cre recombinase and SCT techniques we can introduce Jak2V617F into murine megakaryocytes and platelets, hematopoietic stem cells, and endothelial cells, alone or in combination, in order to probe the role of the mutant kinase in various cells on several aspects of the MPNs. Using these tools we have found that the expression of Jak2V617F in HSCs and ECs drives a MPN characterized by neutrophilia, thrombocytosis and splenomegaly, eventually evolving into myelosclerosis. Somewhat surprisingly, we found that Jak2V617F-bearing ECs were required for many features of the MPN, such as enhancing the growth of Jak2V617F-bearing HSCs over that of wild type HSCs, its characteristic radioresistance, and a hemostatic defect. Altogether, our studies suggest that the malignant vascular niche is a critical element in the pathogenesis of MPNs, and a more thorough understanding of the molecular basis for these findings could lead to improved treatment for patients with these disorders.
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Affiliation(s)
| | - Huichun Zhan
- Stony Brook University School of Medicine, Stony Brook, NY, USA
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124
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McLornan DP, Szydlo R, Robin M, van Biezen A, Koster L, Blok HJP, Van Lint MT, Finke J, Vitek A, Carlson K, Griskevicius L, Holler E, Itälä-Remes M, Schaap M, Socié G, Bay JO, Beguin Y, Bruno B, Cornelissen JJ, Gedde-Dahl T, Ljungman P, Rubio MT, Yakoub-Agha I, Klyuchnikov E, Olavarria E, Chalandon Y, Kröger N. Outcome of patients with Myelofibrosis relapsing after allogeneic stem cell transplant: a retrospective study by the Chronic Malignancies Working Party of EBMT. Br J Haematol 2018; 182:418-422. [PMID: 29808926 DOI: 10.1111/bjh.15407] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2017] [Accepted: 03/19/2018] [Indexed: 11/29/2022]
Abstract
Allogeneic Haematopoietic Stem Cell Transplant (allo-HSCT) remains the only curative approach for Myelofibrosis (MF). Scarce information exists in the literature on the outcome and, indeed, management of those MF patients who relapse following transplant. We hereby report on the management and outcome of 202 patients who relapsed post allo-HSCT for MF.
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Affiliation(s)
- Donal P McLornan
- Comprehensive Cancer Centre, Division of Haematology, King's College, London
| | - Richard Szydlo
- Hammersmith Hospital NHS Foundation Trust, London, United Kingdom
| | - Marie Robin
- Service d'Hématologie-Greffe, Hôpital Saint-Louis, Assistance Publique Hôpitaux de Paris, Paris, France
| | - Anja van Biezen
- EBMT Data Office, University Medical Centre, Leiden, the Netherlands
| | - Linda Koster
- EBMT Data Office, University Medical Centre, Leiden, the Netherlands
| | - Henrik J P Blok
- EBMT Data Office, University Medical Centre, Leiden, the Netherlands
| | | | | | - Antonin Vitek
- Institute of Haematology and Blood Transfusion, Prague, Czech Republic
| | | | - Laimonas Griskevicius
- Haematology, Oncology& Transfusion Centre, Vilnius University Hospital Santaros Klinikos, Vilnius, Lithuania
| | - Ernst Holler
- Department of Haematology and Oncology, University of Regensburg, Regensburg, Germany
| | - Maija Itälä-Remes
- Stem Cell Transplant Unit, Turku University Hospital, Turku, Finland
| | - Michel Schaap
- Department of Haematology, Radboud University Medical Centre, Nijmegen, the Netherlands
| | - Gerard Socié
- Service d'Hématologie-Greffe, Hôpital Saint-Louis, Assistance Publique Hôpitaux de Paris, Paris, France
| | - Jacques-Olivier Bay
- Service d'hématologie clinique Adulte et pédiatrie, CHU ESTAING, Clermont, France
| | - Yves Beguin
- Department of Haematology, University of Liege, Liege, Belgium
| | - Benedetto Bruno
- A.O.U Citta della Salute e della Scienza di Torino, S.S.C.V.D Trapianto di Cellule Staminali, Torino, Italy
| | - Jan J Cornelissen
- Erasmus MC Cancer Institute, University Medical Centre, Rotterdam, the Netherlands
| | - Tobias Gedde-Dahl
- Clinic for Cancer, Surgery and Transplantation, Oslo University Hospital, Rikshospitalet, Norway
| | - Per Ljungman
- Department of Haematology, Karolinska University Hospital, Stockholm, Sweden
| | - Marie T Rubio
- Department of Haematology, Hopital d`Enfants, Nancy, France
| | | | | | | | - Yves Chalandon
- Division of Haematology, Geneva University Hospitals, Geneva, Switzerland
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Comparison of reduced intensity conditioning regimens used in patients undergoing hematopoietic stem cell transplantation for myelofibrosis. Bone Marrow Transplant 2018; 54:204-211. [PMID: 29795431 DOI: 10.1038/s41409-018-0226-1] [Citation(s) in RCA: 36] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2018] [Revised: 04/23/2018] [Accepted: 04/24/2018] [Indexed: 02/06/2023]
Abstract
The aim of this study is to compare clinical outcomes of patients who underwent allogeneic stem cell transplantation (HCT) for myelofibrosis with reduced intensity conditioning (RIC) using either Busulfan Fludarabine (BuFlu), Fludarabine Bis-chlorethyl-nitroso-urea/ carmustine Melphalan (FBM) or Fludarabine Melphalan (FluMel) regimens. Sixty-one patients were identified who underwent HCT with one of these RIC regimens. Overall survival (OS) was not different in the 3 groups. However, 100% donor chimerism was seen in more frequently at day +30 and day +100 in patients who received FBM or FluMel than BuFlu, in both CD3 and CD33 fractions. For instance, 100% donor chimerism in CD33 fraction was present in 100% patients in FBM cohort, 90% in FluMel cohort while 44% in BuFlu cohort at day +100. Acute graft-versus host disease, grade 2-4 and grade 3-4, was not statistically different in the 3 groups (BuFlu 47 and 35%, FBM 68 and 27%, FluMel 68 and 46%; p = 0.31 and 0.45). Relapses and non-relapse mortality was also not statistically significantly different. Our study shows similar OS with these 3 RIC regimens in myelofibrosis; although donor chimerism at day +30 and day +100 was better in patients who received FBM and FluMel.
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Kröger N, Shahnaz Syed Abd Kadir S, Zabelina T, Badbaran A, Christopeit M, Ayuk F, Wolschke C. Peritransplantation Ruxolitinib Prevents Acute Graft-versus-Host Disease in Patients with Myelofibrosis Undergoing Allogenic Stem Cell Transplantation. Biol Blood Marrow Transplant 2018; 24:2152-2156. [PMID: 29800615 DOI: 10.1016/j.bbmt.2018.05.023] [Citation(s) in RCA: 54] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2018] [Accepted: 05/18/2018] [Indexed: 12/21/2022]
Abstract
JAK inhibition by ruxolitinib is approved for treating myelofibrosis and also has shown efficacy in treating steroid-resistant acute and chronic graft-versus-host disease (GVHD). In 12 patients with myelofibrosis (median age, 63 years; range, 43 to 71 years) who were treated with ruxolitinib and underwent allogeneic stem cell transplantation (ASCT), ruxolitinib was continued (2 × 5 mg daily) until stable engraftment. No graft failure was observed, and leukocyte engraftment was achieved after a median of 12 days (range, 11 to 18 days). One patient developed fever of unknown origin after discontinuation of ruxolitinib; otherwise, no withdrawal syndrome was observed. Overall, only 1 patient each experienced acute GVHD grade I or II, resulting in an 8% incidence of acute GVHD grade II-IV at day +100, with no nonrelapse mortality. Complete chimerism was achieved in 11 patients after a median of 40 days, and molecular clearance of the underlying driver mutation was noted in 10 patients after a median of 32 days. Cytomegalovirus (CMV) reactivation occurred in 5 patients (41%), 1 of whom had CMV colitis as well, but all resolved after ganciclovir treatment. In 2 patients, ruxolitinib had to be discontinued on day 17 and day 18 after ASCT due to cytopenia after engraftment. Levels of inflammatory cytokines IL-8, IL-10, IL-6, TNFR2, INF-α, and INF-β were reduced after ruxolitinib treatment. After day +100, 4 patients developed acute GVHD (1 with grade I, 2 with grade II, and 1 with grade III) after tapering of cyclosporine, and all patients were alive at a median follow-up of 17 months (range, 12 to 18 months).
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Affiliation(s)
- Nicolaus Kröger
- Department of Stem Cell Transplantation, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.
| | - Sharifah Shahnaz Syed Abd Kadir
- Department of Stem Cell Transplantation, University Medical Center Hamburg-Eppendorf, Hamburg, Germany; Department of Haematology, Ampang Hospital, Selangor, Malaysia
| | - Tatjana Zabelina
- Department of Stem Cell Transplantation, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Anita Badbaran
- Department of Stem Cell Transplantation, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Maximilian Christopeit
- Department of Stem Cell Transplantation, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Francis Ayuk
- Department of Stem Cell Transplantation, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Christine Wolschke
- Department of Stem Cell Transplantation, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
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127
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Transplant Decisions in Patients with Myelofibrosis: Should Mutations Be the Judge? Biol Blood Marrow Transplant 2018; 24:649-658. [DOI: 10.1016/j.bbmt.2017.10.037] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2017] [Accepted: 10/26/2017] [Indexed: 02/06/2023]
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Lin CHS, Zhang Y, Kaushansky K, Zhan H. JAK2V617F-bearing vascular niche enhances malignant hematopoietic regeneration following radiation injury. Haematologica 2018; 103:1160-1168. [PMID: 29567773 PMCID: PMC6029534 DOI: 10.3324/haematol.2017.185736] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2017] [Accepted: 03/14/2018] [Indexed: 12/20/2022] Open
Abstract
Myeloproliferative neoplasms are clonal stem cell disorders characterized by hematopoietic stem/progenitor cell expansion. The acquired kinase mutation JAK2V617F plays a central role in these disorders. Abnormalities of the marrow microenvironment are beginning to be recognized as an important factor in the development of myeloproliferative neoplasms. Endothelial cells are an essential component of the hematopoietic vascular niche. Endothelial cells carrying the JAK2V617F mutation can be detected in patients with myeloproliferative neoplasms, suggesting that the mutant vascular niche is involved in the pathogenesis of these disorders. Here, using a transgenic mouse expressing JAK2V617F specifically in all hematopoietic cells (including hematopoietic stem/progenitor cells) and endothelial cells, we show that the JAK2V617F-mutant hematopoietic stem/progenitor cells are relatively protected by the JAK2V617F-bearing vascular niche from an otherwise lethal dose of irradiation during conditioning for stem cell transplantation. Gene expression analysis revealed that chemokine (C-X-C motif) ligand 12, epidermal growth factor, and pleiotrophin are up-regulated in irradiated JAK2V617F-bearing endothelial cells compared to wild-type cells. Our findings suggest that the mutant vascular niche may contribute to the high incidence of disease relapse in patients with myeloproliferative neoplasms following allogeneic stem cell transplantation, the only curative treatment for these disorders.
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Affiliation(s)
| | - Yu Zhang
- Biopharmaceutical R&D Center, Chinese Academy of Medical Sciences & Peking Union Medical College, Suzhou, China
| | - Kenneth Kaushansky
- Office of the Sr. Vice President, Health Sciences, Stony Brook School of Medicine, NY, USA
| | - Huichun Zhan
- Department of Medicine, Stony Brook School of Medicine, NY, USA .,Northport VA Medical Center, Northport, NY, USA
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Liu HX, Yang J, Jiang JL, Cai Y, Wan LP, Wu L, Shao S, Wang C. [Outcomes of reduced-intensity conditioning allogeneic hematopoietic stem cell transplantation for 10 patients with myelofibrosis]. ZHONGHUA XUE YE XUE ZA ZHI = ZHONGHUA XUEYEXUE ZAZHI 2018; 39:225-230. [PMID: 29562468 PMCID: PMC7342987 DOI: 10.3760/cma.j.issn.0253-2727.2018.03.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Download PDF] [Subscribe] [Scholar Register] [Received: 09/09/2017] [Indexed: 11/05/2022]
Abstract
Objective: To evaluate the efficacy of reduced-intensity conditioning allogeneic hematopoietic stem cell transplantation (RIC-allo-HSCT) for patients with myelofibrosis (MF). Methods: The clinical data of 10 patients with myelofibrosis (MF) who underwent RIC-allo-HSCT. Results: Of all 10 patients, 6 were male and 4 women, with a median age of 28.5 (22-54). Using fludarabine/busulfan plus total body irradiation (FB+TBI) pretreatment scheme based. Hematopoiesis reconstitution was achieved in 9 patients (90%). The median time of neutrophil and platelet engraftment was 13.5 (10-22) day and 16.5 (13-40) day, respectively. Acute GVHD occurred in 4 cases while chronic GVHD in 5 cases. The prospective OS for 3 years was (90.0±8.5)% after a median follow-up time of 17 months. Transplant related mortality was 1 case. Conclusion: RIC-HSCT with FB+TBI is a feasible and effective alternative for MF patients.
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Affiliation(s)
- H X Liu
- Department of Hematology, Shanghai General Hospital of Nanjing Medical University, Shanghai 200080, China
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130
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Shreenivas A, Mascarenhas J. Emerging drugs for the treatment of Myelofibrosis. Expert Opin Emerg Drugs 2018; 23:37-49. [DOI: 10.1080/14728214.2018.1445718] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Affiliation(s)
- Aditya Shreenivas
- Division of Hematology and Oncology, Icahn School of Medicine at Mount Sinai, Tisch Cancer Institute, New York, NY, USA
| | - John Mascarenhas
- Division of Hematology and Oncology, Icahn School of Medicine at Mount Sinai, Tisch Cancer Institute, New York, NY, USA
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Abstract
PURPOSE OF REVIEW Allogeneic hematopoietic stem-cell transplantation (HSCT) remains the only curative therapy for myelofibrosis. The number of HSCTs performed for this indication has been steadily increasing over the past years, even after the approval of the Janus kinase (JAK) inhibitor, ruxolitinib. This increase may be attributed to improved patient selection based on new prognostic molecular markers, more frequent use of matched unrelated donors, secondary to better (high-resolution) human leukocyte antigen typing and supportive care. Ruxolitinib approval raises new questions regarding the role of JAK inhibitors in the transplant setting. RECENT FINDINGS The current review summarizes recent updates on HSCT in myelofibrosis. Predictors for transplant outcomes, and specific considerations related to myelofibrosis patient selection for HSCT (e.g. molecular risk stratification) are reviewed. In addition, this review will consider management of myelofibrosis patients in the peritransplant period, including the role of ruxolitinib in the pretransplant period, pre and posttransplant splenomegaly, transplant protocols, posttransplant follow-up of minimal residual disease and interventions in the event of poor engraftment. SUMMARY HSCT remains a highly relevant treatment option for myelofibrosis in the era of JAK inhibitors. Recent advances may contribute to a refined definition of HSCT eligibility and identification of the optimal transplantation time, conditioning protocols and posttransplant management.
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132
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Jain T, Mesa RA, Palmer JM. Allogeneic Stem Cell Transplantation in Myelofibrosis. Biol Blood Marrow Transplant 2017; 23:1429-1436. [PMID: 28499938 PMCID: PMC8148877 DOI: 10.1016/j.bbmt.2017.05.007] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2017] [Accepted: 05/08/2017] [Indexed: 12/16/2022]
Abstract
Myeloproliferative neoplasm (MPN) is a category in the World Health Organization classification of myeloid tumors. BCR-ABL1-negative MPN is a subcategory that includes primary myelofibrosis (MF), post-essential thrombocythemia MF, and post-polycythemia vera MF. These disorders are characterized by stem cell-derived clonal myeloproliferation. Clinically, these diseases present with anemia and splenomegaly and significant constitutional symptoms such as severe fatigue, symptoms associated with an enlarged spleen and liver, pruritus, fevers, night sweats, and bone pain. Multiple treatment options may provide symptom relief and improved survival; however, allogeneic stem cell transplantation (HCT) remains the only potentially curative option. The decision for a transplant is based on patient prognosis, age, comorbidities, and functional status. This review describes the recent data on various peritransplantation factors and their effect on outcomes of patients with MF and new therapeutic areas, such as the use and timing of Janus kinase inhibitors with HCT and gives overall conclusions from the available data in the published literature.
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Affiliation(s)
- Tania Jain
- Division of Hematology and Medical Oncology, Mayo Clinic, Phoenix, Arizona.
| | - Ruben A Mesa
- Division of Hematology and Medical Oncology, Mayo Clinic, Phoenix, Arizona
| | - Jeanne M Palmer
- Division of Hematology and Medical Oncology, Mayo Clinic, Phoenix, Arizona
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133
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Zhan H, Lin CHS, Segal Y, Kaushansky K. The JAK2V617F-bearing vascular niche promotes clonal expansion in myeloproliferative neoplasms. Leukemia 2017; 32:462-469. [PMID: 28744010 PMCID: PMC5783797 DOI: 10.1038/leu.2017.233] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2017] [Revised: 06/15/2017] [Accepted: 07/10/2017] [Indexed: 12/17/2022]
Abstract
The acquired kinase mutation JAK2V617F plays a central role in myeloproliferative neoplasms (MPNs). However, the mechanisms responsible for the malignant hematopoietic stem/progenitor cell (HSPC) expansion seen in patients with MPNs are not fully understood, limiting the effectiveness of current treatment. Endothelial cells (ECs) are an essential component of the hematopoietic niche, and they have been shown to express the JAK2V617F mutation in patients with MPNs. We show that the JAK2V617F-bearing vascular niche promotes the expansion of the JAK2V617F HSPCs in preference to JAK2WT HSPCs, potentially contributing to poor donor cell engraftment and disease relapse following stem cell transplantation. The expression of Chemokine (C-X-C motif) ligand 12 (CXCL12) and stem cell factor (SCF) were upregulated in JAK2V617F-bearing ECs compared to wild-type ECs, potentially accounting for this observation. We further identify that the thrombopoietin (TPO)/MPL signaling pathway is critical for the altered vascular niche function. A better understanding of how the vascular niche contributes to HSPC expansion and MPN development is essential for the design of more effective therapeutic strategies for patients with MPNs.
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Affiliation(s)
- H Zhan
- Northport VA Medical Center, Northport, NY, USA.,Department of Medicine, Stony Brook Medicine, Stony Brook, NY, USA
| | - C H S Lin
- Department of Medicine, Stony Brook Medicine, Stony Brook, NY, USA
| | - Y Segal
- Northport VA Medical Center, Northport, NY, USA
| | - K Kaushansky
- Department of Medicine, Stony Brook Medicine, Stony Brook, NY, USA.,Office of the Sr. Vice President, Health Sciences, Stony Brook Medicine, Stony Brook, NY, USA
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134
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Wolschke C, Badbaran A, Zabelina T, Christopeit M, Ayuk F, Triviai I, Zander A, Alchalby H, Bacher U, Fehse B, Kröger N. Impact of molecular residual disease post allografting in myelofibrosis patients. Bone Marrow Transplant 2017; 52:1526-1529. [PMID: 28714945 DOI: 10.1038/bmt.2017.157] [Citation(s) in RCA: 37] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2016] [Revised: 03/09/2017] [Accepted: 04/29/2017] [Indexed: 01/13/2023]
Abstract
We screened 136 patients with myelofibrosis and a median age of 58 years who underwent allogeneic stem cell transplantation (AHSCT) for molecular residual disease for JAKV617F (n=101), thrombopoietin receptor gene (MPL) (n=4) or calreticulin (CALR) (n=31) mutation in peripheral blood on day +100 and +180 after AHSCT. After a median follow-up of 78 months, the 5-year estimated overall survival was 60% (95% confidence interval (CI): 50-70%) and the cumulative incidence of relapse at 5 years was 26% (95% CI: 18-34%) for the entire study population. The percentage of molecular clearance on day 100 was higher in CALR-mutated patients (92%) in comparison with MPL- (75%) and JAKV617F-mutated patients (67%). Patients with detectable mutation at day +100 or at day +180 had a significant higher risk of clinical relapse at 5 years than molecular-negative patients (62% vs 10%, P<0.001) and 70% vs 10%, P<0.001, respectively) irrespectively of the underlying mutation. In a multivariate analysis, high-risk diseases status (hazard ratio (HR) 2.5; 95% CI: 1.18-5.25, P=0.016) and detectable MRD at day 180 (HR 8.36, 95% CI: 2.76-25.30, P<0.001) were significant factors for a higher risk of relapse.
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Affiliation(s)
- C Wolschke
- Department of Stem Cell Transplantation, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - A Badbaran
- Department of Stem Cell Transplantation, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - T Zabelina
- Department of Stem Cell Transplantation, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - M Christopeit
- Department of Stem Cell Transplantation, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - F Ayuk
- Department of Stem Cell Transplantation, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - I Triviai
- Department of Stem Cell Transplantation, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - A Zander
- Department of Stem Cell Transplantation, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - H Alchalby
- Department of Stem Cell Transplantation, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - U Bacher
- Department of Hematology and Oncology, University Hospital Göttingen, Göttingen, Germany
| | - B Fehse
- Department of Stem Cell Transplantation, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - N Kröger
- Department of Stem Cell Transplantation, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
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135
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Lestang E, Peterlin P, Le Bris Y, Dubruille V, Delaunay J, Godon C, Theisen O, Blin N, Mahe B, Gastinne T, Garnier A, Touzeau C, Voldoire M, Bene MC, Le Gouill S, Milpied N, Mohty M, Moreau P, Guillaume T, Chevallier P. Is allogeneic stem cell transplantation for myelofibrosis still indicated at the time of molecular markers and JAK inhibitors era? Eur J Haematol 2017; 99:60-69. [DOI: 10.1111/ejh.12891] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/27/2017] [Indexed: 12/26/2022]
Affiliation(s)
- Elsa Lestang
- Hematology Department; CHU Hotel-Dieu; Nantes France
| | | | - Yannick Le Bris
- Hematology/Biology Department; CHU Hotel-Dieu; Nantes France
| | | | | | - Catherine Godon
- Hematology/Biology Department; CHU Hotel-Dieu; Nantes France
| | - Olivier Theisen
- Hematology/Biology Department; CHU Hotel-Dieu; Nantes France
| | - Nicolas Blin
- Hematology Department; CHU Hotel-Dieu; Nantes France
| | - Beatrice Mahe
- Hematology Department; CHU Hotel-Dieu; Nantes France
| | | | - Alice Garnier
- Hematology Department; CHU Hotel-Dieu; Nantes France
| | | | - Maud Voldoire
- Hematology Department; CHU Hotel-Dieu; Nantes France
| | - Marie C. Bene
- Hematology/Biology Department; CHU Hotel-Dieu; Nantes France
| | | | - Noel Milpied
- Hematology Department; CHU Hotel-Dieu; Nantes France
| | - Mohamad Mohty
- Hematology Department; CHU Hotel-Dieu; Nantes France
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136
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Zhang LN, Chen X, Feng SZ. [Advances in allogeneic hematopoietic stem cell transplantation for myelofibrosis]. ZHONGHUA XUE YE XUE ZA ZHI = ZHONGHUA XUEYEXUE ZAZHI 2017; 38:352-356. [PMID: 28468103 PMCID: PMC7342713 DOI: 10.3760/cma.j.issn.0253-2727.2017.04.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Download PDF] [Subscribe] [Scholar Register] [Received: 09/08/2016] [Indexed: 11/09/2022]
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137
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Iurlo A, Cattaneo D. Treatment of Myelofibrosis: Old and New Strategies. Clin Med Insights Blood Disord 2017; 10:1179545X17695233. [PMID: 28579852 PMCID: PMC5428134 DOI: 10.1177/1179545x17695233] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2016] [Accepted: 01/30/2017] [Indexed: 01/19/2023]
Abstract
Myelofibrosis (MF) is a BCR-ABL1-negative myeloproliferative neoplasm that is mainly characterised by reactive bone marrow fibrosis, extramedullary haematopoiesis, anaemia, hepatosplenomegaly, constitutional symptoms, leukaemic progression, and shortened survival. As such, this malignancy is still orphan of curative treatments; indeed, the only treatment that has a clearly demonstrated impact on disease progression is allogeneic haematopoietic stem cell transplantation, but only a minority of patients are eligible for such intensive therapy. However, more recently, the discovery of JAK2 mutations has also led to the development of small-molecule JAK1/2 inhibitors, the first of which, ruxolitinib, has been approved for the treatment of MF in the United States and Europe. In this article, we report on old and new therapeutic strategies that proved effective in early preclinical and clinical trials, and subsequently in the daily clinical practice, for patients with MF, particularly concerning the topics of anaemia, splenomegaly, iron overload, and allogeneic stem cell transplantation.
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Affiliation(s)
- Alessandra Iurlo
- Oncohematology Division, IRCCS Ca’ Granda – Maggiore Policlinico Hospital Foundation, Milan, Italy
| | - Daniele Cattaneo
- Oncohematology Division, IRCCS Ca’ Granda – Maggiore Policlinico Hospital Foundation, Milan, Italy
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138
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The Impact of Splenectomy in Myelofibrosis Patients before Allogeneic Hematopoietic Stem Cell Transplantation. Biol Blood Marrow Transplant 2017; 23:958-964. [PMID: 28263921 DOI: 10.1016/j.bbmt.2017.03.002] [Citation(s) in RCA: 52] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2016] [Accepted: 03/01/2017] [Indexed: 11/22/2022]
Abstract
Performing a pretransplantation splenectomy in patients with myelofibrosis (MF) is a matter of debate, as while the procedure improves hematological recovery, it may lead to severe morbidities. We retrospectively analyzed data from 85 consecutive patients who underwent transplantation in our center for MF, including 39 patients who underwent splenectomy before their transplantation. A majority of them had primary MF (78%), were considered high-risk patients (84% dynamic international prognostic scoring system intermediate-2 or higher), and had received transplants from HLA-matched sibling donors (56%) after a reduced-intensity conditioning regimen (82%). One-half of all splenectomized patients presented surgical or postsurgical morbidities, most frequently thrombosis and hemorrhage. After adjustment using Cox models, pretransplantation splenectomy was not associated with nonrelapse mortality or post-transplantation relapse but with an improved overall survival (OS) and event-free survival (EFS). We conclude that some patients with huge splenomegaly may undergo pretransplantation splenectomy without a deleterious impact on post-transplantation outcomes. OS and EFS improvement should in confirmed in controlled study.
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139
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Atilla E, Ataca Atilla P, Demirer T. A Review of Myeloablative vs Reduced Intensity/Non-Myeloablative Regimens in Allogeneic Hematopoietic Stem Cell Transplantations. Balkan Med J 2017; 34:1-9. [PMID: 28251017 PMCID: PMC5322516 DOI: 10.4274/balkanmedj.2017.0055] [Citation(s) in RCA: 36] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2017] [Accepted: 01/19/2017] [Indexed: 02/07/2023] Open
Abstract
Allogeneic hematopoietic stem cell transplantation (Allo-HSCT) is a curative treatment option for both malignant and some benign hematological diseases. During the last decade, many of the newer high-dose regimens in different intensity have been developed specifically for patients with hematologic malignancies and solid tumors. Today there are three main approaches used prior to allogeneic transplantation: Myeloablative (MA), Reduced Intensity Conditioning (RIC) and Non-MA (NMA) regimens. MA regimens cause irreversible cytopenia and there is a requirement for stem cell support. Patients who receive NMA regimen have minimal cytopenia and this type of regimen can be given without stem cell support. RIC regimens do not fit the criteria of MA and NMA: the cytopenia is reversible and the stem cell support is necessary. NMA/RIC for Allo-HSCT has opened a new era for treating elderly patients and those with comorbidities. The RIC conditioning was used for 40% of all Allo-HSCT and this trend continue to increase. In this paper, we will review these regimens in the setting of especially allogeneic HSCT and our aim is to describe the history, features and impact of these conditioning regimens on specific diseases.
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Affiliation(s)
- Erden Atilla
- Department of Hematology, Ankara University School of Medicine, Ankara, Turkey
| | - Pınar Ataca Atilla
- Department of Hematology, Ankara University School of Medicine, Ankara, Turkey
| | - Taner Demirer
- Department of Hematology, Ankara University School of Medicine, Ankara, Turkey
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140
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Devlin R, Gupta V. Myelofibrosis: to transplant or not to transplant? HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2016; 2016:543-551. [PMID: 27913527 PMCID: PMC6142493 DOI: 10.1182/asheducation-2016.1.543] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/13/2023]
Abstract
Hematopoietic cell transplantation (HCT) is the only curative therapeutic modality for myelofibrosis (MF) at present. The optimal timing of HCT is not known in the presence of wider availability of less risky nontransplant therapies such as JAK 1/2 inhibitors. Careful review of patient, disease, and transplant-related factors is required in the appropriate selection of HCT vs the best available nontransplant therapies. We highlight some of the relevant issues and positioning of HCT in light of evolving data on JAK 1/2 inhibitors. The goal of this study is to provide the reader with updated evidence of HCT for MF, recognizing that knowledge in this area is limited by the absence of comparative studies between HCT and nontransplant therapies. Prospective studies are needed for better information on: the determination of optimal timing and conditioning regimens, the best way to integrate JAK inhibitors in the HCT protocols, and the impact of JAK inhibitors on graft-versus-host disease.
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Affiliation(s)
- Rebecca Devlin
- The Elizabeth and Tony Comper Myeloproliferative Neoplasm Program, Princess Margaret Cancer Center, Toronto, Ontario, Canada
| | - Vikas Gupta
- The Elizabeth and Tony Comper Myeloproliferative Neoplasm Program, Princess Margaret Cancer Center, Toronto, Ontario, Canada
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141
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Keyzner A, Han S, Shapiro S, Moshier E, Schorr E, Petersen B, Najfeld V, Kremyanskaya M, Isola L, Hoffman R, Mascarenhas J. Outcome of Allogeneic Hematopoietic Stem Cell Transplantation for Patients with Chronic and Advanced Phase Myelofibrosis. Biol Blood Marrow Transplant 2016; 22:2180-2186. [PMID: 27596130 DOI: 10.1016/j.bbmt.2016.08.029] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2016] [Accepted: 08/31/2016] [Indexed: 01/01/2023]
Abstract
Myelofibrosis (MF) is a chronic progressive hematologic malignancy with a median overall survival (OS) of approximately 6 years. Allogeneic hematopoietic stem cell transplantation (HSCT) is the sole treatment approach that offers curative potential. The use of reduced-intensity conditioning regimens has expanded the application of HSCT to patients with MF up to age 70 years. Recent retrospective and prospective reports have suggested worse HSCT outcomes for patients with MF receiving an unrelated donor graft compared with those receiving a related donor graft. To identify patient- and HSCT-specific variables influencing outcomes, we conducted a retrospective analysis of 42 patients with chronic and advanced-phase MF who underwent HSCT at our institution. For this cohort, at a median follow-up of 43 months, progression-free survival (PFS) was 15 months and OS was 25 months. In multivariable analysis, the sole clinical variable that negatively influenced outcome was the use of an unrelated donor, with a median PFS and OS both of 11 months versus not yet reached in patients receiving a related donor graft. At 2 years, OS was 38% (95% confidence interval [CI], 20%-56%) and nonrelapse mortality (NRM) was 53% (95% CI, 36%-78%) in the unrelated donor graft group, compared with 75% (95% CI, 46%-90%) and 21% (95% CI, 9%-47%) in the related donor graft group. There was no difference in the rates of grade III-IV acute graft-versus-host disease between the unrelated and related donor groups (38% versus 38%). Despite a more aggressive disease state, 2-year PFS and OS were both 42% (95% CI, 15%-67%) in patients with myeloproliferative neoplasm-blast phase undergoing HSCT. Graft failure rate was higher in patients receiving a mismatched donor graft compared with those receiving a matched donor graft (60% versus 13%; P = .0398). Retransplantation of patients with graft failure resulted in long-term survival. Baseline splenomegaly did not affect transplantation outcomes. Given the particularly poor outcomes seen in the unrelated donor cohort here and elsewhere, a formal exploration of alternative hematopoietic stem cell sources is warranted.
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Affiliation(s)
- Alla Keyzner
- Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Sarah Han
- Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Samantha Shapiro
- Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Erin Moshier
- Department of Population Health Science and Policy, TCI Biostatistics Shared Resource Facility, Icahn School of Medicine, New York, New York
| | - Emily Schorr
- Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Bruce Petersen
- Department of Pathology, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Vesna Najfeld
- Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, New York; Department of Pathology, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Marina Kremyanskaya
- Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Luis Isola
- Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Ronald Hoffman
- Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, New York
| | - John Mascarenhas
- Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, New York.
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142
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Tefferi A. Primary myelofibrosis: 2017 update on diagnosis, risk-stratification, and management. Am J Hematol 2016; 91:1262-1271. [PMID: 27870387 DOI: 10.1002/ajh.24592] [Citation(s) in RCA: 112] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2016] [Accepted: 10/20/2016] [Indexed: 12/13/2022]
Abstract
Disease overview: Primary myelofibrosis (PMF) is a myeloproliferative neoplasm (MPN) characterized by stem cell-derived clonal myeloproliferation that is often but not always accompanied by JAK2, CALR or MPL mutation, abnormal cytokine expression, bone marrow fibrosis, anemia, splenomegaly, extramedullary hematopoiesis (EMH), constitutional symptoms, cachexia, leukemic progression and shortened survival. DIAGNOSIS Diagnosis is based on bone marrow morphology. The presence of JAK2, CALR or MPL mutation is supportive but not essential for diagnosis; approximately 90% of patients carry one of these mutations and 10% are "triple-negative." None of these mutations are specific to PMF and are also seen in essential thrombocythemia (ET). According to the revised 2016 World Health Organization (WHO) classification and diagnostic criteria, "prefibrotic" PMF (pre-PMF) is distinguished from "overtly fibrotic" PMF; the former might mimic ET in its presentation and it is prognostically relevant to distinguish the two. Risk stratification: The Dynamic International Prognostic Scoring System-plus (DIPSS-plus) uses eight predictors of inferior survival: age >65 years, hemoglobin <10 g/dL, leukocytes >25 × 109 /L, circulating blasts ≥1%, constitutional symptoms, red cell transfusion dependency, platelet count <100 × 109 /L and unfavorable karyotype (i.e., complex karyotype or sole or two abnormalities that include +8, -7/7q-, i(17q), inv(3), 5/5q-, 12p-, or 11q23 rearrangement). The presence of 0, 1, "2 or 3" and ≥4 adverse factors defines low, intermediate-1, intermediate-2 and high-risk disease with median survivals of approximately 15.4, 6.5, 2.9 and 1.3 years, respectively. Most recently, DIPSS-plus-independent adverse prognostic relevance has been demonstrated for certain mutations including ASXL1 and SRSF2 whereas patients with type 1/like CALR mutations, compared to their counterparts with other driver mutations, displayed significantly better survival. Risk-adapted therapy: Observation alone is a reasonable treatment strategy for asymptomatic low or intermediate-1 DIPSS-plus risk disease, especially in the absence of high-risk mutations. All other patients with high or intermediate-2 risk disease, or those harboring high-risk mutations such as ASXL1 or SRSF2, should be considered for stem cell transplant, which is currently the only treatment modality with the potential to favorably modify the natural history of the disease. Non-transplant candidates should be encouraged to participate in clinical trials, since the value of conventional drug therapy, including the use of JAK2 inhibitors, is limited to symptoms palliation and reduction in spleen size. Specifically, JAK2 inhibitors have not been shown to induce complete clinical or cytogenetic remissions or significantly affect JAK2/CALR/MPL mutant allele burden. Splenectomy is considered for drug-refractory splenomegaly. Involved field radiotherapy is most useful for post-splenectomy hepatomegaly, non-hepatosplenic EMH, PMF-associated pulmonary hypertension and extremity bone pain. Am. J. Hematol. 91:1262-1271, 2016. © 2016 Wiley Periodicals, Inc.
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Affiliation(s)
- Ayalew Tefferi
- Division of Hematology, Department of MedicineMayo ClinicRochester Minnesota
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143
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The effects of hematopoietic stem cell transplant on splenic extramedullary hematopoiesis in patients with myeloproliferative neoplasm-associated myelofibrosis. Hematol Oncol Stem Cell Ther 2016; 9:96-104. [DOI: 10.1016/j.hemonc.2016.07.002] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2016] [Revised: 06/15/2016] [Accepted: 07/03/2016] [Indexed: 11/23/2022] Open
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144
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Hart C, Klatt S, Barop J, Müller G, Schelker R, Holler E, Huber E, Herr W, Grassinger J. Splenic pooling and loss of VCAM-1 causes an engraftment defect in patients with myelofibrosis after allogeneic hematopoietic stem cell transplantation. Haematologica 2016; 101:1407-1416. [PMID: 27662011 DOI: 10.3324/haematol.2016.146811] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2016] [Accepted: 08/03/2016] [Indexed: 11/09/2022] Open
Abstract
Myelofibrosis is a myeloproliferative neoplasm that results in cytopenia, bone marrow fibrosis and extramedullary hematopoiesis. Allogeneic hematopoietic stem cell transplantation is the only curative treatment but is associated with a risk of delayed engraftment and graft failure. In this study, patients with myelofibrosis (n=31) and acute myeloid leukemia (n=31) were analyzed for time to engraftment, graft failure and engraftment-related factors. Early and late neutrophil engraftment and late thrombocyte engraftment were significantly delayed in patients with myelofibrosis as compared to acute myeloid leukemia, and graft failure only occurred in myelofibrosis (6%). Only spleen size had a significant influence on engraftment efficiency in myelofibrosis patients. To analyze the cause for the engraftment defect, clearance of hematopoietic stem cells from peripheral blood was measured and immunohistological staining of bone marrow sections was performed. Numbers of circulating CD34+ were significantly reduced at early time points in myelofibrosis patients, whereas CD34+CD38- and colony-forming cells showed no significant difference in clearance. Staining of bone marrow sections for homing proteins revealed a loss of VCAM-1 in myelofibrosis with a corresponding significant increase in the level of soluble VCAM-1 within the peripheral blood. In conclusion, our data suggest that reduced engraftment and graft failure in myelofibrosis patients is caused by an early pooling of CD34+ hematopoietic stem cells in the spleen and a bone marrow homing defect caused by the loss of VCAM-1. Improved engraftment in myelofibrosis might be achieved by approaches that reduce spleen size and cleavage of VCAM-1 in these patients prior to hematopoietic stem cell transplantation.
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Affiliation(s)
- Christina Hart
- Department of Hematology and Oncology, Internal Medicine III, University Hospital Regensburg, Germany
| | - Sabine Klatt
- Department of Hematology and Oncology, Internal Medicine III, University Hospital Regensburg, Germany
| | - Johann Barop
- Department of Hematology and Oncology, Internal Medicine III, University Hospital Regensburg, Germany
| | - Gunnar Müller
- Department of Hematology and Oncology, Internal Medicine III, University Hospital Regensburg, Germany
| | - Roland Schelker
- Department of Hematology and Oncology, Internal Medicine III, University Hospital Regensburg, Germany
| | - Ernst Holler
- Department of Hematology and Oncology, Internal Medicine III, University Hospital Regensburg, Germany
| | - Elisabeth Huber
- Institute of Pathology, University Hospital of Regensburg, Germany
| | - Wolfgang Herr
- Department of Hematology and Oncology, Internal Medicine III, University Hospital Regensburg, Germany
| | - Jochen Grassinger
- Department of Hematology and Oncology, Internal Medicine III, University Hospital Regensburg, Germany
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145
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Ecsedi M, Schmohl J, Zeiser R, Drexler B, Halter J, Medinger M, Duyster J, Kanz L, Passweg J, Finke J, Bethge W, Lengerke C. Anti-thymocyte globulin-induced hyperbilirubinemia in patients with myelofibrosis undergoing allogeneic hematopoietic cell transplantation. Ann Hematol 2016; 95:1627-36. [PMID: 27480090 DOI: 10.1007/s00277-016-2758-z] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2016] [Accepted: 07/11/2016] [Indexed: 12/15/2022]
Abstract
Allogeneic hematopoietic cell transplantation (allo-HCT) remains the only curative treatment option for myelofibrosis (MF) despite the emergence of novel targeted therapies. To reduce graft rejection and graft-versus-host disease (GvHD), current allo-HCT protocols often include in vivo T lymphocyte depletion using polyclonal anti-thymocyte globulin (ATG). Shortly after ATG administration, an immediate inflammatory response with fever, chills, and laboratory alterations such as cytopenias, elevation of serum C-reactive protein, bilirubin, and transaminases can develop. Here, we explore whether MF patients, who commonly exhibit extramedullary hematopoiesis in the liver, might be particularly susceptible to ATG-induced liver toxicity. To test this hypothesis, we analyzed 130 control and 94 MF patients from three transplant centers treated with or without ATG during the allo-HCT conditioning regimen. Indeed, hyperbilirubinemia was found in nearly every MF patient treated with ATG (MF-ATG 54/60 = 90 %) as compared to non-ATG treated MF (MF-noATG 15/34 = 44.1 %, p < 0.001) and respectively ATG-treated non-MF patients of the control group (control-ATG, 43/77 = 56 %, p < 0.001). In contrast, transaminases were only inconsistently elevated. Hyperbilirubinemia was in most cases self-limiting and not predictive of increased incidence of non-relapse mortality, hepatic sinusoidal obstruction syndrome (SOS) or liver GvHD. In sum, awareness of this stereotypic bilirubin elevation in MF patients treated with ATG provides a relatively benign explanation for hyperbilirubinemia occurring in these patients during the early transplant. However, attention to drug levels of biliary excreted drugs is warranted, since altered bile flow may influence their clearance and enhance toxicity (e.g., busulfan, antifungal agents).
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Affiliation(s)
- Matyas Ecsedi
- Division of Hematology, University Hospital Basel, Petersgraben 4, 4031, Basel, Switzerland
| | - Jörg Schmohl
- Department of Hematology and Oncology, Medical Center, University of Tuebingen, 72076, Tuebingen, Germany
| | - Robert Zeiser
- Department of Hematology, Oncology and Stem Cell Transplantation, Freiburg University Medical Center, 79106, Freiburg, Germany
| | - Beatrice Drexler
- Division of Hematology, University Hospital Basel, Petersgraben 4, 4031, Basel, Switzerland
| | - Jörg Halter
- Division of Hematology, University Hospital Basel, Petersgraben 4, 4031, Basel, Switzerland
| | - Michael Medinger
- Division of Hematology, University Hospital Basel, Petersgraben 4, 4031, Basel, Switzerland
| | - Justus Duyster
- Department of Hematology, Oncology and Stem Cell Transplantation, Freiburg University Medical Center, 79106, Freiburg, Germany
| | - Lothar Kanz
- Department of Hematology and Oncology, Medical Center, University of Tuebingen, 72076, Tuebingen, Germany
| | - Jakob Passweg
- Division of Hematology, University Hospital Basel, Petersgraben 4, 4031, Basel, Switzerland
| | - Jürgen Finke
- Department of Hematology, Oncology and Stem Cell Transplantation, Freiburg University Medical Center, 79106, Freiburg, Germany
| | - Wolfgang Bethge
- Department of Hematology and Oncology, Medical Center, University of Tuebingen, 72076, Tuebingen, Germany
| | - Claudia Lengerke
- Division of Hematology, University Hospital Basel, Petersgraben 4, 4031, Basel, Switzerland.
- Department for Biomedicine, University Hospital Basel, Hebelstr. 20, 4031, Basel, Switzerland.
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146
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Farhadfar N, Cerquozzi S, Patnaik M, Tefferi A. Allogeneic Hematopoietic Stem-Cell Transplantation for Myelofibrosis: A Practical Review. J Oncol Pract 2016; 12:611-21. [DOI: 10.1200/jop.2016.013268] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Myelofibrosis is a myeloproliferative neoplasm with cardinal features of extramedullary hematopoiesis, hepatosplenomegaly, cytopenias, and constitutional symptoms that result in shortened survival and leukemic transformation. It is a disease predominantly of the elderly, and currently available therapies only offer symptom control without curative benefit or ability to alter disease progression. Allogeneic hematopoietic stem-cell transplant (HSCT) is the only potentially curative intervention; however, this is only feasible in younger and medically fit patients and selectively offered to those with high-risk disease. Despite ongoing advancements, HSCT is associated with substantial morbidity and mortality, and the determination of which patients with myelofibrosis are ideal candidates and the selection of the opportune moment to proceed with transplantation remains challenging. This review summarizes our current recommendations for the role of and indications for HSCT in myelofibrosis.
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147
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Derlin T, Alchalby H, Bannas P, Laqmani A, Ayuk F, Triviai I, Kreipe HH, Bengel FM, Kröger N. Serial 18F-FDG PET for Monitoring Treatment Response After Allogeneic Stem Cell Transplantation for Myelofibrosis. J Nucl Med 2016; 57:1556-1559. [PMID: 27230931 DOI: 10.2967/jnumed.115.166348] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2015] [Accepted: 04/19/2016] [Indexed: 11/16/2022] Open
Abstract
Our objective was to assess the feasibility of 18F-FDG PET/CT for noninvasive monitoring of treatment response after allogeneic stem cell transplantation (SCT) for myelofibrosis. METHODS Twelve patients with myelofibrosis underwent 18F-FDG PET/CT before and after SCT. Bone marrow uptake, spleen uptake, and spleen size were assessed before and after SCT and compared with hematologic response criteria and bone marrow biopsies. RESULTS All patients who did not achieve complete remission remained PET-positive (P = 0.02). Extent of disease, bone marrow metabolism, spleen metabolism, and spleen volume decreased significantly in patients with complete remission (P = 0.03). PET/CT after SCT had a sensitivity of 1.0 (95% confidence interval [CI], 0.54-1.0), a specificity of 0.83 (95% CI, 0.36-1.0), a negative predictive value of 1.0 (95% CI, 0.48-1.0), and a positive predictive value of 0.86 (95% CI, 0.42-1.0) for diagnosis of residual disease. CONCLUSION 18F-FDG PET/CT is feasible for noninvasive monitoring of treatment response after allogeneic SCT for myelofibrosis.
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Affiliation(s)
- Thorsten Derlin
- Department of Nuclear Medicine, Hannover Medical School, Hannover, Germany
| | - Haefaa Alchalby
- Clinic for Stem Cell Transplantation, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Peter Bannas
- Department of Diagnostic and Interventional Radiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany; and
| | - Azien Laqmani
- Department of Diagnostic and Interventional Radiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany; and
| | - Francis Ayuk
- Clinic for Stem Cell Transplantation, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Ioanna Triviai
- Clinic for Stem Cell Transplantation, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | | | - Frank M Bengel
- Department of Nuclear Medicine, Hannover Medical School, Hannover, Germany
| | - Nicolaus Kröger
- Clinic for Stem Cell Transplantation, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
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148
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Similar outcome of calreticulin type I and calreticulin type II mutations following RIC allogeneic haematopoietic stem cell transplantation for myelofibrosis. Bone Marrow Transplant 2016; 51:1391-1393. [DOI: 10.1038/bmt.2016.128] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
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149
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Al-Ali HK, Vannucchi AM. Managing patients with myelofibrosis and low platelet counts. Ann Hematol 2016; 96:537-548. [PMID: 27209535 DOI: 10.1007/s00277-016-2697-8] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2016] [Accepted: 05/10/2016] [Indexed: 12/18/2022]
Abstract
Myelofibrosis (MF) is a chronic myeloproliferative neoplasm characterized by bone marrow fibrosis, ineffective hematopoiesis, splenomegaly, constitutional symptoms, and shortened survival. Patients often experience multiple disease-associated, as well as treatment-emergent, cytopenias, including thrombocytopenia. However, patients with MF with thrombocytopenia have few therapeutic options, and there is little information on the management of these patients. Several Janus kinase (JAK) inhibitors have been developed for the treatment of MF, with one (ruxolitinib) having been approved. However, given their mechanism of action, JAK inhibitors are associated with high rates of thrombocytopenia. Patients can be successfully managed with dose modifications, but little is known about the safety and efficacy of these agents in patients with thrombocytopenia. Recent studies of JAK inhibitors in patients with MF who have low platelet counts have had mixed results. This review discusses the prevalence, prognostic implications, and management of thrombocytopenia in MF and the different therapeutic options available for this patient population, with an emphasis on current clinical experience with targeted therapies, as well as recent findings from several clinical studies currently underway.
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Affiliation(s)
| | - Alessandro M Vannucchi
- CRIMM, Center for Research and Innovation of Myeloproliferative Neoplasms, AOU Careggi, Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
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150
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Damlaj M, Alkhateeb HB, Hefazi M, Partain DK, Hashmi S, Gastineau DA, Al-Kali A, Wolf RC, Gangat N, Litzow MR, Hogan WJ, Patnaik MM. Fludarabine-Busulfan Reduced-Intensity Conditioning in Comparison with Fludarabine-Melphalan Is Associated with Increased Relapse Risk In Spite of Pharmacokinetic Dosing. Biol Blood Marrow Transplant 2016; 22:1431-1439. [PMID: 27164061 DOI: 10.1016/j.bbmt.2016.04.026] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2016] [Accepted: 04/30/2016] [Indexed: 11/16/2022]
Abstract
Fludarabine with busulfan (FB) and fludarabine with melphalan (FM) are commonly used reduced-intensity conditioning (RIC) regimens. Pharmacokinetic dosing of busulfan (Bu) is frequently done for myeloablative conditioning, but evidence for its use is limited in RIC transplants. We compared transplant outcomes of FB versus FM using i.v. Bu targeted to the area under the curve (AUC). A total of 134 RIC transplants (47 FB and 87 FM) for acute myelogenous leukemia and myelodysplastic syndrome were identified, and median follow-up of the cohort was 40 months (range, 0 to 63.3). A significantly higher 2-year cumulative incidence of relapse (CIR) was associated with FB versus FM at 35.6% versus 17.3%, respectively (P = .0058). Furthermore, 2-year progression-free survival rates were higher for FM versus FB at 60.5% versus 48.7%, respectively (P = .04). However, 2-year rates of nonrelapse mortality (NRM) and overall survival (OS) were similar. The need for dose adjustment based on AUC did not alter relapse risk or NRM. Patients with Karnofsky performance status ≥ 90 who received FM had a 2-year OS rate of 74.8% versus 48.3% for FB (P = .03). FB use remained prognostic for relapse in multivariable analysis (hazard ratio, 2.75; 95% confidence interval, 1.28 to 5.89; P = .0097). In summary, in spite of AUC-directed dosing, FB compared with FM was associated with a significantly higher CIR.
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Affiliation(s)
- Moussab Damlaj
- Division of Hematology & HSCT, Department of Oncology, King AbdulAziz Medical City, Riyadh, Saudi Arabia; Division of Hematology, Department of Medicine, Mayo Clinic, Rochester, Minnesota.
| | - Hassan B Alkhateeb
- Division of Hematology, Department of Medicine, Mayo Clinic, Rochester, Minnesota
| | - Mehrdad Hefazi
- Department of Internal Medicine, Mayo Clinic, Rochester, Minnesota
| | - Daniel K Partain
- Department of Internal Medicine, Mayo Clinic, Rochester, Minnesota
| | - Shahrukh Hashmi
- Division of Hematology, Department of Medicine, Mayo Clinic, Rochester, Minnesota
| | - Dennis A Gastineau
- Division of Hematology, Department of Medicine, Mayo Clinic, Rochester, Minnesota
| | - Aref Al-Kali
- Division of Hematology, Department of Medicine, Mayo Clinic, Rochester, Minnesota
| | - Robert C Wolf
- Department of Pharmacy Services, Mayo Clinic, Rochester, Minnesota
| | - Naseema Gangat
- Division of Hematology, Department of Medicine, Mayo Clinic, Rochester, Minnesota
| | - Mark R Litzow
- Division of Hematology, Department of Medicine, Mayo Clinic, Rochester, Minnesota
| | - William J Hogan
- Division of Hematology, Department of Medicine, Mayo Clinic, Rochester, Minnesota
| | - Mrinal M Patnaik
- Division of Hematology, Department of Medicine, Mayo Clinic, Rochester, Minnesota
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