151
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Tuberculosis and atypical mycobacterial infections in ruxolitinib-treated patients with primary or secondary myelofibrosis or polycythemia vera. Int J Infect Dis 2019; 80:134-136. [DOI: 10.1016/j.ijid.2019.01.002] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2018] [Revised: 12/23/2018] [Accepted: 01/04/2019] [Indexed: 12/13/2022] Open
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152
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Mikulska M, Cesaro S, de Lavallade H, Di Blasi R, Einarsdottir S, Gallo G, Rieger C, Engelhard D, Lehrnbecher T, Ljungman P, Cordonnier C. Vaccination of patients with haematological malignancies who did not have transplantations: guidelines from the 2017 European Conference on Infections in Leukaemia (ECIL 7). THE LANCET. INFECTIOUS DISEASES 2019; 19:e188-e199. [PMID: 30744964 DOI: 10.1016/s1473-3099(18)30601-7] [Citation(s) in RCA: 86] [Impact Index Per Article: 17.2] [Reference Citation Analysis] [Abstract] [Subscribe] [Scholar Register] [Received: 05/08/2018] [Revised: 08/21/2018] [Accepted: 09/18/2018] [Indexed: 12/28/2022]
Abstract
Patients with haematological malignancies are at high risk of infection because of various mechanisms of humoral and cell-mediated immune deficiencies, which mainly depend on underlying disease and specific therapies. Some of these infections are vaccine preventable. However, these malignancies are different from each other, and the treatment approaches are diverse and rapidly evolving, so it is difficult to have a common programme for vaccination in a haematology ward. Additionally, because of insufficient training about the topic, vaccination is an area often neglected by haematologists, and influenced by cultural differences, even among health-care workers, in compliance to vaccines. Several issues are encountered when addressing vaccination in haematology: the small size of the cohorts that makes it difficult to show the clinical benefits of vaccination, the subsequent need to rely on biological parameters, their clinical pertinence not being established in immunocompromised patients, scarcity of clarity on the optimal timing of vaccination in complex treatment schedules, and the scarcity of data on long-term protection in patients receiving treatments. Moreover, the risk of vaccine-induced disease with live-attenuated vaccines strongly limits their use. Here we summarise guidelines for patients without transplantations, and address the issue by the haematological group-myeloid and lymphoid-of diseases, with a special consideration for children with acute leukaemia.
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Affiliation(s)
- Malgorzata Mikulska
- University of Genoa (DISSAL) and IRCCS Ospedale Policlinico San Martino, Genova, Italy
| | - Simone Cesaro
- Pediatric Hematology Oncology Unit, Department of Mother and Child, Azienda Ospedaliera Universitaria Integrata, Verona, Italy
| | - Hugues de Lavallade
- Deparment of Haematological Medicine, King's College Hospital NHS Foundation Trust, London, UK
| | - Roberta Di Blasi
- Haematology Department, Henri Mondor Hospital, Assistance Publique-Hopitaux de Paris, Créteil, France
| | - Sigrun Einarsdottir
- Section of Hematology, Department of Medicine, Sahlgrenska University Hospital, Sahlgrenska Academy, Göteborg, Sweden
| | - Giuseppe Gallo
- Pediatric Hematology Oncology Unit, Department of Mother and Child, Azienda Ospedaliera Universitaria Integrata, Verona, Italy
| | - Christina Rieger
- Department of Hematology Oncology, University of Munich, Germering, Germany
| | - Dan Engelhard
- Department of Pediatrics, Hadassah-Hebrew University Medical Center, Ein-Kerem Jerusalem, Israel
| | - Thomas Lehrnbecher
- Paediatric Haematology and Oncology Department, Hospital for Children and Adolescents, University of Frankfurt, Frankfurt, Germany
| | - Per Ljungman
- Department of Cellular Therapy and Allogenenic Stem Cell Transplantation, Karolinska University Hospital, Stockholm, Sweden; Karolinska Institutet, Stockholm, Sweden
| | - Catherine Cordonnier
- Haematology Department, Henri Mondor Hospital, Assistance Publique-Hopitaux de Paris, Créteil, France; University Paris-Est Créteil, Créteil, France.
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153
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Moruno-Rodríguez A, Sánchez-Vicente JL, Rueda-Rueda T, Lechón-Caballero B, Muñoz-Morales A, López-Herrero F. Invasive aspergillosis manifesting as retinal necrosis in a patient treated with ruxolitinib. ACTA ACUST UNITED AC 2019; 94:237-241. [PMID: 30712951 DOI: 10.1016/j.oftal.2018.12.006] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2018] [Revised: 12/03/2018] [Accepted: 12/15/2018] [Indexed: 11/24/2022]
Abstract
A 30 year-old man with acute myeloblastic leukaemia and secondary myelodysplastic syndrome developed graft-versus-host disease. The patient was treated with ruxolitinib. After being treated for 3 months with ruxolitinib, an inhibitor of Janus kinase, he developed Aspergillus retinal necrosis resistant to common treatment. Treatment with Janus kinase inhibitors may lead to an increased incidence of opportunistic infections. Janus kinase inhibitor administration may result in poor treatment efficacy.
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Affiliation(s)
- A Moruno-Rodríguez
- Sección de Uveítis, Departamento de Oftalmología, Hospital Universitario Virgen del Rocío, Sevilla, España.
| | - J L Sánchez-Vicente
- Sección de Retina Quirúrgica, Departamento de Oftalmología, Hospital Universitario Virgen del Rocío, Sevilla, España
| | - T Rueda-Rueda
- Sección General, Departamento de Oftalmología, Hospital Universitario Virgen del Rocío, Sevilla, España
| | - B Lechón-Caballero
- Sección General, Departamento de Oftalmología, Hospital Universitario Virgen del Rocío, Sevilla, España
| | - A Muñoz-Morales
- Sección de Córnea, Departamento de Oftalmología, Hospital Universitario Virgen del Rocío, Sevilla, España
| | - F López-Herrero
- Sección de Retina Médica, Departamento de Oftalmología, Hospital Universitario Virgen del Rocío, Sevilla, España
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154
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Gilhar A, Keren A, Paus R. JAK inhibitors and alopecia areata. Lancet 2019; 393:318-319. [PMID: 30696569 DOI: 10.1016/s0140-6736(18)32987-8] [Citation(s) in RCA: 49] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2018] [Revised: 10/05/2018] [Accepted: 11/13/2018] [Indexed: 12/18/2022]
Affiliation(s)
- Amos Gilhar
- Skin Research Laboratory, Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel.
| | - Aviad Keren
- Skin Research Laboratory, Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel
| | - Ralf Paus
- Department of Dermatology & Cutaneous Surgery, University of Miami Miller School of Medicine, Miami, FL, USA; Centre for Dermatology Research, University of Manchester and NIHR Manchester Biomedical Research Centre, Manchester, UK
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155
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Gonzalez Vicent M, Molina B, Fabregat M, Segura M, Diaz MA. Toxoplasmosis and secondary Guillain-Barré associated with ruxolitinib as graft-versus-host disease treatment. Pediatr Blood Cancer 2019; 66:e27446. [PMID: 30207078 DOI: 10.1002/pbc.27446] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2018] [Revised: 08/17/2018] [Accepted: 08/20/2018] [Indexed: 11/07/2022]
Affiliation(s)
| | - Blanca Molina
- Stem Cell Transplant Unit, Hospital Niño Jesús, Madrid, Spain
| | - María Fabregat
- Stem Cell Transplant Unit, Hospital Niño Jesús, Madrid, Spain
| | - María Segura
- Stem Cell Transplant Unit, Hospital Niño Jesús, Madrid, Spain
| | - Miguel A Diaz
- Stem Cell Transplant Unit, Hospital Niño Jesús, Madrid, Spain
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156
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Helbig G. Classical Philadelphia-negative myeloproliferative neoplasms: focus on mutations and JAK2 inhibitors. Med Oncol 2018; 35:119. [PMID: 30074114 PMCID: PMC6096973 DOI: 10.1007/s12032-018-1187-3] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2018] [Accepted: 07/31/2018] [Indexed: 12/18/2022]
Abstract
Classical Philadelphia- negative myeloproliferative neoplasms (MPNs) encompass three main myeloid malignancies: polycythemia vera (PV), essential thrombocythemia (ET), and myelofibrosis (MF). Phenotype-driver mutations in Janus kinase 2 (JAK2), calreticulin (CALR), and myeloproliferative leukemia virus oncogene (MPL) genes are mutually exclusive and occur with a variable frequency. Driver mutations influence disease phenotype and prognosis. PV patients with JAK2 exon 14 mutation do not differ in number of thrombotic events, risk of leukemic and fibrotic transformation, and overall survival to those with JAK2 exon 12 mutation. Type 2-like CALR-mutated ET patients have lower risk of thrombosis if compared with those carrying JAK2 or type 1-like CALR mutation. For ET, overall survival is comparable between patients with JAK2 and either type 1-like and type 2-like CALR mutations. For MF, better OS is demonstrated for patients harboring a type 1-like CALR mutation than those with type 2-like CALR or JAK2. The discovery of driver mutations in MPNs has prompted the development of molecularly targeted therapy. Among JAK2 inhibitors, ruxolitinib (RUX) has been approved for (1) treatment of intermediate-2 and high-risk MF and (2) PV patients who are resistant to or intolerant to hydroxyurea. RUX reduces spleen size and alleviates disease symptoms in a proportion of MF patients. RUX in MF leads to prolonged survival and reduces risk of death. RUX controls hematocrit, reduces spleen size and alleviates symptoms in PV. Adverse events of RUX are moderate, however, its long-term use may be associated with opportunistic infections. Trials with other JAK2 inhibitors are ongoing.
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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.
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157
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How I treat myelofibrosis after failure of JAK inhibitors. Blood 2018; 132:492-500. [PMID: 29866811 DOI: 10.1182/blood-2018-02-785923] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2018] [Accepted: 05/28/2018] [Indexed: 12/16/2022] Open
Abstract
The introduction of JAK inhibitors, leading to regulatory approval of ruxolitinib, represents a major therapeutic advance in myelofibrosis (MF). Most patients experience reduction in splenomegaly and improved quality of life from symptom improvement. It is a paradox, however, that, despite inhibition of signaling downstream of disease-related driver mutations, JAK inhibitor treatment is not associated with consistent molecular or pathologic responses in MF. Furthermore, there are important limitations to JAK inhibitor therapy including development of dose-limiting cytopenias and/or nonhematological toxicities such as neuropathy or opportunistic infections. Over half of the patients discontinue treatment within 3 years of starting treatment. Although data are sparse, clinical outcome after JAK inhibitor "failure" is likely poor; consequently, it is important to understand patterns of failure to select appropriate salvage treatment(s). An algorithmic approach, particularly one that incorporates cytogenetics/molecular data, is most helpful in selecting stem cell transplant candidates. Treatment of transplant-ineligible patients relies on a problem-based approach that includes use of investigational drugs, or consideration of splenectomy or radiotherapy. Data from early phase ruxolitinib combination studies, despite promising preclinical data, have not shown clear benefit over monotherapy thus far. Development of effective treatment strategies for MF patients failing JAK inhibitors remains a major unmet need.
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158
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Tefferi A, Barraco D, Lasho TL, Shah S, Begna KH, Al-Kali A, Hogan WJ, Litzow MR, Hanson CA, Ketterling RP, Gangat N, Pardanani A. Momelotinib therapy for myelofibrosis: a 7-year follow-up. Blood Cancer J 2018; 8:29. [PMID: 29515114 PMCID: PMC5841331 DOI: 10.1038/s41408-018-0067-6] [Citation(s) in RCA: 45] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2017] [Revised: 01/21/2018] [Accepted: 01/25/2018] [Indexed: 11/08/2022] Open
Abstract
One-hundred Mayo Clinic patients with high/intermediate-risk myelofibrosis (MF) received momelotinib (MMB; JAK1/2 inhibitor) between 2009 and 2010, as part of a phase 1/2 trial (NCT00935987); 73% harbored JAK2 mutations, 16% CALR, 7% MPL, 44% ASXL1, and 18% SRSF2. As of July 2017, MMB was discontinued in 91% of the patients, after a median treatment duration of 1.4 years. Grade 3/4 toxicity included thrombocytopenia (34%) and liver/pancreatic test abnormalities (<10%); grade 1/2 peripheral neuropathy occurred in 47%. Clinical improvement (CI) occurred in 57% of patients, including 44% anemia and 43% spleen response. CI was more likely to occur in ASXL1-unmutated patients (66% vs 44%) and in those with <2% circulating blasts (66% vs 42%). Response was more durable in the presence of CALR type 1/like and absence of very high-risk karyotype. In multivariable analysis, absence of CALR type 1/like (HR 3.0; 95% CI 1.2-7.6) and presence of ASXL1 (HR 1.9; 95% CI 1.1-3.2) or SRSF2 (HR 2.4, 95% CI 1.3-4.5) mutations adversely affected survival. SRSF2 mutations (HR 4.7, 95% CI 1.3-16.9), very high-risk karyotype (HR 7.9, 95% CI 1.9-32.1), and circulating blasts ≥2% (HR 3.9, 95% CI 1.4-11.0) predicted leukemic transformation. Post-MMB survival (median 3.2 years) was not significantly different than that of a risk-matched MF cohort not receiving MMB.
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Affiliation(s)
- Ayalew Tefferi
- Division of Hematology, Department of Internal Medicine, Mayo Clinic, Rochester, MN, USA.
| | - Daniela Barraco
- Division of Hematology, Department of Internal Medicine, Mayo Clinic, Rochester, MN, USA
| | - Terra L Lasho
- Division of Hematology, Department of Internal Medicine, Mayo Clinic, Rochester, MN, USA
| | - Sahrish Shah
- Division of Hematology, Department of Internal Medicine, Mayo Clinic, Rochester, MN, USA
| | - Kebede H Begna
- Division of Hematology, Department of Internal Medicine, Mayo Clinic, Rochester, MN, USA
| | - Aref Al-Kali
- Division of Hematology, Department of Internal Medicine, Mayo Clinic, Rochester, MN, USA
| | - William J Hogan
- Division of Hematology, Department of Internal Medicine, Mayo Clinic, Rochester, MN, USA
| | - Mark R Litzow
- Division of Hematology, Department of Internal Medicine, Mayo Clinic, Rochester, MN, USA
| | - Curtis A Hanson
- Division of Hematopathology, Department of Laboratory Medicine, Mayo Clinic, Rochester, MN, USA
| | - Rhett P Ketterling
- Division of Cytogenetics, Department of Laboratory Medicine, Mayo Clinic, Rochester, MN, USA
| | - Naseema Gangat
- Division of Hematology, Department of Internal Medicine, Mayo Clinic, Rochester, MN, USA
| | - Animesh Pardanani
- Division of Hematology, Department of Internal Medicine, Mayo Clinic, Rochester, MN, USA
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