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Abstract
PURPOSE OF REVIEW Myeloproliferative neoplasms (MPNs) are recognized for their debilitating symptom burdens. The purpose of this review is to understand the complexity of the MPN symptom burden and identify how validated MPN Patient Reported Outcome (PRO) tools may be integrated into clinical practice to assess the MPN symptom burden. RECENT FINDINGS Significant heterogeneity exists both within and between MPN subtypes. Surrogates of disease burden such as risk scores and MPN chronicity often fail to correlate with symptomatic burden. Validated MPN PROs allow for precise and rapid assessment of the MPN symptom burden in clinical and trial settings. Their growing use among investigators has resulted in improved understanding of how the MPN disease burden and overall patient experience is impacted by novel and traditional therapies. PRO tools are an integral part of National Comprehensive Cancer Center (NCCN) guidelines for MPN treatment and should be regularly employed in disease burden assessment.
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Affiliation(s)
- Holly Geyer
- Division of Hospital Internal Medicine, Mayo Clinic, Scottsdale, AZ, USA
| | - Ruben A Mesa
- Division of Hematology and Medical Oncology, Mayo Clinic, 5777 E Mayo Blvd, Phoenix, AZ, 85054, USA.
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202
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Kamory E, Schmidt T, Broquere C, Peters H, Hocher B. Two Novel Monoallelic Calreticulin Mutations in a Patient With Essential Thrombocythemia. J Hematol 2017; 6:105-108. [PMID: 32300403 PMCID: PMC7155843 DOI: 10.14740/jh335w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2017] [Accepted: 08/30/2017] [Indexed: 11/24/2022] Open
Abstract
Recently, mutations have been identified in the calreticulin (CALR) gene in JAK2 or myeloproliferative leukemia negative patients with myeloproliferative neoplasm. A 49-year-old male patient with incidental thrombocytosis was investigated for CALR mutation by direct sequencing method. The patient carried two novel monoallelic somatic mutations, the L367fs*52 and the p.R368W in the CALR gen, which resulted in a novel C-terminal sequence. The absent endoplasmatic reticulum retention signal in the mutant CALR results in an altered subcellular localization of the mutant protein. The new positively charged C-terminal domain has an importance for oncogenicity, effecting different signaling pathways, activating the cytokine-independent growth of the cells and down-regulating the apoptotic signaling. But the new, alternative C-terminal domain offers an opportunity for immunologic therapy as it represents a cancer-specific epitope.
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Affiliation(s)
- Eniko Kamory
- IFLb Laboratoriumsmedizin Berlin GmbH, Windscheidstraße 18, 10627 Berlin, Germany
| | | | - Cedric Broquere
- IFLb Laboratoriumsmedizin Berlin GmbH, Windscheidstraße 18, 10627 Berlin, Germany
| | - Hartmut Peters
- Institute of Medical Genetics and Humangenetics, Charite, Berlin, Germany
| | - Berthold Hocher
- IFLb Laboratoriumsmedizin Berlin GmbH, Windscheidstraße 18, 10627 Berlin, Germany
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203
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Samuelson Bannow BT, Salit RB, Storer BE, Stevens EA, Wu D, Yeung C, Fang M, Petersdorf EW, Linenberger ML, Woo J, Sorror ML, Doney K, Sandmaier BM, Deeg HJ, Scott BL. Hematopoietic Cell Transplantation for Myelofibrosis: the Dynamic International Prognostic Scoring System Plus Risk Predicts Post-Transplant Outcomes. Biol Blood Marrow Transplant 2017; 24:386-392. [PMID: 28970176 DOI: 10.1016/j.bbmt.2017.09.016] [Citation(s) in RCA: 44] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2017] [Accepted: 09/21/2017] [Indexed: 01/21/2023]
Abstract
Hematopoietic cell transplantation (HCT) provides potentially curative treatment for patients with myelofibrosis (MF). HCT outcomes are associated with the Dynamic International Prognostic Scoring System (DIPSS) risk scores. In the present study we analyzed results in 233 patients to determine if the DIPSS plus classification, which adds cytogenetics, thrombocytopenia, and RBC transfusion dependence as risk factors, would better predict post-HCT outcomes than the original DIPSS. Multivariate analysis showed that each risk parameter incorporated into the DIPPS plus model contributed to its predictive power of overall mortality, relapse-free survival, and nonrelapse mortality. The 5-year overall survival (OS), relapse, and treatment-related mortality (TRM) rates for patients with low/intermediate-1 risk MF were 78%, 5%, and 20%, respectively. The 5-year OS, relapse, and TRM rates for patients with high-risk MF were 35%, 28%, and 40%, respectively. The HCT-specific comorbidity index of 3 or greater was associated with higher nonrelapse and overall mortality and reduced relapse-free survival. The relapse incidence was significantly increased in older patients (HR, 3.02; P = .0007). With a median follow-up of 8 years 124 patients (53%) were surviving. The components of the DIPSS plus classification still have prognostic relevance after adjustment by the DIPSS classification. This information should enhance our ability to advise patients when making decisions regarding timing of transplant.
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Affiliation(s)
- Bethany T Samuelson Bannow
- Fred Hutchinson Cancer Research Center, the University of Washington Medical Center/Seattle Cancer Care Alliance, Seattle, Washington
| | - Rachel B Salit
- Fred Hutchinson Cancer Research Center, the University of Washington Medical Center/Seattle Cancer Care Alliance, Seattle, Washington
| | - Barry E Storer
- Fred Hutchinson Cancer Research Center, the University of Washington Medical Center/Seattle Cancer Care Alliance, Seattle, Washington
| | - Emily A Stevens
- Fred Hutchinson Cancer Research Center, the University of Washington Medical Center/Seattle Cancer Care Alliance, Seattle, Washington
| | - David Wu
- Fred Hutchinson Cancer Research Center, the University of Washington Medical Center/Seattle Cancer Care Alliance, Seattle, Washington
| | - Cecilia Yeung
- Fred Hutchinson Cancer Research Center, the University of Washington Medical Center/Seattle Cancer Care Alliance, Seattle, Washington
| | - Min Fang
- Fred Hutchinson Cancer Research Center, the University of Washington Medical Center/Seattle Cancer Care Alliance, Seattle, Washington
| | - Effie W Petersdorf
- Fred Hutchinson Cancer Research Center, the University of Washington Medical Center/Seattle Cancer Care Alliance, Seattle, Washington
| | - Michael L Linenberger
- Fred Hutchinson Cancer Research Center, the University of Washington Medical Center/Seattle Cancer Care Alliance, Seattle, Washington
| | - Janghee Woo
- Fred Hutchinson Cancer Research Center, the University of Washington Medical Center/Seattle Cancer Care Alliance, Seattle, Washington
| | - Mohamed L Sorror
- Fred Hutchinson Cancer Research Center, the University of Washington Medical Center/Seattle Cancer Care Alliance, Seattle, Washington
| | - Kris Doney
- Fred Hutchinson Cancer Research Center, the University of Washington Medical Center/Seattle Cancer Care Alliance, Seattle, Washington
| | - Brenda M Sandmaier
- Fred Hutchinson Cancer Research Center, the University of Washington Medical Center/Seattle Cancer Care Alliance, Seattle, Washington
| | - H Joachim Deeg
- Fred Hutchinson Cancer Research Center, the University of Washington Medical Center/Seattle Cancer Care Alliance, Seattle, Washington
| | - Bart L Scott
- Fred Hutchinson Cancer Research Center, the University of Washington Medical Center/Seattle Cancer Care Alliance, Seattle, Washington.
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204
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Lucijanic M, Livun A, Stoos-Veic T, Pejsa V, Jaksic O, Cicic D, Lucijanic J, Romic Z, Orehovec B, Aralica G, Miletic M, Kusec R. High absolute basophil count is a powerful independent predictor of inferior overall survival in patients with primary myelofibrosis. Hematology 2017; 23:201-207. [PMID: 28906207 DOI: 10.1080/10245332.2017.1376843] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
Affiliation(s)
- Marko Lucijanic
- Hematology Department, University Hospital Dubrava, Zagreb, Croatia
| | - Ana Livun
- Divison of Molecular Diagnosis and Genetics, Clinical Department of Laboratory Diagnostics, University Hospital Dubrava, Zagreb, Croatia
| | - Tajana Stoos-Veic
- Department of Clinical Cytology and Cytometry, University Hospital Dubrava, Zagreb, Croatia
- Faculty of Medicine, University of Osijek, Osijek, Croatia
| | - Vlatko Pejsa
- Hematology Department, University Hospital Dubrava, Zagreb, Croatia
- School of Medicine, University of Zagreb, Zagreb, Croatia
| | - Ozren Jaksic
- Hematology Department, University Hospital Dubrava, Zagreb, Croatia
- School of Medicine, University of Zagreb, Zagreb, Croatia
| | - David Cicic
- Hematology Department, University Hospital Dubrava, Zagreb, Croatia
| | | | - Zeljko Romic
- Clinical Department of Laboratory Diagnostics, University Hospital Dubrava, Zagreb, Croatia
| | - Biserka Orehovec
- Clinical Department of Laboratory Diagnostics, University Hospital Dubrava, Zagreb, Croatia
| | - Gorana Aralica
- School of Medicine, University of Zagreb, Zagreb, Croatia
- Pathology Department, University Hospital Dubrava, Zagreb, Croatia
| | - Marko Miletic
- Radiology Department, General Hospital Dubrovnik, Dubrovnik, Croatia
| | - Rajko Kusec
- Hematology Department, University Hospital Dubrava, Zagreb, Croatia
- Divison of Molecular Diagnosis and Genetics, Clinical Department of Laboratory Diagnostics, University Hospital Dubrava, Zagreb, Croatia
- School of Medicine, University of Zagreb, Zagreb, Croatia
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205
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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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206
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Korkmaz S. Non-Classic Myeloproliferative Neoplasms: Are We Really Aware of These Rare Diseases in Daily Practice? EUROPEAN MEDICAL JOURNAL 2017. [DOI: 10.33590/emj/10313765] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Chronic neutrophilic leukaemia (CNL), chronic eosinophilic leukaemia-not otherwise specified (CEL-NOS), and myeloproliferative neoplasm (MPN), unclassifiable are rare clonal diseases, known as ‘non-classic myeloproliferative neoplasms’. They are diagnosed largely based on exclusion of underlying reactive causes by patient history, physical examination, serological tests, and imaging studies. As well as peripheral blood testing, bone marrow examination is mandatory to exclude bone marrow infiltrating conditions such as multiple myeloma, acute leukaemias, etc. Today, molecular genetic classification should be undertaken to establish accurate diagnosis, in addition to the traditional morphological classification of MPN. Therefore, molecular genetic testing should take part in the diagnostic work-up of suspected patients with rare MPN. Of CNL patients, 90% (and in some datasets 100%) have mutations in CSF3R, which has led to the addition of this finding to the diagnostic criteria for CNL. The absence of rearrangements of FIP1L1/PDGFRA, PDGFRA, PDGFRB, FGFR1, and PCM1-JAK2 fusions should prompt consideration of a diagnosis of chronic eosinophilic leukaemia-not otherwise specified. MPN, unclassifiable, the least frequent type, is considered when an MPN has definite MPN features but does not meet diagnostic criteria for either the classic or the other non-classic MPN. They all share common symptoms and findings. Transformation to acute leukaemia is still a major clinical problem. Since no standard of care exists, the treatment approach is still symptomatic for all. This is an indicator that we really need disease-modifying drugs against initial diagnostic molecular markers, such as CSF3R inhibitors, which might change the natural history of these disorders. Therefore, participation in clinical trials is mandatory for this extremely rare patient population.
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Affiliation(s)
- Serdal Korkmaz
- Department of Hematology, Kayseri Training and Research Hospital, Kayseri, Turkey
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207
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ElNahass YH, Mahmoud HK, Mattar MM, Fahmy OA, Samra MA, Abdelfattah RM, ElRefaey FA, Fahmy HM, Fathy GM, Abdulgawad A, AbdelKader M, Elleithy HN, Gamil M, Talaat M, Nader HA, ElMetnawy WH. MPN10 score and survival of molecularly annotated myeloproliferative neoplasm patients. Leuk Lymphoma 2017; 59:844-854. [DOI: 10.1080/10428194.2017.1365852] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Affiliation(s)
| | | | | | | | | | | | | | | | | | | | | | | | - Mona Gamil
- Faculty of Medicine, Cairo University, Cairo, Egypt
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208
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Tefferi A, Vannucchi AM. Genetic Risk Assessment in Myeloproliferative Neoplasms. Mayo Clin Proc 2017; 92:1283-1290. [PMID: 28778261 DOI: 10.1016/j.mayocp.2017.06.002] [Citation(s) in RCA: 46] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2017] [Revised: 06/05/2017] [Accepted: 06/06/2017] [Indexed: 12/31/2022]
Abstract
The World Health Organization classification system recognizes 4 variants of JAK2 mutation-enriched myeloproliferative neoplasms (for expansion of gene symbols, use search tool at www.genenames.org): essential thrombocythemia (ET), polycythemia vera (PV), primary myelofibrosis (PMF), and prefibrotic PMF. All 4 disorders are characterized by stem cell-derived clonal myeloproliferation with mutually exclusive driver mutations, including JAK2, CALR, and MPL. The median survival is approximately 20 years for ET, 14 years for PV, and 6 years for PMF; age is the most important determinant of survival with the corresponding median of 33, 24, and 15 years in patients younger than 60 years. Genetic information is the second most important prognostic tool and includes karyotype, driver mutational status, and presence of specific other mutations. Karyotype has been shown to carry prognostic relevance in PV (abnormal vs normal) and PMF (unfavorable vs favorable abnormalities). Driver mutational status is prognostically most relevant in PMF; type 1/type 1-like CALR vs other driver mutational status has been associated with superior survival. In ET, arterial thrombosis risk is higher in patients with JAK2 or MPL mutations whereas MPL-mutated patients might be at risk for accelerated fibrotic progression. ASXL1 and SRSF2 mutations have been associated with inferior overall, leukemia-free, or fibrosis-free survival in both PV and PMF, and a recent targeted sequencing study has identified additional other adverse mutations in both these disorders, as well as in ET. Further enhancement of genetic risk stratification in myeloproliferative neoplasms is possible by combining cytogenetic and mutation information and developing a prognostic model that is adjusted for age.
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Affiliation(s)
- Ayalew Tefferi
- Division of Hematology, Department of Medicine, Mayo Clinic, Rochester, MN.
| | - Alessandro Maria Vannucchi
- Department of Experimental and Clinical Medicine, CRIMM, Center Research and Innovation of Myeloproliferative Neoplasms, Azienda Ospedaliera Universitaria Careggi, University of Florence, Florence, Italy
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209
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Nangalia J, Grinfeld J, Green AR. Pathogenesis of Myeloproliferative Disorders. ANNUAL REVIEW OF PATHOLOGY-MECHANISMS OF DISEASE 2017; 11:101-26. [PMID: 27193452 DOI: 10.1146/annurev-pathol-012615-044454] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Myeloproliferative neoplasms (MPNs) are a set of chronic hematopoietic neoplasms with overlapping clinical and molecular features. Recent years have witnessed considerable advances in our understanding of their pathogenetic basis. Due to their protracted clinical course, the evolution to advanced hematological malignancies, and the accessibility of neoplastic tissue, the study of MPNs has provided a window into the earliest stages of tumorigenesis. With the discovery of mutations in CALR, the majority of MPN patients now bear an identifiable marker of clonal disease; however, the mechanism by which mutated CALR perturbs megakaryopoiesis is currently unresolved. We are beginning to understand better the role of JAK2(V617F) homozygosity, the function of comutations in epigenetic regulators and spliceosome components, and how these mutations cooperate with JAK2(V617F) to modulate MPN phenotype.
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Affiliation(s)
- Jyoti Nangalia
- Department of Haematology, Cambridge Institute for Medical Research and Wellcome Trust/MRC Stem Cell Institute, University of Cambridge, Cambridge CB2 0XY, United Kingdom; .,Department of Haematology, Addenbrooke's Hospital, Cambridge CB2 2QR, United Kingdom
| | - Jacob Grinfeld
- Department of Haematology, Cambridge Institute for Medical Research and Wellcome Trust/MRC Stem Cell Institute, University of Cambridge, Cambridge CB2 0XY, United Kingdom; .,Department of Haematology, Addenbrooke's Hospital, Cambridge CB2 2QR, United Kingdom
| | - Anthony R Green
- Department of Haematology, Cambridge Institute for Medical Research and Wellcome Trust/MRC Stem Cell Institute, University of Cambridge, Cambridge CB2 0XY, United Kingdom; .,Department of Haematology, Addenbrooke's Hospital, Cambridge CB2 2QR, United Kingdom
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210
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Margolskee E, Hasserjian RP, Hassane D, Tam W, Mathew S, Ok CY, Wang SA, Oak J, Arber DA, Orazi A. Myelodysplastic Syndrome, Unclassifiable (MDS-U) With 1% Blasts Is a Distinct Subgroup of MDS-U With a Poor Prognosis. Am J Clin Pathol 2017; 148:49-57. [PMID: 28927162 DOI: 10.1093/ajcp/aqx043] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
OBJECTIVES Three situations qualify as myelodysplastic syndrome, unclassifiable (MDS-U): (1) refractory cytopenia with dysplasia and 1% blasts in peripheral blood (BL), (2) pancytopenia with unilineage dysplasia (Pan), and (3) persistent cytopenia, less than 5% bone marrow blasts, and less than 10% dysplastic cells and presence of MDS-defining cytogenetic abnormalities (CG). We compared the clinicopathologic features and mutational profiles for these three groups. METHODS MDS-U cases were reviewed at four major academic institutions. Targeted next-generation sequencing for genes implicated in myeloid neoplasms was performed in a subset of cases. RESULTS Twenty-seven patients were identified (six MDS-U BL, 13 MDS-U Pan, and eight MDS-U CG). Clonal cytogenetic abnormalities were found in six of six, seven of 13, and eight of eight cases in MDS-U BL, Pan, and CG, respectively (P > .05). Overall, four of six patients with MDS-U BL progressed to acute myeloid leukemia; no MDS-U Pan or CG patients did. The rates of progression-free survival and mortality (overall survival) were significantly higher in MDS-U BL compared with Pan and CG (P < .001 for both). CONCLUSIONS We find that MDS-U BL is a distinct subset of MDS-U with a poor prognosis, while MDS-U Pan and CG are relatively indolent. Evaluation of peripheral blood smears in patients with MDS is essential for accurate classification and prognosis.
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Affiliation(s)
- Elizabeth Margolskee
- Department of Pathology and Laboratory Medicine, Weill Cornell Medical College/New York Presbyterian Hospital, New York, NY
| | | | - Duane Hassane
- Department of Pathology and Laboratory Medicine, Weill Cornell Medical College/New York Presbyterian Hospital, New York, NY
| | - Wayne Tam
- Department of Pathology and Laboratory Medicine, Weill Cornell Medical College/New York Presbyterian Hospital, New York, NY
| | - Susan Mathew
- Department of Pathology and Laboratory Medicine, Weill Cornell Medical College/New York Presbyterian Hospital, New York, NY
| | - Chi Young Ok
- Department of Hematopathology, University of Texas M.D. Anderson Cancer Center, Houston
| | - Sa A Wang
- Department of Hematopathology, University of Texas M.D. Anderson Cancer Center, Houston
| | - Jean Oak
- Department of Pathology, Stanford University Medical Center, Stanford, CA
| | - Daniel A Arber
- Department of Pathology, Stanford University Medical Center, Stanford, CA
| | - Attilio Orazi
- Department of Pathology and Laboratory Medicine, Weill Cornell Medical College/New York Presbyterian Hospital, New York, NY
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211
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Yogarajah M, Tefferi A. Leukemic Transformation in Myeloproliferative Neoplasms: A Literature Review on Risk, Characteristics, and Outcome. Mayo Clin Proc 2017; 92:1118-1128. [PMID: 28688466 DOI: 10.1016/j.mayocp.2017.05.010] [Citation(s) in RCA: 73] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2017] [Revised: 05/08/2017] [Accepted: 05/17/2017] [Indexed: 01/01/2023]
Abstract
Myeloproliferative neoplasms (MPNs) operationally include essential thrombocythemia, polycythemia vera, primary myelofibrosis (PMF), and prefibrotic PMF. All 4 MPN variants might progress into blast-phase disease (MPN-BP). For essential thrombocythemia, reported risk factors for leukemic transformation include advanced age, extreme thrombocytosis, anemia, leukocytosis, and sequence variants/mutations involving TP53 and EZH2 (for expansion of gene symbols, see www.genenames.org); for polycythemia vera, advanced age, leukocytosis, abnormal karyotype, mutations involving SRSF2 and IDH2, and treatment with pipobroman, chlorambucil, or P32; and for PMF, increased blast percentage, thrombocytopenia, abnormal karyotype, triple-negative driver mutational status, and sequence variants/mutations involving SRSF2, RUNX1, CEBPA, and SH2B3. The reported median survival figures for MPN-BP range from 1.5 to 2.5 months in patients treated with supportive care only, from 2.5 to 10 months in those receiving hypomethylating agents or low-dose chemotherapy, and from 3.9 to 9.4 months in those receiving induction chemotherapy. Three-year survival after allogeneic stem cell transplant was reported in 16% to 33% of patients. These observations validate the extremely poor prognosis associated with MPN-BP and the lack of effective drug therapy and highlight the need for urgent assessment of therapeutic values of investigational agents. In the meantime, affected patients might be best served with aggressive chemotherapy followed by allogeneic stem cell transplant after adequate blast clearance.
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Affiliation(s)
- Meera Yogarajah
- Division of Hematology and Oncology, Brody School of Medicine, East Carolina University, Greenville, NC
| | - Ayalew Tefferi
- Division of Hematology, Department of Medicine, Mayo Clinic, Rochester, MN.
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212
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Saeed I, McLornan D, Harrison CN. Managing side effects of JAK inhibitors for myelofibrosis in clinical practice. Expert Rev Hematol 2017; 10:617-625. [PMID: 28571503 DOI: 10.1080/17474086.2017.1337507] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
INTRODUCTION Myelofibrosis (MF) is characterized by bone marrow fibrosis, abnormalities in peripheral counts, extramedullary hematopoiesis, splenomegaly and an increased risk of transformation to acute myeloid leukaemia. The disease course is often heterogeneous and management can range from observation alone through to allogeneic stem cell transplantation. As of 2017, the only approved medication for MF remains the JAK Inhibitor (JAKi), ruxolitinib (Novartis Pharmaceuticals, Basel, Switzerland; Incyte, Wilmington, Detroit, USA) although several others have reached advanced stages of clinical trials. Areas covered: In this review, we focus on the management of both common and uncommon side effects arising from the use of currently approved and clinical trial JAKi. Most of the discussion concerns ruxolitinib although we also cover both pacritinib (CTI BioPharma) and momelotinib (Gilead Sciences, Foster City, California) which have been in recent large, multinational phase III trials. The various approaches to management of JAKi-related side effects are discussed - with particular emphasis to anaemia, thrombocytopaenia and infection risk. Expert commentary: JAK inhibitors are effective in many individuals with MF and have revolutionized the current treatment paradigm. The side effect profile, in the most, is predictable and manageable with high degrees of clinical surveillance and dose modifications.
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Affiliation(s)
- Iram Saeed
- a Department of Haematological Medicine , King's College Hospital NHS Foundation Trust , London , UK
| | - Donal McLornan
- a Department of Haematological Medicine , King's College Hospital NHS Foundation Trust , London , UK.,b Department of Haematology , Guy's and St Thomas' NHS Foundation Trust , London , UK
| | - Claire N Harrison
- a Department of Haematological Medicine , King's College Hospital NHS Foundation Trust , London , UK
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213
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A clinical-molecular prognostic model to predict survival in patients with post polycythemia vera and post essential thrombocythemia myelofibrosis. Leukemia 2017; 31:2726-2731. [PMID: 28561069 DOI: 10.1038/leu.2017.169] [Citation(s) in RCA: 210] [Impact Index Per Article: 30.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2017] [Revised: 04/27/2017] [Accepted: 05/18/2017] [Indexed: 12/26/2022]
Abstract
Polycythemia vera (PV) and essential thrombocythemia (ET) are myeloproliferative neoplasms with variable risk of evolution into post-PV and post-ET myelofibrosis, from now on referred to as secondary myelofibrosis (SMF). No specific tools have been defined for risk stratification in SMF. To develop a prognostic model for predicting survival, we studied 685 JAK2, CALR, and MPL annotated patients with SMF. Median survival of the whole cohort was 9.3 years (95% CI: 8-not reached-NR-). Through penalized Cox regressions we identified negative predictors of survival and according to beta risk coefficients we assigned 2 points to hemoglobin level <11 g/dl, to circulating blasts ⩾3%, and to CALR-unmutated genotype, 1 point to platelet count <150 × 109/l and to constitutional symptoms, and 0.15 points to any year of age. Myelofibrosis Secondary to PV and ET-Prognostic Model (MYSEC-PM) allocated SMF patients into four risk categories with different survival (P<0.0001): low (median survival NR; 133 patients), intermediate-1 (9.3 years, 95% CI: 8.1-NR; 245 patients), intermediate-2 (4.4 years, 95% CI: 3.2-7.9; 126 patients), and high risk (2 years, 95% CI: 1.7-3.9; 75 patients). Finally, we found that the MYSEC-PM represents the most appropriate tool for SMF decision-making to be used in clinical and trial settings.
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214
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Alvarez-Larrán A, Senín A, Fernández-Rodríguez C, Pereira A, Arellano-Rodrigo E, Gómez M, Ferrer-Marin F, Martínez-López J, Camacho L, Colomer D, Angona A, Navarro B, Cervantes F, Besses C, Bellosillo B, Hernández-Boluda JC. Impact of genotype on leukaemic transformation in polycythaemia vera and essential thrombocythaemia. Br J Haematol 2017; 178:764-771. [DOI: 10.1111/bjh.14762] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2017] [Accepted: 03/29/2017] [Indexed: 12/25/2022]
Affiliation(s)
- Alberto Alvarez-Larrán
- Haematology Department; Hospital del Mar-IMIM; Universidad Autónoma de Barcelona; Barcelona Spain
| | - Alicia Senín
- Haematology Department; Hospital del Mar-IMIM; Universidad Autónoma de Barcelona; Barcelona Spain
| | | | - Arturo Pereira
- Haemotherapy and Haemostasis Department; Hospital Clínic-IDIBAPS; Barcelona Spain
| | | | - Montse Gómez
- Haematology Department; Hospital Clínico-INCLIVA; Valencia Spain
| | - Francisca Ferrer-Marin
- Haematology and Medical Oncology; Hospital Morales-Messeguer; CIBERER; UCAM; Murcia Spain
| | | | - Laura Camacho
- Pathology Department-IMIM; Hospital del Mar; Universidad Pompeu Fabra; Barcelona Spain
| | - Dolors Colomer
- Haematopathology Unit; Hospital Clínic-IDIBAPS; Barcelona Spain
| | - Anna Angona
- Haematology Department; Hospital del Mar-IMIM; Universidad Autónoma de Barcelona; Barcelona Spain
| | - Blanca Navarro
- Haematology Department; Hospital Clínico-INCLIVA; Valencia Spain
| | | | - Carlos Besses
- Haematology Department; Hospital del Mar-IMIM; Universidad Autónoma de Barcelona; Barcelona Spain
| | - Beatriz Bellosillo
- Pathology Department-IMIM; Hospital del Mar; Universidad Pompeu Fabra; Barcelona Spain
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Co-mutated CALR and MPL driver genes in a patient with myeloproliferative neoplasm. Ann Hematol 2017; 96:1399-1401. [PMID: 28516193 DOI: 10.1007/s00277-017-3023-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2017] [Accepted: 05/08/2017] [Indexed: 12/13/2022]
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216
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Finazzi MC, Lussana F, Salmoiraghi S, Spinelli O, Rambaldi A. Detection of driver and subclonal mutations in myelofibrosis: clinical impact on pharmacologic and transplant based treatment strategies. Expert Rev Hematol 2017; 10:627-636. [PMID: 28504024 DOI: 10.1080/17474086.2017.1331125] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
INTRODUCTION Myelofibrosis (MF) is the most aggressive form among Philadelphia negative (Ph-) myeloproliferative neoplasms (MPNs). In the last years, the mutational landscape of MF has expanded remarkably by the identification of additional recurrent mutations, called subclonal mutations. Areas covered: Here we describe the available data about the currently identified subclonal mutations and their prognostic value in MF patients. We also review the practical value of including such molecular information in available prognostic models for both outcome prediction and possibly treatment decision with regards to transplant indication. Lastly, we covered the available data on the application of molecular markers for minimal residual disease (MRD) monitoring after transplantation. Expert commentary: The demonstration of the prognostic value of additional mutations suggests to define this molecular profile at diagnosis and when an allogeneic transplant can be advised, particularly in younger patients. The presence of molecular markers might offer the possibility to evaluate the depth of remission and to monitor MRD after transplantation. Prospective clinical studies are needed to validate the use of this molecular data in the routine clinical practice.
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Affiliation(s)
- Maria Chiara Finazzi
- a Hematology and Bone Marrow Transplant Unit, Azienda Socio Sanitaria Territoriale Papa Giovanni XXIII , Bergamo , Italy
| | - Federico Lussana
- a Hematology and Bone Marrow Transplant Unit, Azienda Socio Sanitaria Territoriale Papa Giovanni XXIII , Bergamo , Italy
| | - Silvia Salmoiraghi
- a Hematology and Bone Marrow Transplant Unit, Azienda Socio Sanitaria Territoriale Papa Giovanni XXIII , Bergamo , Italy
| | - Orietta Spinelli
- a Hematology and Bone Marrow Transplant Unit, Azienda Socio Sanitaria Territoriale Papa Giovanni XXIII , Bergamo , Italy
| | - Alessandro Rambaldi
- a Hematology and Bone Marrow Transplant Unit, Azienda Socio Sanitaria Territoriale Papa Giovanni XXIII , Bergamo , Italy.,b Department of Oncology and Hematology , Università degli Studi di Milano , Milan , Italy
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217
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Tashkandi H, Moore EM, Tomlinson B, Goebel T, Sadri N. Co-occurrence of type I CALR and two MPL mutations in patient with primary myelofibrosis. Ann Hematol 2017; 96:1417-1418. [PMID: 28502030 DOI: 10.1007/s00277-017-3022-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2017] [Accepted: 05/08/2017] [Indexed: 01/19/2023]
Affiliation(s)
- Hammad Tashkandi
- Department of Pathology and Laboratory Medicine, Case Western Reserve University School of Medicine, Cleveland, OH, USA
| | - Erika M Moore
- Department of Pathology and Laboratory Medicine, Case Western Reserve University School of Medicine, Cleveland, OH, USA
| | - Benjamin Tomlinson
- Department of Hematology and Oncology, Case Western Reserve University School of Medicine, Cleveland, OH, USA
| | - Teresa Goebel
- Department of Hematology and Oncology, Case Western Reserve University School of Medicine, Cleveland, OH, USA
| | - Navid Sadri
- Department of Pathology and Laboratory Medicine, Case Western Reserve University School of Medicine, Cleveland, OH, USA. .,University Hospitals Cleveland Medical Center, 11100 Euclid Avenue, Cleveland, OH, 44106, USA.
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218
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Bose P, Abou Zahr A, Verstovsek S. Investigational Janus kinase inhibitors in development for myelofibrosis. Expert Opin Investig Drugs 2017; 26:723-734. [PMID: 28441920 DOI: 10.1080/13543784.2017.1323871] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
INTRODUCTION Since the discovery of the activating V617F mutation in Janus kinase 2 (JAK2), a number of pharmacologic inhibitors of JAK2 have entered clinical trials for patients with myelofibrosis. However, ruxolitinib, approved in 2011, remains the only one currently available for treatment of myelofibrosis, with many others having been discontinued for toxicity, and considerable uncertainty surrounding the future of those still in development. Areas covered: The available clinical data on pacritinib and momelotinib, the two agents in the most advanced phases of clinical testing in myelofibrosis, are examined in detail. NS-018 and INCB039110, selective inhibitors of JAK2 and JAK1, respectively, are also discussed. Finally, the JAK2 inhibitors no longer in clinical development are summarized in tabular form. Expert opinion: The different agents evaluated clearly differ in their kinomes, toxicity profiles and potential for myelosuppression. If approved, the JAK2-specific non-myelosuppressive inhibitor pacritinib could fulfill a major unmet need, that of patients with significant cytopenias. However, toxicity concerns persist. The data from the pivotal trials of momelotinib do not support its approval, although improvement of anemia is an important benefit. Selective JAK1 inhibition alone is unlikely to succeed in myelofibrosis. In these circumstances, rational ruxolitinib-based combinations may represent the best way forward.
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Affiliation(s)
- Prithviraj Bose
- a Department of Leukemia , University of TX MD Anderson Cancer Center , Houston , TX , USA
| | - Abdallah Abou Zahr
- a Department of Leukemia , University of TX MD Anderson Cancer Center , Houston , TX , USA
| | - Srdan Verstovsek
- a Department of Leukemia , University of TX MD Anderson Cancer Center , Houston , TX , USA
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219
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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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Abstract
INTRODUCTION Myelofibrosis (MF) is characterized by bone marrow fibrosis with subsequent extramedullary hematopoiesis and abnormal cytokine expression leading to splenomegaly, constitutional symptoms and cytopenias. The discovery of the JAK2 V617F mutation in the majority of MF patients has been followed by significant progress in drug development for MF. Areas covered: In this article, we review advances in the understanding of the underlying disease biology, prognostic assessment and therapeutic modalities for MF. We provide clinical trial evidence behind using the JAK2 inhibitor ruxolitinib, erythropoiesis stimulating agents, androgens, immunomodulatory drugs, interferon, cytoreductive drugs and hypomethylating agents in MF. Finally, we review novel therapeutic options for MF including the new JAK1/2 inhibitors, ruxolitinib based combination approaches as well as novel therapeutic agents. Expert commentary: Despite significant reduction of splenomegaly and improvement of symptom burden and a signal for survival improvement, ruxolitinib does not lead to major reductions in JAK2 V617F allele burden and bone marrow fibrosis. No ruxolitinib-based combination approach has so far demonstrated superiority over ruxolitinib monotherapy. The novel JAK2 inhibitors pacritinib and momelotinib, other JAK inhibitors, telomerase inhibitors, anti-fibrosis agents and hsp90 inhibitors are in different stages of development.
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Affiliation(s)
- Maximilian Stahl
- a Yale University School of Medicine , Department of Internal Medicine, Section of Hematology and the Yale Cancer Center , New Haven , CT , USA
| | - Amer M Zeidan
- a Yale University School of Medicine , Department of Internal Medicine, Section of Hematology and the Yale Cancer Center , New Haven , CT , USA
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221
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Guglielmelli P, Pietra D, Pane F, Pancrazzi A, Cazzola M, Vannucchi AM, Tura S, Barosi G. Recommendations for molecular testing in classical Ph1-neg myeloproliferative disorders-A consensus project of the Italian Society of Hematology. Leuk Res 2017; 58:63-72. [PMID: 28460339 DOI: 10.1016/j.leukres.2017.04.006] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2017] [Revised: 03/26/2017] [Accepted: 04/20/2017] [Indexed: 12/21/2022]
Abstract
The discovery that Philadelphia-negative classical myeloproliferative neoplasms (MPNs) present with several molecular abnormalities, including the mostly represented JAK2V617F mutation, opened new horizons in the diagnosis, prognosis, and monitoring of these disorders. However, the great strides in the knowledge on molecular genetics need parallel progresses on the best approach to methods for detecting and reporting disease-associated mutations, and to shape the most effective and rationale testing pathway in the diagnosis, prognosis and monitoring of MPNs. The MPN taskforce of the Italian Society of Hematology (SIE) assessed the scientific literature and composed a framework of the best, possibly evidence-based, recommendations for optimal molecular methods as well as insights about the applicability and interpretation of those tests in the clinical practice, and clinical decision for testing MPNs patients. The issues dealt with: source of samples and nucleic acid template, the most appropriate molecular abnormalities and related detection methods required for diagnosis, prognosis, and monitoring of MPNs, how to report a diagnostic molecular test, calibration and quality control. For each of these issues, practice recommendations were provided.
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Affiliation(s)
- Paola Guglielmelli
- CRIMM-Centro Ricerca e Innovazione delle Malattie Mieloproliferative, Azienda Ospedaliera-Universitaria Careggi, Florence, Italy; Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
| | - Daniela Pietra
- Department of Molecular Medicine, University of Pavia, Pavia, Italy
| | | | - Alessandro Pancrazzi
- CRIMM-Centro Ricerca e Innovazione delle Malattie Mieloproliferative, Azienda Ospedaliera-Universitaria Careggi, Florence, Italy; Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
| | - Mario Cazzola
- Department of Molecular Medicine, University of Pavia, Pavia, Italy; Department of Haematology Oncology, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Policlinico San Matteo, Pavia, Italy
| | - Alessandro M Vannucchi
- CRIMM-Centro Ricerca e Innovazione delle Malattie Mieloproliferative, Azienda Ospedaliera-Universitaria Careggi, Florence, Italy; Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
| | | | - Giovanni Barosi
- Center for the Study of Myelofibrosis, Biotechnology Research Area, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Policlinico S. Matteo, Pavia, Italy.
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222
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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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223
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Impact of Molecular Genetics on Outcome in Myelofibrosis Patients after Allogeneic Stem Cell Transplantation. Biol Blood Marrow Transplant 2017; 23:1095-1101. [PMID: 28389256 DOI: 10.1016/j.bbmt.2017.03.034] [Citation(s) in RCA: 78] [Impact Index Per Article: 11.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2016] [Accepted: 03/23/2017] [Indexed: 12/30/2022]
Abstract
Molecular genetics may influence outcome for patients with myelofibrosis. To determine the impact of molecular genetics on outcome after allogeneic stem cell transplantation, we screened 169 patients with primary myelofibrosis (n = 110), post-essential thrombocythemia/polycythemia vera myelofibrosis (n = 46), and myelofibrosis in transformation (n = 13) for mutations in 16 frequently mutated genes. The most frequent mutation was JAK2V617F (n = 101), followed by ASXL1 (n = 49), calreticulin (n = 34), SRSF2 (n = 16), TET2 (n = 10), U2AF1 (n = 11), EZH2 (n = 7), MPL (n = 6), IDH2 (n = 5), IDH1 (n = 4), and CBL (n = 1). The cumulative incidence of nonrelapse mortality (NRM) at 1 year was 21% and of relapse at 5 years 25%. The 5-year rates progression-free (PFS) and overall survival (OS) were and 56%, respectively. In a multivariate analysis CALR mutation was an independent factor for lower NRM (HR, .415; P = .05), improved PFS (HR, .393; P = .01), and OS (HR, .448; P = .03). ASXL1 and IDH2 mutations were independent risk factors for lower PFS (HR, 1.53 [P = .008], and HR, 5.451 [P = .002], respectively), whereas no impact was observed for "triple negative" patients. Molecular genetics, especially CALR, IDH2, and ASXL1 mutations, may thus be useful to predict outcome independently from known clinical risk factors after allogeneic stem cell transplantation for myelofibrosis.
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224
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Myeloproliferative leukemia protein activation directly induces fibrocyte differentiation to cause myelofibrosis. Leukemia 2017; 31:2709-2716. [PMID: 28386106 DOI: 10.1038/leu.2017.112] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2016] [Revised: 03/22/2017] [Accepted: 03/28/2017] [Indexed: 12/26/2022]
Abstract
Myelofibrosis (MF) may be caused by various pathogenic mechanisms such as elevation in circulating cytokine levels, cellular interactions and genetic mutations. However, the underlying mechanism of MF still remains unknown. Recent studies have revealed that fibrocytes, the spindle-shaped fibroblast-like hematopoietic cells, and the thrombopoietin (TPO)/myeloproliferative leukemia protein (MPL; TPO receptor) signaling pathway play a certain role in the development of MF. In the present study, we aimed to investigate the relationship between fibrocytes and MPL activation. We showed that TPO or a TPO receptor agonist directly induces fibrocyte differentiation using murine fibrocyte cell lines and a murine MF model. Conversely, elimination of macrophages expressing MPL by clodronate liposomes reversed the MF phenotype of the murine model, suggesting that fibrocyte differentiation induced by MPL activation contributes to the progression of MF. Furthermore, we revealed that SLAMF7high MPLhigh monocytes in human peripheral blood mononuclear cells were possible fibrocyte precursors and that these cells increased in number in MF patients not treated with ruxolitinib. Our findings confirmed a link between fibrocytes and the TPO/MPL signaling pathway, which could result in a greater understanding of the pathogenesis of MF and lead to the development of novel therapeutic interventions.
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225
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Presentation and outcome of patients with 2016 WHO diagnosis of prefibrotic and overt primary myelofibrosis. Blood 2017; 129:3227-3236. [PMID: 28351937 DOI: 10.1182/blood-2017-01-761999] [Citation(s) in RCA: 122] [Impact Index Per Article: 17.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2017] [Accepted: 03/22/2017] [Indexed: 01/14/2023] Open
Abstract
The 2016 revision of the World Health Organization (WHO) classification of myeloproliferative neoplasms defines 2 stages of primary myelofibrosis (PMF): prefibrotic/early (pre-PMF) and overt fibrotic (overt PMF) phase. In this work, we studied the clinical and molecular features of patients belonging to these categories of PMF. The diagnosis of 661 PMF patients with a bone marrow biopsy at presentation was revised according to modern criteria; clinical information and annotation of somatic mutations in both driver and selected nondriver myeloid genes were available for all patients. Compared with pre-PMF, overt PMF was enriched in patients with anemia, thrombocytopenia, leukopenia, higher blast count, symptoms, large splenomegaly, and unfavorable karyotype. The different types of driver mutations were similarly distributed between the 2 categories, whereas selected mutations comprising the high mutation risk (HMR) category (any mutations in ASXL1, SRSF2, IDH1/2, EZH2) were more represented in overt PMF. More patients with overt PMF were in higher International Prognostic Scoring System risk categories at diagnosis, and the frequency increased during follow-up, suggesting greater propensity to disease progression compared with pre-PMF. Median survival was significantly shortened in overt PMF (7.2 vs 17.6 years), with triple negativity for driver mutations and presence of HMR mutations representing independent predictors of unfavorable outcome. The findings of this "real-life" study indicate that adherence to 2016 WHO criteria allows for identification of 2 distinct categories of patients with PMF where increased grades of fibrosis are associated with more pronounced disease manifestations, adverse mutation profile, and worse outcome, overall suggesting they might represent a phenotypic continuum.
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226
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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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227
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Ahmed AK, Youssef A, Skeik N. Medical Management of Extensive Arterial Thromboembolism in a Patient with Essential Thrombocythemia and Warfarin Failure. Ann Vasc Surg 2017; 42:306.e5-306.e10. [PMID: 28259826 DOI: 10.1016/j.avsg.2017.01.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2016] [Revised: 12/27/2016] [Accepted: 01/02/2017] [Indexed: 12/13/2022]
Abstract
Chronic myeloproliferative disorders share a stem cell-derived clonal myeloproliferation. This group of disorders include essential thrombocythemia (ET), polycythemia vera (PV), chronic myeloid leukemia, and primary myelofibrosis (PMF), with the respective features of thrombocytosis, erythrocytosis, and bone marrow fibrosis. These disorders can be associated with genetic mutations affecting protein tyrosine kinases, resulting in different configurations of abnormal signal transduction. The Janus tyrosine kinase 2 mutation can be used as a key diagnostic tool for diagnosing MPDs, specifically, ET, PV, and PMF. Patients with ET and PV are at an increased risk for thromboembolic and hemorrhagic events. We present a unique case of ET causing extensive arterial thromboembolism, despite being on adequate antithrombotic agents including warfarin and aspirin.
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Affiliation(s)
- Aisha K Ahmed
- Minneapolis Heart Institute Research Foundation, Abbott Northwestern Hospital, Minneapolis, MN
| | - Alicia Youssef
- Minneapolis Heart Institute Research Foundation, Abbott Northwestern Hospital, Minneapolis, MN
| | - Nedaa Skeik
- Minneapolis Heart Institute Research Foundation, Abbott Northwestern Hospital, Minneapolis, MN.
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228
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Strati P, Bose P, Lyle L, Gaw K, Zhou L, Pierce SA, Huynh-Lu J, Hirsch-Ginsberg CF, Bueso-Mendoza DE, Bueso-Ramos CE, Verstovsek S. Novel hematological parameters for the evaluation of patients with myeloproliferative neoplasms: the immature platelet and reticulocyte fractions. Ann Hematol 2017; 96:733-738. [DOI: 10.1007/s00277-017-2956-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2017] [Accepted: 02/10/2017] [Indexed: 11/29/2022]
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229
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Lussana F, Carobbio A, Salmoiraghi S, Guglielmelli P, Vannucchi AM, Bottazzi B, Leone R, Mantovani A, Barbui T, Rambaldi A. Driver mutations (JAK2V617F, MPLW515L/K or CALR), pentraxin-3 and C-reactive protein in essential thrombocythemia and polycythemia vera. J Hematol Oncol 2017; 10:54. [PMID: 28228104 PMCID: PMC5322581 DOI: 10.1186/s13045-017-0425-z] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2016] [Accepted: 02/17/2017] [Indexed: 11/24/2022] Open
Abstract
Background The driver mutations JAK2V617F, MPLW515L/K and CALR influence disease phenotype of myeloproliferative neoplasms (MPNs) and might sustain a condition of chronic inflammation. Pentraxin 3 (PTX3) and high-sensitivity C-reactive protein (hs-CRP) are inflammatory biomarkers potentially useful for refining prognostic classification of MPNs. Methods We evaluated 305 with essential thrombocythemia (ET) and 172 polycythemia vera (PV) patients diagnosed according to the 2016 WHO criteria and with full molecular characterization for driver mutations. Results PTX3 levels were significantly increased in carriers of homozygous JAK2V617F mutation compared to all the other genotypes and triple negative ET patients, while hs-CRP levels were independent of the mutational profile. The risk of haematological evolution and death from any cause was about 2- and 1.5-fold increased in individuals with high PTX-3 levels, while the thrombosis rate tended to be lower. High hs-CRP levels were associated with risk of haematological evolution, death and also major thrombosis. After sequential adjustment for potential confounders (age, gender, diagnosis and treatments) and the presence of JAK2V617F homozygous status, high hs-CRP levels remained significant for all outcomes, while JAK2V617F homozygous status as well as treatments were the factors independently accounting for adverse outcomes among patients with high PTX3 levels. Conclusions These results provide evidence that JAK2V617F mutation influences MPN-associated inflammation with a strong correlation between allele burden and PTX3 levels. Plasma levels of hs-CRP and PTX3 might be of prognostic value for patients with ET and PV, but their validation in future prospective studies is needed.
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Affiliation(s)
- Federico Lussana
- Hematology and Bone Marrow Transplant Unit, ASST Papa Giovanni XXIII Bergamo, Piazza OMS, 1, 24127, Bergamo, Italy.
| | | | - Silvia Salmoiraghi
- Hematology and Bone Marrow Transplant Unit, ASST Papa Giovanni XXIII Bergamo, Piazza OMS, 1, 24127, Bergamo, Italy
| | - Paola Guglielmelli
- Department of Experimental and Clinical Medicine, CRIMM, Center Research and Innovation of Myeloproliferative Neoplasms, Azienda Ospedaliera Universitaria Careggi, University of Florence, Florence, Italy
| | - Alessandro Maria Vannucchi
- Department of Experimental and Clinical Medicine, CRIMM, Center Research and Innovation of Myeloproliferative Neoplasms, Azienda Ospedaliera Universitaria Careggi, University of Florence, Florence, Italy
| | | | - Roberto Leone
- Humanitas Clinical and Research Center, Rozzano, Milan, Italy
| | - Alberto Mantovani
- Humanitas Clinical and Research Center, Rozzano, Milan, Italy.,Humanitas University, Rozzano, Milan, Italy
| | - Tiziano Barbui
- Research Foundation, ASST Papa Giovanni XXIII, Bergamo, Italy
| | - Alessandro Rambaldi
- Hematology and Bone Marrow Transplant Unit, ASST Papa Giovanni XXIII Bergamo, Piazza OMS, 1, 24127, Bergamo, Italy.,Department of Oncology and Hematology, University of Milan, Milan, Italy
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230
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Abstract
Myeloproliferative neoplasms (MPNs) are a group of related clonal hematologic disorders characterized by excess accumulation of one or more myeloid cell lineages and a tendency to transform to acute myeloid leukemia. Deregulated JAK2 signaling has emerged as the central phenotypic driver of BCR -ABL1-negative MPNs and a unifying therapeutic target. In addition, MPNs show unexpected layers of genetic complexity, with multiple abnormalities associated with disease progression, interactions between inherited factors and phenotype driver mutations, and effects related to the order in which mutations are acquired. Although morphology and clinical laboratory analysis continue to play an important role in defining these conditions, genomic analysis is providing a platform for better disease definition, more accurate diagnosis, direction of therapy, and refined prognostication. There is an emerging consensus with regard to many prognostic factors, but there is a clear need to synthesize genomic findings into robust, clinically actionable and widely accepted scoring systems as well as the need to standardize the laboratory methodologies that are used.
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Affiliation(s)
- Katerina Zoi
- Katerina Zoi, Biomedical Research Foundation of the Academy of Athens, Athens, Greece; Nicholas C.P. Cross, Salisbury District Hospital, Salisbury; and University of Southampton, Southampton, United Kingdom
| | - Nicholas C P Cross
- Katerina Zoi, Biomedical Research Foundation of the Academy of Athens, Athens, Greece; Nicholas C.P. Cross, Salisbury District Hospital, Salisbury; and University of Southampton, Southampton, United Kingdom
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231
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Jeong JH, Lee HT, Seo JY, Seo YH, Kim KH, Kim MJ, Lee JH, Park J, Hong JS, Park PW, Ahn JY. Screening PCR Versus Sanger Sequencing: Detection of CALR Mutations in Patients With Thrombocytosis. Ann Lab Med 2017; 36:291-9. [PMID: 27139600 PMCID: PMC4855047 DOI: 10.3343/alm.2016.36.4.291] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2015] [Revised: 12/01/2015] [Accepted: 01/14/2016] [Indexed: 01/25/2023] Open
Abstract
Background Mutations in calreticulin (CALR) have been reported to be key markers in the molecular diagnosis of myeloid proliferative neoplasms. In most previous reports, CALR mutations were analyzed by using Sanger sequencing. Here, we report a new, rapid, and convenient system for screening CALR mutations without sequencing. Methods Eighty-three bone marrow samples were obtained from 81 patients with thrombocytosis. PCR primers were designed to detect wild-type CALR (product: 357 bp) and CALR with type 1 (product: 302 bp) and type 2 mutations (product: 272 bp) in one reaction. The results were confirmed by Sanger sequencing and compared with results from fragment analysis. Results The minimum detection limit of the screening PCR was 10 ng for type 1, 1 ng for type 2, and 0.1 ng for cases with both mutations. CALR type 1 and type 2 mutants were detected with screening PCR with a maximal analytical sensitivity of 3.2% and <0.8%, respectively. The screening PCR detected 94.1% (16/17) of mutation cases and showed concordant results with sequencing in the cases of type 1 and type 2 mutations. Sanger sequencing identified one novel mutation (c.1123_1132delinsTGC). Compared with sequencing, the screening PCR showed 94.1% sensitivity, 100.0% specificity, 100.0% positive predictive value, and 98.5% negative predictive value. Compared with fragment analysis, the screening PCR presented 88.9% sensitivity and 100.0% specificity. Conclusions This screening PCR is a rapid, sensitive, and cost-effective method for the detection of major CALR mutations.
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Affiliation(s)
- Ji Hun Jeong
- Department of Laboratory Medicine, Gachon University Gil Medical Center, Incheon, Korea
| | - Hwan Tae Lee
- Department of Laboratory Medicine, Gachon University Gil Medical Center, Incheon, Korea
| | - Ja Young Seo
- Department of Laboratory Medicine, Gachon University Gil Medical Center, Incheon, Korea
| | - Yiel Hea Seo
- Department of Laboratory Medicine, Gachon University Gil Medical Center, Incheon, Korea
| | - Kyung Hee Kim
- Department of Laboratory Medicine, Gachon University Gil Medical Center, Incheon, Korea
| | - Moon Jin Kim
- Department of Laboratory Medicine, Gachon University Gil Medical Center, Incheon, Korea
| | - Jae Hoon Lee
- Department of Internal Medicine, Gachon University Gil Medical Center, Incheon, Korea
| | - Jinny Park
- Department of Internal Medicine, Gachon University Gil Medical Center, Incheon, Korea
| | - Jun Shik Hong
- Department of Internal Medicine, Gachon University Gil Medical Center, Incheon, Korea
| | - Pil Whan Park
- Department of Laboratory Medicine, Gachon University Gil Medical Center, Incheon, Korea.
| | - Jeong Yeal Ahn
- Department of Laboratory Medicine, Gachon University Gil Medical Center, Incheon, Korea.
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232
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Ding N, Zhang Z, Yang W, Ren L, Zhang Y, Zhang J, Li Z, Zhang P, Zhu X, Chen X, Fang X. Transcriptome Analysis of Monozygotic Twin Brothers with Childhood Primary Myelofibrosis. GENOMICS PROTEOMICS & BIOINFORMATICS 2017; 15:37-48. [PMID: 28185911 PMCID: PMC5339410 DOI: 10.1016/j.gpb.2016.12.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/26/2015] [Revised: 08/30/2016] [Accepted: 12/02/2016] [Indexed: 12/04/2022]
Abstract
Primary myelofibrosis (PMF) is a chronic myeloproliferative disorder in human bone marrow. Over 50% of patients with myelofibrosis have mutations in JAK2, MPL, or CALR. However, these mutations are rarely detected in children, suggesting a difference in the pathogenesis of childhood PMF. In this study, we investigated the response to drug treatment of a monozygotic twin pair with typical childhood PMF. The twin exhibited different clinical outcomes despite following the same treatment regimen. The transcriptomic profiles of patient samples after drug treatment (E2 and Y2) were significantly different between the twin pair, which is consistent with the observation that the drug treatment was effective only in the younger brother, despite the twin being genetically identical. Bioinformatics analysis of the drug-responsive genes showed that the JAK-STAT pathway was activated in the cured younger brother, which is opposite to the pathway inhibition observed in adult PMF cases following treatment. Moreover, apoptosis and cell cycle processes were both significantly influenced by drug treatment in the sample of younger brother (Y2), implying their potential association with the pathogenesis of childhood PMF. Gene mutations in JAK2, MPL, or CALR were not observed; however, mutations in genes including SRSF2 and SF3B1 occurred in this twin pair with childhood PMF. Gene fusion events were extensively screened in the twin pair samples and the occurrence of IGLV2-14-IGLL5 gene fusion was confirmed. The current study reported at transcriptomic level the different responses of monozygotic twin brothers with childhood PMF to the same androgen/prednisone treatment regimen providing new insights into the potential pathogenesis of childhood PMF for further research and clinical applications.
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Affiliation(s)
- Nan Ding
- CAS Key Laboratory of Genome Sciences and Information, Beijing Institute of Genomics, Chinese Academy of Sciences, Beijing 100101, China; College of Life Sciences, University of Chinese Academy of Sciences, Beijing 100049, China
| | - Zhaojun Zhang
- CAS Key Laboratory of Genome Sciences and Information, Beijing Institute of Genomics, Chinese Academy of Sciences, Beijing 100101, China; Sino-Danish College, University of Chinese Academy of Sciences, Beijing 100190, China
| | - Wenyu Yang
- State Key Laboratory of Experimental Hematology, Institute of Hematology and Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin 300020, China
| | - Lan Ren
- CAS Key Laboratory of Genome Sciences and Information, Beijing Institute of Genomics, Chinese Academy of Sciences, Beijing 100101, China; College of Life Sciences, University of Chinese Academy of Sciences, Beijing 100049, China
| | - Yingchi Zhang
- State Key Laboratory of Experimental Hematology, Institute of Hematology and Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin 300020, China
| | - Jingliao Zhang
- State Key Laboratory of Experimental Hematology, Institute of Hematology and Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin 300020, China
| | - Zhanqi Li
- State Key Laboratory of Experimental Hematology, Institute of Hematology and Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin 300020, China
| | - Peihong Zhang
- State Key Laboratory of Experimental Hematology, Institute of Hematology and Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin 300020, China
| | - Xiaofan Zhu
- State Key Laboratory of Experimental Hematology, Institute of Hematology and Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin 300020, China
| | - Xiaojuan Chen
- State Key Laboratory of Experimental Hematology, Institute of Hematology and Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin 300020, China.
| | - Xiangdong Fang
- CAS Key Laboratory of Genome Sciences and Information, Beijing Institute of Genomics, Chinese Academy of Sciences, Beijing 100101, China; College of Life Sciences, University of Chinese Academy of Sciences, Beijing 100049, China; Sino-Danish College, University of Chinese Academy of Sciences, Beijing 100190, China.
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233
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Martin S, Wright CM, Scott LM. Progenitor genotyping reveals a complex clonal architecture in a subset ofCALR-mutated myeloproliferative neoplasms. Br J Haematol 2017; 177:55-66. [DOI: 10.1111/bjh.14512] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2016] [Accepted: 10/31/2016] [Indexed: 01/11/2023]
Affiliation(s)
- Sarah Martin
- The University of Queensland Diamantina Institute; University of Queensland; Translational Research Institute; Brisbane Australia
| | - Casey M. Wright
- The University of Queensland Diamantina Institute; University of Queensland; Translational Research Institute; Brisbane Australia
| | - Linda M. Scott
- The University of Queensland Diamantina Institute; University of Queensland; Translational Research Institute; Brisbane Australia
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Clinicopathological differences exist between CALR- and JAK2-mutated myeloproliferative neoplasms despite a similar molecular landscape: data from targeted next-generation sequencing in the diagnostic laboratory. Ann Hematol 2017; 96:725-732. [DOI: 10.1007/s00277-017-2937-6] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2016] [Accepted: 01/28/2017] [Indexed: 01/15/2023]
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235
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Leiva O, Ng SK, Chitalia S, Balduini A, Matsuura S, Ravid K. The role of the extracellular matrix in primary myelofibrosis. Blood Cancer J 2017; 7:e525. [PMID: 28157219 PMCID: PMC5386340 DOI: 10.1038/bcj.2017.6] [Citation(s) in RCA: 39] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2016] [Accepted: 12/20/2016] [Indexed: 02/06/2023] Open
Abstract
Primary myelofibrosis (PMF) is a myeloproliferative neoplasm that arises from clonal proliferation of hematopoietic stem cells and leads to progressive bone marrow (BM) fibrosis. While cellular mutations involved in the development of PMF have been heavily investigated, noteworthy is the important role the extracellular matrix (ECM) plays in the progression of BM fibrosis. This review surveys ECM proteins contributors of PMF, and highlights how better understanding of the control of the ECM within the BM niche may lead to combined therapeutic options in PMF.
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Affiliation(s)
- O Leiva
- Department of Medicine and Whitaker Cardiovascular Institute, Boston University School of Medicine, Boston, MA, USA
| | - S K Ng
- Department of Medicine and Whitaker Cardiovascular Institute, Boston University School of Medicine, Boston, MA, USA
| | - S Chitalia
- Department of Medicine and Whitaker Cardiovascular Institute, Boston University School of Medicine, Boston, MA, USA
| | - A Balduini
- Department of Molecular Medicine, University of Pavia, Pavia, Italy.,Laboratory of Biotechnology, IRCCS San Matteo Foundation, Pavia, Italy
| | - S Matsuura
- Department of Medicine and Whitaker Cardiovascular Institute, Boston University School of Medicine, Boston, MA, USA
| | - K Ravid
- Department of Medicine and Whitaker Cardiovascular Institute, Boston University School of Medicine, Boston, MA, USA
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Ahmed RZ, Rashid M, Ahmed N, Nadeem M, Shamsi TS. Coexisting JAK2V617F and CALR Exon 9 Mutations in Myeloproliferative Neoplasms - Do They Designate a New Subtype? Asian Pac J Cancer Prev 2017; 17:923-6. [PMID: 27039813 DOI: 10.7314/apjcp.2016.17.3.923] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
The classic BCR-ABL1-negative myeloproliferative neoplasm is an operational sub-category of MPNs that includes polycythemia vera (PV), essential thrombocythemia (ET), and primary myelofibrosis (PMF). The JAK2V617F mutation is found in ~ 95% of PV and 50-60% of ET or PMF. In most of the remaining JAK2V617F- negative PV cases, JAK2 exon 12 mutations are present. Amongst the JAK2V617F-negative ET or PMF 5-10% of patients carry mutations in the MPL gene. Prior to 2013, there was no specific molecular marker described in the remaining 30-40% ET and PMF. In December 2013, two research groups independently reported mutations in the gene CALR found specifically in ET (67-71%) and PMF (56-88%) but not in PV. Initially CALR mutations were reported mutually exclusive with JAK2 or MPL. However, co-occurrence of CALR mutations with JAK2V617F has been reported recently in a few MPN cases. Many studies have reported important diagnostic and prognostic significance of CALR mutations in ET and PMF patients and CALR mutation screening has been proposed to be incorporated into WHO diagnostic criteria for MPN. It is suggestive in diagnostic workup of MPN that CALR mutations should not be studied in MPN patients who carry JAK2 or MPL mutations. However JAK2V617F and CALR positive patients might have a different phenotype and clinical course, distinct from the JAK2-positive or CALR-positive subgroups and identification of the true frequency of these patients may be an important factor for defining the prognosis, risk factors and outcomes for MPN patients.
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Affiliation(s)
- Rifat Zubair Ahmed
- Department of Postgraduate Studies and Research, National Institute of Blood Disease and Bone Marrow Transplantation, Karachi, Pakistan E-mail :
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Mesa RA, Passamonti F. Individualizing Care for Patients With Myeloproliferative Neoplasms: Integrating Genetics, Evolving Therapies, and Patient-Specific Disease Burden. Am Soc Clin Oncol Educ Book 2017; 35:e324-35. [PMID: 27249739 DOI: 10.1200/edbk_159322] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
Individualized medicine is important for patients with myeloproliferative neoplasms (MPNs), including essential thrombocythemia, polycythemia vera, and myelofibrosis, which are heterogeneous in terms of genetic mutation profile, prognosis, disease burden, and symptoms. Status of MPN driver mutations in JAK2, CALR, and MPL (or lack of one of these mutations) and other myeloid mutations (ASXL1, SRSF2, CBL, and IDH1/2, among others) affects diagnosis and prognosis. Management begins with estimating the prognosis, disease burden including MPN symptoms, and prevention of vascular events. Allogeneic stem cell transplantation is the definitive therapy in a subset of patients with myelofibrosis, the majority of whom receive JAK inhibition with ruxolitinib to relieve splenomegaly and symptoms and to prolong survival. Ruxolitinib is now a second-line therapy in polycythemia vera, with pegylated interferon being evaluated as a potential front-line therapy compared with hydroxyurea. The therapeutic landscape is evolving to include new JAK inhibitors, which may affect cytopenias (pacritinib and momelotinib), combination therapies including ruxolitinib, and novel targets such as pentraxin and telomerase. Assessing the therapeutic efficacy (including symptom impact) and toxicity of these new approaches is necessary to determine longitudinal management of MPNs in clinical practice and is a key component of "individualizing" care for patients with MPNs.
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Affiliation(s)
- Ruben A Mesa
- From the Mayo Clinic Cancer Center, Phoenix, AZ; Division of Hematology, Department of Clinical and Experimental Medicine, University of Insubria, Varese, Italy
| | - Francesco Passamonti
- From the Mayo Clinic Cancer Center, Phoenix, AZ; Division of Hematology, Department of Clinical and Experimental Medicine, University of Insubria, Varese, Italy
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238
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Tefferi A, Barbui T. Polycythemia vera and essential thrombocythemia: 2017 update on diagnosis, risk-stratification, and management. Am J Hematol 2017; 92:94-108. [PMID: 27991718 DOI: 10.1002/ajh.24607] [Citation(s) in RCA: 139] [Impact Index Per Article: 19.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2016] [Accepted: 11/11/2016] [Indexed: 12/12/2022]
Abstract
DISEASE OVERVIEW Polycythemia Vera (PV) and essential thrombocythemia (ET) are myeloproliferative neoplasms respectively characterized by erythrocytosis and thrombocytosis; other disease features include leukocytosis, splenomegaly, thrombosis, bleeding, microcirculatory symptoms, pruritus, and risk of leukemic or fibrotic transformation. DIAGNOSIS PV is defined by a JAK2 mutation, whose absence, combined with normal or increased serum erythropoietin level, makes the diagnosis unlikely. JAK2, CALR, and MPL mutations are the mutually exclusive "driver" mutations in ET with respective incidences of 55%, 25%, and 3%; approximately 17% are triple-negative. However, the same molecular markers might also be present in prefibrotic myelofibrosis, whose morphological distinction from ET is prognostically relevant. SURVIVAL AND LEUKEMIC/FIBROTIC TRANSFORMATION Median survivals are approximately 14 years for PV and 20 years for ET; the corresponding values for younger patients (age <60 years) are 24 and 33 years. Life-expectancy in ET is inferior to the control population. Driver mutational status has not been shown to affect survival in ET whereas the presence of JAK2/MPL mutations has been associated with higher risk of arterial thrombosis and that of MPL with higher risk of fibrotic progression. Risk factors for overall survival in both ET and PV include advanced age, leukocytosis and thrombosis. Leukemic transformation rates at 20 years are estimated at <10% for PV and 5% for ET; fibrotic transformation rates are slightly higher. Most recently, ASXL1, SRSF2, and IDH2 mutations have been associated with inferior overall, leukemia-free or fibrosis-free survival in PV; similarly adverse mutations in ET included SH2B3, SF3B1, U2AF1, TP53, IDH2, and EZH2. THROMBOSIS RISK STRATIFICATION Current risk stratification in PV and ET is designed to estimate the likelihood of recurrent thrombosis. Accordingly, PV includes two risk categories: high-risk (age >60 years or thrombosis history) and low-risk (absence of both risk factors). In ET, risk stratification includes four categories: very low risk (age ≤60 years, no thrombosis history, JAK2/MPL un-mutated), low risk (age ≤60 years, no thrombosis history, JAK2/MPL mutated), intermediate risk (age >60 years, no thrombosis history, JAK2/MPL un-mutated), and high risk (thrombosis history or age >60 years with JAK2/MPL mutation). In addition, presence of extreme thrombocytosis (platelets >1000 × 10(9)/L) might be associated with acquired von Willebrand syndrome (AvWS) and, therefore, risk of bleeding. RISK-ADAPTED THERAPY The main goal of therapy in PV and ET is to prevent thrombohemorrhagic complications. All patients with PV require phlebotomy to keep hematocrit below 45% and once-daily aspirin (81 mg). In addition, high-risk patients with PV require cytoreductive therapy. Very low risk ET patients might not require any form of therapy while low-risk patients require at least once-daily aspirin therapy. Cytoreductive therapy is also recommended for high-risk ET patients but it is not mandatory for intermediate-risk patients. First-line drug of choice for cytoreductive therapy, in both ET and PV, is hydroxyurea and second-line drugs of choice are interferon-α and busulfan. We currently do not recommend treatment with ruxolutinib or other JAK2 inhibitors in PV or ET, unless in the presence of severe and protracted pruritus or marked splenomegaly that is not responding to the aforementioned drugs. Screening for AvWS is recommended before administrating aspirin, in the presence of extreme thrombocytosis. Am. J. Hematol. 92:95-108, 2017. © 2016 Wiley Periodicals, Inc.
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Affiliation(s)
- Ayalew Tefferi
- Division of Hematology, Department of Medicine; Mayo Clinic; Rochester Minnesota USA
| | - Tiziano Barbui
- Research Foundation, Papa Giovanni XXIII Hospital; Bergamo Italy
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239
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Grinfeld J, Nangalia J, Green AR. Molecular determinants of pathogenesis and clinical phenotype in myeloproliferative neoplasms. Haematologica 2017; 102:7-17. [PMID: 27909216 PMCID: PMC5210228 DOI: 10.3324/haematol.2014.113845] [Citation(s) in RCA: 61] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2016] [Accepted: 09/27/2016] [Indexed: 12/22/2022] Open
Abstract
The myeloproliferative neoplasms are a heterogeneous group of clonal disorders characterized by the overproduction of mature cells in the peripheral blood, together with an increased risk of thrombosis and progression to acute myeloid leukemia. The majority of patients with Philadelphia-chromosome negative myeloproliferative neoplasms harbor somatic mutations in Janus kinase 2, leading to constitutive activation. Acquired mutations in calreticulin or myeloproliferative leukemia virus oncogene are found in a significant number of patients with essential thrombocythemia or myelofibrosis, and mutations in numerous epigenetic regulators and spliceosome components are also seen. Although the cellular and molecular consequences of many of these mutations remain unclear, it seems likely that they interact with germline and microenvironmental factors to influence disease pathogenesis. This review will focus on the determinants of specific myeloproliferative neoplasm phenotypes as well as on how an improved understanding of molecular mechanisms can inform our understanding of the disease entities themselves.
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Affiliation(s)
- Jacob Grinfeld
- Department of Haematology, Cambridge Institute for Medical Research and Wellcome Trust/MRC Stem Cell Institute, University of Cambridge, Cambridge, UK
- Department of Haematology, Addenbrooke's Hospital, Cambridge, UK
| | - Jyoti Nangalia
- Department of Haematology, Cambridge Institute for Medical Research and Wellcome Trust/MRC Stem Cell Institute, University of Cambridge, Cambridge, UK
- Department of Haematology, Addenbrooke's Hospital, Cambridge, UK
| | - Anthony R Green
- Department of Haematology, Cambridge Institute for Medical Research and Wellcome Trust/MRC Stem Cell Institute, University of Cambridge, Cambridge, UK
- Department of Haematology, Addenbrooke's Hospital, Cambridge, UK
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240
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Diagnosis, risk stratification, and response evaluation in classical myeloproliferative neoplasms. Blood 2016; 129:680-692. [PMID: 28028026 DOI: 10.1182/blood-2016-10-695957] [Citation(s) in RCA: 162] [Impact Index Per Article: 20.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2016] [Accepted: 12/02/2016] [Indexed: 12/14/2022] Open
Abstract
Philadelphia-negative classical myeloproliferative neoplasms (MPNs) include polycythemia vera (PV), essential thrombocythemia (ET), and primary myelofibrosis (PMF). The 2016 revision of the WHO Classification of Tumours of Haematopoietic and Lymphoid Tissues includes new criteria for the diagnosis of these disorders. Somatic mutations in the 3 driver genes, that is, JAK2, CALR, and MPL, represent major diagnostic criteria in combination with hematologic and morphological abnormalities. PV is characterized by erythrocytosis with suppressed endogenous erythropoietin production, bone marrow panmyelosis, and JAK2 mutation. Thrombocytosis, bone marrow megakaryocytic proliferation, and presence of JAK2, CALR, or MPL mutation are the main diagnostic criteria for ET. PMF is characterized by bone marrow megakaryocytic proliferation, reticulin and/or collagen fibrosis, and presence of JAK2, CALR, or MPL mutation. Prefibrotic myelofibrosis represents an early phase of myelofibrosis, and is characterized by granulocytic/megakaryocytic proliferation and lack of reticulin fibrosis in the bone marrow. The genomic landscape of MPNs is more complex than initially thought and involves several mutant genes beyond the 3 drivers. Comutated, myeloid tumor-suppressor genes contribute to phenotypic variability, phenotypic shifts, and progression to more aggressive disorders. Patients with myeloid neoplasms are at variable risk of vascular complications, including arterial or venous thrombosis and bleeding. Current prognostic models are mainly based on clinical and hematologic parameters, but innovative models that include genetic data are being developed for both clinical and trial settings. In perspective, molecular profiling of MPNs might also allow for accurate evaluation and monitoring of response to innovative drugs that target the mutant clone.
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241
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Austrian recommendations for the management of primary myelofibrosis, post-polycythemia vera myelofibrosis and post-essential thrombocythemia myelofibrosis: an expert statement. Wien Klin Wochenschr 2016; 129:293-302. [PMID: 27966016 DOI: 10.1007/s00508-016-1120-8] [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: 08/08/2016] [Accepted: 10/19/2016] [Indexed: 12/22/2022]
Abstract
The entity "myelofibrosis" represents a subgroup of the Philadelphia chromosome-negative myeloproliferative neoplasms. It comprises primary myelofibrosis, post-polycythemia vera myelofibrosis and post-essential thrombocythemia myelofibrosis. This heterogeneous disease is characterized by clonal myeloproliferation, dysregulated kinase signalling and the abnormal expression of several proinflammatory cytokines. Clinically, patients present with symptoms related to thrombocytosis/leukocytosis, anemia and/or progressive splenomegaly. Mutations in Janus kinase 2, an enzyme that is essential for the normal development of erythrocytes, granulocytes, and platelets, notably the V617F mutation, have been identified in approximately 60% of patients with primary myelofibrosis. Recent molecular advances have not only elucidated critical pathways in the pathogenesis of the disease, but also contributed to a more precise assessment of a patient's individual risk. While allogeneic stem cell transplantation remains the only curative treatment, the natural course of the disease and the patient's survival and quality of life may be improved by new treatments, notably ruxolitinib, the first Janus kinase 1/2 inhibitor approved for the management of myelofibrosis. Additional treatment options are being explored.
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242
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Virtgaym E, Tremblay D, Iancu-Rubin C, Hoffman R, Mascarenhas J. Imetelstat for treatment of myelofibrosis. Expert Opin Orphan Drugs 2016. [DOI: 10.1080/21678707.2017.1266934] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Affiliation(s)
- E. Virtgaym
- Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - D. Tremblay
- Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - C. Iancu-Rubin
- Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - R. Hoffman
- Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - J. Mascarenhas
- Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
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Pathophysiological Significance of Store-Operated Calcium Entry in Megakaryocyte Function: Opening New Paths for Understanding the Role of Calcium in Thrombopoiesis. Int J Mol Sci 2016; 17:ijms17122055. [PMID: 27941645 PMCID: PMC5187855 DOI: 10.3390/ijms17122055] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2016] [Revised: 11/28/2016] [Accepted: 11/28/2016] [Indexed: 12/16/2022] Open
Abstract
Store-Operated Calcium Entry (SOCE) is a universal calcium (Ca2+) influx mechanism expressed by several different cell types. It is now known that Stromal Interaction Molecule (STIM), the Ca2+ sensor of the intracellular compartments, together with Orai and Transient Receptor Potential Canonical (TRPC), the subunits of Ca2+ permeable channels on the plasma membrane, cooperate in regulating multiple cellular functions as diverse as proliferation, differentiation, migration, gene expression, and many others, depending on the cell type. In particular, a growing body of evidences suggests that a tight control of SOCE expression and function is achieved by megakaryocytes along their route from hematopoietic stem cells to platelet production. This review attempts to provide an overview about the SOCE dynamics in megakaryocyte development, with a focus on most recent findings related to its involvement in physiological and pathological thrombopoiesis.
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244
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Park J, Song M, Jang W, Chae H, Lee GD, Kim K, Park H, Kim M, Kim Y. Peptide nucleic acid probe-based fluorescence melting curve analysis for rapid screening of common JAK2, MPL, and CALR mutations. Clin Chim Acta 2016; 465:82-90. [PMID: 27939919 DOI: 10.1016/j.cca.2016.12.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2016] [Revised: 11/30/2016] [Accepted: 12/02/2016] [Indexed: 01/26/2023]
Abstract
BACKGROUND We developed and evaluated the feasibility of peptide nucleic acid (PNA)-based fluorescence melting curve analysis (FMCA) to detect common mutations in myeloproliferative neoplasms (MPNs). METHODS We have set up two separate reactions of PNA-based FMCA: JAK2 V617F &CALR p.Leu367fs*46 (set A) and MPL W515L/K &CALR p.Lys385fs*47 (set B). Clinical usefulness was validated with allele-specific real-time PCR, fragment analysis, Sanger sequencing in 57 BCR-ABL1-negative MPNs. RESULTS The limit of detection (LOD) of PNA-based FMCA was approximately 10% for each mutation and interference reactions using mixtures of different mutations were not observed. Non-specific amplification was not observed in normal control. PNA-based FMCA was able to detect all JAK2 V617F (n=20), CALR p.Leu367fs*46 (n=10) and p.Lys385fs*47 (n=8). Three of six MPL mutations were detected except three samples with low mutant concentration in out of LOD. JAK2 exon 12 mutations (n=7) were negative without influencing V617F results. Among six variant CALR exon 9 mutations, two were detected by this method owing to invading of probe binding site. CONCLUSIONS PNA-based FMCA for detecting common JAK2, MPL, and CALR mutations is a rapid, simple, and sensitive technique in BCR-ABL1-negative MPNs with >10% mutant allele at the time of initial diagnosis.
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Affiliation(s)
- Joonhong Park
- Department of Laboratory Medicine, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea; Catholic Genetic Laboratory Center, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Minsik Song
- SeaSun Biomaterials, Daejeon, Republic of Korea
| | - Woori Jang
- Department of Laboratory Medicine, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea; Catholic Genetic Laboratory Center, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Hyojin Chae
- Department of Laboratory Medicine, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea; Catholic Genetic Laboratory Center, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Gun Dong Lee
- Catholic Genetic Laboratory Center, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | | | | | - Myungshin Kim
- Department of Laboratory Medicine, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea; Catholic Genetic Laboratory Center, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea.
| | - Yonggoo Kim
- Department of Laboratory Medicine, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea; Catholic Genetic Laboratory Center, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea.
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245
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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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246
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Passamonti F, Maffioli M. Update from the latest WHO classification of MPNs: a user's manual. HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2016; 2016:534-542. [PMID: 27913526 PMCID: PMC6142477 DOI: 10.1182/asheducation-2016.1.534] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/24/2023]
Abstract
The 2016 multiparameter World Health Organization (WHO) classification for Philadelphia-negative myeloproliferative neoplasms (MPNs) integrates clinical features, morphology, and genetic data to diagnose polycythemia vera (PV), essential thrombocythemia (ET), and primary myelofibrosis (PMF). The main novelties are: (1) the reduction of the hemoglobin (Hb) level threshold to diagnose PV, now established at 16.5 g/dL for men and 16 g/dL for women (based on the identification of MPN patients with PV-consistent bone marrow [BM] features and a Hb level lower than that established in the 2008 WHO classification for PV); (2) the recognition of prefibrotic/early PMF, distinguishable from ET on the basis of BM morphology, an entity having a higher tendency to develop overt myelofibrosis or acute leukemia, and characterized by inferior survival; (3) the central role of BM morphology in the diagnosis of ET, prefibrotic/early PMF, PMF, and PV with borderline Hb values; megakaryocyte number and morphology (typical in ET, atypical in both PMF forms) accompanied by a new distinction of reticulin fibrosis grade in PMF (grade 1 in prefibrotic/early PMF and grade 2-3 in PMF) constitute diagnostic criteria; and (4) the inclusion of all mutually exclusive MPN driver mutations (JAK2, CALR, and MPL) as major diagnostic criteria in ET and PMF; 10% to 15% of these patients are triple negative, and in these cases the search for an additional clonal marker (eg, mutations in ASXL1, EZH2, TET2, IDH1/IDH2, SRSF2, and SF3B1) is warranted.
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Affiliation(s)
- Francesco Passamonti
- Department of Experimental and Clinical Medicine, University of Insubria, Varese, Italy; and
- Hematology, Department of Specialistic Medicine, Ospedale di Circolo, Azienda Socio Sanitaria Territoriale Sette Laghi, Varese, Italy
| | - Margherita Maffioli
- Hematology, Department of Specialistic Medicine, Ospedale di Circolo, Azienda Socio Sanitaria Territoriale Sette Laghi, Varese, Italy
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Xia D, Hasserjian RP. Molecular testing for JAK2, MPL, and CALR in myeloproliferative neoplasms. Am J Hematol 2016; 91:1277-1280. [PMID: 27727468 DOI: 10.1002/ajh.24578] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2016] [Revised: 10/05/2016] [Accepted: 10/06/2016] [Indexed: 01/02/2023]
Abstract
Polycythemia vera (PV), essential thrombocythemia (ET), and primary myelofibrosis (PMF) are myeloproliferative neoplasms characterized by recurrent somatic mutations in JAK2, CALR, and MPL. This short review addresses (1) the spectrum of mutations seen in PV, ET, and PMF, (2) the emerging genotype-phenotype correlations, (3) the current role of molecular testing in disease classification and management, and (4) several important considerations for selecting an appropriate molecular test. In our view, sequential testing algorithms and simultaneous assessment of multiple mutations by next-generation sequencing are both valid approaches to testing. Am. J. Hematol. 91:1277-1280, 2016. © 2016 Wiley Periodicals, Inc.
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Affiliation(s)
- Daniel Xia
- Department of PathologyMassachusetts General HospitalBoston Massachusetts
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Abstract
INTRODUCTION Primary myelofibrosis (PMF) is the least common but the most aggressive of the classic Philadelphia chromosome-negative myeloproliferative neoplasms. Survival is much shorter in PMF than in polycythemia vera (PV) or essential thrombocythemia (ET). Post-PV/ET myelofibrosis (MF) is clinically indistinguishable from PMF and approached similarly. Areas covered: Current pharmacologic therapy of MF revolves around the Janus kinase 1/2 (JAK1/2) inhibitor ruxolitinib, which dramatically improves constitutional symptoms and splenomegaly in the majority of patients, and improves overall survival (OS). However, allogeneic stem cell transplantation remains the only potential cure. Other JAK inhibitors continue to be developed for MF, and momelotinib and pacritinib are in phase III clinical trials. Anemia is common in MF, and initially worsened by ruxolitinib. Momelotinib and pacritinib may prove advantageous in this regard. Current strategies for managing anemia of MF include danazol, immunomodulatory drugs and erythroid stimulating agents, either alone or in combination with ruxolitinib. Expert opinion: A number of other agents, representing diverse drug classes, are in various stages of development for MF. These include newer JAK inhibitors, other signaling inhibitors, epigenetic modifiers, anti-fibrotic agents, telomerase inhibitors, and activin receptor ligand traps (for anemia). Hopefully, these novel therapies will further extend the clinical benefits of ruxolitinib.
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Affiliation(s)
- Prithviraj Bose
- Department of Leukemia, University of Texas MD Anderson Cancer Center, Houston, TX
| | - Srdan Verstovsek
- Department of Leukemia, University of Texas MD Anderson Cancer Center, Houston, TX
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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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Targeted deep sequencing in primary myelofibrosis. Blood Adv 2016; 1:105-111. [PMID: 29296803 DOI: 10.1182/bloodadvances.2016000208] [Citation(s) in RCA: 169] [Impact Index Per Article: 21.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2016] [Accepted: 10/12/2016] [Indexed: 11/20/2022] Open
Abstract
A myeloid neoplasm-relevant 27-gene panel was used for next-generation sequencing of bone marrow or whole blood DNA in 182 patients with primary myelofibrosis (PMF). DNA sequence variants/mutations other than JAK2/CALR/MPL were detected in 147 patients (81%), with the most frequent being ASXL1 (36%), TET2 (18%), SRSF2 (18%), and U2AF1 (16%); furthermore, 35%, 26%, 10%, and 9% of the patients harbored 1, 2, 3, or 4 or more such variants/mutations, respectively. Adverse variants/mutations were identified by age-adjusted multivariable analysis of impact on overall survival or leukemia-free survival and included ASXL1, SRSF2, CBL, KIT, RUNX1, SH2B3, and CEBPA; their combined prevalence was 56%. Adverse variants/mutations were associated with inferior overall survival (median, 3.6 vs 8.5 years; P < .001) and leukemia-free survival (7-year risk, 25% vs 4%; P < .001), and the effect on survival was independent of both the Dynamic International Prognostic Scoring System Plus and JAK2/CALR/MPL mutational status, with respective hazard ratios of 2.0 (95% confidence interval [CI], 1.3-3.1) and 2.9 (95% CI, 1.9-4.4). Additional prognostic information was obtained by considering the number of adverse variants/mutations; median survivals in patients with zero (n = 80), 1 or 2 (n = 93), or 3 or more (n = 9) adverse variants/mutations were 8.5, 4, and 0.7 years, respectively (P < .001). Additional data were obtained on pattern of mutation co-segregation and phenotypic correlation, including significant associations between U2AF1 and JAK2 mutations (P = .04) and U2AF1 mutations and anemia (P = .003) and thrombocytopenia (P = .006). We conclude that DNA variants/mutations other than JAK2/CALR/MPL are prevalent in PMF and are qualitatively and quantitatively relevant in predicting overall and leukemia-free survival.
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