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Da W, Song Z, Liu X, Wang Y, Wang S, Ma J. The role of TET2 in solid tumors and its therapeutic potential: a comprehensive review. Clin Transl Oncol 2024; 26:2156-2165. [PMID: 38598002 DOI: 10.1007/s12094-024-03478-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2024] [Accepted: 03/22/2024] [Indexed: 04/11/2024]
Abstract
Indeed, tumors are a significant health concern worldwide, and understanding the underlying mechanisms of tumor development is crucial for effective prevention and treatment. Epigenetics, which refers to changes in gene expression that are not caused by alterations in the DNA sequence itself, plays a critical role in the entire process of tumor development. It goes without saying that the effect of methylation on tumors is a significant aspect of epigenetics. Among the methylation modifications, DNA methylation is an important part, which plays a regulatory role in tumor-related genes. Ten-eleven translocation 2 (TET2) is a highly influential protein involved in the modification of DNA methylation. Its primary role is associated with the suppression of tumor development, making it a significant player in cancer research. However, TET2 is frequently mentioned in hematological diseases, its role in solid tumors has received little attention. Studying the changes of TET2 in solid tumors and the regulatory mechanism will facilitate its investigation as a clinical target for targeted therapy and may also provide directions for clinical treatment of malignant tumors.
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Affiliation(s)
- Wenxin Da
- Department of Immunology, Jiangsu Key Laboratory of Laboratory Medicine, Department of Laboratory Medicine, School of Medicine, Jiangsu University, Xuefu Road No. 301, Zhenjiang, 212013, China
| | - Ziyu Song
- Department of Immunology, Jiangsu Key Laboratory of Laboratory Medicine, Department of Laboratory Medicine, School of Medicine, Jiangsu University, Xuefu Road No. 301, Zhenjiang, 212013, China
| | - Xiaodong Liu
- Department of Immunology, Jiangsu Key Laboratory of Laboratory Medicine, Department of Laboratory Medicine, School of Medicine, Jiangsu University, Xuefu Road No. 301, Zhenjiang, 212013, China
| | - Yahui Wang
- Department of Immunology, Jiangsu Key Laboratory of Laboratory Medicine, Department of Laboratory Medicine, School of Medicine, Jiangsu University, Xuefu Road No. 301, Zhenjiang, 212013, China
| | - Shengjun Wang
- Department of Immunology, Jiangsu Key Laboratory of Laboratory Medicine, Department of Laboratory Medicine, School of Medicine, Jiangsu University, Xuefu Road No. 301, Zhenjiang, 212013, China
| | - Jie Ma
- Department of Immunology, Jiangsu Key Laboratory of Laboratory Medicine, Department of Laboratory Medicine, School of Medicine, Jiangsu University, Xuefu Road No. 301, Zhenjiang, 212013, China.
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Vardell VA, Ose J, Rets AV, Tantravahi SK, Patel AB. Chronic Myelomonocytic Leukemia and Atypical Chronic Myeloid Leukemia: A National Analysis. CLINICAL LYMPHOMA, MYELOMA & LEUKEMIA 2024:S2152-2650(24)00283-0. [PMID: 39179449 DOI: 10.1016/j.clml.2024.07.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/01/2024] [Revised: 07/22/2024] [Accepted: 07/23/2024] [Indexed: 08/26/2024]
Abstract
BACKGROUND Myelodysplastic/myeloproliferative overlap syndromes (MDS/MPN) are rare blood cancers characterized by concomitant myeloid hyperplasia and dysplasia. These heterogenous disorders include chronic myelomonocytic leukemia (CMML) and atypical chronic myeloid leukemia (aCML). METHODS Using two large national cancer databases to examine a total of 15,704 CMML and 702 aCML patients, we report the largest study to date on the incidence, survival and demographic characteristics of CMML and aCML in the United States. RESULTS Overall age-adjusted incidence of CMML and aCML was 0.63 per 100,000 Americans per year and 0.03 per 100,000 per year, respectively. CMML incidence in the U.S. was noted to rise steadily in the years between 2001 and 2019. Median patient age was 75 and 72 years for CMML and aCML, and the majority of CMML and aCML patients were male (62.9% and 62.0%) and White (90.1% and 86.3%). Median OS was 17.4 months for CMML, and 15.2 months for aCML. Multivariate Cox regression demonstrated features associated with reduced survival, including increasing age, comorbidities, Medicaid insurance status, and low-income residential zip code, highlighting survival disparities in underinsured and socioeconomically disadvantaged patients. In CMML, Black race was associated with inferior survival, while female sex, management at an academic center, and later calendar-year of diagnosis were associated with improved OS. CONCLUSION These findings underscore the need to better understand the biological basis for such differences in survival and reflect the importance of access to specialized care for patients with these rare disorders.
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Affiliation(s)
- Victoria A Vardell
- Department of Internal Medicine, University of Utah, Salt Lake City, UT; Huntsman Cancer Institute, University of Utah, Salt Lake City, UT
| | - Jennifer Ose
- Department of Population Health Sciences, University of Utah, Salt Lake City, UT; Huntsman Cancer Institute, University of Utah, Salt Lake City, UT
| | - Anton V Rets
- Department of Pathology, University of Utah, Salt Lake City, UT; ARUP Laboratories, University of Utah, Salt Lake City, UT
| | - Srinivas K Tantravahi
- Department of Internal Medicine, University of Utah, Salt Lake City, UT; Huntsman Cancer Institute, University of Utah, Salt Lake City, UT; Division of Hematology and Hematologic Malignancies, University of Utah, Salt Lake City, UT
| | - Ami B Patel
- Department of Internal Medicine, University of Utah, Salt Lake City, UT; Huntsman Cancer Institute, University of Utah, Salt Lake City, UT; Division of Hematology and Hematologic Malignancies, University of Utah, Salt Lake City, UT.
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Montalban-Bravo G, Jabbour E, Chien K, Hammond D, Short N, Ravandi F, Konopleva M, Borthakur G, Daver N, Kanagal-Shammana R, Loghavi S, Qiao W, Huang X, Schneider H, Meyer M, Kantarjian H, Garcia-Manero G. Phase 1 study of azacitidine in combination with quizartinib in patients with FLT3 or CBL mutated MDS and MDS/MPN. Leuk Res 2024; 142:107518. [PMID: 38744144 DOI: 10.1016/j.leukres.2024.107518] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2024] [Revised: 04/29/2024] [Accepted: 05/07/2024] [Indexed: 05/16/2024]
Abstract
We conducted a phase 1 study evaluating 3 dose levels of quizartinib (30 mg, 40 mg or 60 mg) in combination with azacitidine for HMA-naïve or relapsed/refractory MDS or MDS/MPN with FLT3 or CBL mutations. Overall, 12 patients (HMA naïve: n=9, HMA failure: n=3) were enrolled; 7 (58 %) patients had FLT3 mutations and 5 (42 %) had CBL mutations. The maximum tolerated dose was not reached. Most common grade 3-4 treatment-emergent adverse events were thrombocytopenia (n=5, 42 %), anemia (n=4, 33 %), lung infection (n=2, 17 %), skin infection (n=2, 17 %), hyponatremia (n=2, 17 %) and sepsis (n=2, 17 %). The overall response rate was 83 % with median relapse-free and overall survivals of 15.1 months (95 % CI 0.0-38.4 months) and 17.5 months (95 % CI NC-NC), respectively. FLT3 mutation clearance was observed in 57 % (n=4) patients. These data suggest quizartinib is safe and shows encouraging activity in FLT3-mutated MDS and MDS/MPN. This study is registered at Clinicaltrials.gov as NCT04493138.
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Affiliation(s)
| | - Elias Jabbour
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, USA
| | - Kelly Chien
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, USA
| | - Danielle Hammond
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, USA
| | - Nicholas Short
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, USA
| | - Farhad Ravandi
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, USA
| | - Marina Konopleva
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, USA
| | - Gautam Borthakur
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, USA
| | - Naval Daver
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, USA
| | | | - Sanam Loghavi
- Department of Hematopathology, The University of Texas MD Anderson Cancer Center, USA
| | - Wei Qiao
- Department of Biostatistics, The University of Texas MD Anderson Cancer Center, USA
| | - Xuelin Huang
- Department of Biostatistics, The University of Texas MD Anderson Cancer Center, USA
| | - Heather Schneider
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, USA
| | - Meghan Meyer
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, USA
| | - Hagop Kantarjian
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, USA
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Patnaik MM, Tefferi A. Chronic myelomonocytic leukemia: 2024 update on diagnosis, risk stratification and management. Am J Hematol 2024; 99:1142-1165. [PMID: 38450850 PMCID: PMC11096042 DOI: 10.1002/ajh.27271] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2024] [Accepted: 02/09/2024] [Indexed: 03/08/2024]
Abstract
DISEASE OVERVIEW Chronic myelomonocytic leukemia (CMML) is a clonal hematopoietic stem cell disorder with overlapping features of myelodysplastic syndromes and myeloproliferative neoplasms, characterized by prominent monocytosis and an inherent risk for leukemic transformation (~15%-20% over 3-5 years). DIAGNOSIS Newly revised diagnostic criteria include sustained (>3 months) peripheral blood (PB) monocytosis (≥0.5 × 109/L; monocytes ≥10% of leukocyte count), consistent bone marrow (BM) morphology, <20% BM or PB blasts (including promonocytes), and cytogenetic or molecular evidence of clonality. Cytogenetic abnormalities occur in ~30% of patients, while >95% harbor somatic mutations: TET2 (~60%), SRSF2 (~50%), ASXL1 (~40%), RAS pathway (~30%), and others. The presence of ASXL1 and DNMT3A mutations and absence of TET2 mutations negatively impact overall survival (ASXL1WT/TET2MT genotype being favorable). RISK STRATIFICATION Several risk models serve similar purposes in identifying high-risk patients that are considered for allogeneic stem cell transplant (ASCT) earlier than later. Risk factors in the Mayo Molecular Model (MMM) include presence of truncating ASXL1 mutations, absolute monocyte count >10 × 109/L, hemoglobin <10 g/dL, platelet count <100 × 109/L, and the presence of circulating immature myeloid cells; the resulting 4-tiered risk categorization includes high (≥3 risk factors), intermediate-2 (2 risk factors), intermediate-1 (1 risk factor), and low (no risk factors); the corresponding median survivals were 16, 31, 59, and 97 months. CMML is also classified as being "myeloproliferative (MP-CMML)" or "myelodysplastic (MD-CMML)," based on the presence or absence of leukocyte count of ≥13 × 109/L. TREATMENT ASCT is the only treatment modality that secures cure or long-term survival and is appropriate for MMM high/intermediate-2 risk disease. Drug therapy is currently not disease-modifying and includes hydroxyurea and hypomethylating agents; a recent phase-3 study (DACOTA) comparing hydroxyurea and decitabine, in high-risk MP-CMML, showed similar overall survival at 23.1 versus 18.4 months, respectively, despite response rates being higher for decitabine (56% vs. 31%). UNIQUE DISEASE ASSOCIATIONS These include systemic inflammatory autoimmune diseases, leukemia cutis and lysozyme-induced nephropathy; the latter requires close monitoring of renal function during leukocytosis and is a potential indication for cytoreductive therapy.
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Affiliation(s)
- Mrinal M Patnaik
- Division of Hematology, Department of Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Ayalew Tefferi
- Division of Hematology, Department of Medicine, Mayo Clinic, Rochester, Minnesota, USA
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5
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Alawieh D, Cysique-Foinlan L, Willekens C, Renneville A. RAS mutations in myeloid malignancies: revisiting old questions with novel insights and therapeutic perspectives. Blood Cancer J 2024; 14:72. [PMID: 38658558 PMCID: PMC11043080 DOI: 10.1038/s41408-024-01054-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2024] [Revised: 04/11/2024] [Accepted: 04/12/2024] [Indexed: 04/26/2024] Open
Abstract
NRAS and KRAS activating point mutations are present in 10-30% of myeloid malignancies and are often associated with a proliferative phenotype. RAS mutations harbor allele-specific structural and biochemical properties depending on the hotspot mutation, contributing to variable biological consequences. Given their subclonal nature in most myeloid malignancies, their clonal architecture, and patterns of cooperativity with other driver genetic alterations may potentially have a direct, causal influence on the prognosis and treatment of myeloid malignancies. RAS mutations overall tend to be associated with poor clinical outcome in both chronic and acute myeloid malignancies. Several recent prognostic scoring systems have incorporated RAS mutational status. While RAS mutations do not always act as independent prognostic factors, they significantly influence disease progression and survival. However, their clinical significance depends on the type of mutation, disease context, and treatment administered. Recent evidence also indicates that RAS mutations drive resistance to targeted therapies, particularly FLT3, IDH1/2, or JAK2 inhibitors, as well as the venetoclax-azacitidine combination. The investigation of novel therapeutic strategies and combinations that target multiple axes within the RAS pathway, encompassing both upstream and downstream components, is an active field of research. The success of direct RAS inhibitors in patients with solid tumors has brought renewed optimism that this progress will be translated to patients with hematologic malignancies. In this review, we highlight key insights on RAS mutations across myeloid malignancies from the past decade, including their prevalence and distribution, cooperative genetic events, clonal architecture and dynamics, prognostic implications, and therapeutic targeting.
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Affiliation(s)
- Dana Alawieh
- INSERM U1287, Gustave Roussy, Paris-Saclay University, Villejuif, France
| | - Leila Cysique-Foinlan
- INSERM U1287, Gustave Roussy, Paris-Saclay University, Villejuif, France
- Department of Hematology, Gustave Roussy, Villejuif, France
| | - Christophe Willekens
- INSERM U1287, Gustave Roussy, Paris-Saclay University, Villejuif, France
- Department of Hematology, Gustave Roussy, Villejuif, France
| | - Aline Renneville
- INSERM U1287, Gustave Roussy, Paris-Saclay University, Villejuif, France.
- Department of Medical Biology and Pathology, Gustave Roussy, Villejuif, France.
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Brunner AM, Esteve J, Porkka K, Knapper S, Traer E, Scholl S, Garcia-Manero G, Vey N, Wermke M, Janssen JJWM, Narayan R, Fleming S, Loo S, Tovar N, Kontro M, Ottmann OG, Naidu P, Sun H, Han M, White R, Zhang N, Mohammed A, Sabatos-Peyton CA, Steensma DP, Rinne ML, Borate UM, Wei AH. Phase Ib study of sabatolimab (MBG453), a novel immunotherapy targeting TIM-3 antibody, in combination with decitabine or azacitidine in high- or very high-risk myelodysplastic syndromes. Am J Hematol 2024; 99:E32-E36. [PMID: 37994196 DOI: 10.1002/ajh.27161] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2023] [Revised: 10/13/2023] [Accepted: 11/02/2023] [Indexed: 11/24/2023]
Abstract
The safety and efficacy of sabatolimab, a novel immunotherapy targeting T-cell immunoglobulin domain and mucin domain-3 (TIM-3), was assessed in combination with hypomethylating agents (HMAs) in patients with HMA-naive revised International Prognostic System Score (IPSS-R) high- or very high-risk myelodysplastic syndromes (HR/vHR-MDS) or chronic myelomonocytic leukemia (CMML). Sabatolimab + HMA had a safety profile similar to that reported for HMA alone and demonstrated durable clinical responses in patients with HR/vHR-MDS. These results support the ongoing evaluation of sabatolimab-based combination therapy in MDS, CMML, and acute myeloid leukemia.
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Affiliation(s)
| | | | - Kimmo Porkka
- Helsinki University Hospital Comprehensive Cancer Center, Helsinki, Finland
| | | | - Elie Traer
- Oregon Health & Science University, Portland, Oregon, USA
| | | | | | | | - Martin Wermke
- TU Dresden, NCT/UCC Early Clinical Trial Unit, Dresden, Germany
| | | | - Rupa Narayan
- Massachusetts General Hospital, Boston, Massachusetts, USA
| | | | - Sun Loo
- The Alfred Hospital, Melbourne, Victoria, Australia
| | | | - Mika Kontro
- Helsinki University Hospital Comprehensive Cancer Center, Helsinki, Finland
| | | | | | - Haiying Sun
- Novartis Pharmaceuticals Corporation, East Hanover, New Jersey, USA
| | - May Han
- Cure Ventures, Boston, Massachusetts, USA
| | | | - Na Zhang
- Novartis Institutes for BioMedical Research, Cambridge, Massachusetts, USA
| | - Anisa Mohammed
- Novartis Pharmaceuticals Corporation, East Hanover, New Jersey, USA
| | | | - David P Steensma
- Novartis Institutes for BioMedical Research, Cambridge, Massachusetts, USA
| | | | - Uma M Borate
- Oregon Health & Science University, Portland, Oregon, USA
| | - Andrew H Wei
- The Peter MacCallum Cancer Centre and Royal Melbourne Hospital Walter and Eliza Hall Institute of Medical Research, Melbourne, Victoria, Australia
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7
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Li C, Deng C, Wu P, Liu K, Huang X, Li M, Chen X, Geng S, Lai P, Weng J, Du X. Outcomes of intermediate or high-risk CMML patients treated with hypomethylating agents combined with venetoclax: A single center experience. Clin Transl Sci 2024; 17:e13711. [PMID: 38129985 PMCID: PMC10777606 DOI: 10.1111/cts.13711] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2023] [Revised: 11/21/2023] [Accepted: 12/14/2023] [Indexed: 12/23/2023] Open
Abstract
Chronic myelomonocytic leukemia (CMML) treatment remains a pressing clinical challenge. We conducted a retrospective analysis on 52 CMML cases, exploring the effectiveness of combining venetoclax (Vene) with hypomethylating agents (HMAs). The study's findings show promise: the HMAs plus Vene group (n = 13, 53.8%) demonstrated superior overall response rates compared to the HMA monotherapy (mono) group (n = 19, 31.6%) and HMA plus arsenic trioxide group (n = 9, 22.2%) by the second cycle, and notably higher response rates (53.8% vs. 15.7%, p = 0.04) compared to the HMA mono group after four cycles. Over a median follow-up of 14.7 months, the HMAs plus Vene group exhibited significantly lower cumulative mortality (23.1%) compared to the other two groups (p = 0.003 and p = 0.008, respectively). Furthermore, this group displayed extended overall survival compared to the others. The study also delved into the molecular mechanisms, revealing significant BCL2 mRNA overexpression in patients with CMML. These findings suggest the potential for HMAs combined with Vene therapy in CMML but emphasize the necessity for further prospective studies to determine its precise role in managing CMML.
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Affiliation(s)
- Chao Li
- School of MedicineSouth China University of TechnologyGuangzhouChina
- Department of HematologyGuangdong Provincial People’s Hospital (Guangdong Academy of Medical Sciences), Southern Medical UniversityGuangzhouChina
| | - ChengXin Deng
- Department of HematologyGuangdong Provincial People’s Hospital (Guangdong Academy of Medical Sciences), Southern Medical UniversityGuangzhouChina
| | - Ping Wu
- Department of HematologyGuangdong Provincial People’s Hospital (Guangdong Academy of Medical Sciences), Southern Medical UniversityGuangzhouChina
| | - KaiFan Liu
- School of MedicineSouth China University of TechnologyGuangzhouChina
- Department of HematologyGuangdong Provincial People’s Hospital (Guangdong Academy of Medical Sciences), Southern Medical UniversityGuangzhouChina
| | - Xin Huang
- Department of HematologyGuangdong Provincial People’s Hospital (Guangdong Academy of Medical Sciences), Southern Medical UniversityGuangzhouChina
| | - MingMin Li
- Department of HematologyGuangdong Provincial People’s Hospital (Guangdong Academy of Medical Sciences), Southern Medical UniversityGuangzhouChina
| | - XiaoMei Chen
- Department of HematologyGuangdong Provincial People’s Hospital (Guangdong Academy of Medical Sciences), Southern Medical UniversityGuangzhouChina
| | - SuXia Geng
- Department of HematologyGuangdong Provincial People’s Hospital (Guangdong Academy of Medical Sciences), Southern Medical UniversityGuangzhouChina
| | - PeiLong Lai
- Department of HematologyGuangdong Provincial People’s Hospital (Guangdong Academy of Medical Sciences), Southern Medical UniversityGuangzhouChina
| | - JianYu Weng
- Department of HematologyGuangdong Provincial People’s Hospital (Guangdong Academy of Medical Sciences), Southern Medical UniversityGuangzhouChina
| | - Xin Du
- School of MedicineSouth China University of TechnologyGuangzhouChina
- Department of HematologyGuangdong Provincial People’s Hospital (Guangdong Academy of Medical Sciences), Southern Medical UniversityGuangzhouChina
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8
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Oh S, Kim E. Efficacy of epigenetic agents for older patients with acute myeloid leukemia and myelodysplastic syndrome in randomized controlled trials: a systematic review and network meta-analysis. Clin Exp Med 2023; 23:2705-2714. [PMID: 36964818 DOI: 10.1007/s10238-023-01041-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2023] [Accepted: 03/02/2023] [Indexed: 03/26/2023]
Abstract
Myelodysplastic syndromes (MDS) and acute myeloid leukemia (AML) are hematologic malignancies that mostly affect the elderly and have poor prognoses. Mutations in epigenetic regulatory genes cause AML/MDS through changes in DNA methylation and histone modifications. Some epigenetic agents are used in patients with AML and MDS. However, most studies have focused on azacitidine (AZA) or decitabine (DEC), and few studies have been conducted on combination therapies or other epigenetic therapies. This network meta-analysis (NMA) aimed to compare the efficacy of epigenetic agents overall in patients with AML and MDS. A systematic review and NMA of all available II-III phase randomized controlled trials (RCTs) comparing epigenetic agents were performed. The Embase and PubMed databases were searched for relevant studies. The Bayesian model was used in the NMA, and the surface under the cumulative ranking curve (SUCRA) was used to rank comparisons. The primary endpoint was overall survival (OS), and the secondary endpoints were complete response (CR) and partial response (PR). OS was extended by AZA + venetoclax (SUCRA 0.94) in patients with AML and MDS. DEC (SUCRA 0.78) relatively improved CR and PR. In this study, AZA-related treatment was relatively effective in improving the OS of patients with AML and MDS, and DEC-related treatment showed a relatively high effect on CR and PR. The protocol for this systematic review was registered with the International Prospective Register of Systematic Reviews (CRD42022303601).
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Affiliation(s)
- SuA Oh
- Data Science, Evidence-Based and Clinical Research Laboratory, Department of Health, Social and Clinical Pharmacy, College of Pharmacy, Chung-Ang University, Seoul, 06974, Republic of Korea
| | - EunYoung Kim
- Data Science, Evidence-Based and Clinical Research Laboratory, Department of Health, Social and Clinical Pharmacy, College of Pharmacy, Chung-Ang University, Seoul, 06974, Republic of Korea.
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9
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Zhou JY, Wang S, Yuan HL, Xu YJ, Huang XB, Gao SJ, Zhang YC, Zhou F, Liu Y, Song XM, Cai Y, Liu XL, Luo Y, Yang LX, Yang JM, Wang LB, Li YH, Huang R, Wang SQ, Zhou M, Dong YJ, Wang Q, Zhang X, Feng YM, Du X, Ling W, Zhu H, Zhu ZM, Chen XL, Wang SY, Meng FK, Bi KH, Huang N, Jiang M, Niu T, Ji J, Wan DM, Bian ZL, Chen Y, Liu L, Yan XQ, Yang X, Yi H, Wei XD, Li X, Cheng Q, Yuan CL, Wang W, Zhou YH, Ye BD, Ding J, Wu YJ, Huang QS, Zhu XL, Chen YH, He Y, Wang FR, Zhang YY, Mo XD, Han W, Wang JZ, Wang Y, Chen H, Zhao XY, Chang YJ, Liu KY, Huang XJ, Zhang XH. Impact of a novel prognostic model on allogeneic hematopoietic stem cell transplantation outcomes in patients with CMML. Am J Hematol 2023; 98:1394-1406. [PMID: 37366294 DOI: 10.1002/ajh.26999] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2023] [Revised: 05/30/2023] [Accepted: 06/07/2023] [Indexed: 06/28/2023]
Abstract
Chronic myelomonocytic leukemia (CMML) is a clonal hematopoietic stem cell malignancy, and allogeneic hematopoietic stem cell transplantation (allo-HSCT) is the only curable treatment. The outcomes after transplant are influenced by both disease characteristics and patient comorbidities. To develop a novel prognostic model to predict the post-transplant survival of CMML patients, we identified risk factors by applying univariable and multivariable Cox proportional hazards regression to a derivation cohort. In multivariable analysis, advanced age (hazard ratio [HR] 3.583), leukocyte count (HR 3.499), anemia (HR 3.439), bone marrow blast cell count (HR 2.095), and no chronic graft versus host disease (cGVHD; HR 4.799) were independently associated with worse survival. A novel prognostic model termed ABLAG (Age, Blast, Leukocyte, Anemia, cGVHD) was developed and the points were assigned according to the regression equation. The patients were categorized into low risk (0-1), intermediate risk (2, 3), and high risk (4-6) three groups and the 3-year overall survival (OS) were 93.3% (95%CI, 61%-99%), 78.9% (95%CI, 60%-90%), and 51.6% (95%CI, 32%-68%; p < .001), respectively. In internal and external validation cohort, the area under the receiver operating characteristic (ROC) curves of the ABLAG model were 0.829 (95% CI, 0.776-0.902) and 0.749 (95% CI, 0.684-0.854). Compared with existing models designed for the nontransplant setting, calibration plots, and decision curve analysis showed that the ABLAG model revealed a high consistency between predicted and observed outcomes and patients could benefit from this model. In conclusion, combining disease and patient characteristic, the ABLAG model provides better survival stratification for CMML patients receiving allo-HSCT.
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Affiliation(s)
- Jian-Ying Zhou
- Peking University People's Hospital, Peking University Institute of Hematology, National Clinical Research Center for Hematologic Disease, Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing, China
| | - Song Wang
- Peking University People's Hospital, Peking University Institute of Hematology, National Clinical Research Center for Hematologic Disease, Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing, China
| | - Hai-Long Yuan
- Department of Hematology, The First Affiliated Hospital of Xinjiang Medical University, Urumqi, China
| | - Ya-Jing Xu
- Department of Hematology, Xiangya Hospital of Central South University, Changsha, China
| | - Xiao-Bing Huang
- Department of Hematology, Sichuan Academy of Medical Sciences, Sichuan Provincial People's Hospital, University of Electronic Science and Technology of China, Chengdu, China
| | - Su-Jun Gao
- Hematology Section, Cancer Center, The First Hospital of Jilin University, Changchun, China
| | - Yi-Cheng Zhang
- Department of Hematology, Tongji Hospital of Tongji Medical College of Huazhong University of Science and Technology, Wuhan, China
| | - Fang Zhou
- Hematology Department, The 960th Hospital of The People's Liberation Army (PLA) Joint Logistics Support Force, Jinan, China
| | - Yue Liu
- Hematology Department, The 960th Hospital of The People's Liberation Army (PLA) Joint Logistics Support Force, Jinan, China
| | - Xian-Min Song
- Department of Hematology, Shanghai General Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Yu Cai
- Department of Hematology, Shanghai General Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Xiao-Liang Liu
- Hematology Section, Cancer Center, The First Hospital of Jilin University, Changchun, China
| | - Yi Luo
- Department of Hematology, Bone Marrow Transplant Center, The First Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, China
| | - Lu-Xin Yang
- Department of Hematology, Bone Marrow Transplant Center, The First Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, China
| | - Jian-Min Yang
- Department of Hematology, Changhai Hospital, The Naval Medical University, Shanghai, China
| | - Li-Bing Wang
- Department of Hematology, Changhai Hospital, The Naval Medical University, Shanghai, China
| | - Yu-Hua Li
- Department of Hematology, Zhujiang Hospital of Southern Medical University, Guangzhou, China
| | - Rui Huang
- Department of Hematology, Zhujiang Hospital of Southern Medical University, Guangzhou, China
| | - Shun-Qing Wang
- Department of Hematology, Guangzhou First People's Hospital, School of Medicine, South China University of Technology, Guangzhou, China
| | - Ming Zhou
- Department of Hematology, Guangzhou First People's Hospital, School of Medicine, South China University of Technology, Guangzhou, China
| | - Yu-Jun Dong
- Department of Hematology, Peking University First Hospital, Beijing, China
| | - Qian Wang
- Department of Hematology, Peking University First Hospital, Beijing, China
| | - Xi Zhang
- Xinqiao Hospital, The Third Military Medical University, Chongqing, China
| | - Yi-Mei Feng
- Xinqiao Hospital, The Third Military Medical University, Chongqing, China
| | - Xin Du
- Department of Hematology, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Wei Ling
- Department of Hematology, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Han Zhu
- Department of Hematology, Jiangsu Province Hospital, The First Affiliated Hospital With Nanjing Medical University, Nanjing, China
| | - Zun-Min Zhu
- Department of Hematology, Henan Provincial People's Hospital, Zhengzhou University People's Hospital, Zhengzhou, China
| | - Xiang-Li Chen
- Department of Hematology, Henan Provincial People's Hospital, Zhengzhou University People's Hospital, Zhengzhou, China
| | - Shi-Yu Wang
- Department of Hematology, Xiangya Hospital of Central South University, Changsha, China
| | - Fan-Kai Meng
- Department of Hematology, Tongji Hospital of Tongji Medical College of Huazhong University of Science and Technology, Wuhan, China
| | - Ke-Hong Bi
- Department of Hematology, School of First Affiliated Hospital of Shandong First Medical University, Shandong Province Qianfoshan Hospital, Jinan, China
| | - Ning Huang
- Department of Hematology, School of First Affiliated Hospital of Shandong First Medical University, Shandong Province Qianfoshan Hospital, Jinan, China
| | - Ming Jiang
- Department of Hematology, The First Affiliated Hospital of Xinjiang Medical University, Urumqi, China
| | - Ting Niu
- Department of Hematology, West China Hospital, Sichuan University, Chengdu, China
| | - Jie Ji
- Department of Hematology, West China Hospital, Sichuan University, Chengdu, China
| | - Ding-Ming Wan
- Department of Hematology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Zhi-Lei Bian
- Department of Hematology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Yi Chen
- Department of Hematology, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Li Liu
- Department of Hematology, The Second Affiliated Hospital (Tangdu Hospital) of Air Force Medical University, Xi'an, China
| | - Xue-Qian Yan
- Department of Hematology, The Second Affiliated Hospital (Tangdu Hospital) of Air Force Medical University, Xi'an, China
| | - Xi Yang
- Department of Hematology, Sichuan Academy of Medical Sciences, Sichuan Provincial People's Hospital, University of Electronic Science and Technology of China, Chengdu, China
| | - Hai Yi
- Department of Hematology, Western Theater General Hospital of the People's Liberation Army of China, Chengdu, China
| | - Xu-Dong Wei
- Department of Hematology, The Affiliated Cancer Hospital of Zhengzhou University and Henan Cancer Hospital, Zhengzhou, China
| | - Xin Li
- Department of Hematology, The Third Xiangya Hospital of Central South University, Changsha, China
| | - Qian Cheng
- Department of Hematology, The Third Xiangya Hospital of Central South University, Changsha, China
| | - Cheng-Lu Yuan
- Department of Hematology, Qilu Hospital, Shandong University, Jinan, China
| | - Wen Wang
- Department of Hematology, Qilu Hospital, Shandong University, Jinan, China
| | - Yu-Hong Zhou
- Department of Hematology, The First Affiliated Hospital of Zhejiang Chinese Medical University (Zhejiang Provincial Hospital of Chinese Medicine), Hangzhou, China
| | - Bao-Dong Ye
- Department of Hematology, The First Affiliated Hospital of Zhejiang Chinese Medical University (Zhejiang Provincial Hospital of Chinese Medicine), Hangzhou, China
| | - Jing Ding
- Peking University People's Hospital, Peking University Institute of Hematology, National Clinical Research Center for Hematologic Disease, Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing, China
| | - Ye-Jun Wu
- Peking University People's Hospital, Peking University Institute of Hematology, National Clinical Research Center for Hematologic Disease, Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing, China
| | - Qiu-Sha Huang
- Peking University People's Hospital, Peking University Institute of Hematology, National Clinical Research Center for Hematologic Disease, Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing, China
| | - Xiao-Lu Zhu
- Peking University People's Hospital, Peking University Institute of Hematology, National Clinical Research Center for Hematologic Disease, Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing, China
| | - Yu-Hong Chen
- Peking University People's Hospital, Peking University Institute of Hematology, National Clinical Research Center for Hematologic Disease, Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing, China
| | - Yun He
- Peking University People's Hospital, Peking University Institute of Hematology, National Clinical Research Center for Hematologic Disease, Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing, China
| | - Feng-Rong Wang
- Peking University People's Hospital, Peking University Institute of Hematology, National Clinical Research Center for Hematologic Disease, Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing, China
| | - Yuan-Yuan Zhang
- Peking University People's Hospital, Peking University Institute of Hematology, National Clinical Research Center for Hematologic Disease, Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing, China
| | - Xiao-Dong Mo
- Peking University People's Hospital, Peking University Institute of Hematology, National Clinical Research Center for Hematologic Disease, Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing, China
| | - Wei Han
- Peking University People's Hospital, Peking University Institute of Hematology, National Clinical Research Center for Hematologic Disease, Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing, China
| | - Jing-Zhi Wang
- Peking University People's Hospital, Peking University Institute of Hematology, National Clinical Research Center for Hematologic Disease, Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing, China
| | - Yu Wang
- Peking University People's Hospital, Peking University Institute of Hematology, National Clinical Research Center for Hematologic Disease, Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing, China
| | - Huan Chen
- Peking University People's Hospital, Peking University Institute of Hematology, National Clinical Research Center for Hematologic Disease, Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing, China
| | - Xiang-Yu Zhao
- Peking University People's Hospital, Peking University Institute of Hematology, National Clinical Research Center for Hematologic Disease, Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing, China
| | - Ying-Jun Chang
- Peking University People's Hospital, Peking University Institute of Hematology, National Clinical Research Center for Hematologic Disease, Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing, China
| | - Kai-Yan Liu
- Peking University People's Hospital, Peking University Institute of Hematology, National Clinical Research Center for Hematologic Disease, Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing, China
| | - Xiao-Jun Huang
- Peking University People's Hospital, Peking University Institute of Hematology, National Clinical Research Center for Hematologic Disease, Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing, China
| | - Xiao-Hui Zhang
- Peking University People's Hospital, Peking University Institute of Hematology, National Clinical Research Center for Hematologic Disease, Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing, China
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10
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Reiser J, Geissler K. Treatment options and survival in real life during the past three decades in patients with chronic myelomonocytic leukemia. Wien Med Wochenschr 2023; 173:34-40. [PMID: 36282401 PMCID: PMC9877071 DOI: 10.1007/s10354-022-00976-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2021] [Accepted: 09/27/2022] [Indexed: 01/29/2023]
Abstract
The impact of treatment on the outcome of chronic myelomonocytic leukemia (CMML) patients over a longer period of time and the potential role of predictive factors are not well defined. In a retrospective observational study, we analyzed 168 CMML patients regarding treatment options and survival during the past three decades. The proportion of patients treated with hydroxyurea (HU), intensive chemotherapy, and azacitidine (AZA) was 65/19/0% before 2000, 51/25/32% from 2000-2010, and 36/12/53% after 2010, respectively. Median overall survival (OS) increased from 10 months before 2000 to 23 months thereafter (p = 0.021). AZA-treated patients but not patients treated with other treatment options had improved survival as compared to CMML patients without AZA therapy (19 vs. 25 months, p = 0.041). When looking at subgroups, the following patient cohorts had a significant survival benefit in association with AZA therapy: patients with Hb > 10 g/dL, patients with monocytosis > 10 G/L, and patients with mutations in RASopathy genes.
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Affiliation(s)
- Julia Reiser
- Medical School, Sigmund Freud University, Vienna, Austria
| | - Klaus Geissler
- Medical School, Sigmund Freud University, Vienna, Austria.
- Department of Internal Medicine V with Hematology, Oncology and Palliative Care, Hospital Hietzing, Wolkersbergenstraße 1, 1130, Vienna, Austria.
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11
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Symeonidis A, Chondropoulos S, Verigou E, Lazaris V, Kourakli A, Tsirigotis P. Allogeneic Hematopoietic Stem Cell Transplantation for Mixed or Overlap Myelodysplastic/Myeloproliferative Disorders. Front Oncol 2022; 12:884723. [PMID: 35992818 PMCID: PMC9389581 DOI: 10.3389/fonc.2022.884723] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2022] [Accepted: 05/23/2022] [Indexed: 12/30/2022] Open
Abstract
Chronic myelomonocytic leukemia (CMML) and the remaining, less frequent hybrid, mixed, or overlap myelodysplastic syndromes/myeloproliferative neoplasms (MDSs/MPNs) are difficult to treat neoplastic hematological disorders, exhibiting substantial clinical and prognostic heterogeneity, for which clear therapeutic guidelines or effective treatment options are still missing. CMML has an overall survival ranging from a few months to several years. Although patients with proliferative or dysplastic features may benefit from hydroxyurea and hypomethylating agent treatment, respectively, none of these treatments can establish long-term remission and prevent the inevitable transformation to acute leukemia. Novel targeted treatment approaches are emerging but are still under investigation. Therefore, currently, allogeneic stem cell transplantation (allo-SCT) remains the only treatment modality with a curative potential, but its widespread application is limited, due to significant morbidity and mortality associated with the procedure, especially in the elderly and in patients with comorbidities. Recognition of patient eligibility for allo-SCT is crucial, and the procedure should be addressed to patients with a good performance status without severe comorbidities and mainly to those in intermediate- to high-risk category, with a suitable stem cell donor available. The issues of best timing for performing transplantation, patient and donor eligibility, the type of conditioning regimen, and the outcomes after various allo-SCT procedures are the topics of this review.
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Affiliation(s)
- Argiris Symeonidis
- University of Patras Medical School, Hematology Division, Patras, Greece
- *Correspondence: Argiris Symeonidis, ; orcid.org/0000-0002-0543-046X
| | | | - Evgenia Verigou
- Hematology Division, General University Hospital of Patras, Rion of Patras, Greece
| | - Vasileios Lazaris
- Hematology Division, General University Hospital of Patras, Rion of Patras, Greece
| | - Alexandra Kourakli
- Hematology Division, General University Hospital of Patras, Rion of Patras, Greece
| | - Panagiotis Tsirigotis
- Department of Medicine, School of Health Sciences, National and Kapodistrian University of Athens, Athens, Greece
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12
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Walsh C, Hunter A, Lasho T, Finke C, Ketterling R, Komrokji R, Tefferi A, Mangaonkar A, Howard M, Gangat N, Al-Kali A, Ali NA, Padron E, Patnaik MM. Differential prognostic impact of IDH1 and IDH2 mutations in chronic myelomonocytic leukemia. Leukemia 2022; 36:1693-1696. [DOI: 10.1038/s41375-022-01551-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2022] [Revised: 03/10/2022] [Accepted: 03/16/2022] [Indexed: 11/09/2022]
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13
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Patnaik MM, Tefferi A. Chronic myelomonocytic leukemia: 2022 update on diagnosis, risk stratification, and management. Am J Hematol 2022; 97:352-372. [PMID: 34985762 DOI: 10.1002/ajh.26455] [Citation(s) in RCA: 37] [Impact Index Per Article: 18.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2021] [Accepted: 01/03/2022] [Indexed: 12/19/2022]
Abstract
DISEASE OVERVIEW Chronic myelomonocytic leukemia (CMML) is a clonal hematopoietic stem cell disorder with overlapping features of myelodysplastic syndromes and myeloproliferative neoplasms, with an inherent risk for leukemic transformation (~15% over 3-5 years). DIAGNOSIS Diagnosis is based on the presence of sustained (>3 months) peripheral blood monocytosis (≥1 × 109 /L; monocytes ≥10%), usually with accompanying bone marrow dysplasia. Clonal cytogenetic abnormalities occur in ~30% of patients, while >90% have somatic gene mutations. Mutations involving TET2 (~60%), SRSF2 (~50%), ASXL1 (~40%), and the oncogenic RAS pathway (~30%) are frequent, while the presence of ASXL1 and DNMT3A mutations and the absence of TET2 mutations negatively impact overall survival. RISK-STRATIFICATION Molecularly integrated prognostic models include the Groupe Français des Myélodysplasies, Mayo Molecular Model (MMM), and the CMML specific prognostic model. Risk factors incorporated into the MMM include presence of truncating ASXL1 mutations, absolute monocyte count >10 × 109 /L, hemoglobin <10 g/dL, platelet count <100 × 109 /L, and the presence of circulating immature myeloid cells. The MMM stratifies CMML patients into four groups: high (≥3 risk factors), intermediate-2 (2 risk factors), intermediate-1 (1 risk factor), and low (no risk factors), with median survivals of 16, 31, 59, and 97 months, respectively. RISK-ADAPTED THERAPY Hypomethylating agents such as 5-azacitidine and decitabine are commonly used, with overall response rates of ~40%-50% and complete remission rates of ~7%-17%; with no impact on mutational allele burdens. Allogeneic stem cell transplant is the only potentially curative option but is associated with significant morbidity and mortality.
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Affiliation(s)
- Mrinal M. Patnaik
- Division of Hematology, Department of Medicine Mayo Clinic Rochester Minnesota USA
| | - Ayalew Tefferi
- Division of Hematology, Department of Medicine Mayo Clinic Rochester Minnesota USA
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14
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Real-world data on efficacy and safety of azacitidine therapy in chronic myelomonocytic leukemia in China: results from a multicenter, retrospective study. Invest New Drugs 2022; 40:1117-1124. [PMID: 35834039 PMCID: PMC9395485 DOI: 10.1007/s10637-022-01283-x] [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: 04/19/2022] [Accepted: 07/04/2022] [Indexed: 12/15/2022]
Abstract
Chronic myelomonocytic leukemia (CMML) is a rare and aggressive myeloid malignancy with overlapped features of myelodysplastic syndromes/myeloproliferative neoplasms. Azacitidine (AZA), a hypomethylating agent, has been approved for the treatment of CMML in China, but real-world data are limited. Medical records of CMML patients who had received subcutaneously injected AZA were reviewed from January 2018 at five participating sites in China. Response was assessed according to the modified International Working Group (IWG 2006) criteria. Between January 2018 and November 2020, a total of 24 patients with CMML were included with a median age of 63 years. Patients received a median of 3 cycles of AZA treatment (range, 1-8). Overall response rate (ORR) was 37.5% (9 of 24); CR rate, PR rate, and mCR/HI rate were 8.3% (n = 2), 8.3% (n = 2), and 20.8% (n = 5), respectively. At a median duration of follow-up of 14.0 months (range 0.0-22.0 months), the median overall survival (OS) was 23.0 months. Univariate analysis revealed that ≥ 3 cycles of treatment was significantly associated with a higher 1-year OS rate compared with < 3 cycles of AZA treatment. Treatment was generally well-tolerated. The most common (> 10%) AEs were thrombocytopenia (n = 7, 29.2%), pneumonitis (n = 4, 16.7%) and fever (n = 3, 12.5%). This study provides valuable real-life data in China on the treatment schedules, efficacy and safety of AZA in the treatment of CMML.
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15
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Geissler K. Molecular Pathogenesis of Chronic Myelomonocytic Leukemia and Potential Molecular Targets for Treatment Approaches. Front Oncol 2021; 11:751668. [PMID: 34660314 PMCID: PMC8514979 DOI: 10.3389/fonc.2021.751668] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2021] [Accepted: 08/26/2021] [Indexed: 12/19/2022] Open
Abstract
Numerous examples in oncology have shown that better understanding the pathophysiology of a malignancy may be followed by the development of targeted treatment concepts with higher efficacy and lower toxicity as compared to unspecific treatment. The pathophysiology of chronic myelomonocytic leukemia (CMML) is heterogenous and complex but applying different research technologies have yielded a better and more comprehensive understanding of this disease. At the moment treatment for CMML is largely restricted to the unspecific use of cytotoxic drugs and hypomethylating agents (HMA). Numerous potential molecular targets have been recently detected by preclinical research which may ultimately lead to treatment concepts that will provide meaningful benefits for certain subgroups of patients.
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Affiliation(s)
- Klaus Geissler
- Medical School, Sigmund Freud University, Vienna, Austria.,Department of Internal Medicine V with Hematology, Oncology and Palliative Care, Hospital Hietzing, Vienna, Austria
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16
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Renneville A, Patnaik MM, Chan O, Padron E, Solary E. Increasing recognition and emerging therapies argue for dedicated clinical trials in chronic myelomonocytic leukemia. Leukemia 2021; 35:2739-2751. [PMID: 34175902 DOI: 10.1038/s41375-021-01330-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2021] [Revised: 06/11/2021] [Accepted: 06/14/2021] [Indexed: 02/06/2023]
Abstract
Chronic myelomonocytic leukemia (CMML) is a clonal hematopoietic stem cell disorder with overlapping features of myelodysplastic syndromes (MDS) and myeloproliferative neoplasms (MPN). Median overall survival of this aggressive myeloid malignancy is only 2-3 years, with a 15-30% risk of acute leukemic transformation. The paucity of clinical trials specifically designed for CMML has made therapeutic management of CMML patients challenging. As a result, treatment paradigms for CMML patients are largely borrowed from MDS and MPN. The standard of care still relies on hydroxyurea, hypomethylating agents (HMA), and allogeneic stem cell transplantation, this latter option remaining the only potentially curative therapy. To date, approved drugs for CMML treatment are HMA, including azacitidine, decitabine, and more recently the oral combination of decitabine and cedazuridine. However, HMA treatment does not meaningfully alter the natural course of this disease. New treatment approaches for improving CMML-associated cytopenias or targeting the CMML malignant clone are emerging. More than 25 therapeutic agents are currently being evaluated in phase 1 or phase 2 clinical trials for CMML and other myeloid malignancies, often in combination with a HMA backbone. Several novel agents, such as sotatercept, ruxolitinib, lenzilumab, and tagraxofusp have shown promising clinical efficacy in CMML. Current evidence supports the idea that effective treatment in CMML will likely require combination therapy targeting multiple pathways, which emphasizes the need for additional new therapeutic options. This review focuses on recent therapeutic advances and innovative treatment strategies in CMML, including global and molecularly targeted approaches. We also discuss what may help to make progress in the design of rationally derived and disease-modifying therapies for CMML.
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Affiliation(s)
| | - Mrinal M Patnaik
- Division of Hematology, Department of Internal Medicine, Mayo Clinic, Rochester, MN, USA
| | - Onyee Chan
- Department of Malignant Hematology, Moffitt Cancer Center, Tampa, FL, USA
| | - Eric Padron
- Department of Malignant Hematology, Moffitt Cancer Center, Tampa, FL, USA
| | - Eric Solary
- INSERM U1287, Gustave Roussy Cancer Campus, Villejuif, France. .,Faculty of Medicine, Université Paris-Sud, Le Kremlin-Bicêtre, France. .,Department of Hematology, Gustave Roussy Cancer Campus, Villejuif, France.
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17
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Mądry K, Lis K, Tukiendorf A, Szwedyk P, Kapelko-Słowik K, Subocz E, Gołos A, Makowska W, Masternak A, Kopińska A, Czemerska M, Zawadzka-Leska S, Rusicka P, Drozd-Sokołowska J, Wiater E, Hołojda J, Pogłódek B, Centkowski P, Waszczuk-Gajda A, Machowicz R, Hałka J, Czerw T, Basak G, Dwilewicz-Trojaczek J. Low serum albumin level deteriorates prognosis in azacitidine-treated myelodysplastic syndromes patients - results of the PALG study 'PolAZA'. ACTA ACUST UNITED AC 2021; 26:556-564. [PMID: 34384334 DOI: 10.1080/16078454.2021.1956182] [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: 10/20/2022]
Abstract
BACKGROUND Azacitidine (AZA) is the standard of care for higher-risk myelodysplastic syndrome (HR-MDS) patients ineligible for intensive therapy. Clinical outcome discrepancies reported in clinical trials and real-life settings stimulate the search for new prognostic factors. METHODS We retrospectively evaluated 315 MDS, 20-30% blast acute myeloid leukemia (AML) and chronic myelomonocytic leukemia (CMML) patients treated with azacitidine in 12 centers cooperating within the Polish Adult Leukemia Group (PALG). RESULTS The median number of AZA cycles was 7 (1-69) and 24% patients received fewer than 4 cycles (early failure, EF). Serum albumin level was an independent predictor of EF occurrence. Complete remission (CR) was obtained in 20% and partial remission (PR) in 12% of patients. Hematologic improvement - erythroid (HI-E), neutrophil (HI-N), or platelet (HI-P) was achieved in 51%, 36%, and 48% of patients, respectively. No factors significantly predicted CR or PR in the multivariate analysis. For HI-E and HI-P, lower LDH level predicted response. Median survival was 15 (13-19) months. Lower serum albumin level, serious infection and receiving <4 AZA cycles independently predicted a worse overall survival (OS) (p < 0.05). CONCLUSION Serum albumin assessment before azacitidine treatment can help to identify patients with higher risk of early failure and worse clinical outcome.
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Affiliation(s)
- Krzysztof Mądry
- Department of Hematology, Oncology and Internal Diseases, Medical University, Warsaw, Poland
| | - Karol Lis
- Department of Hematology, Oncology and Internal Diseases, Medical University, Warsaw, Poland
| | - Andrzej Tukiendorf
- Department of Public Health, Wrocław Medical University, Wrocław, Poland
| | - Paweł Szwedyk
- Department of Hematology, Voivodal Specialist Hospital, Kraków, Poland
| | - Katarzyna Kapelko-Słowik
- Department of Hematology, Blood Neoplasms and Bone Marrow Transplantation, University Hospital, Wrocław, Poland
| | - Edyta Subocz
- Department of Hematology, Warmian-Masurian Cancer Center of the Ministry of the Interior and Administration's Hospital, Olsztyn, Poland
| | - Aleksandra Gołos
- Department of Hematology, Institute of Hematology and Blood Transfusion, Warsaw, Poland
| | - Wioletta Makowska
- Department of Hematology, Institute of Hematology and Blood Transfusion, Warsaw, Poland
| | - Anna Masternak
- Department of Hematology and Hematooncology, District Specialist Hospital, Opole, Poland
| | - Anna Kopińska
- Department of Hematology and Bone Marrow Transplantation, Medical University of Silesia, Katowice, Poland
| | | | - Sara Zawadzka-Leska
- Department of Hematology, Oncology and Internal Diseases, Medical University, Warsaw, Poland
| | - Patrycja Rusicka
- Department of Hematology, Oncology and Internal Diseases, Medical University, Warsaw, Poland
| | - Joanna Drozd-Sokołowska
- Department of Hematology, Oncology and Internal Diseases, Medical University, Warsaw, Poland
| | - Elżbieta Wiater
- Department of Hematology, District Hospital in Toruń, Toruń, Poland
| | - Jadwiga Hołojda
- Department of Hematology, District Specialist Hospital in Legnica, Legnica, Poland
| | | | - Piotr Centkowski
- Department of Hematology, District Specialist Hospital in Biała Podlaska, Biała Podlaska, Poland
| | - Anna Waszczuk-Gajda
- Department of Hematology, Oncology and Internal Diseases, Medical University, Warsaw, Poland
| | - Rafał Machowicz
- Department of Hematology, Oncology and Internal Diseases, Medical University, Warsaw, Poland
| | - Janusz Hałka
- Department of Hematology, Warmian-Masurian Cancer Center of the Ministry of the Interior and Administration's Hospital, Olsztyn, Poland
| | - Tomasz Czerw
- Department of Bone Marrow Transplantation and Oncohematology, Maria Sklodowska-Curie National Research Institute of Oncology, Gliwice Branch, Warszawa, Poland
| | - Grzegorz Basak
- Department of Hematology, Oncology and Internal Diseases, Medical University, Warsaw, Poland
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18
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Chan O, Renneville A, Padron E. Chronic myelomonocytic leukemia diagnosis and management. Leukemia 2021; 35:1552-1562. [PMID: 33714974 DOI: 10.1038/s41375-021-01207-3] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2020] [Revised: 01/23/2021] [Accepted: 02/18/2021] [Indexed: 01/31/2023]
Abstract
Chronic myelomonocytic leukemia (CMML) is a rare, heterogeneous myeloid malignancy classified as a myelodysplastic syndromes/myeloproliferative neoplasm (MDS/MPN) overlap syndrome by the World Health Organization (WHO). Its initial presentation can be incidental or associated with myelodysplastic or myeloproliferative symptoms and up to 20% of patients harbor a concurrent inflammatory or autoimmune condition. Persistent monocytosis is the hallmark of CMML but diagnosis can be challenging. Increased understanding of human monocyte subsets, chromosomal abnormalities, and somatic gene mutations have led to more accurate diagnosis and improved prognostication. A number of risk stratification systems have been developed and validated but using those that incorporate molecular information such as CMML Prognostic Scoring System (CPSS)-Mol, Mayo Molecular, and Groupe Francophone des Myelodysplasies (GFM) are preferred. Symptom-directed approaches forms the basis of CMML management. Outcomes vary substantially depending on risk ranging from observation for a number of years to rapidly progressive disease and acute myeloid leukemia (AML) transformation. Patients who are low risk but with symptoms from cytopenias or proliferative features such as splenomegaly may be treated with hypomethylating agents (HMAs) or cytoreductive therapy, respectively, with the goal of durable symptoms control. Allogeneic hematopoietic cell transplantation should be considered for intermediate to high risk patients. The lack of effective pharmaceutical options has generated interest in novel therapeutics for this disease, and early phase clinical trial results are promising.
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Affiliation(s)
- Onyee Chan
- Department of Malignant Hematology, Moffitt Cancer Center, Tampa, FL, USA
| | | | - Eric Padron
- Department of Malignant Hematology, Moffitt Cancer Center, Tampa, FL, USA.
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19
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Carr RM, Vorobyev D, Lasho T, Marks DL, Tolosa EJ, Vedder A, Almada LL, Yurcheko A, Padioleau I, Alver B, Coltro G, Binder M, Safgren SL, Horn I, You X, Solary E, Balasis ME, Berger K, Hiebert J, Witzig T, Buradkar A, Graf T, Valent P, Mangaonkar AA, Robertson KD, Howard MT, Kaufmann SH, Pin C, Fernandez-Zapico ME, Geissler K, Droin N, Padron E, Zhang J, Nikolaev S, Patnaik MM. RAS mutations drive proliferative chronic myelomonocytic leukemia via a KMT2A-PLK1 axis. Nat Commun 2021; 12:2901. [PMID: 34006870 PMCID: PMC8131698 DOI: 10.1038/s41467-021-23186-w] [Citation(s) in RCA: 43] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2020] [Accepted: 04/20/2021] [Indexed: 12/24/2022] Open
Abstract
Proliferative chronic myelomonocytic leukemia (pCMML), an aggressive CMML subtype, is associated with dismal outcomes. RAS pathway mutations, mainly NRASG12D, define the pCMML phenotype as demonstrated by our exome sequencing, progenitor colony assays and a Vav-Cre-NrasG12D mouse model. Further, these mutations promote CMML transformation to acute myeloid leukemia. Using a multiomics platform and biochemical and molecular studies we show that in pCMML RAS pathway mutations are associated with a unique gene expression profile enriched in mitotic kinases such as polo-like kinase 1 (PLK1). PLK1 transcript levels are shown to be regulated by an unmutated lysine methyl-transferase (KMT2A) resulting in increased promoter monomethylation of lysine 4 of histone 3. Pharmacologic inhibition of PLK1 in RAS mutant patient-derived xenografts, demonstrates the utility of personalized biomarker-driven therapeutics in pCMML.
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MESH Headings
- Animals
- Cell Cycle Proteins/genetics
- Cell Cycle Proteins/metabolism
- GTP Phosphohydrolases/genetics
- GTP Phosphohydrolases/metabolism
- Gene Expression Profiling/methods
- Gene Expression Regulation, Leukemic
- Histone-Lysine N-Methyltransferase/genetics
- Histone-Lysine N-Methyltransferase/metabolism
- Kaplan-Meier Estimate
- Leukemia, Myelomonocytic, Chronic/genetics
- Leukemia, Myelomonocytic, Chronic/metabolism
- Leukemia, Myelomonocytic, Chronic/therapy
- Membrane Proteins/genetics
- Membrane Proteins/metabolism
- Mice, Inbred C57BL
- Mice, Knockout
- Mice, Transgenic
- Mutation
- Myeloid-Lymphoid Leukemia Protein/genetics
- Myeloid-Lymphoid Leukemia Protein/metabolism
- Protein Serine-Threonine Kinases/genetics
- Protein Serine-Threonine Kinases/metabolism
- Proto-Oncogene Proteins/genetics
- Proto-Oncogene Proteins/metabolism
- Signal Transduction/genetics
- Stem Cell Transplantation/methods
- Transplantation, Homologous
- Exome Sequencing/methods
- Xenograft Model Antitumor Assays/methods
- Polo-Like Kinase 1
- Mice
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Affiliation(s)
- Ryan M Carr
- Division of Hematology, Department of Internal Medicine, Mayo Clinic, MN, USA
- Schulze Center for Novel Therapeutics, Division of Oncology Research, Mayo Clinic, MN, USA
| | - Denis Vorobyev
- INSERM U981, Gustave Roussy Cancer Center, Villejuif, France
| | - Terra Lasho
- Division of Hematology, Department of Internal Medicine, Mayo Clinic, MN, USA
| | - David L Marks
- Schulze Center for Novel Therapeutics, Division of Oncology Research, Mayo Clinic, MN, USA
| | - Ezequiel J Tolosa
- Schulze Center for Novel Therapeutics, Division of Oncology Research, Mayo Clinic, MN, USA
| | - Alexis Vedder
- Chemical Biology and Molecular Medicine Program, Moffitt Cancer Center, Tampa, FL, USA
| | - Luciana L Almada
- Schulze Center for Novel Therapeutics, Division of Oncology Research, Mayo Clinic, MN, USA
| | - Andrey Yurcheko
- INSERM U981, Gustave Roussy Cancer Center, Villejuif, France
| | | | - Bonnie Alver
- Molecular Pharmacology and Experimental Therapeutics, Mayo Clinic, MN, USA
| | - Giacomo Coltro
- Division of Hematology, Department of Internal Medicine, Mayo Clinic, MN, USA
| | - Moritz Binder
- Division of Hematology, Department of Internal Medicine, Mayo Clinic, MN, USA
| | - Stephanie L Safgren
- Schulze Center for Novel Therapeutics, Division of Oncology Research, Mayo Clinic, MN, USA
| | - Isaac Horn
- Schulze Center for Novel Therapeutics, Division of Oncology Research, Mayo Clinic, MN, USA
| | - Xiaona You
- McArdle Laboratory for Cancer Research, University of Wisconsin-Madison, Madison, WI, USA
| | - Eric Solary
- INSERM U1170 and Department of Hematology, Gustave Roussy Cancer Center, Villejuif, France
| | - Maria E Balasis
- Chemical Biology and Molecular Medicine Program, Moffitt Cancer Center, Tampa, FL, USA
| | - Kurt Berger
- London Regional Transgenic and Gene Targeting Facility, Lawson Health Research Institute University of Western Ontario, London, ON, Canada
| | - James Hiebert
- Division of Hematology, Department of Internal Medicine, Mayo Clinic, MN, USA
| | - Thomas Witzig
- Division of Hematology, Department of Internal Medicine, Mayo Clinic, MN, USA
| | - Ajinkya Buradkar
- Division of Hematology, Department of Internal Medicine, Mayo Clinic, MN, USA
| | - Temeida Graf
- 5TH Department of Internal Medicine I, Division of Hematology and Hemostaseology, Medical University of Vienna, Vienna, Austria
| | - Peter Valent
- 5TH Department of Internal Medicine I, Division of Hematology and Hemostaseology, Medical University of Vienna, Vienna, Austria
- Ludwig Boltzmann Institute for Hematology and Hemostaseology, Medical University of Vienna, Vienna, Austria
| | | | - Keith D Robertson
- Molecular Pharmacology and Experimental Therapeutics, Mayo Clinic, MN, USA
| | - Matthew T Howard
- Department of Laboratory Medicine and Pathology, Mayo Clinic, MN, USA
| | - Scott H Kaufmann
- Division of Hematology, Department of Internal Medicine, Mayo Clinic, MN, USA
| | - Christopher Pin
- London Regional Transgenic and Gene Targeting Facility, Lawson Health Research Institute University of Western Ontario, London, ON, Canada
| | | | | | - Nathalie Droin
- INSERM U1170 and Department of Hematology, Gustave Roussy Cancer Center, Villejuif, France
| | - Eric Padron
- Chemical Biology and Molecular Medicine Program, Moffitt Cancer Center, Tampa, FL, USA
| | - Jing Zhang
- McArdle Laboratory for Cancer Research, University of Wisconsin-Madison, Madison, WI, USA
| | - Sergey Nikolaev
- INSERM U981, Gustave Roussy Cancer Center, Villejuif, France.
| | - Mrinal M Patnaik
- Division of Hematology, Department of Internal Medicine, Mayo Clinic, MN, USA.
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20
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Kwon J. Diagnosis and treatment of chronic myelomonocytic leukemia. Blood Res 2021; 56:S5-S16. [PMID: 33935030 PMCID: PMC8094002 DOI: 10.5045/br.2021.2020321] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2020] [Revised: 01/20/2021] [Accepted: 03/09/2021] [Indexed: 12/14/2022] Open
Abstract
Chronic myelomonocytic leukemia (CMML) is a clonal disorder of hematopoietic cells and is a complex of heterogeneous conditions with both myeloproliferative and myelodysplastic features. The diagnosis of CMML is made using morphologic criteria including monocyte-dominant leukocytosis, dysplastic changes, and increased blasts in the bone marrow. Recently, the identification of monocyte subtypes in peripheral blood using multiparameter flow cytometry has been actively studied. Chromosomal abnormalities are the basis of CMML risk stratification, and mutations in several genes including ASXL1 are known to be important not only for the diagnosis and treatment of this disease but also for predicting its prognosis. The standard treatment principles for CMML have not yet been clearly defined; however, hypomethylating agents are mainly considered the frontline therapy in most cases. Although allogeneic hematopoietic stem cell transplantation has limited applications owing to its toxicity, it still plays an important role as the only curative treatment option. Researchers are continuing to develop new drugs for CMML treatment and to prove their clinical usefulness. This review summarizes what is known to date on the diagnosis, treatment, and prognostic factors of CMML and presents future directions by analyzing recent research trends.
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Affiliation(s)
- Jihyun Kwon
- Division of Hematology and Oncology, Department of Internal Medicine, Chungbuk National University College of Medicine, Chungbuk National University Hospital, Cheongju, Korea
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21
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Jian J, Qiao Y, Li Y, Guo Y, Ma H, Liu B. Mutations in chronic myelomonocytic leukemia and their prognostic relevance. Clin Transl Oncol 2021; 23:1731-1742. [PMID: 33861431 DOI: 10.1007/s12094-021-02585-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2020] [Accepted: 03/06/2021] [Indexed: 12/19/2022]
Abstract
Chronic myelomonocytic leukemia (CMML) is a hematologic malignancy that overlaps with myeloproliferative neoplasms (MPN) and myelodysplastic syndromes (MDS) and tends to transform into acute myeloid leukemia (AML). Among cases of CMML, > 90% have gene mutations, primarily involving TET2 (~ 60%), ASXL1 (~ 40%), SRSF2 (~ 50%), and the RAS pathways (~ 30%). These gene mutations are associated with both the clinical phenotypes and the prognosis of CMML, special CMML variants and pre-phases of CMML. Cytogenetic abnormalities and the size of genome are also associated with prognosis. Meanwhile, cases with ASXL1, DNMT3A, NRAS, SETBP1, CBL and RUNX1 mutations may have inferior prognoses, but only ASXL1 mutations were confirmed to be independent predictors of the patient outcome and were included in three prognostic models. Novel treatment targets related to the various gene mutations are emerging. Therefore, this review provides new insights to explore the correlations among gene mutations, clinical phenotypes, prognosis, and novel drugs in CMML.
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Affiliation(s)
- J Jian
- The First Clinical Medical College, Lanzhou University, Lanzhou, Gansu, China
| | - Y Qiao
- Institute of Hematology, Xi'an Central Hospital, Xi'an, Shaanxi, China
| | - Y Li
- The First Clinical Medical College, Lanzhou University, Lanzhou, Gansu, China
| | - Y Guo
- The First Clinical Medical College, Lanzhou University, Lanzhou, Gansu, China
| | - H Ma
- The First Clinical Medical College, Lanzhou University, Lanzhou, Gansu, China. .,Department of Hematology, The First Affiliated Hospital, Lanzhou University, 1 Donggangxilu street, Lanzhou, Gansu, China.
| | - B Liu
- The First Clinical Medical College, Lanzhou University, Lanzhou, Gansu, China. .,Department of Hematology, The First Affiliated Hospital, Lanzhou University, 1 Donggangxilu street, Lanzhou, Gansu, China.
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22
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Bewersdorf JP, Zeidan AM. Risk-Adapted, Individualized Treatment Strategies of Myelodysplastic Syndromes (MDS) and Chronic Myelomonocytic Leukemia (CMML). Cancers (Basel) 2021; 13:1610. [PMID: 33807279 PMCID: PMC8036734 DOI: 10.3390/cancers13071610] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2021] [Revised: 03/18/2021] [Accepted: 03/26/2021] [Indexed: 02/06/2023] Open
Abstract
Myelodysplastic syndrome (MDS) and chronic myelomonocytic leukemia (CMML) are two distinct blood cancers with a variable clinical symptom burden and risk of progression to acute myeloid leukemia. Management decisions should be guided by individual patient and disease characteristics and based on validated risk stratification tools. While supportive care with red blood cell transfusions, erythropoiesis-stimulating agents, and iron chelation remains the mainstay of therapy for lower-risk (LR)-MDS patients, luspatercept has recently been approved for transfusion-dependent anemic LR-MDS patients ending a decade without any new drug approvals for MDS. For higher-risk patients, allogeneic hematopoietic cell transplant (allo-HCT) remains the only curative therapy for both MDS and CMML but most patients are not eligible for allo-HCT. For those patients, the hypomethylating agents (HMA) azacitidine and decitabine remain standard of care with azacitidine being the only agent that has shown an overall survival benefit in randomized trials. Although early results from novel molecularly driven agents such as IDH1/2 inhibitors, venetoclax, magrolimab, and APR-246 for MDS as well as tagraxofusp, tipifarnib, and lenzilumab for CMML appear encouraging, confirmatory randomized trials must be completed to fully assess their safety and efficacy prior to routine clinical use. Herein, we review the current management of MDS and CMML and conclude with a critical appraisal of novel therapies and general trends in this field.
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Affiliation(s)
| | - Amer M. Zeidan
- Department of Internal Medicine, Section of Hematology, Yale University School of Medicine, 333 Cedar Street, P.O. Box 208028, New Haven, CT 06520-8028, USA;
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23
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Ma L, Jiang L, Yang W, Luo Y, Mei C, Zhou X, Xu G, Xu W, Ye L, Ren Y, Lu C, Lin P, Jin J, Tong H. Real-world data of chronic myelomonocytic leukemia: A chinese single-center retrospective study. Cancer Med 2021; 10:1715-1725. [PMID: 33559357 PMCID: PMC7940209 DOI: 10.1002/cam4.3774] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2020] [Revised: 12/14/2020] [Accepted: 01/20/2021] [Indexed: 12/15/2022] Open
Abstract
Chronic myelomonocytic leukemia (CMML) is a rare disease of elderly people characterized by the presence of sustained peripheral blood monocytosis, overlapping features of myeloproliferation, and myelodysplasia. We present a large retrospective study of 156 CMML patients in China. Mean age at diagnosis was 68 years old (range 23‐91). According to the CMML‐specific prognostic scoring system (CPSS), 10 patients (8.3%) were low risk, 27 patients (22.5%) were intermediate‐1 risk, 72 patients (60%) were intermediate‐2 risk, and 11 patients (9.2%) were high risk. A total of 90 patients (57.7%) received hypomethylating agents (HMAs) treatment, 19 patients (12.2%) received chemotherapy and 47 patients (30.1%) received the best supportive care. Seventeen patients (10.9%) underwent allogeneic hematopoietic stem cell transplantation (allo‐SCT) after HMAs treatment or chemotherapy. With a median follow‐up of 35.3 months, overall response rate (ORR) was 69.5% in the HMAs ± chemotherapy group, 79.5% in the HMAs monotherapy group, 60.0% in the HMAs + chemotherapy group, and 37.5% in the chemotherapy group. HMAs monotherapy group had prolonged OS compared with the chemotherapy group (23.57 months vs. 11.73 months; p = 0.035). Patients who achieved ORR had prolonged OS (25.83 months vs. 8.00 months; p < 0.001) and LFS (20.53 months vs. 6.80 months; p < 0.001) compared with those not achieved ORR in the HMA ± chemotherapy group. By univariate analysis, only higher hemoglobulin (≥80 g/L) and lower serum LDH levels (<300 U/L) predicted for better OS and LFS. By multivariate analysis, only Hb ≥ 80 g/L predicted for prolonged OS, Hb ≥ 80 g/L, and monocytes < 3 × 109/L predicted for prolonged LFS. In summary, our study highlights the benefit of HMAs therapy in CMML, but we still need to develop novel therapeutics to achieve better outcomes.
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Affiliation(s)
- Liya Ma
- Myelodysplastic Syndrome Center, Department of Hematology, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China
| | - Lingxu Jiang
- Myelodysplastic Syndrome Center, Department of Hematology, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China
| | - Wenli Yang
- Myelodysplastic Syndrome Center, Department of Hematology, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China
| | - Yingwan Luo
- Myelodysplastic Syndrome Center, Department of Hematology, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China
| | - Chen Mei
- Myelodysplastic Syndrome Center, Department of Hematology, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China
| | - Xinping Zhou
- Myelodysplastic Syndrome Center, Department of Hematology, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China
| | - Gaixiang Xu
- Myelodysplastic Syndrome Center, Department of Hematology, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China
| | - Weilai Xu
- Myelodysplastic Syndrome Center, Department of Hematology, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China
| | - Li Ye
- Myelodysplastic Syndrome Center, Department of Hematology, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China
| | - Yanlin Ren
- Myelodysplastic Syndrome Center, Department of Hematology, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China
| | - Chenxi Lu
- Myelodysplastic Syndrome Center, Department of Hematology, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China
| | - Peipei Lin
- Dapartment of Radiotherapy, Taizhou Central Hospital, Taizhou, Zhejiang, China
| | - Jie Jin
- Myelodysplastic Syndrome Center, Department of Hematology, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China
| | - Hongyan Tong
- Myelodysplastic Syndrome Center, Department of Hematology, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China
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24
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Patnaik MM, Sallman DA, Mangaonkar AA, Heuer R, Hirvela J, Zblewski D, Al-Kali A, Binder M, Balasis ME, Newman H, Letson C, Kruer TL, Gangat N, Komrokji RS, Tefferi A, Lo A, Shih T, Durrant C, List AF, Padron E. Phase 1 study of lenzilumab, a recombinant anti-human GM-CSF antibody, for chronic myelomonocytic leukemia. Blood 2020; 136:909-913. [PMID: 32294158 PMCID: PMC7531999 DOI: 10.1182/blood.2019004352] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
In this phase 1 trial, inhibition of granulocyte-macrophage colony-stimulating factor (GM-CSF) was associated with clinically meaningful responses in 5 of 15 patients with relapsed or refractory chronic myelomonocytic leukemia (CMML). Preliminary data suggest that this approach may be tractable in CMML bearing activating NRAS mutations.
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MESH Headings
- Aged
- Aged, 80 and over
- Antibodies, Monoclonal/administration & dosage
- Antibodies, Monoclonal/adverse effects
- Antibodies, Monoclonal/pharmacokinetics
- Antibodies, Monoclonal, Humanized/administration & dosage
- Antibodies, Monoclonal, Humanized/adverse effects
- Antibodies, Monoclonal, Humanized/pharmacokinetics
- Antineoplastic Agents, Immunological/administration & dosage
- Antineoplastic Agents, Immunological/adverse effects
- Antineoplastic Agents, Immunological/pharmacokinetics
- Chemotherapy, Adjuvant
- Dose-Response Relationship, Drug
- Drug-Related Side Effects and Adverse Reactions/blood
- Drug-Related Side Effects and Adverse Reactions/immunology
- Female
- Granulocyte-Macrophage Colony-Stimulating Factor/immunology
- Humans
- Leukemia, Myelomonocytic, Chronic/drug therapy
- Leukemia, Myelomonocytic, Chronic/metabolism
- Leukemia, Myelomonocytic, Chronic/therapy
- Male
- Maximum Tolerated Dose
- Middle Aged
- Recombinant Proteins/administration & dosage
- Recombinant Proteins/adverse effects
- Recombinant Proteins/pharmacokinetics
- Treatment Outcome
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Affiliation(s)
- Mrinal M Patnaik
- Division of Hematology, Department of Internal Medicine, Mayo Clinic, Rochester, MN
| | - David A Sallman
- Department of Hematologic Malignancies, Moffitt Cancer Center, Tampa, FL
| | | | - Rachel Heuer
- Division of Hematology, Department of Internal Medicine, Mayo Clinic, Rochester, MN
| | - Jeffery Hirvela
- Division of Hematology, Department of Internal Medicine, Mayo Clinic, Rochester, MN
| | - Darci Zblewski
- Division of Hematology, Department of Internal Medicine, Mayo Clinic, Rochester, MN
| | - Aref Al-Kali
- Division of Hematology, Department of Internal Medicine, Mayo Clinic, Rochester, MN
| | - Moritz Binder
- Division of Hematology, Department of Internal Medicine, Mayo Clinic, Rochester, MN
| | - Maria E Balasis
- Department of Hematologic Malignancies, Moffitt Cancer Center, Tampa, FL
| | - Hannah Newman
- Department of Hematologic Malignancies, Moffitt Cancer Center, Tampa, FL
| | - Christopher Letson
- Department of Hematologic Malignancies, Moffitt Cancer Center, Tampa, FL
| | - Traci L Kruer
- Department of Hematologic Malignancies, Moffitt Cancer Center, Tampa, FL
| | - Naseema Gangat
- Division of Hematology, Department of Internal Medicine, Mayo Clinic, Rochester, MN
| | - Rami S Komrokji
- Department of Hematologic Malignancies, Moffitt Cancer Center, Tampa, FL
| | - Ayalew Tefferi
- Division of Hematology, Department of Internal Medicine, Mayo Clinic, Rochester, MN
| | | | | | | | - Alan F List
- Department of Hematologic Malignancies, Moffitt Cancer Center, Tampa, FL
| | - Eric Padron
- Department of Hematologic Malignancies, Moffitt Cancer Center, Tampa, FL
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25
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Patnaik MM, Tefferi A. Chronic Myelomonocytic leukemia: 2020 update on diagnosis, risk stratification and management. Am J Hematol 2020; 95:97-115. [PMID: 31736132 DOI: 10.1002/ajh.25684] [Citation(s) in RCA: 89] [Impact Index Per Article: 22.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2019] [Accepted: 11/13/2019] [Indexed: 12/12/2022]
Abstract
DISEASE OVERVIEW Chronic myelomonocytic leukemia (CMML) is a clonal hematopoietic stem cell disorder with overlapping features of myelodysplastic syndromes and myeloproliferative neoplasms, with an inherent risk for leukemic transformation (~15% over 3-5 years). DIAGNOSIS Diagnosis is based on the presence of sustained (>3 months) peripheral blood monocytosis (≥1 × 109 /L; monocytes ≥10%), along with bone marrow dysplasia. Clonal cytogenetic abnormalities occur in ~ 30% of patients, while >90% have gene mutations. Mutations involving TET2 (~60%), SRSF2 (~50%), ASXL1 (~40%) and the oncogenic RAS pathway (~30%) are frequent; while the presence of ASXL1 and DNMT3A mutations and the absence of TET2 mutations negatively impact over-all survival. RISK STRATIFICATION Molecularly integrated prognostic models include; the Groupe Français des Myélodysplasies (GFM), Mayo Molecular Model (MMM) and the CMML specific prognostic model (CPSS-Mol). Risk factors incorporated into the MMM include presence of nonsense or frameshift ASXL1 mutations, absolute monocyte count>10 × 109 /L, hemoglobin <10 g/dL, platelet count <100 × 109 /L and the presence of circulating immature myeloid cells. The MMM stratifies CMML patients into four groups; high (≥3 risk factors), intermediate-2 (2 risk factors), intermediate-1 (1 risk factor) and low (no risk factors), with median survivals of 16, 31, 59 and 97 months, respectively. RISK-ADAPTED THERAPY Hypomethylating agents such as 5-azacitidine and decitabine are commonly used, with overall response rates of ~40%-50% and complete remission rates of ~7%-17%; with no impact on mutational allele burdens. Allogeneic stem cell transplant is the only potentially curative option, but is associated with significant morbidity and mortality.
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Affiliation(s)
- Mrinal M. Patnaik
- Division of Hematology, Department of MedicineMayo Clinic Rochester Minnesota
| | - Ayalew Tefferi
- Division of Hematology, Department of MedicineMayo Clinic Rochester Minnesota
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26
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Clinical, molecular, and prognostic correlates of number, type, and functional localization of TET2 mutations in chronic myelomonocytic leukemia (CMML)-a study of 1084 patients. Leukemia 2019; 34:1407-1421. [PMID: 31836856 DOI: 10.1038/s41375-019-0690-7] [Citation(s) in RCA: 66] [Impact Index Per Article: 13.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2019] [Revised: 11/18/2019] [Accepted: 12/05/2019] [Indexed: 12/17/2022]
Abstract
Loss-of-function TET2 mutations (TET2MT) are frequent early clonal events in myeloid neoplasms and are thought to confer a fitness advantage to hematopoietic precursors. This large, multi-institutional study (n = 1084), investigated the TET2 mutational landscape and prognostic implications of the number, type, and location of TET2MT and the epistatic relationship with other somatic events in chronic myelomonocytic leukemia (CMML). Nine hundred and forty-two TET2MT were identified in 604 (56%) patients, of which 710 (75%) were predicted to be truncating (involving the catalytic domain). Three hundred and sixteen (29%) patients had ≥1 TET2MT, with 28%, 1%, and 0.2% harboring 2, 3, and 5 mutations, respectively. In comparison to TET2WT, TET2MT patients were older in age, more likely to have dysplastic CMML, a higher number of co-occurring mutations, and lower-risk stratification. Importantly, TET2MT were associated with a survival advantage (49 vs. 30 months, p < 0.0001), especially in the context of multiple TET2MT (≥2; 57 months, p < 0.001), and truncating TET2MT (51 months, p < 0.001). In addition, the adverse prognostic impact of ASXL1MT was partially mitigated by concurrent TET2MT, with the ASXL1WT/TET2MT genotype having better outcomes and resulting in further risk stratification of ASXL1 inclusive CMML prognostic models, in comparison to ASXL1MT alone.
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27
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Chronic Myelomonocytic Leukemia: Insights into Biology, Prognostic Factors, and Treatment. Curr Oncol Rep 2019; 21:101. [DOI: 10.1007/s11912-019-0855-6] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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