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Gagelmann N, Bose P, Gupta V, McLornan DP, Vachhani P, Al-Ali HK, Ali H, Treskes P, Buckley S, Roman-Torres K, Scott B. Consistency of Spleen and Symptom Reduction Regardless of Cytopenia in Patients With Myelofibrosis Treated With Pacritinib. CLINICAL LYMPHOMA, MYELOMA & LEUKEMIA 2024:S2152-2650(24)00246-5. [PMID: 39034203 DOI: 10.1016/j.clml.2024.06.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/23/2024] [Revised: 06/28/2024] [Accepted: 06/28/2024] [Indexed: 07/23/2024]
Abstract
BACKGROUND Pacritinib is a JAK2/IRAK1/ACVR1 inhibitor that is approved in the United States for the treatment of patients with myelofibrosis who have a platelet count < 50 × 109/L. Phase 3 clinical studies of pacritinib included patients across a wide range of baseline platelet and hemoglobin levels. PATIENTS AND METHODS In order to assess the impact of baseline blood counts on pacritinib efficacy, an analysis of efficacy outcomes by baseline platelet and hemoglobin levels was performed using data pooled from 2 Phase 3 studies of pacritinib in patients with MF (PERSIST-1 and PERSIST-2). RESULTS Of 276 patients evaluable for spleen response, spleen volume reduction occurred consistently across platelet subgroups (< 100 × 109/L or ≥ 100 × 109/L) and hemoglobin subgroups (< 8 g/dL, ≥ 8 to < 10 g/dL, or > 10 g/dL), with no diminution in treatment effect in patients with severe thrombocytopenia or anemia. Among 159 patients evaluable for symptoms response, improvement in total symptom score (TTS) was similar across platelet subgroups. A ≥ 50% improvement of TSS occurred more frequently in patients with baseline hemoglobin < 8 g/dL compared with those with baseline hemoglobin ≥ 8 to < 10 g/dL or > 10 g/dL. Patients with baseline hemoglobin < 8 g/dL also experienced improved hemoglobin sustained over 24 weeks, whereas subgroups with less severe anemia had stable hemoglobin levels over time. Symptom improvement as assessed using the Patient Global Impression of Change instrument was generally consistent across platelet and hemoglobin subgroups. CONCLUSION Pacritinib demonstrates consistent efficacy in patients with MF regardless of baseline platelet and hemoglobin counts.
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Affiliation(s)
- Nico Gagelmann
- Department of Stem Cell Transplantation, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.
| | - Prithviraj Bose
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Vikas Gupta
- Princess Margaret Cancer Centre, University Health Network, Toronto, ON, Canada
| | - Donal P McLornan
- Department of Haematology, University College London Hospitals NHS Foundation Trust, London, UK
| | - Pankit Vachhani
- Department of Medicine, O'Neal Comprehensive Cancer Center at the University of Alabama at Birmingham, AL
| | | | - Haris Ali
- Department of Hematology & Hematopoietic Cell Transplantation, City of Hope National Medical Center, Duarte, CA
| | | | | | | | - Bart Scott
- Transplantation Program, Fred Hutchinson Cancer Research Center, Seattle, WA
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Ranalli P, Natale A, Guardalupi F, Santarone S, Cantò C, La Barba G, Di Ianni M. Myelofibrosis and allogeneic transplantation: critical points and challenges. Front Oncol 2024; 14:1396435. [PMID: 38966064 PMCID: PMC11222377 DOI: 10.3389/fonc.2024.1396435] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2024] [Accepted: 05/23/2024] [Indexed: 07/06/2024] Open
Abstract
New available drugs allow better control of systemic symptoms associated with myelofibrosis (MF) and splenomegaly but they do not modify the natural history of progressive and poor prognosis disease. Thus, hematopoietic stem cell transplantation (HSCT) is still considered the only available curative treatment for patients with MF. Despite the increasing number of procedures worldwide in recent years, HSCT for MF patients remains challenging. An increasingly complex network of the patient, disease, and transplant-related factors should be considered to understand the need for and the benefits of the procedure. Unfortunately, prospective trials are often lacking in this setting, making an evidence-based decision process particularly arduous. In the present review, we will analyze the main controversial points of allogeneic transplantation in MF, that is, the development of more sophisticated models for the identification of eligible patients; the need for tools offering a more precise definition of expected outcomes combining comorbidity assessment and factors related to the procedure; the decision-making process about the best transplantation time; the evaluation of the most appropriate platform for curative treatment; the impact of splenomegaly; and splenectomy on outcomes.
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Affiliation(s)
- Paola Ranalli
- Hematology Unit, Pescara Hospital, Pescara, Italy
- Department of Medicine and Aging Sciences, University of Chieti-Pescara, Chieti, Italy
| | | | - Francesco Guardalupi
- Department of Medicine and Aging Sciences, University of Chieti-Pescara, Chieti, Italy
| | | | - Chiara Cantò
- Hematology Unit, Pescara Hospital, Pescara, Italy
| | | | - Mauro Di Ianni
- Hematology Unit, Pescara Hospital, Pescara, Italy
- Department of Medicine and Aging Sciences, University of Chieti-Pescara, Chieti, Italy
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3
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Zulch E, Inoue Y, Cioccio J, Rakszawski K, Songdej N, Nickolich M, Zheng H, Naik S, Rybka W, Ehmann C, Sivik J, Mierski J, Silar B, Vajdic C, Greiner R, Brown V, Hohl R, Claxton D, Shike H, Paules CI, Mineishi S, Minagawa K. Impact of post-transplant cyclophosphamide and splenomegaly on primary graft failure and multi-lineage cytopenia after allogeneic hematopoietic cell transplantation. Leuk Res 2024; 143:107530. [PMID: 38852515 DOI: 10.1016/j.leukres.2024.107530] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2024] [Revised: 05/21/2024] [Accepted: 06/01/2024] [Indexed: 06/11/2024]
Abstract
Primary graft failure (PGF) and multi-lineage cytopenia (MLC) increase the risk of nonrelapse mortality in allogeneic hematopoietic cell transplants (HCT). We evaluated the impact of post-transplant cyclophosphamide (PTCy) and splenomegaly on PGF and MLC for hematological malignancies. This study included patients with PTCy (N=84) and conventional graft-vs.-host disease prophylaxis (N=199). The occurrence of splenomegaly varied widely, ranging from 17.1 % (acute myeloid leukemia) to 66.7 % (myeloproliferative neoplasms). Ten patients (N=8 in the PTCy and N=2 in the non- PTCy) developed PGF, and 44 patients developed MLC (both N=22). PTCy and severe splenomegaly (≥20 cm) were risk factors for PGF (odds ratio (OR): 10.40, p<0.01 and 6.74, p=0.01 respectively). Moreover, severe splenomegaly was a risk factor for PGF in PTCy patients (OR: 10.20, p=0.01). PTCy (hazard ratio (HR) 2.09, p=0.02), moderate (≥15, <20 cm, HR 4.36, p<0.01), and severe splenomegaly (HR 3.04, p=0.01) were independent risk factors for MLC. However, in subgroup analysis in PTCy patients, only mild splenomegaly (≥12, <15 cm, HR 4.62, p=0.01) was a risk factor for MLC. We recommend all patients be screened for splenomegaly before HCT, and PTCy is cautioned in those with splenomegaly.
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Affiliation(s)
- Emma Zulch
- Blood and Marrow Transplant Program, Division of Hematology and Oncology, Penn State Cancer Institute, Hershey, PA, USA; Penn State College of Medicine, Hershey, PA, USA
| | - Yoshitaka Inoue
- Blood and Marrow Transplant Program, Division of Hematology and Oncology, Penn State Cancer Institute, Hershey, PA, USA; Penn State College of Medicine, Hershey, PA, USA; Department of Hematology, Kumamoto University, Kumamoto, Japan.
| | - Joseph Cioccio
- Blood and Marrow Transplant Program, Division of Hematology and Oncology, Penn State Cancer Institute, Hershey, PA, USA
| | - Kevin Rakszawski
- Blood and Marrow Transplant Program, Division of Hematology and Oncology, Penn State Cancer Institute, Hershey, PA, USA
| | - Natthapol Songdej
- Blood and Marrow Transplant Program, Division of Hematology and Oncology, Penn State Cancer Institute, Hershey, PA, USA
| | - Myles Nickolich
- Blood and Marrow Transplant Program, Division of Hematology and Oncology, Penn State Cancer Institute, Hershey, PA, USA
| | - Hong Zheng
- Blood and Marrow Transplant Program, Division of Hematology and Oncology, Penn State Cancer Institute, Hershey, PA, USA
| | - Seema Naik
- Blood and Marrow Transplant Program, Division of Hematology and Oncology, Penn State Cancer Institute, Hershey, PA, USA
| | - Witold Rybka
- Blood and Marrow Transplant Program, Division of Hematology and Oncology, Penn State Cancer Institute, Hershey, PA, USA
| | - Christopher Ehmann
- Blood and Marrow Transplant Program, Division of Hematology and Oncology, Penn State Cancer Institute, Hershey, PA, USA
| | - Jeffrey Sivik
- Department of Pharmacy, Penn State Cancer Institute, Hershey, PA, USA
| | - Jseph Mierski
- Blood and Marrow Transplant Program, Division of Hematology and Oncology, Penn State Cancer Institute, Hershey, PA, USA
| | - Brooke Silar
- Blood and Marrow Transplant Program, Division of Hematology and Oncology, Penn State Cancer Institute, Hershey, PA, USA
| | - Caitlin Vajdic
- Blood and Marrow Transplant Program, Division of Hematology and Oncology, Penn State Cancer Institute, Hershey, PA, USA
| | - Robert Greiner
- Division of Pediatric Hematology/Oncology, Penn State Health Children's Hospital, Hershey, PA, USA
| | - Valerie Brown
- Division of Pediatric Hematology/Oncology, Penn State Health Children's Hospital, Hershey, PA, USA
| | - Raymond Hohl
- Blood and Marrow Transplant Program, Division of Hematology and Oncology, Penn State Cancer Institute, Hershey, PA, USA
| | - David Claxton
- Blood and Marrow Transplant Program, Division of Hematology and Oncology, Penn State Cancer Institute, Hershey, PA, USA
| | - Hiroko Shike
- Department of Pathology, Penn State Cancer Institute, Hershey, PA, USA
| | - Catharine I Paules
- Penn State College of Medicine, Hershey, PA, USA; Penn State Health Milton S. Hershey Medical Center, Hershey, PA, USA
| | - Shin Mineishi
- Blood and Marrow Transplant Program, Division of Hematology and Oncology, Penn State Cancer Institute, Hershey, PA, USA
| | - Kentaro Minagawa
- Blood and Marrow Transplant Program, Division of Hematology and Oncology, Penn State Cancer Institute, Hershey, PA, USA
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4
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Ali H, Bacigalupo A. 2024 update on allogeneic hematopoietic stem cell transplant for myelofibrosis: A review of current data and applications on risk stratification and management. Am J Hematol 2024; 99:938-945. [PMID: 38450790 DOI: 10.1002/ajh.27274] [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: 02/01/2024] [Accepted: 02/06/2024] [Indexed: 03/08/2024]
Abstract
BACKGROUND Allogeneic hemopoietic stem cell transplantation (HSCT) currently remains the only curative treatment for patients with myelofibrosis (MF). Transplant related mortality (TRM) and relapse, remain two significant complications which need to be addressed. AIMS The aim of this manuscript is to review current available reports on changes which have recently occurred, to improve the outcome of MF patients undergoing an allogeneic HSCT. METHODS Published papers were used to analyze different aspects of allogeneic HSCT. RESULTS Changes and updates are provided on selection of patients, prognostic systems, managing splenomegaly, conditioning regimens, predicting transplant outcome, stem cell sources, stem cell donors, graft versus host disease (GvHD) prophylaxis, patients with blast phase, hematopoietic reconstitution, disease markers, donor chimerism, and treatment of relapse. CONCLUSIONS The review outlines new transplant platforms which are now available for patients with myelofibrosis, together with persisting problems, among which, older age combined with marrow fibrosis and an inflammatory disease. Relapse also requires aggressive monitoring of drivers mutations, and early cellular therapy.
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Affiliation(s)
- Haris Ali
- Divison of Leukemia, Department of Hematology and Hemopoietic Cell Transplantation, City of Hope, Duarte, California, USA
| | - Andrea Bacigalupo
- Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, Fondazione Policlinico Universitario A. Gemelli IRCCS, Roma, Italy
- Sezione di Ematologia, Dipartimento di Scienze Radiologiche ed Ematologiche, Università Cattolica del Sacro Cuore, Roma, Italy
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5
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Finazzi MC, Tefferi A, Rambaldi A. JAK inhibitor treatment-resistant splenomegaly before transplantation in myelofibrosis: Splenectomy or radiotherapy? Am J Hematol 2024; 99:804-805. [PMID: 38482991 DOI: 10.1002/ajh.27292] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2024] [Revised: 02/27/2024] [Accepted: 03/04/2024] [Indexed: 04/09/2024]
Affiliation(s)
- Maria Chiara Finazzi
- Azienda Socio-Sanitaria Territoriale Papa Giovanni XXIII Piazza OMS, Bergamo, Italy
| | - Ayalew Tefferi
- Division of Hematology, Mayo Clinic, Rochester, Minnesota, USA
- Department of Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Alessandro Rambaldi
- Azienda Socio-Sanitaria Territoriale Papa Giovanni XXIII Piazza OMS, Bergamo, Italy
- Division of Hematology, Mayo Clinic, Rochester, Minnesota, USA
- Department of Medicine, Mayo Clinic, Rochester, Minnesota, USA
- Department of Oncology and Hematology, University of Milan, Milan, Italy
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6
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Polverelli N, Bonneville EF, de Wreede LC, Koster L, Kröger NM, Schroeder T, Peffault de Latour R, Passweg J, Sockel K, Broers AEC, Clark A, Dreger P, Blaise D, Yakoub-Agha I, Petersen SL, Finke J, Chevallier P, Helbig G, Rabitsch W, Sammassimo S, Arcaini L, Russo D, Drozd-Sokolowska J, Raj K, Robin M, Battipaglia G, Czerw T, Hernández-Boluda JC, McLornan DP. Impact of comorbidities and body mass index on the outcomes of allogeneic hematopoietic cell transplantation in myelofibrosis: A study on behalf of the Chronic Malignancies Working Party of EBMT. Am J Hematol 2024; 99:993-996. [PMID: 38385579 DOI: 10.1002/ajh.27262] [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: 12/26/2023] [Revised: 02/07/2024] [Accepted: 02/08/2024] [Indexed: 02/23/2024]
Abstract
Investigating the evaluation of eligibility for transplant in myelofibrosis (MF): The role of HCT-CI and BMI. HCT-CI emerges as a key prognostic factor, while BMI shows limited impact. This study expands insights for better clinical decision-making in MF allo-HCT.
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Affiliation(s)
- Nicola Polverelli
- Unit of Bone Marrow Transplantation, Division of Hematology, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Edouard F Bonneville
- Department of Biomedical Data Sciences, Leiden University Medical Center, Leiden, The Netherlands
- EBMT Leiden Study Unit, Leiden, The Netherlands
| | - Liesbeth C de Wreede
- Department of Biomedical Data Sciences, Leiden University Medical Center, Leiden, The Netherlands
| | | | - Nicolaus Martin Kröger
- Department of Stem Cell Transplantation, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Thomas Schroeder
- Department of Hematology and Stem Cell Transplantation, West German Cancer Center, University Hospital of Essen, Essen, Germany
| | | | - Jakob Passweg
- Hematology Division, University Hospital, Basel, Switzerland
| | | | | | - Andrew Clark
- Beatson West of Scotland Cancer Centre, Glasgow, United Kingdom
| | | | - Didier Blaise
- Programme de Transplantation & Therapie Cellulaire, Marseille, France
| | | | - Soeren Lykke Petersen
- Bone Marrow Transplant Unit, Department of Hematology, Copenhagen University Hospital, Copenhagen, Denmark
| | - Jürgen Finke
- Department of Medicine, Medical Center-University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | | | - Grzegorz Helbig
- Department of Hematology and Bone Marrow Transplantation, School of Medicine in Katowice, Medical University of Silesia, Katowice, Poland
| | - Werner Rabitsch
- BMT Unit, Internal Medicine I, Medical University of Vienna, Vienna, Austria
| | - Simona Sammassimo
- Onco-Hematology Division, IEO, European Institute of Oncology IRCCS, Milan, Italy
| | - Luca Arcaini
- Unit of Bone Marrow Transplantation, Division of Hematology, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
- Department of Molecular Medicine, University of Pavia, Pavia, Italy
| | - Domenico Russo
- Unit of Blood Diseases and Stem Cell Transplantation, Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
| | | | - Kavita Raj
- Department of Haematology and Stem Cell Transplantation, University College London Hospitals NHS Trust, London, UK
| | - Marie Robin
- BMT Unit, Saint-Louis Hospital, Paris, France
| | - Giorgia Battipaglia
- Hematology and Bone Marrow Transplantation Unit, Hematology Department, Federico II University of Naples, Naples, Italy
| | - Tomasz Czerw
- Department of Hematology, Maria Skłodowska-Curie National Research Institute of Oncology, Gliwice, Poland
| | | | - Donal P McLornan
- Department of Haematology and Stem Cell Transplantation, University College London Hospitals NHS Trust, London, UK
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7
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Malagola M, Iurlo A, Bucelli C, Abruzzese E, Bonifacio M, Stagno F, Binotto G, D'Adda M, Lunghi M, Crugnola M, Ferrari ML, Lunghi F, Castagnetti F, Rosti G, Lemoli RM, Sancetta R, Coppi MR, Corsetti MT, De Gobbi M, Romano A, Tiribelli M, Russo Rossi A, Russo S, Defina M, Farina M, Bernardi S, Butturini G, Pellizzeri S, Roccaro AM, Russo D. The Italian Multicentric Randomized OPTkIMA Trial on Fixed vs Progressive Intermittent TKI Therapy in CML Elderly Patients: 3-Years of Molecular Response and Quality of Life Monitoring After Completing the Treatment Plan. CLINICAL LYMPHOMA, MYELOMA & LEUKEMIA 2024; 24:323-331. [PMID: 38369436 DOI: 10.1016/j.clml.2024.01.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/08/2023] [Revised: 01/15/2024] [Accepted: 01/15/2024] [Indexed: 02/20/2024]
Abstract
BACKGROUND Intermittent treatment with tyrosine kinase inhibitors (TKIs) is an option for elderly chronic myeloid leukemia (CML) patients who are often candidates for life-long treatment. MATERIALS AND METHODS The Italian phase III multicentric randomized Optimize TKIs Multiple Approaches (OPTkIMA) study aimed to evaluate if a progressive de-escalation of TKIs is able to maintain the molecular remission (MR)3.0 and to improve Health-Related Quality of Life (HRQoL) in CML elderly patients. RESULTS A total of 215 patients in stable MR3.0/MR4.0 were randomized to receive an intermittent TKI schedule 1 month ON-1 month OFF for 3 years (FIXED arm; n = 111) vs. a progressive de-escalation TKI dose up to one-third of the starting dose at the 3rd year (PROGRESSIVE arm; n = 104). Two hundred three patients completed the 3rd year of OPTkIMA study. At the last follow-up, MR3.0 loss was 27% vs. 46% (P = .005) in the FIXED vs PROGRESSIVE arm, respectively. None of these patients experienced disease progression. The 3-year probability of maintaining the MR3.0 was 59% vs. 53%, respectively (P = .13). HRQoL globally improved from the baseline to the 3rd year, without any significant difference between the 2 arms. After the 3rd year, the proportion of patients who was address to TKI discontinuation in the 2 arms was 36% (FIXED) vs. 58% (PROGRESSIVE) (P = .03). CONCLUSIONS The intensification of intermittent TKI therapy is associated with a higher incidence of MR3.0 loss, but those patients who maintain the MR3.0 molecular response at the end of the study have been frequently considered eligible for TFR. The HRQoL generally improved during the de-escalation therapy in both randomization arms.
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Affiliation(s)
- Michele Malagola
- Chair of Hematology, Department of Clinical and Experimental Sciences, University of Brescia, Unit of Blood Disease and Stem Cell Transplantation, ASST-Spedali Civili, Brescia, Italy.
| | - Alessandra Iurlo
- Hematology Division, Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milano, Italy
| | - Cristina Bucelli
- Hematology Division, Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milano, Italy
| | - Elisabetta Abruzzese
- Division of Hematology, S. Eugenio Hospital, ASL ROMA2, Tor Vergata University, Roma, Italy
| | - Massimiliano Bonifacio
- Department of Engineering for Innovation Medicine, Section of Innovation Biomedicine, Hematology Area - University of Verona, Italy
| | - Fabio Stagno
- Hematology Unit, AOU Policlinico "G. Martino", University of Messina, Italy
| | - Gianni Binotto
- Hematology and Clinical Immunology, Department of Medicine, Padua School of Medicine, Padova, Italy
| | - Marienlla D'Adda
- Division of Hematology, ASST-Spedali Civili di Brescia, Brescia, Italy
| | - Monia Lunghi
- Division of Hematology, Department of Translation Medicine, University of Eastern Piedmont, Novara, Italy
| | - Monica Crugnola
- Hematology Unit and BMT Center University Hospital of Parma, Italy
| | - Maria Luisa Ferrari
- Hematology and Bone Marrow Transplant Unit, ASST Papa Giovanni XXIII, Bergamo, Italy
| | - Francesca Lunghi
- Hematology and Bone Marrow Transplantation (BMT) Unit, San Raffaele Scientific Institute, Milano, Italy
| | - Fausto Castagnetti
- Institute of Hematology "Seràgnoli" IRCCS Azienda Ospedaliero-Universitaria di Bologna, Italy; Department of Medical and Surgical Sciences University of Bologna, Bologna, Italy
| | - Gianantonio Rosti
- IRCCS Istituto Romagnolo per lo Studio dei Tumori (IRST) "Dino Amadori", Meldola (FC), Italy
| | - Roberto Massimo Lemoli
- Chair of Hematology, Internal Medicine Dpt, University of Genova, Italy; Clinic of Hematology, IRCCS Policlinico San Martino, Genova, Italy
| | | | | | - Maria Teresa Corsetti
- Hematology Division, Azienda Ospedaliera Santi Antonio e Biagio e Cesare Arrigo, Alessandria, Italy
| | - Marco De Gobbi
- Hematology and Internal Medicine Division, San Luigi Hospital, Department of Clinical and Biological Sciences, University of Turin, Orbassano, Italy
| | - Atelda Romano
- IRCCS Regina Elena National Cancer Institute-Roma, Italy
| | - Mario Tiribelli
- Division of Hematology and BMT, Department of Medicine, University of Udine, Udine, Italy
| | | | - Sabina Russo
- Division of Hematology, Dipartimento di Patologia Umana dell'Adulto e dell'Età Evolutiva, Policlinico G Martino, University of Messina, Messina, Italy
| | - Marzia Defina
- Hematology Unit, Dipartimento Terapie Cellulari, Ematologia e Medicina di Laboratorio, Azienda Ospedaliera Universitaria Senese, University of Siena, Siena, Italy
| | - Mirko Farina
- Chair of Hematology, Department of Clinical and Experimental Sciences, University of Brescia, Unit of Blood Disease and Stem Cell Transplantation, ASST-Spedali Civili, Brescia, Italy
| | - Simona Bernardi
- Chair of Hematology, Department of Clinical and Experimental Sciences, University of Brescia, Unit of Blood Disease and Stem Cell Transplantation, ASST-Spedali Civili, Brescia, Italy; CREA Laboratory (Hematological-Research AIL Centre), ASST-Spedali Civili Brescia, Italy
| | - Giulia Butturini
- Chair of Hematology, Department of Clinical and Experimental Sciences, University of Brescia, Unit of Blood Disease and Stem Cell Transplantation, ASST-Spedali Civili, Brescia, Italy
| | - Simone Pellizzeri
- Chair of Hematology, Department of Clinical and Experimental Sciences, University of Brescia, Unit of Blood Disease and Stem Cell Transplantation, ASST-Spedali Civili, Brescia, Italy
| | - Aldo Maria Roccaro
- Clinical Trial Center. Translational Research and Phase I Unit, ASST Spedali Civili, Brescia, Italy
| | - Domenico Russo
- Chair of Hematology, Department of Clinical and Experimental Sciences, University of Brescia, Unit of Blood Disease and Stem Cell Transplantation, ASST-Spedali Civili, Brescia, Italy
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8
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Gagelmann N, Hobbs GS, Campodonico E, Helbig G, Novak P, Schroeder T, Schneider A, Rautenberg C, Reinhardt HC, Bosques L, Heuser M, Panagiota V, Thol F, Gurnari C, Maciejewski JP, Ciceri F, Rathje K, Robin M, Pagliuca S, Rubio MT, Rocha V, Funke V, Hamerschlak N, Salit R, Scott BL, Duarte F, Mitrus I, Czerw T, Greco R, Kröger N. Splenic irradiation for myelofibrosis prior to hematopoietic cell transplantation: A global collaborative analysis. Am J Hematol 2024; 99:844-853. [PMID: 38357714 DOI: 10.1002/ajh.27252] [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: 11/23/2023] [Revised: 01/11/2024] [Accepted: 01/31/2024] [Indexed: 02/16/2024]
Abstract
Splenomegaly is the clinical hallmark of myelofibrosis. Splenomegaly at the time of allogeneic hematopoietic cell transplantation (HCT) is associated with graft failure and poor graft function. Strategies to reduce spleen size before HCT especially after failure to Janus kinase (JAK) inhibition represent unmet clinical needs in the field. Here, we leveraged a global collaboration to investigate the safety and efficacy of splenic irradiation as part of the HCT platform for patients with myelofibrosis. We included 59 patients, receiving irradiation within a median of 2 weeks (range, 0.9-12 weeks) before HCT. Overall, the median spleen size prior to irradiation was 23 cm (range, 14-35). Splenic irradiation resulted in a significant and rapid spleen size reduction in 97% of patients (57/59), with a median decrease of 5.0 cm (95% confidence interval, 4.1-6.3 cm). The most frequent adverse event was thrombocytopenia, with no correlation between irradiation dose and hematological toxicities. The 3-year overall survival was 62% (95% CI, 48%-76%) and 1-year non-relapse mortality was 26% (95% CI, 14%-38%). Independent predictors for survival were severe thrombocytopenia and anemia before irradiation, transplant-specific risk score, higher-intensity conditioning, and present portal vein thrombosis. When using a propensity score matching adjusted for common confounders, splenic irradiation was associated with significantly reduced relapse (p = .01), showing a 3-year incidence of 12% for splenic irradiation versus 29% for patients with immediate HCT and 38% for patients receiving splenectomy. In conclusion, splenic irradiation immediately before HCT is a reasonable approach in patients experiencing JAK inhibition failure and is associated with a low incidence of relapse.
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Affiliation(s)
- Nico Gagelmann
- Department of Stem Cell Transplantation, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Gabriela S Hobbs
- Department of Medical Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Edoardo Campodonico
- Hematology and Bone Marrow Transplantation Unit, IRCCS San Raffaele Hospital, University Vita-Salute San Raffaele, Milan, Italy
| | - Grzegorz Helbig
- Department of Hematology and Bone Marrow Transplantation, School of Medicine in Katowice, Medical University of Silesia, Katowice, Poland
| | - Polona Novak
- Department of Hematology, University Medical Center Ljubljana, Ljubljana, Slovenia
| | - Thomas Schroeder
- Department of Hematology and Stem Cell Transplantation, West German Cancer Center, University Hospital of Essen, Germany
| | - Artur Schneider
- Department of Hematology and Stem Cell Transplantation, West German Cancer Center, University Hospital of Essen, Germany
| | - Christina Rautenberg
- Department of Hematology and Stem Cell Transplantation, West German Cancer Center, University Hospital of Essen, Germany
| | - Hans Christian Reinhardt
- Department of Hematology and Stem Cell Transplantation, West German Cancer Center, University Hospital of Essen, Germany
| | - Linette Bosques
- Department of Medical Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Michael Heuser
- Department of Hematology, Hemostasis, Oncology and Stem Cell Transplantation, Hannover Medical School, Hannover, Germany
| | - Victoria Panagiota
- Department of Hematology, Hemostasis, Oncology and Stem Cell Transplantation, Hannover Medical School, Hannover, Germany
| | - Felicitas Thol
- Department of Hematology, Hemostasis, Oncology and Stem Cell Transplantation, Hannover Medical School, Hannover, Germany
| | - Carmelo Gurnari
- Translational Hematology and Oncology Research Department, Taussig Cancer Center, Cleveland Clinic, Cleveland, Ohio, USA
- Department of Biomedicine and Prevention, Tor Vergata University of Rome, Rome, Italy
| | - Jaroslaw P Maciejewski
- Translational Hematology and Oncology Research Department, Taussig Cancer Center, Cleveland Clinic, Cleveland, Ohio, USA
- Leukemia Program, Department of Hematology and Medical Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Fabio Ciceri
- Hematology and Bone Marrow Transplantation Unit, IRCCS San Raffaele Hospital, University Vita-Salute San Raffaele, Milan, Italy
| | - Kristin Rathje
- Department of Stem Cell Transplantation, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Marie Robin
- Service d'Hématologie-Greffe, Hôpital Saint-Louis, Assistance Publique Hôpitaux de Paris, Paris, France
| | - Simona Pagliuca
- Department of Hematology, Brabois Hospital, Centre Hospitalier Régional Universitaire (CHRU), Nancy, France
| | - Marie-Thérèse Rubio
- Department of Hematology, Brabois Hospital, Centre Hospitalier Régional Universitaire (CHRU), Nancy, France
| | - Vanderson Rocha
- Hospital de Clinicas, Hematology, Transfusion and Cell Therapy Service, University of São Paulo, Sao Paulo, Brazil
| | - Vaneuza Funke
- Blood and Marrow Transplantation Programme, Hospital de Clínicas, Federal University of Parana, Curitiba, Paraná, Brazil; Hospital Nossa Senhora das Graças, Curitiba, Brazil
| | | | - Rachel Salit
- Fred Hutchinson Cancer Research Center, Seattle, USA
| | - Bart L Scott
- Fred Hutchinson Cancer Research Center, Seattle, USA
| | - Fernando Duarte
- Hospital Universitario Walter Cantídio, Universidade Federal do Ceara, Fortaleza, Brazil
| | - Iwona Mitrus
- Hematology Department, Maria Skłodowska-Curie National Research Institute of Oncology, Gliwice, Poland
| | - Tomasz Czerw
- Hematology Department, Maria Skłodowska-Curie National Research Institute of Oncology, Gliwice, Poland
| | - Raffaella Greco
- Hematology and Bone Marrow Transplantation Unit, IRCCS San Raffaele Hospital, University Vita-Salute San Raffaele, Milan, Italy
| | - Nicolaus Kröger
- Department of Stem Cell Transplantation, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
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9
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Oechsler S, Gagelmann N, Wolschke C, Janson D, Badbaran A, Klyuchnikov E, Massoud R, Rathje K, Richter J, Schäfersküpper M, Niederwieser C, Kunte A, Heidenreich S, Ayuk F, Kröger N. Graft-versus-host disease and impact on relapse in myelofibrosis undergoing hematopoietic stem cell transplantation. Bone Marrow Transplant 2024; 59:550-557. [PMID: 38321269 PMCID: PMC10994836 DOI: 10.1038/s41409-024-02220-7] [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: 11/19/2023] [Revised: 01/12/2024] [Accepted: 01/19/2024] [Indexed: 02/08/2024]
Abstract
Allogeneic hematopoietic stem cell transplantation (alloHSCT) remains the only curative treatment for myelofibrosis (MF). Relapse occurs in 10-30% and remains a major factor for dismal outcomes. Previous work suggested that graft-versus-host disease (GVHD) might be associated with risk of relapse. This study included 341 patients undergoing their first (n = 308) or second (n = 33) alloHSCT. Anti-T-lymphocyte or antithymocyte globulin was used for GVHD prophylaxis in almost all patients. Median time to neutrophile and platelet engraftment was 13 days and 19 days, respectively. The cumulative incidence of acute GVHD grade II-IV was 41% (median, 31 days; range, 7-112). Grade III-IV acute GVHD was observed in 22%. The cumulative incidence of chronic GVHD was 61%. Liver was affected in 23% of acute GVHD cases and 46% of chronic GVHD cases. Severe acute GVHD was associated with high non-relapse mortality. The development of acute GVHD grade II and moderate GVHD was an independent factor for reduced risk for relapse after transplantation without increased risk for non-relapse mortality, while especially acute GVHD grade IV was associated with high non-relapse mortality. Last, we identified that ongoing response to ruxolitinib, accelerated-phase MF at time of transplantation and splenectomy prior to transplantation were independent predictors for relapse.
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Affiliation(s)
- Sofia Oechsler
- University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Nico Gagelmann
- University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | | | | | - Anita Badbaran
- University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | | | - Radwan Massoud
- University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Kristin Rathje
- University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Johanna Richter
- University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | | | | | - Ameya Kunte
- University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | | | - Francis Ayuk
- University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Nicolaus Kröger
- University Medical Center Hamburg-Eppendorf, Hamburg, Germany.
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10
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McLornan DP, Psaila B, Ewing J, Innes A, Arami S, Brady J, Butt NM, Cargo C, Cross NCP, Francis S, Frewin R, Garg M, Godfrey AL, Green A, Khan A, Knapper S, Lambert J, McGregor A, McMullin MF, Nangalia J, Neelakantan P, Woodley C, Mead A, Somervaille TCP, Harrison CN. The management of myelofibrosis: A British Society for Haematology Guideline. Br J Haematol 2024; 204:136-150. [PMID: 38037886 DOI: 10.1111/bjh.19186] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2023] [Revised: 10/03/2023] [Accepted: 10/20/2023] [Indexed: 12/02/2023]
Affiliation(s)
- Donal P McLornan
- Department of Haematology, University College London Hospitals, London, UK
| | - Bethan Psaila
- MRC Weatherall Institute of Molecular Medicine, University of Oxford, Oxford, UK
- Department of Haematology, Churchill Hospital, Oxford University NHS Trust, Oxford, UK
| | - Joanne Ewing
- Department of Haematology, University Hospitals Birmingham Trust, London, UK
| | - Andrew Innes
- Department of Haematology, Imperial College, London, UK
| | - Siamak Arami
- Department of Haematology, London Northwest Healthcare University NHS Trust, London, UK
| | - Jessica Brady
- Department of Clinical Oncology, Guy's and St. Thomas' NHS Foundation Trust, London, UK
| | - Nauman M Butt
- Department of Haematology, The Clatterbridge Cancer Centre NHS Foundation Trust, Liverpool, UK
| | - Catherine Cargo
- Department of Haematology, Leeds Teaching Hospitals NHS Foundation Trust, Leeds, UK
| | | | - Sebastian Francis
- Department of Haematology, Sheffield Teaching Hospital NHS Foundation Trust, Sheffield, UK
| | - Rebecca Frewin
- Department of Haematology, Gloucestershire Hospitals NHS Foundation Trust, Gloucester, UK
| | - Mamta Garg
- Department of Haematology, University Hospitals Leicester NHS Trust, Leicester, UK
| | - Anna L Godfrey
- Haematopathology & Oncology Diagnostics Service, Department of Haematology, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Anna Green
- Department of Histopathology, Guy's and St. Thomas' NHS Foundation Trust, London, UK
| | - Alesia Khan
- Department of Haematology, Leeds Teaching Hospitals NHS Foundation Trust, Leeds, UK
| | - Steve Knapper
- Department of Haematology, Cardiff University, Cardiff, UK
| | - Jonathan Lambert
- Department of Haematology, University College London Hospitals, London, UK
| | | | | | - Jyoti Nangalia
- Wellcome Sanger Institute, University of Cambridge, Cambridge, UK
| | - Pratap Neelakantan
- Department of Haematology, Royal Berkshire NHS Foundation Trust, London, UK
| | - Claire Woodley
- Department of Haematology, Guy's and St. Thomas' NHS Foundation Trust, London, UK
| | - Adam Mead
- MRC Weatherall Institute of Molecular Medicine, University of Oxford, Oxford, UK
- Department of Haematology, Churchill Hospital, Oxford University NHS Trust, Oxford, UK
| | - Tim C P Somervaille
- Cancer Research UK Manchester Institute & The Christie NHS Foundation Trust, Manchester, UK
| | - Claire N Harrison
- Department of Haematology, Guy's and St. Thomas' NHS Foundation Trust, London, UK
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11
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Kröger N, Bacigalupo A, Barbui T, Ditschkowski M, Gagelmann N, Griesshammer M, Gupta V, Hamad N, Harrison C, Hernandez-Boluda JC, Koschmieder S, Jain T, Mascarenhas J, Mesa R, Popat UR, Passamonti F, Polverelli N, Rambaldi A, Robin M, Salit RB, Schroeder T, Scott BL, Tamari R, Tefferi A, Vannucchi AM, McLornan DP, Barosi G. Indication and management of allogeneic haematopoietic stem-cell transplantation in myelofibrosis: updated recommendations by the EBMT/ELN International Working Group. Lancet Haematol 2024; 11:e62-e74. [PMID: 38061384 DOI: 10.1016/s2352-3026(23)00305-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2023] [Revised: 09/26/2023] [Accepted: 10/03/2023] [Indexed: 12/24/2023]
Abstract
New options for medical therapy and risk scoring systems containing molecular data are leading to increased complexity in the management of patients with myelofibrosis. To inform patients' optimal care, we updated the 2015 guidelines on indications for and management of allogeneic haematopoietic stem-cell transplantation (HSCT) with the support of the European Society for Blood and Marrow Transplantation (EBMT) and European LeukemiaNet (ELN). New recommendations were produced using a consensus-building methodology after a comprehensive review of articles released from January, 2015 to December, 2022. Seven domains and 18 key questions were selected through a series of questionnaires using a Delphi process. Key recommendations in this update include: patients with primary myelofibrosis and an intermediate-2 or high-risk Dynamic International Prognostic Scoring System score, or a high-risk Mutation-Enhanced International Prognostic Score Systems (MIPSS70 or MIPSS70-plus) score, or a low-risk or intermediate-risk Myelofibrosis Transplant Scoring System score should be considered candidates for allogeneic HSCT. All patients who are candidates for allogeneic HSCT with splenomegaly greater than 5 cm below the left costal margin or splenomegaly-related symptoms should receive a spleen-directed treatment, ideally with a JAK-inhibitor; HLA-matched sibling donors remain the preferred donor source to date. Reduced intensity conditioning and myeloablative conditioning are both valid options for patients with myelofibrosis. Regular post-transplantation driver mutation monitoring is recommended to detect and treat early relapse with donor lymphocyte infusion. In a disease where evidence-based guidance is scarce, these recommendations might help clinicians and patients in shared decision making.
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Affiliation(s)
- Nicolaus Kröger
- Department of Stem Cell Transplantation, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.
| | - Andrea Bacigalupo
- Department of Hematology, Fondazione Policlinico Universitario Gemelli IRCCS, Universita' Cattolica del Sacro Cuore, Rome, Italy
| | - Tiziano Barbui
- FROM Research Foundation, Papa Giovanni XXIII Hospital, Bergamo, Italy
| | - Markus Ditschkowski
- Department of Hematology and Stem Cell Transplantation, West German Cancer Center, University Hospital of Essen, Essen, Germany
| | - Nico Gagelmann
- Department of Stem Cell Transplantation, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Martin Griesshammer
- University Clinic for Hematology, Oncology, Haemostaseology and Palliative Care, Johannes Wesling Medical Center Minden, University of Bochum, Bochum, Germany
| | - Vikas Gupta
- Princess Margaret Cancer Centre, Toronto, ON, Canada
| | - Nada Hamad
- School of Clinical Medicine, Faculty of Medicine and Health, UNSW Sydney, Sydney, NSW, Australia; Department of Haematology, St Vincent's Hospital, Sydney, NSW, Australia; School of Medicine, University of Notre Dame, Sydney, NSW, Australia
| | | | | | - Steffen Koschmieder
- Center for Integrated Oncology Aachen Bonn Cologne Düsseldorf, Aachen, Germany; Department of Hematology, Oncology, Hemostaseology, and Stem Cell Transplantation, Faculty of Medicine, RWTH Aachen University, Aachen, Germany
| | - Tania Jain
- Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University, Baltimore, MD, USA
| | - John Mascarenhas
- Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Ruben Mesa
- Atrium Health Wake Forest Baptist Comprehensive Cancer Center, Winston-Salem, NC, USA
| | - Uday R Popat
- The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Francesco Passamonti
- Università degli Studi di Milano; Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Nicola Polverelli
- Division of Hematology, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Alessandro Rambaldi
- Department of Oncology and Hemato-Oncology, University of Milan, Milan, Italy; Azienda Socio-Sanitaria Territoriale Papa Giovanni XXIII, Bergamo, Italy
| | - Marie Robin
- Department of Hematology, University Hospital of Saint Louis, Paris, France
| | | | - Thomas Schroeder
- Department of Hematology and Stem Cell Transplantation, West German Cancer Center, University Hospital of Essen, Essen, Germany
| | | | - Roni Tamari
- Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Ayalew Tefferi
- Division of Hematology, Department of Medicine, Mayo Clinic, Rochester, MN, USA
| | - Alessandro M Vannucchi
- Centro Ricerca e Innovazione delle Malattie Mieloproliferative, Azienda Ospedaliera-Universitaria Careggi, Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
| | - Donal P McLornan
- Department of Haematology and Stem Cell Transplantation, University College London Hospitals NHS Trust, London, UK
| | - Giovanni Barosi
- Center for the Study of Myelofibrosis, IRCCS Policlinico S Matteo, Pavia, Italy
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12
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Palmer J. Are transplant indications changing for myelofibrosis? HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2023; 2023:676-681. [PMID: 38066916 PMCID: PMC10727025 DOI: 10.1182/hematology.2023000453] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/18/2023]
Abstract
Myelofibrosis is a devastating myeloid malignancy characterized by dysregulation of the JAK-STAT pathway, resulting in splenomegaly, constitutional symptoms, anemia, thrombocytopenia, leukocytosis, and an increased likelihood of progression to acute leukemia. The only curative option is allogeneic stem cell transplantation. The numbers of transplants have been increasing every year, and although there have been improvements in survival, there remain many unanswered questions. In this review, we will evaluate patient selection and appropriate timing for transplantation. We will cover the current prognostic scoring systems, which can aid in the decision of when to move forward with transplant. We will also review the different donor options, as well as the conditioning regimens. The peritransplant management of splenomegaly will be reviewed. We will discuss management of posttransplant complications such as loss of donor chimerism or disease relapse. Finally, we will review what is known about the outlook of patients who have undergone allogeneic stem cell transplant with regards to quality of life and long-term survival.
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Affiliation(s)
- Jeanne Palmer
- Division of Hematology/Medical Oncology, Mayo Clinic, Phoenix, AZ
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13
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Kröger N, Wolschke C, Gagelmann N. How I treat transplant-eligible patients with myelofibrosis. Blood 2023; 142:1683-1696. [PMID: 37647853 DOI: 10.1182/blood.2023021218] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2023] [Revised: 08/14/2023] [Accepted: 08/18/2023] [Indexed: 09/01/2023] Open
Abstract
Despite the approval of Janus kinase inhibitors and novel agents for patients with myelofibrosis (MF), disease-modifying responses remain limited, and hematopoietic stem cell transplantation (HSCT) remains the only potentially curative treatment option. The number of HSCTs for MF continues to increase worldwide, but its inherent therapy-related morbidity and mortality limit its use for many patients. Furthermore, patients with MF often present at an older age, with cytopenia, splenomegaly, and severe bone marrow fibrosis, posing challenges in managing them throughout the HSCT procedure. Although implementation of molecular analyses enabled improved understanding of disease mechanisms and subsequently sparked development of novel drugs with promising activity, prospective trials in the HSCT setting are often lacking, making an evidence-based decision process particularly difficult. To illustrate how we approach patients with MF with respect to HSCT, we present 3 different clinical scenarios to capture relevant aspects that influence our decision making regarding indication for, or against, HSCT. We describe how we perform HSCT according to different risk categories and, furthermore, discuss our up-to-date approach to reduce transplant-related complications. Last, we show how to harness graft-versus-MF effects, particularly in the posttransplant period to achieve the best possible outcomes for patients.
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Affiliation(s)
- Nicolaus Kröger
- Department of Stem Cell Transplantation, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Christine Wolschke
- Department of Stem Cell Transplantation, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Nico Gagelmann
- Department of Stem Cell Transplantation, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
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14
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Pohlmann A, Bentgens E, Schülke C, Kuron D, Reicherts C, Marx J, Angenendt L, Mikesch JH, Lenz G, Stelljes M, Schliemann C. Pretransplant spleen volume and outcome after hematopoietic stem cell transplantation (HSCT) in patients with acute myeloid leukemia (AML). Ann Hematol 2023; 102:2543-2553. [PMID: 37428201 PMCID: PMC10444671 DOI: 10.1007/s00277-023-05353-9] [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: 05/17/2022] [Accepted: 07/01/2023] [Indexed: 07/11/2023]
Abstract
Allogeneic hematopoietic stem cell transplantation (HSCT) is an effective treatment modality for patients with acute myeloid leukemia (AML). Here, we investigated the predictive value of spleen volume on outcome parameters and engraftment kinetics after HSCT in a large cohort of AML patients. A total of 402 patients who received their first HSCT between January 2012 and March 2019 were included in this retrospective study. Spleen volume was correlated to clinical outcome and engraftment kinetics. Median follow-up was 33.7 months (95% confidence interval [CI], 28.9-37.4 months). Patients were subdivided based on median spleen volume of 238.0 cm3 (range 55.7-2693.5 cm3) into a small spleen volume (SSV) and a large spleen volume (LSV) group. LSV was associated with inferior overall survival (OS) after HSCT (55.7% vs. 66.6% at 2 years; P = 0.009) and higher cumulative incidence of NRM (28.8% vs. 20.2% at 2 years; P = 0.048). The adjusted hazard ratio for NRM in the LSV group was 1.55 (95% CI, 1.03-2.34). Time to neutrophil or platelet engraftment and the occurrence of acute or chronic graft-versus-host disease (GVHD) were not significantly different between both groups. Higher spleen volume at the time of HSCT was independently linked to adverse outcomes such as inferior OS and higher cumulative incidence of NRM in AML patients after HSCT. Engraftment kinetics and GVHD were not associated with spleen volume.
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Affiliation(s)
- Alexander Pohlmann
- Department of Medicine A, University Hospital Münster, Münster, Germany.
| | - Eva Bentgens
- Department of Medicine A, University Hospital Münster, Münster, Germany
| | - Christoph Schülke
- Department of Clinical Radiology, University Hospital Münster, Münster, Germany
| | - David Kuron
- Department of Medicine II, University Hospital Schleswig-Holstein, 24105, Kiel, Germany
| | | | - Julia Marx
- Department of Medicine A, University Hospital Münster, Münster, Germany
| | - Linus Angenendt
- Department of Medicine A, University Hospital Münster, Münster, Germany
| | | | - Georg Lenz
- Department of Medicine A, University Hospital Münster, Münster, Germany
| | - Matthias Stelljes
- Department of Medicine A, University Hospital Münster, Münster, Germany
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15
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Jungius S, Adam FC, Grosheintz K, Medinger M, Buser A, Passweg JR, Halter JP, Meyer SC. Characterization of engraftment dynamics in myelofibrosis after allogeneic hematopoietic cell transplantation including novel conditioning schemes. Front Oncol 2023; 13:1205387. [PMID: 37637037 PMCID: PMC10449533 DOI: 10.3389/fonc.2023.1205387] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2023] [Accepted: 07/24/2023] [Indexed: 08/29/2023] Open
Abstract
Introduction Myelofibrosis (MF) is a rare hematopoietic stem cell disorder progressing to bone marrow (BM) failure or blast phase. Allogeneic hematopoietic cell transplantation (HCT) represents a potentially curative therapy for a limited subset of patients with advanced MF, who are eligible, but engraftment in MF vs. AML is delayed which promotes complications. As determinants of engraftment in MF are incompletely characterized, we studied engraftment dynamics at our center. Methods A longitudinal cohort of 71 allogeneic HCT performed 2000-2019 with >50% after 2015 was evaluated. Results Median time to neutrophil engraftment ≥0.5x109/l was +20 days post-transplant and associated with BM fibrosis, splenomegaly and infused CD34+ cell number. Engraftment dynamics were similar in primary vs. secondary MF and were independent of MF driver mutations in JAK2, CALR and MPL. Neutrophil engraftment occurred later upon haploidentical HCT with thiotepa-busulfan-fludarabine conditioning, post-transplant cyclophosphamide and G-CSF (TBF-PTCy/G-CSF) administered to 9.9% and 15.6% of patients in 2000-2019 and after 2015, respectively. Engraftment of platelets was similarly delayed, while reconstitution of reticulocytes was not affected. Conclusions Since MF is a rare hematologic malignancy, this data from a large number of HCT for MF is essential to substantiate that later neutrophil and platelet engraftment in MF relates both to host and treatment-related factors. Observations from this longitudinal cohort support that novel conditioning schemes administered also to rare entities such as MF, require detailed evaluation in larger, multi-center cohorts to assess also indicators of long-term graft function and overall outcome in patients with this infrequent hematopoietic neoplasm undergoing allogeneic transplantation.
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Affiliation(s)
- Sarah Jungius
- Department of Biomedicine, University Hospital Basel and University of Basel, Basel, Switzerland
- Department of Biomedical Research, University of Bern, Bern, Switzerland
| | - Franziska C. Adam
- Division of Hematology, University Hospital Basel, Basel, Switzerland
| | | | - Michael Medinger
- Division of Hematology, University Hospital Basel, Basel, Switzerland
| | - Andreas Buser
- Division of Hematology, University Hospital Basel, Basel, Switzerland
| | - Jakob R. Passweg
- Division of Hematology, University Hospital Basel, Basel, Switzerland
| | - Jörg P. Halter
- Division of Hematology, University Hospital Basel, Basel, Switzerland
| | - Sara C. Meyer
- Department of Biomedicine, University Hospital Basel and University of Basel, Basel, Switzerland
- Department of Biomedical Research, University of Bern, Bern, Switzerland
- Division of Hematology, University Hospital Basel, Basel, Switzerland
- Department of Hematology and Central Hematology Laboratory, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
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16
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Tamari R, McLornan DP, Ahn KW, Estrada-Merly N, Hernández-Boluda JC, Giralt S, Palmer J, Gale RP, DeFilipp Z, Marks DI, van der Poel M, Verdonck LF, Battiwalla M, Diaz MA, Gupta V, Ali H, Litzow MR, Lazarus HM, Gergis U, Bashey A, Liesveld J, Hashmi S, Pu JJ, Beitinjaneh A, Bredeson C, Rizzieri D, Savani BN, Abid MB, Ganguly S, Agrawal V, Ulrike Bacher V, Wirk B, Jain T, Cutler C, Aljurf M, Kindwall-Keller T, Kharfan-Dabaja MA, Hildebrandt GC, Pawarode A, Solh MM, Yared JA, Grunwald MR, Nathan S, Nishihori T, Seo S, Scott BL, Nakamura R, Oran B, Czerw T, Yakoub-Agha I, Saber W. A simple prognostic system in patients with myelofibrosis undergoing allogeneic stem cell transplantation: a CIBMTR/EBMT analysis. Blood Adv 2023; 7:3993-4002. [PMID: 37134306 PMCID: PMC10410129 DOI: 10.1182/bloodadvances.2023009886] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2023] [Revised: 04/17/2023] [Accepted: 04/17/2023] [Indexed: 05/05/2023] Open
Abstract
To develop a prognostic model for patients undergoing allogeneic hematopoietic cell transplantation (allo-HCT) for myelofibrosis (MF), we examined the data of 623 patients undergoing allo-HCT between 2000 and 2016 in the United States (the Center for International Blood and Marrow Transplant Research [CIBMTR] cohort). A Cox multivariable model was used to identify factors prognostic of mortality. A weighted score using these factors was assigned to patients who received transplantation in Europe (the European Bone Marrow Transplant [EBMT] cohort; n = 623). Patient age >50 years (hazard ratio [HR], 1.39; 95% confidence interval [CI], 0.98-1.96), and HLA-matched unrelated donor (HR, 1.29; 95% CI, 0.98-1.7) were associated with an increased hazard of death and were assigned 1 point. Hemoglobin levels <100 g/L at time of transplantation (HR, 1.63; 95% CI, 1.2-2.19) and a mismatched unrelated donor (HR, 1.78; 95% CI, 1.25-2.52) were assigned 2 points. The 3-year overall survival (OS) in patients with a low (1-2 points), intermediate (3-4 points), and high score (5 points) were 69% (95% CI, 61-76), 51% (95% CI, 46-56.4), and 34% (95% CI, 21-49), respectively (P < .001). Increasing score was predictive of increased transplant-related mortality (TRM; P = .0017) but not of relapse (P = .12). The derived score was predictive of OS (P < .001) and TRM (P = .002) but not of relapse (P = .17) in the EBMT cohort as well. The proposed system was prognostic of survival in 2 large cohorts, CIBMTR and EBMT, and can easily be applied by clinicians consulting patients with MF about the transplantation outcomes.
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Affiliation(s)
- Roni Tamari
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Donal P. McLornan
- Department of Medicine, University College Hospital, London, United Kingdom
| | - Kwang Woo Ahn
- Division of Biostatistics, Institute for Health and Equity, Medical College of Wisconsin, Milwaukee, WI
- Department of Medicine, Center for International Blood and Marrow Transplant Research, Medical College of Wisconsin, Milwaukee, WI
| | - Noel Estrada-Merly
- Department of Medicine, Center for International Blood and Marrow Transplant Research, Medical College of Wisconsin, Milwaukee, WI
| | | | - Sergio Giralt
- Department of Internal Medicine, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Jeanne Palmer
- Department of Medicine, Mayo Clinic Arizona and Phoenix Children’s Hospital, Phoenix, AZ
| | - Robert Peter Gale
- Department of Immunology and Inflammation, Haematology Centre, Imperial College London, London, United Kingdom
| | - Zachariah DeFilipp
- Department of Medicine, Hematopoietic Cell Transplant and Cellular Therapy Program, Massachusetts General Hospital, Boston, MA
| | - David I. Marks
- Adult Bone Marrow Transplant, University Hospitals Bristol NHS Trust, Bristol, United Kingdom
| | - Marjolein van der Poel
- Division of Hematology, Department of Internal Medicine, GROW School for Oncology and Developmental Biology, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Leo F. Verdonck
- Department of Hematology/Oncology, Isala Clinic, Zwolle, The Netherlands
| | - Minoo Battiwalla
- Outcomes Research, Sarah Cannon Blood Cancer Network, Nashville, TN
| | - Miguel Angel Diaz
- Department of Hematology/Oncology, Hospital Infantil Universitario Niño Jesus, Madrid, Spain
| | - Vikas Gupta
- Department of Internal Medicine, Princess Margaret Cancer Centre, University of Toronto, Toronto, Canada
| | - Haris Ali
- Department of Hematology & Hematopoietic Cell Transplantation, City of Hope, Duarte, CA
| | - Mark Robert Litzow
- Division of Hematology and Transplant Center, Mayo Clinic, Rochester, MN
| | - Hillard M. Lazarus
- Department of Hematology and Internal Medicine, University Hospitals Cleveland Medical Center, Case Western Reserve University, Cleveland, OH
| | - Usama Gergis
- Division of Hematological Malignancies, Department of Medicine Oncology, Thomas Jefferson University, Philadelphia, PA
| | - Asad Bashey
- Department of Medicine, Blood and Marrow Transplant Program at Northside Hospital, Atlanta, GA
| | - Jane Liesveld
- Department of Medicine, University of Rochester Medical Center, Rochester, NY
| | - Shahrukh Hashmi
- Department of Internal Medicine, Mayo Clinic, Rochester, MN
- Department of Medicine, Sheikh Shakhbout Medical City, Abu Dhabi, United Arab Emirates
| | - Jeffrey J. Pu
- Department of Medicine, Banner University Medical Center Tucson, Syracuse, NY
| | - Amer Beitinjaneh
- Divison of Transplantation and Cellular Therapy, University of Miami Hospital and Clinics, Sylvester Comprehensive Cancer Center, Miami, FL
| | - Christopher Bredeson
- Department of Medicine, The Ottawa Hospital Transplant & Cellular Therapy Program, Ottawa, ON, Canada
| | | | - Bipin N. Savani
- Division of Hematology/Oncology, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN
| | - Muhammad Bilal Abid
- Divisions of Hematology/Oncology & Infectious Diseases, Department of Medicine, Medical College of Wisconsin, Milwaukee, WI
| | - Siddhartha Ganguly
- Department of Medicine, Houston Methodist Hospital and Cancer Center, Houston, TX
| | - Vaibhav Agrawal
- Division of Leukemia, Department of Hematology & Hematopoietic Cell Transplantation, City of Hope National Medical Center, Duarte, CA
| | - Vera Ulrike Bacher
- Department of Hematology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Baldeep Wirk
- Department of Medicine, Bone Marrow Transplant Program, Penn State Cancer Institute, Hershey, PA
| | - Tania Jain
- Division of Hematological Malignancies and Bone Marrow Transplantation, Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University, Baltimore, MD
| | - Corey Cutler
- Stem Cell Transplantation and Cellular Therapy, Dana-Farber Cancer Institute, Boston, MA
| | - Mahmoud Aljurf
- Department of Oncology, King Faisal Specialist Hospital Center & Research, Riyadh, Saudi Arabia
| | - Tamila Kindwall-Keller
- Division of Hematology/Oncology, University of Virginia Health System, Charlottesville, VA
| | - Mohamed A. Kharfan-Dabaja
- Division of Hematology-Oncology, Blood and Marrow Transplantation Program, Mayo Clinic, Jacksonville, FL
| | | | - Attaphol Pawarode
- Division of Hematology/Oncology, Department of Internal Medicine, Blood and Marrow Transplantation Program, University of Michigan Medical School, Ann Arbor, MI
| | - Melhem M. Solh
- The Blood and Marrow Transplant Program, Northside Hospital Cancer Institute, Atlanta, GA
| | - Jean A. Yared
- Division of Hematology/Oncology, Department of Medicine, Transplantation & Cellular Therapy Program, Greenebaum Comprehensive Cancer Center, University of Maryland, Baltimore, MD
| | - Michael R. Grunwald
- Department of Hematologic Oncology and Blood Disorders, Levine Cancer Institute, Atrium Health, Charlotte, NC
| | - Sunita Nathan
- Department of Internal Medicine, Section of Bone Marrow Transplant and Cell Therapy, Rush University Medical Center, Chicago, IL
| | - Taiga Nishihori
- Department of Blood & Marrow Transplant and Cellular Immunotherapy, Moffitt Cancer Center, Tampa, FL
| | - Sachiko Seo
- Department of Hematology and Oncology, Dokkyo Medical University, Tochigi, Japan
| | - Bart L. Scott
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, WA
| | - Ryotaro Nakamura
- Department of Hematology & Hematopoietic Cell Transplantation, City of Hope, Duarte, CA
| | - Betul Oran
- Division of Cancer Medicine, Department of Stem Cell Transplantation, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Tomasz Czerw
- Department of Haematology and BMT, Maria Skłodowska-Curie National Research Institute of Oncology, Gliwice, Poland
| | | | - Wael Saber
- Department of Medicine, Center for International Blood and Marrow Transplant Research, Medical College of Wisconsin, Milwaukee, WI
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Amé S, Barraco F, Ianotto J, Jourdan E, Rey J, Viallard J, Wémeau M, Kiladjian J. Advances in management of primary myelofibrosis and polycythaemia vera: Implications in clinical practice. EJHAEM 2023; 4:779-791. [PMID: 37601853 PMCID: PMC10435696 DOI: 10.1002/jha2.734] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/25/2023] [Accepted: 05/31/2023] [Indexed: 08/22/2023]
Abstract
Primary myelofibrosis (PMF) and polycythaemia vera (PV) are rare BCR-ABL1-negative myeloproliferative neoplasms, associated with an increased risk of thrombosis, haemorrhagic complications and progression to fibrosis or leukaemia or fibrosis for PV. Both diseases are characterised by biological and clinical heterogeneity, leading to great variability in their management in routine clinical practice. In this review, we present an updated overview of the diagnosis, prognosis and treatment of PMF and PV, and we discuss how our multidisciplinary expert group based across France translates this evidence-based knowledge into routine clinical practice.
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Affiliation(s)
- Shanti Amé
- Department of HaematologyInstitut de Cancérologie Strasbourg Europe (ICANS)StrasbourgFrance
| | - Fiorenza Barraco
- Department of HaematologyLyon Sud Hospital CentrePierre‐BéniteFrance
| | | | - Eric Jourdan
- Department of Clinical HaematologyUniversity Hospital of NimesNimesFrance
| | - Jérôme Rey
- Department of HaematologyInstitute Paoli‐CalmettesMarseilleFrance
| | | | - Mathieu Wémeau
- Department of HaematologyHospital Centre of RoubaixRoubaixFrance
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18
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Luther M, Henes FO, Zabelina T, Massoud R, Janson D, Wolschke C, Klyuchnikov E, Gagelmann N, Fehse B, Adam G, Kröger N, Ayuk F. Spleen volume and length determined by computed tomography impact outcome after allogeneic stem cell transplantation for myelofibrosis. Bone Marrow Transplant 2023; 58:755-761. [PMID: 37002409 DOI: 10.1038/s41409-023-01968-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2022] [Revised: 02/22/2023] [Accepted: 03/20/2023] [Indexed: 04/03/2023]
Abstract
Splenomegaly is a hallmark of myelofibrosis (MF), and reports on the impact of spleen size on the outcome of allo-HSCT have been conflicting, possibly due to differences in methods of assessment. We retrospectively analysed the impact of spleen volume and length measured by computed tomography on allo-HSCT outcome in 93 patients, 74% of whom had prior ruxolitinib treatment. Median spleen volume and length were 1.58 dm3 and 20 cm, respectively. We found a strong correlation between spleen volume and length (Pearson's r = 0.95, p < 0.001), Spearman (rho = 0.96, p < 0.001). After a median follow-up of 41.7 months, 5-year overall and disease-free survival were 66% and 59%, respectively. Spleen size did not impact overall survival or non-relapse mortality. Larger spleen volume and length as continuous variables were associated with slower platelet and leucocyte engraftment and a higher risk of disease relapse in univariate and multivariate analyses. Spleen length measured precisely by imaging is a good surrogate for spleen volume. In the era of JAK inhibitors, larger spleen size reflects advanced disease in MF and is associated with an increased risk of relapse but has no impact on non-relapse mortality and overall survival after allo-HSCT.
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Affiliation(s)
- Marlene Luther
- Department of Stem Cell Transplantation, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany
| | - Frank Oliver Henes
- Department of Diagnostic and Interventional Radiology and Nuclear Medicine, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany
| | - Tatjana Zabelina
- Department of Stem Cell Transplantation, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany
| | - Radwan Massoud
- Department of Stem Cell Transplantation, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany
| | - Dietlinde Janson
- Department of Stem Cell Transplantation, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany
| | - Christine Wolschke
- Department of Stem Cell Transplantation, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany
| | - Evgeny Klyuchnikov
- Department of Stem Cell Transplantation, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany
| | - Nico Gagelmann
- Department of Stem Cell Transplantation, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany
| | - Boris Fehse
- Department of Stem Cell Transplantation, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany
| | - Gerhard Adam
- Department of Diagnostic and Interventional Radiology and Nuclear Medicine, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany
| | - Nicolaus Kröger
- Department of Stem Cell Transplantation, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany
| | - Francis Ayuk
- Department of Stem Cell Transplantation, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany.
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Campodonico E, Xue E, Piemontese S, Chiara A, Bruno A, Scorpio G, Nitti R, Sannipoli D, Orofino G, Fiore P, Quattrocchi MC, Diral E, Clerici D, Farina F, Corti C, Lunghi F, Lupo-Stanghellini MT, Di Muzio N, Ciceri F, Greco R, Peccatori J. Splenic irradiation prior to allogeneic transplant conditioning in myelofibrosis: A pilot experience. Curr Res Transl Med 2023; 71:103400. [PMID: 37331224 DOI: 10.1016/j.retram.2023.103400] [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: 04/05/2023] [Revised: 06/02/2023] [Accepted: 06/08/2023] [Indexed: 06/20/2023]
Abstract
INTRODUCTION In the era of JAK inhibitors, allogeneic stem cell transplantation (HSCT) remains the only curative treatment for patients with Myelofibrosis (MF). Splenic irradiation (SI) may be used to reduce spleen size and related symptoms. METHODS We conducted a retrospective analysis on 14 patients with MF who underwent HSCT with SI from any donor source at our center between June 2016 and March 2021. All patients received a conditioning backbone based on treosulfan and fludarabine, with post-transplant cyclophosphamide (PTCy) and sirolimus as graft-versus-host disease (GvHD) prophylaxis. Patients received SI with 10 Gy involved-field radiotherapy in five 2-Gy fractions over the course of a week prior to the beginning of conditioning. RESULTS At transplant all patients were transfusion-dependent and had splenomegaly (median bipolar diameter by ultrasound: 20.75 cm). Overall, 12 patients had received ruxolitinib prior to transplant. Re-evaluation of spleen dimensions was available for 13 patients: median splenic bipolar diameter after at least 3 months from transplant decreased by a median of 25%. With a median post-transplant follow-up of 25 months, 6 patients remain in CR with full-donor chimerism, 3 patients died due to NRM. Overall, 4 patients relapsed. At last follow-up, nine patients are currently alive and achieved transfusion-independence. CONCLUSIONS In a small cohort of mostly ruxolitinib pre-treated patients, SI and treosulfan-based conditioning appeared a safe and effective tool to reduce spleen dimensions and ameliorate symptoms. Future prospective studies with adequate sample size are warranted to further investigate the usefulness and safety of this approach in MF.
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Affiliation(s)
- Edoardo Campodonico
- Hematology and Bone Marrow Transplantation Unit, IRCCS San Raffaele Hospital, via Olgettina 60, Milano 20132, Italy; University Vita-Salute San Raffaele, Milan, Italy
| | - Elisabetta Xue
- Hematology and Bone Marrow Transplantation Unit, IRCCS San Raffaele Hospital, via Olgettina 60, Milano 20132, Italy
| | - Simona Piemontese
- Hematology and Bone Marrow Transplantation Unit, IRCCS San Raffaele Hospital, via Olgettina 60, Milano 20132, Italy
| | - Anna Chiara
- Department of radiotherapy, IRCCS San Raffaele Hospital, Milan, Italy
| | - Alessandro Bruno
- Hematology and Bone Marrow Transplantation Unit, IRCCS San Raffaele Hospital, via Olgettina 60, Milano 20132, Italy; University Vita-Salute San Raffaele, Milan, Italy
| | - Gianluca Scorpio
- Hematology and Bone Marrow Transplantation Unit, IRCCS San Raffaele Hospital, via Olgettina 60, Milano 20132, Italy; University Vita-Salute San Raffaele, Milan, Italy
| | - Rosamaria Nitti
- Hematology and Bone Marrow Transplantation Unit, IRCCS San Raffaele Hospital, via Olgettina 60, Milano 20132, Italy; University Vita-Salute San Raffaele, Milan, Italy
| | - Daniele Sannipoli
- Hematology and Bone Marrow Transplantation Unit, IRCCS San Raffaele Hospital, via Olgettina 60, Milano 20132, Italy; University Vita-Salute San Raffaele, Milan, Italy
| | - Giorgio Orofino
- Hematology and Bone Marrow Transplantation Unit, IRCCS San Raffaele Hospital, via Olgettina 60, Milano 20132, Italy; University Vita-Salute San Raffaele, Milan, Italy
| | - Paolo Fiore
- Hematology and Bone Marrow Transplantation Unit, IRCCS San Raffaele Hospital, via Olgettina 60, Milano 20132, Italy; University Vita-Salute San Raffaele, Milan, Italy
| | - Maria Chiara Quattrocchi
- Hematology and Bone Marrow Transplantation Unit, IRCCS San Raffaele Hospital, via Olgettina 60, Milano 20132, Italy; University Vita-Salute San Raffaele, Milan, Italy
| | - Elisa Diral
- Hematology and Bone Marrow Transplantation Unit, IRCCS San Raffaele Hospital, via Olgettina 60, Milano 20132, Italy
| | - Daniela Clerici
- Hematology and Bone Marrow Transplantation Unit, IRCCS San Raffaele Hospital, via Olgettina 60, Milano 20132, Italy
| | - Francesca Farina
- Hematology and Bone Marrow Transplantation Unit, IRCCS San Raffaele Hospital, via Olgettina 60, Milano 20132, Italy
| | - Consuelo Corti
- Hematology and Bone Marrow Transplantation Unit, IRCCS San Raffaele Hospital, via Olgettina 60, Milano 20132, Italy
| | - Francesca Lunghi
- Hematology and Bone Marrow Transplantation Unit, IRCCS San Raffaele Hospital, via Olgettina 60, Milano 20132, Italy
| | | | - Nadia Di Muzio
- Department of radiotherapy, IRCCS San Raffaele Hospital, Milan, Italy
| | - Fabio Ciceri
- Hematology and Bone Marrow Transplantation Unit, IRCCS San Raffaele Hospital, via Olgettina 60, Milano 20132, Italy; University Vita-Salute San Raffaele, Milan, Italy
| | - Raffaella Greco
- Hematology and Bone Marrow Transplantation Unit, IRCCS San Raffaele Hospital, via Olgettina 60, Milano 20132, Italy.
| | - Jacopo Peccatori
- Hematology and Bone Marrow Transplantation Unit, IRCCS San Raffaele Hospital, via Olgettina 60, Milano 20132, Italy
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20
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Tremblay D, Mascarenhas J. Pharmacotherapeutic advances for splenomegaly in myelofibrosis. Expert Opin Pharmacother 2023; 24:577-585. [PMID: 36922391 DOI: 10.1080/14656566.2023.2192350] [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: 03/18/2023]
Abstract
INTRODUCTION Myelofibrosis is a hematologic malignancy with a variety of clinical manifestations including splenomegaly, which is present in approximately 80% of newly diagnosed patients. JAK inhibitors are the mainstay of pharmacologic treatment for splenomegaly in myelofibrosis, although spleen size reduction is not universal, and the duration of benefit is only moderately durable. AREAS COVERED We first discuss the pathobiology of splenomegaly in myelofibrosis before detailing approved and novel pharmacotherapies that can reduce spleen size while also highlighting non-pharmacologic approaches. In this review, efficacy of these treatments is measured solely by spleen volume reduction, acknowledging that other outcome measures such as symptom improvement and survival are also critical. EXPERT OPINION Currently, ruxolitinib can be administered to the majority of frontline patients although those with severe thrombocytopenia should receive pacritinib to address spleen burden. Momelotinib may be particularly well suited for patients with significant anemia and novel combination treatments in clinical development may improve the depth and duration of spleen responses. After frontline treatment failure, fedratinib, or pacritinib are commercial options for patients with persistent symptomatic splenomegaly. Novel agents given alone or in combination with a JAK inhibitor are being explored in trials, which may ameliorate splenomegaly and ultimately improve disease progression.
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Affiliation(s)
- Douglas Tremblay
- Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - John Mascarenhas
- Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
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21
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Busulfan or Treosulfan Conditioning Platform for Allogeneic Stem Cell Transplantation in Patients Aged >60 Y With Acute Myeloid Leukemia/Myelodysplastic Syndrome: A Subanalysis of the GITMO AlloEld Study. Transplant Direct 2023; 9:e1451. [PMID: 36845852 PMCID: PMC9949804 DOI: 10.1097/txd.0000000000001451] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2022] [Revised: 11/21/2022] [Accepted: 12/04/2022] [Indexed: 02/25/2023] Open
Abstract
The conditioning regimens with different alkylators at different doses can influence the outcome of allogeneic stem cell transplantation (SCT), but conclusive data are missing. Methods With the aim to analyze real-life allogeneic SCTs performed in Italy between 2006 and 2017 in elderly patients (aged >60 y) with acute myeloid leukemia or myelodysplastic syndrome, we collected 780 first transplants data. For analysis purposes, patients were grouped according to the type of alkylator included in the conditioning (busulfan [BU]-based; n = 618; 79%; treosulfan [TREO]-based; n=162; 21%). Results No significant differences were observed in nonrelapse mortality, cumulative incidence of relapse, and overall survival, although in the TREO-based group, we observed a greater proportion of elderly patients (P < 0.001); more active diseases at the time of SCT (P < 0.001); a higher prevalence of patients with either hematopoietic cell transplantation-comorbidity index ≥3 (P < 0.001) or a good Karnofsky performance status (P = 0.025); increased use of peripheral blood stem cells as graft sources (P < 0.001); and greater use of reduced intensity conditioning regimens (P = 0.013) and of haploidentical donors (P < 0.001). Moreover, the 2-y cumulative incidence of relapse with myeloablative doses of BU was significantly lower than that registered with reduced intensity conditioning (21% versus 31%; P = 0.0003). This was not observed in the TREO-based group. Conclusions Despite a higher number of risk factors in the TREO group, no significant differences were observed in nonrelapse mortality, cumulative incidence of relapse, and overall survival according to the type of alkylator, suggesting that TREO has no advantage over BU in terms of efficacy and toxicity in acute myeloid leukemia and myelodysplastic syndrome.
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22
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Srour M, Fayard A, Giannotti F, Giltat A, Guenounou S, Roy J, Schmitt J, Servais S, Alsuliman T, Agha IY, Guillerm G. [Graft failure, poor graft function erythroblastopenia: Actualization of definitions, diagnosis and treatment: Guidelines from the SFGM-TC]. Bull Cancer 2023; 110:S67-S78. [PMID: 36307323 DOI: 10.1016/j.bulcan.2022.09.003] [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: 07/06/2022] [Revised: 09/03/2022] [Accepted: 09/05/2022] [Indexed: 11/06/2022]
Abstract
In this article, we discuss again the definition, the risk factor and guideline to treat the graft failure, the poor graft function and erythrobalstopenia. Graft failure is a severe but rare complication after hematopoietic cell transplantation (HCT). Despite disparity in the literature, we defined this complication and discussed the factor risks and recommendation for treatment based on new studies. Poor graft function is also a more frequent complication after HCT. New studies will soon be available to prove or not the current recommendation suggested in this article based on therapeutics medicine or cellular therapy. Erythroblastopenia, is a rarer complication post HCT. Despite anticipation for a better choice of compatibility donor/recipient, some patients still suffer from this complication.
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Affiliation(s)
- Micha Srour
- Hôpital Huriez, CHRU Lille, maladies du sang, rue Michel-Polonowski, 59000 Lille, France
| | - Amandine Fayard
- CHU de Clermont-Ferrand, service hématologie, 1, rue Lucie- et Raymond-Aubrac, 63003 Clermont-Ferrand, France
| | - Federica Giannotti
- HUG, service hématologie, rue Gabrielle-Perret-Gentil, 4, 1205 Genève, Suisse
| | - Aurelien Giltat
- CHU d'Angers, service hématologie, 4, rue Larrey, 49933 Angers cedex 9, France
| | - Sarah Guenounou
- Institut universitaire du cancer de Toulouse-Oncopole, service d'hématologie, 1, avenue Irène-Joliot-Curie, 31059 Toulouse cedex, France
| | - Jean Roy
- Hématologie, 5415, boulevard de l'assomption, QC H1T 2M4 Montréal, Canada
| | - Justine Schmitt
- CHU de Liège, service d'hématologie biologique et d'immuno-hématologie, Liège, Belgique
| | - Sophie Servais
- CHU de Liège, service d'hématologie clinique, Liège, Belgique
| | - Tamim Alsuliman
- AP-HP, hôpital Saint-Antoine, Sorbonne université, service d'hématologie, Paris, France.
| | - Ibrahim Yakoub Agha
- Université Lille, CHU de Lille, Infininite, Inserm U1286, 59000 Lille, France
| | - Gaelle Guillerm
- Hôpital Morvan, CHRU Brest, service d'hématologie, 2, avenue Foch, 29609 Brest cedex, France
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23
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Polverelli N, Hernández-Boluda JC, Czerw T, Barbui T, D'Adda M, Deeg HJ, Ditschkowski M, Harrison C, Kröger NM, Mesa R, Passamonti F, Palandri F, Pemmaraju N, Popat U, Rondelli D, Vannucchi AM, Verstovsek S, Robin M, Colecchia A, Grazioli L, Damiani E, Russo D, Brady J, Patch D, Blamek S, Damaj GL, Hayden P, McLornan DP, Yakoub-Agha I. Splenomegaly in patients with primary or secondary myelofibrosis who are candidates for allogeneic hematopoietic cell transplantation: a Position Paper on behalf of the Chronic Malignancies Working Party of the EBMT. Lancet Haematol 2023; 10:e59-e70. [PMID: 36493799 DOI: 10.1016/s2352-3026(22)00330-1] [Citation(s) in RCA: 11] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2022] [Revised: 09/25/2022] [Accepted: 10/04/2022] [Indexed: 12/12/2022]
Abstract
Splenomegaly is a hallmark of myelofibrosis, a debilitating haematological malignancy for which the only curative option is allogeneic haematopoietic cell transplantation (HCT). Considerable splenic enlargement might be associated with a higher risk of delayed engraftment and graft failure, increased non-relapse mortality, and worse overall survival after HCT as compared with patients without significantly enlarged splenomegaly. Currently, there are no standardised guidelines to assist transplantation physicians in deciding optimal management of splenomegaly before HCT. Therefore, the aim of this Position Paper is to offer a shared position statement on this issue. An international group of haematologists, transplantation physicians, gastroenterologists, surgeons, radiotherapists, and radiologists with experience in the treatment of myelofibrosis contributed to this Position Paper. The key issues addressed by this group included the assessment, prevalence, and clinical significance of splenomegaly, and the need for a therapeutic intervention before HCT for the control of splenomegaly. Specific scenarios, including splanchnic vein thrombosis and COVID-19, are also discussed. All patients with myelofibrosis must have their spleen size assessed before allogeneic HCT. Myelofibrosis patients with splenomegaly measuring 5 cm and larger, particularly when exceeding 15 cm below the left costal margin, or with splenomegaly-related symptoms, could benefit from treatment with the aim of reducing the spleen size before HCT. In the absence of, or loss of, response, patients with increasing spleen size should be evaluated for second-line options, depending on availability, patient fitness, and centre experience. Splanchnic vein thrombosis is not an absolute contraindication for HCT, but a multidisciplinary approach is warranted. Finally, prevention and treatment of COVID-19 should adhere to standard recommendations for immunocompromised patients.
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Affiliation(s)
- Nicola Polverelli
- Unit of Blood Diseases and Bone Marrow Transplantation, Cell Therapies and Hematology Research Program, Department of Clinical and Experimental Sciences, University of Brescia, ASST Spedali Civili di Brescia, Brescia, Italy.
| | | | - Tomasz Czerw
- Department of Hematology, Maria Skłodowska-Curie National Research Institute of Oncology, Gliwice, Poland
| | - Tiziano Barbui
- FROM Research Foundation, Papa Giovanni XXIII Hospital, Bergamo, Italy
| | - Mariella D'Adda
- Hematology Division, Department of Oncology, ASST Spedali Civili di Brescia, Brescia, Italy
| | - Hans Joachim Deeg
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, WA, USA
| | - Markus Ditschkowski
- Department of Hematology and Stem Cell Transplantation, West German Cancer Center, University Hospital of Essen, Essen, Germany
| | - Claire Harrison
- Department of Clinical Haematology, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | | | - Ruben Mesa
- Mays Cancer Center at UT Health San Antonio, San Antonio, TX, USA
| | - Francesco Passamonti
- Department of Medicine and Surgery, University of Insubria, ASST Sette Laghi, Varese, Italy
| | - Francesca Palandri
- Institute of Hematology L and A Seràgnoli, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Naveen Pemmaraju
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Uday Popat
- Department of Stem Cell Transplantation and Cellular Therapy, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Damiano Rondelli
- Blood and Marrow Transplant Program, and Center for Global Health, University of Illinois at Chicago, Chicago, IL, USA
| | - Alessandro Maria Vannucchi
- Center for Innovation and Research in Myeloproliferative Neoplasms, Hematology Unit, Azienda Ospedaliera Universitaria Careggi, University of Florence, Florence, Italy
| | - Srdan Verstovsek
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Marie Robin
- Hôpital Saint-Louis, APHP, Université de Paris Cité, Paris, France
| | | | - Luigi Grazioli
- Department of Radiology, ASST Spedali Civili di Brescia, Brescia, Italy
| | - Enrico Damiani
- 2nd Division of General Surgery, Department of Medical and Surgical Sciences, ASST Spedali Civili di Brescia, Brescia, Italy
| | - Domenico Russo
- Unit of Blood Diseases and Bone Marrow Transplantation, Cell Therapies and Hematology Research Program, Department of Clinical and Experimental Sciences, University of Brescia, ASST Spedali Civili di Brescia, Brescia, Italy
| | - Jessica Brady
- Department of Clinical Oncology, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - David Patch
- Hepatology and Liver Transplantation, Royal Free London NHS Foundation Trust, London, UK
| | - Slawomir Blamek
- Department of Radiotherapy, Maria Skłodowska-Curie National Research Institute of Oncology, Gliwice, Poland
| | - Gandhi Laurent Damaj
- Unit of Hematology, Centre Hospitalier Universitaire de Caen, University of Caen-Normandie, Caen, France
| | - Patrick Hayden
- Department of Haematology, Trinity College Dublin, St James's Hospital, Dublin, Ireland
| | - Donal P McLornan
- Department of Stem Cell Transplantation and Haematology, University College London Hospitals, London, UK
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24
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Kim DH, Seo J, Shin DY, Koh Y, Hong J, Kim I, Yoon SS, Byun JM. Reduced-intensity conditioning versus myeloablative conditioning allogeneic stem cell transplantation for patients with myelofibrosis. Blood Res 2022; 57:264-271. [PMID: 36450367 PMCID: PMC9812723 DOI: 10.5045/br.2022.2022194] [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: 09/27/2022] [Revised: 11/21/2022] [Accepted: 11/24/2022] [Indexed: 12/04/2022] Open
Abstract
Background Allogeneic hematopoietic stem cell transplantation (alloSCT) is the sole curative option for myelofibrosis (MF). However, it is unknown as to which of the two, myeloablative conditioning (MAC) or reduced-intensity conditioning (RIC), is a better preconditioning regimen. Methods Twenty-five patients with MF were treated with alloSCT, 12 of whom underwent RIC. Baseline characteristics, response to alloSCT, adverse events, including graft-versus-host disease (GVHD), and survival outcomes were reviewed. Results There was no difference in the neutrophil engraftment rate and time to engraftment between MAC vs. RIC. The time to platelet engraftment was significantly longer in the MAC group (median, 112.8 vs. 28.8 days for MAC vs. RIC, respectively, P=0.049). RIC was more advantageous in terms of achieving complete chimerism (38.5% vs. 83.3%, P=0.041). The incidence of acute GVHD was 84.6% (11 of 13) and 58.3% (7 of 12) in the MAC and RIC groups, respectively. The cumulative incidence of grade III‒IV acute GVHD was significantly higher in the MAC group than in the RIC group (P=0.03). No significant differences were observed in progression-free and overall survival. The 17-month probability of progression-free survival was 38.4% [95% confidence interval (CI), 19.3‒76.5] vs. 47.6% (95% CI, 25.7‒88.2) (P=0.21), and that of overall survival was 53.8% (95% CI, 32.5‒89.1) vs. 48.6% (95% CI, 26.8‒88.3) (P=0.85) for MAC vs. RIC, respectively. Conclusion RIC offers a significant advantage over MAC, even in younger patients with MF undergoing alloSCT, in terms of cell engraftment, rate of complete chimerism achievement, and incidence of acute GVHD.
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Affiliation(s)
- Dong Hyun Kim
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Korea
| | - Jeongmin Seo
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Korea
| | - Dong-Yeop Shin
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Korea
| | - Youngil Koh
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Korea
| | - Junshik Hong
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Korea
| | - Inho Kim
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Korea
| | - Sung-Soo Yoon
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Korea
| | - Ja Min Byun
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Korea,Correspondence to Ja Min Byun, M.D., Ph.D., Department of Internal Medicine, Seoul National University Hospital, 101, Daehak-ro, Jongro-gu, Seoul 03080, Korea , E-mail:
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25
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Polverelli N, Malagola M, Russo D. Refining patients' care in myelofibrosis: looking at second primary malignancies. Leuk Lymphoma 2022; 63:3274-3275. [PMID: 36648137 DOI: 10.1080/10428194.2023.2167493] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Affiliation(s)
- Nicola Polverelli
- Unit of Blood Diseases and Stem Cell Transplantation, ASST Spedali Civili di Brescia, University of Brescia, Brescia, Italy
| | - Michele Malagola
- Unit of Blood Diseases and Stem Cell Transplantation, ASST Spedali Civili di Brescia, University of Brescia, Brescia, Italy
| | - Domenico Russo
- Unit of Blood Diseases and Stem Cell Transplantation, ASST Spedali Civili di Brescia, University of Brescia, Brescia, Italy
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26
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Tefferi A, Pardanani A, Begna KH, Al-Kali A, Hogan WJ, Litzow MR, Hanson CA, Ketterling RP, Gangat N. Momelotinib for myelofibrosis: 12-year survival data and retrospective comparison to ruxolitinib. Am J Hematol 2022; 97:E433-E435. [PMID: 36057774 DOI: 10.1002/ajh.26714] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2022] [Accepted: 08/26/2022] [Indexed: 01/31/2023]
Affiliation(s)
- Ayalew Tefferi
- Division of Hematology, Mayo Clinic, Rochester, Minnesota, USA
| | | | - Kebede H Begna
- Division of Hematology, Mayo Clinic, Rochester, Minnesota, USA
| | - Aref Al-Kali
- Division of Hematology, Mayo Clinic, Rochester, Minnesota, USA
| | - William J Hogan
- Division of Hematology, Mayo Clinic, Rochester, Minnesota, USA
| | - Mark R Litzow
- Division of Hematology, Mayo Clinic, Rochester, Minnesota, USA
| | - Curtis A Hanson
- Division of Hematopathology, Mayo Clinic, Rochester, Minnesota, USA
| | | | - Naseema Gangat
- Division of Hematology, Mayo Clinic, Rochester, Minnesota, USA
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27
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Perram J, Ross DM, McLornan D, Gowin K, Kröger N, Gupta V, Lewis C, Gagelmann N, Hamad N. Innovative strategies to improve hematopoietic stem cell transplant outcomes in myelofibrosis. Am J Hematol 2022; 97:1464-1477. [PMID: 35802782 PMCID: PMC9796730 DOI: 10.1002/ajh.26654] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2022] [Revised: 06/28/2022] [Accepted: 07/05/2022] [Indexed: 01/28/2023]
Abstract
Myelofibrosis (MF) is a clonal myeloproliferative neoplasm characterized by inflammation, marrow fibrosis, and an inherent risk of blastic transformation. Hematopoietic allogeneic stem cell transplant is the only potentially curative therapy for this disease, however, survival gains observed for other transplant indications over the past two decades have not been realized for MF. The role of transplantation may also evolve with the use of novel targeted agents. The chronic inflammatory state associated with MF necessitates pretransplantation assessment of end-organ function. Applying the transplant methodology employed for other myeloid disorders to patients with MF fails to acknowledge differences in the underlying disease pathophysiology. Limited understanding of the causes of poor transplant outcomes in this cohort has prevented refinement of transplant eligibility criteria in MF. There is increasing evidence of heterogeneity in molecular disease grade, beyond the clinical manifestations which have traditionally guided transplant timing. Exploring the physiological consequences of disease chronicity unique to MF, acknowledging the heterogeneity in disease grade, and using advanced prognostic models, molecular diagnostics and other organ function diagnostic tools, we present an innovative review of strategies with the potential to improve transplant outcomes in this disease. Larger, prospective studies which consider the impact of molecular-based disease grade are needed for MF transplantation.
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Affiliation(s)
- Jacinta Perram
- Department of Bone Marrow Transplantation and HaematologySt Vincent's HospitalDarlinghurstNew South WalesAustralia,School of Clinical Medicine, UNSW Medicine & HealthKensingtonNew South WalesAustralia
| | - David M. Ross
- Department of Haematology and Bone Marrow TransplantationRoyal Adelaide HospitalAdelaideSouth AustraliaAustralia,Centre for Cancer BiologySA Pathology and University of South AustraliaAdelaideSouth AustraliaAustralia
| | - Donal McLornan
- Department of Haematology and Stem Cell TransplantationUniversity College London Hospitals NHSLondonUK
| | - Krisstina Gowin
- Department of Hematology and OncologyBone Marrow Transplant and Cellular Therapy, University of ArizonaTucsonArizonaUSA
| | - Nicolas Kröger
- Department of Stem Cell TransplantationUniversity Medical Center Hamburg‐EppendorfHamburgGermany
| | - Vikas Gupta
- Medical Oncology and HaematologyPrincess Margaret Cancer CentreTorontoOntarioCanada
| | - Clinton Lewis
- Department of HaematologyAuckland City HospitalAucklandNew Zealand
| | - Nico Gagelmann
- Department of Stem Cell TransplantationUniversity Medical Center Hamburg‐EppendorfHamburgGermany
| | - Nada Hamad
- Department of Bone Marrow Transplantation and HaematologySt Vincent's HospitalDarlinghurstNew South WalesAustralia,School of Clinical Medicine, UNSW Medicine & HealthKensingtonNew South WalesAustralia,School of MedicineUniversity of Notre Dame AustraliaFremantleWestern AustraliaAustralia
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28
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The role of JAK inhibitors in hematopoietic cell transplantation. Bone Marrow Transplant 2022; 57:857-865. [PMID: 35388118 DOI: 10.1038/s41409-022-01649-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2021] [Revised: 02/07/2022] [Accepted: 03/16/2022] [Indexed: 01/03/2023]
Abstract
The Janus Kinase (JAK)/Signal Transducers and Activators of Transcription (STAT) pathway is essential for both the regulation of hematopoiesis and the control of inflammation. Disruption of this pathway can lead to inflammatory and malignant disease processes. JAK inhibitors, designed to control the downstream effects of pro-inflammatory and pro-angiogenic cytokines, have been successfully used in pre-clinical models and clinical studies of patients with autoimmune diseases, hematologic malignancies, and the hematopoietic cell transplantation (HCT) complication graft versus host disease (GVHD). In the last decade, JAK inhibitors Ruxolitinib, Fedratinib, and most recently Pacritinib have been United States Federal Drug Administration (FDA) approved for the treatment of myelofibrosis (MF). Ruxolitinib was also recently approved for the treatment of steroid refractory acute as well as chronic GVHD; JAK inhibitors are currently under evaluation in the pre-HCT setting in MF and for the prevention of GVHD. This review will focus on the role of JAK inhibitors in the treatment of hematologic malignancies, the potential function of pre-HCT JAK inhibitors in patients with MF, and the role of JAK inhibitors in the prevention and treatment of acute and chronic GVHD.
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29
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Tefferi A, Gangat N, Pardanani A, Crispino JD. Myelofibrosis: Genetic Characteristics and the Emerging Therapeutic Landscape. Cancer Res 2022; 82:749-763. [PMID: 34911786 PMCID: PMC9306313 DOI: 10.1158/0008-5472.can-21-2930] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2021] [Revised: 10/18/2021] [Accepted: 11/30/2021] [Indexed: 01/07/2023]
Abstract
Primary myelofibrosis (PMF) is one of three myeloproliferative neoplasms (MPN) that are morphologically and molecularly inter-related, the other two being polycythemia vera (PV) and essential thrombocythemia (ET). MPNs are characterized by JAK-STAT-activating JAK2, CALR, or MPL mutations that give rise to stem cell-derived clonal myeloproliferation, which is prone to leukemic and, in case of PV and ET, fibrotic transformation. Abnormal megakaryocyte proliferation is accompanied by bone marrow fibrosis and characterizes PMF, while the clinical phenotype is pathogenetically linked to ineffective hematopoiesis and aberrant cytokine expression. Among MPN-associated driver mutations, type 1-like CALR mutation has been associated with favorable prognosis in PMF, while ASXL1, SRSF2, U2AF1-Q157, EZH2, CBL, and K/NRAS mutations have been shown to be prognostically detrimental. Such information has enabled development of exclusively genetic (GIPSS) and clinically integrated (MIPSSv2) prognostic models that facilitate individualized treatment decisions. Allogeneic stem cell transplantation remains the only treatment modality in MF with the potential to prolong survival, whereas drug therapy, including JAK2 inhibitors, is directed mostly at the inflammatory component of the disease and is therefore palliative in nature. Similarly, disease-modifying activity remains elusive for currently available investigational drugs, while their additional value in symptom management awaits controlled confirmation. There is a need for genetic characterization of clinical observations followed by in vitro and in vivo preclinical studies that will hopefully identify therapies that target the malignant clone in MF to improve patient outcomes.
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Affiliation(s)
- Ayalew Tefferi
- Division of Hematology, Department of Medicine, Mayo Clinic, Rochester, Minnesota.,Corresponding Author: Ayalew Tefferi, Division of Hematology, Department of Medicine, Mayo Clinic, 200 First St SW, Rochester, MN 55905. Phone: 507-284-2511; Fax: 507-266-4972; E-mail:
| | - Naseema Gangat
- Division of Hematology, Department of Medicine, Mayo Clinic, Rochester, Minnesota
| | - Animesh Pardanani
- Division of Hematology, Department of Medicine, Mayo Clinic, Rochester, Minnesota
| | - John D. Crispino
- Division of Experimental Hematology, St. Jude Children's Research Hospital, Memphis, Tennessee
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30
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Posttransplantation Cyclophosphamide-based Graft versus Host Disease Prophylaxis with Non-myeloablative Conditioning for Blood or Marrow Transplantation for Myelofibrosis. Transplant Cell Ther 2022; 28:259.e1-259.e11. [PMID: 35158092 PMCID: PMC9081210 DOI: 10.1016/j.jtct.2022.02.004] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2021] [Revised: 02/01/2022] [Accepted: 02/03/2022] [Indexed: 11/20/2022]
Abstract
We describe outcomes with posttransplantation cyclophosphamide and non-myeloablative conditioning based allogeneic blood or marrow transplantation for myelofibrosis using matched or mismatched, family or unrelated donors. The conditioning regimen consisted of fludarabine, cyclophosphamide and total body irradiation. Forty-two patients, with a median age of 63 years, were included, of whom 19% had intermediate-1, 60% had intermediate-2, and 21% had high-risk DIPSS-plus disease, and 60% had atleast one high-risk somatic mutation. Over 90% patients engrafted neutrophils at a median of 19.5 days and 7% had graft failure. At 1 and 3-years, respectively, the overall survival was 65% and 60%, relapse-free survival was 65% and 31%, relapse was 5% and 40%, and non-relapse mortality was 30% and 30%. Acute graft versus host disease grade 3-4 was noted in 17% at 1 year and chronic graft versus host disease requiring systemic therapy in 12% patients. Spleen size ≥ 17 cm or prior splenectomy was associated with inferior relapse-free survival (HR 3.50, 95% CI 1.18-10.37, P=0.02) and higher relapse rate (SDHR not calculable, P=0.01). Age > 60 years (SDHR 0.26, 95% CI: 0.08-0.80, P=0.02) and peripheral blood graft (SDHR 0.34, 95% CI 0.11-0.99, P=0.05) was associated with lower risk of relapse. In our limited sample, the presence of a high-risk mutation was not statistically significantly associated with an inferior outcome although ASXL1 was suggestive of inferior survival (SDHR 2.36. 95% CI 0.85-6.6, P=0.09). Overall, this approach shows comparable outcomes as previously reported and underscores the importance of spleen size in evaluation of transplant candidates.
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31
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How We Manage Myelofibrosis Candidates for Allogeneic Stem Cell Transplantation. Cells 2022; 11:cells11030553. [PMID: 35159362 PMCID: PMC8834299 DOI: 10.3390/cells11030553] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/25/2021] [Revised: 01/31/2022] [Accepted: 02/03/2022] [Indexed: 02/01/2023] Open
Abstract
Moving from indication to transplantation is a critical process in myelofibrosis. Most of guidelines specifically focus on either myelofibrosis disease or transplant procedure, and, currently, no distinct indication for the management of MF candidates to transplant is available. Nevertheless, this period of time is crucial for the transplant outcome because engraftment, non-relapse mortality, and relapse incidence are greatly dependent upon the pre-transplant management. Based on these premises, in this review, we will go through the path of identification of the MF patients suitable for a transplant, by using disease-specific prognostic scores, and the evaluation of eligibility for a transplant, based on performance, comorbidity, and other combined tools. Then, we will focus on the process of donor and conditioning regimens’ choice. The pre-transplant management of splenomegaly and constitutional symptoms, cytopenias, iron overload and transplant timing will be comprehensively discussed. The principal aim of this review is, therefore, to give a practical guidance for managing MF patients who are potential candidates for allo-HCT.
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32
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England J, Gupta V. Novel therapies vs hematopoietic cell transplantation in myelofibrosis: who, when, how? HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2021; 2021:453-462. [PMID: 34889421 PMCID: PMC8791173 DOI: 10.1182/hematology.2021000279] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/05/2023]
Abstract
Myelofibrosis is one of the classical Philadelphia chromosome-negative myeloproliferative neoplasms characterized by progressive marrow failure and chronic inflammation. Discovery of the JAK2 mutation paved the way for development of small molecular inhibitors and further facilitated the research in understanding of molecular biology of the disease. Development of novel medications and synergistic combinations with standard JAK inhibitor (JAKi) therapy may have the potential to improve depth and duration of disease control and symptomatic benefit, whereas advancements in allogeneic hematopoietic stem cell transplantation (HCT) have improved tolerability and donor availability, allowing for more patients to pursue this potentially curative therapy. The increase in options for medical therapy and changing risk profile of HCT is leading to increased complexity in counseling patients on choice of management strategy. In this case-based review, we summarize our approach to symptom-directed medical therapy, including the use of novel drugs and combination therapies currently under study in advanced clinical trials. We outline our recommendations for optimal timing of HCT, including risk-adapted selection for early HCT as opposed to delayed HCT after upfront JAKi therapy, as well as the use of pretransplant JAKi and alternative donor sources.
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Affiliation(s)
- James England
- Princess Margaret Cancer Centre, University of Toronto, Toronto, Ontario, Canada
| | - Vikas Gupta
- Princess Margaret Cancer Centre, University of Toronto, Toronto, Ontario, Canada
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33
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Czerw T, Iacobelli S, Malpassuti V, Koster L, Kröger N, Robin M, Maertens J, Chevallier P, Watz E, Poiré X, Snowden JA, Kuball J, Kinsella F, Blaise D, Reményi P, Mear JB, Cammenga J, Rubio MT, Maury S, Daguindau E, Finnegan D, Hayden P, Hernández-Boluda JC, McLornan D, Yakoub-Agha I. Impact of donor-derived CD34 + infused cell dose on outcomes of patients undergoing allo-HCT following reduced intensity regimen for myelofibrosis: a study from the Chronic Malignancies Working Party of the EBMT. Bone Marrow Transplant 2021; 57:261-270. [PMID: 34853433 DOI: 10.1038/s41409-021-01540-2] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2021] [Revised: 11/11/2021] [Accepted: 11/19/2021] [Indexed: 11/09/2022]
Abstract
The optimal CD34 + cell dose in the setting of RIC allo-HCT for myelofibrosis (MF) remains unknown. We retrospectively analyzed 657 patients with primary or secondary MF transplanted with use of peripheral blood (PB) stem cells after fludarabine/melphalan or fludarabine/busulfan RIC regimen. Median patient age was 58 (range, 22-76) years. Donors were HLA-identical sibling (MSD) or unrelated (UD). Median follow-up was 46 (2-194) months. Patients transplanted with higher doses of CD34 + cells (>7.0 × 106/kg), had an increased chance of achievement of both neutrophil (hazard ratio (HR), 1.46; P < 0.001) and platelet engraftment (HR, 1.43; P < 0.001). In a model with interaction, for patients transplanted from a MSD, higher CD34 + dose was associated with improved overall survival (HR, 0.63; P = 0.04) and relapse-free survival (HR, 0.61; P = 0.02), lower risk of non-relapse mortality (HR, 0.57; P = 0.04) and higher rate of platelet engraftment. The combined effect of higher cell dose and UD was apparent only for higher neutrophil and platelet recovery rate. We did not document any detrimental effect of high CD34 + dose on transplant outcomes. More bulky splenomegaly was an adverse factor for survival, engraftment and NRM. Our analysis suggests a potential benefit for MF patients undergoing RIC PB-allo-HCT receiving more than 7.0 × 106/kg CD34 + cells.
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Affiliation(s)
- Tomasz Czerw
- Maria Skłodowska-Curie National Research Institute of Oncology, Gliwice Branch, Poland.
| | | | | | | | | | - Marie Robin
- Hopital Saint Louis, Assistance Publique Hôpitaux de Paris, Université de Paris, Paris, France
| | | | | | - Emma Watz
- Karolinska University Hospital, Stockholm, Sweden
| | - Xavier Poiré
- Cliniques Universitaires St. Luc, Brussels, Belgium
| | | | | | | | | | | | | | | | | | | | | | | | - Patrick Hayden
- Trinity College Dublin, St. James's Hospital, Dublin, Ireland
| | | | - Donal McLornan
- Guys' and St. Thomas' NHS Foundation Trust and University College London Hospitals, London, UK
| | - Ibrahim Yakoub-Agha
- CHfU de Lille, Université de Lille, INSERM U1286, Infinite, 59000, Lille, France
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34
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Kröger N, Sbianchi G, Sirait T, Wolschke C, Beelen D, Passweg J, Robin M, Vrhovac R, Helbig G, Sockel K, Conneally E, Rubio MT, Beguin Y, Finke J, Bernasconi P, Morozova E, Clausen J, von dem Borne P, Schaap N, Schroyens W, Patriarca F, Di Renzo N, Yeğin ZA, Hayden P, McLornan D, Yakoub-Agha I. Impact of prior JAK-inhibitor therapy with ruxolitinib on outcome after allogeneic hematopoietic stem cell transplantation for myelofibrosis: a study of the CMWP of EBMT. Leukemia 2021; 35:3551-3560. [PMID: 34023851 PMCID: PMC8632691 DOI: 10.1038/s41375-021-01276-4] [Citation(s) in RCA: 38] [Impact Index Per Article: 12.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2021] [Revised: 04/07/2021] [Accepted: 04/29/2021] [Indexed: 11/30/2022]
Abstract
JAK1/2 inhibitor ruxolitinib (RUX) is approved in patients with myelofibrosis but the impact of pretreatment with RUX on outcome after allogeneic hematopoietic stem cell transplantation (HSCT) remains to be determined. We evaluated the impact of RUX on outcome in 551 myelofibrosis patients who received HSCT without (n = 274) or with (n = 277) RUX pretreatment. The overall leukocyte engraftment on day 45 was 92% and significantly higher in RUX responsive patients than those who had no or lost response to RUX (94% vs. 85%, p = 0.05). The 1-year non-relapse mortality was 22% without significant difference between the arms. In a multivariate analysis (MVA) RUX pretreated patients with ongoing spleen response at transplant had a significantly lower risk of relapse (8.1% vs. 19.1%; p = 0.04)] and better 2-year event-free survival (68.9% vs. 53.7%; p = 0.02) in comparison to patients without RUX pretreatment. For overall survival the only significant factors were age > 58 years (p = 0.03) and HLA mismatch donor (p = 0.001). RUX prior to HSCT did not negatively impact outcome after transplantation and patients with ongoing spleen response at time of transplantation had best outcome.
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Affiliation(s)
- Nicolaus Kröger
- Department of Stem Cell Transplantation University Medical Center Hamburg-Eppendorf, Hamburg, Germany.
| | - Giulia Sbianchi
- Department of Biology, University of Rome "Tor Vergata", Rome, Italy
| | | | - Christine Wolschke
- Department of Stem Cell Transplantation University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | | | | | | | | | | | | | | | | | - Yves Beguin
- University of Liege and CHU of Liege, Liege, Belgium
| | | | | | - Elena Morozova
- First State Pavlov Medical University of St. Petersburg, St. Petersburg, Russia
| | | | | | | | | | - Francesca Patriarca
- Division of Hematology and Stem Cell Transplantation Center, University Hospital and DAME, Udine, Italy
| | - Nicola Di Renzo
- Unita Operativa di Ematologia e Trapianto di Cellule Staminali, Lecce, Italy
| | | | - Patrick Hayden
- Department of Haematology, Trinity College Dublin, St. James's Hospital, Dublin 8, Ireland
| | - Donal McLornan
- Department of Haematology, Guy's Hospital and Department of Stem Cell Transplantation, University College London Hospital, London, England
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35
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Malagola M, Polverelli N, Rubini V, Martino M, Patriarca F, Bruno B, Giaccone L, Grillo G, Bramanti S, Bernasconi P, De Gobbi M, Natale A, Terruzzi E, Olivieri A, Chiusolo P, Carella AM, Casini M, Nozzoli C, Mazza P, Bassi S, Onida F, Vacca A, Falcioni S, Luppi M, Iori AP, Pavone V, Skert C, Carluccio P, Borghero C, Proia A, Selleri C, Sacchi N, Mammoliti S, Oldani E, Ciceri F, Russo D, Bonifazi F. GITMO Registry Study on Allogeneic Transplantation in Patients Aged ≥60 Years from 2000 to 2017: Improvements and Criticisms. Transplant Cell Ther 2021; 28:96.e1-96.e11. [PMID: 34818581 DOI: 10.1016/j.jtct.2021.11.006] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2021] [Revised: 10/13/2021] [Accepted: 11/15/2021] [Indexed: 12/18/2022]
Abstract
Today, allogeneic stem cell transplantation (allo-SCT) can be offered to patients up to age 70 to 72 years and represents one of the most effective curative treatments for many hematologic malignancies. The primary objective of the study was to collect data from the allo-SCTs performed in Italy between 2000 and 2017 in patients aged ≥60 years to evaluate the changes in safety and efficacy outcomes, as well as their distribution and characteristics over time. The Italian Group for Bone Marrow Transplantation, Hematopoietic Stem Cells and Cell Therapy (GITMO) AlloEld study (ClinicalTrials.gov identifier NCT04469985) is a retrospective analysis of allo-SCTs performed at 30 Italian transplantation centers in older patients (age ≥60 years) between 2000 and 2017 (n = 1996). For the purpose of this analysis, patients were grouped into 3 time periods: time A, 2000 to 2005 (n = 256; 12%); time B, 2006 to 2011 (n = 584; 29%); and time C, 2012 to 2017 (n = 1156; 59%). After a median follow-up of 5.6 years, the 5-year nonrelapse mortality (NRM) remained stable (time A, 32.8%; time B, 36.2%; and time C, 35.0%; P = .5), overall survival improved (time A, 28.4%; time B, 31.8%; and time C, 37.3%; P = .012), and the cumulative incidence of relapse was reduced (time A, 45.3%; time B, 38.2%; time C, 30.0%; P < .0001). The 2-year incidence of extensive chronic graft-versus-host disease was reduced significantly (time A, 17.2%; time B, 15.8%; time C, 12.2%; P = .004). Considering times A and B together (2000 to 2011), the 2-year NRM was positively correlated with the Hematopoietic Cell Transplantation Comorbidity Index (HCT-CI) score; NRM was 25.2% in patients with an HCT-CI score of 0, 33.9% in those with a score of 1 or 2, and 36.1% in those with a score of 3 (P < .001). However, after 2012, the HCT-CI score was not significantly predictive of NRM. This study shows that the transplantation procedure in elderly patients became more effective over time. Relapse incidence remains the major problem, and strategies to prevent it are currently under investigation (eg, post-transplantation maintenance). The selection of patients aged ≥60 could be improved by combining HCT-CI and frailty assessment to better predict NRM.
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Affiliation(s)
- Michele Malagola
- Blood Diseases and Cell Therapies Unit, Bone Marrow Transplant Unit, "ASST-Spedali Civili" Hospital of Brescia; Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy.
| | - Nicola Polverelli
- Blood Diseases and Cell Therapies Unit, Bone Marrow Transplant Unit, "ASST-Spedali Civili" Hospital of Brescia; Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
| | - Vicky Rubini
- Blood Diseases and Cell Therapies Unit, Bone Marrow Transplant Unit, "ASST-Spedali Civili" Hospital of Brescia; Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
| | - Massimo Martino
- Stem Cell Transplant and Cellular Therapies Unit, "BMM" Hospital, Reggio Calabria, Italy
| | - Francesca Patriarca
- Hematologic Clinic and Transplant Center, University Hospital of Central Friuli, DAME, University of Udine, Udine, Italy
| | - Benedetto Bruno
- Department of Oncology, SSD Allogeneic Stem Cell Transplantation, "Città della Salute e della Scienza", Department of Molecular Biotechnology and Health Sciences, Division of Hematology, University of Turin, Turin, Italy
| | - Luisa Giaccone
- Department of Oncology, SSD Allogeneic Stem Cell Transplantation, "Città della Salute e della Scienza", Department of Molecular Biotechnology and Health Sciences, Division of Hematology, University of Turin, Turin, Italy
| | - Giovanni Grillo
- Division of Hematology and Marrow Transplant, Niguarda Hospital, Milan, Italy
| | | | - Paolo Bernasconi
- Transplant Center, Unit of Hematology, Foundation IRCCS Policlinico San Matteo, Pavia, Italy
| | - Marco De Gobbi
- Department of Clinical and Biological Sciences, University of Turin, Internal Medicine and Hematology Division, San Luigi University Hospital - Orbassano (Turin), Italy
| | - Annalisa Natale
- Hematologic Intensive Care, Pescara Hospital, Pescara, Italy
| | | | - Attilio Olivieri
- Haematology Clinic, "Ospedali Riuniti," University Hospital of Ancona, Ancona, Italy
| | - Patrizia Chiusolo
- Department of Medical Imaging, Radiotherapy, Oncology, and Hematology, "A. Gemelli IRCCS" University Teaching Hospital Foundation, Hematology Division, Department of Radiological and Hematological Sciences, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Angelo Michele Carella
- SSD Hematologic Intensive Care and Cell Therapy Unit; Department of Medical Sciences, "Casa Sollievo della Sofferenza" Foundation, San Giovanni Rotondo, Italy
| | - Marco Casini
- Hematology and Bone Marrow Transplantation, Bolzano Hospital, Bolzano, Italy
| | - Chiara Nozzoli
- Cell Therapy and Ttransfusion Medicine, "Careggi" University Hospital, Florence, Italy
| | - Patrizio Mazza
- PO San Giuseppe Moscati, Department of Hematology with Transplant Division, ASL Taranto, Italy
| | - Simona Bassi
- Hematology Unit, "G. da Saliceto" Hospital, Piacenza, Italy
| | - Francesco Onida
- IRCCS Foundation "Ospedale Maggiore Ca' Granda Policlinico," University of Milan, Milan, Italy
| | - Adriana Vacca
- Hematology Unit, CTMO PO, "A. Businco", ARNAS Brotzu, Cagliari, Italy
| | - Sadia Falcioni
- Unit of Hematology and Cellular Therapy, "C. e G. Mazzoni" Hospital, Ascoli Piceno, Italy
| | - Mario Luppi
- Department of Medical and Surgical Sciences, UNIMORE, Division of Hematology, Azienda Ospedaliera Universitaria di Modena, Modena, Italy
| | - Anna Paola Iori
- Department of Hematology, Oncology, and Dermatology, "Umberto I" University Hospital, Roma Sapienza University, Rome, Italy
| | - Vincenzo Pavone
- Department of Hematology and Bone Marrow Transplantation, "Card. G. Panico" Hospital, Tricase, Italy
| | - Cristina Skert
- Unit of Hematology/Bone Marrow Transplantation, Unit "Ospedale dell'Angelo" Venice, Mestre, Italy
| | - Paola Carluccio
- Hematology and Stem Cell Transplantation Unit, Department of Emergency and Organ Transplantation, "Aldo Moro" University of Bari, Bari, Italy
| | - Carlo Borghero
- Hematology Department, "San Bortolo" Hospital, Vicenza, Italy
| | - Anna Proia
- Unit of Hematology and Stem Cell Transplant Center, "San Camillo" Hospital, Rome, Italy
| | - Carmine Selleri
- "San Giovanni di Dio e Ruggi d'Aragona" University Hospital, Salerno, Italy
| | - Nicoletta Sacchi
- Italian Bone Marrow Donor Registry, E. O. Galliera Hospitals, Genoa, Italy
| | | | - Elena Oldani
- Hematology Unit, "ASST Papa Giovanni XXIII," Bergamo, Italy
| | - Fabio Ciceri
- Department of Onco-Hematology, Hematology and Bone Marrow Transplantation, IRCCS San Raffaele Scientific Institute and Vita-Salute San Raffaele University, Milan, Italy
| | - Domenico Russo
- Blood Diseases and Cell Therapies Unit, Bone Marrow Transplant Unit, "ASST-Spedali Civili" Hospital of Brescia; Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
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36
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Ali H, Bacigalupo A. 2021 Update on allogeneic hematopoietic stem cell transplant for myelofibrosis: A review of current data and applications on risk stratification and management. Am J Hematol 2021; 96:1532-1538. [PMID: 34536293 PMCID: PMC9293100 DOI: 10.1002/ajh.26349] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2021] [Revised: 09/08/2021] [Accepted: 09/11/2021] [Indexed: 12/13/2022]
Abstract
The number of patients with myelofibrosis (MF) undergoing an allogeneic hemopoietic stem cell transplantation (HSCT) is increasing: in the analysis of the European Group for Blood and Marrow Transplantation (EBMT) the number of MF has increased from 515 in 2014 to 748 in 2018 . This reflects the fact that HSCT is currently the only curative treatment, capable of inducing prolonged disease‐free survival. Nevertheless, several problems prevent more patients from undergoing an allogeneic HSCT: we will be discussing indications for HSCT, comorbidities, splenomegaly, older age and disease phase. Donor type and stem cell source are less of a problem. Several transplant platforms exist, including different strategies for graft versus host disease (GvHD) prophylaxis, Age tailored conditioning regimens need to be implemented, to allow older and fragile patients to undergo an allogeneic HSCT.
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Affiliation(s)
- Haris Ali
- Divison of Leukemia, Department of Hematology and Hemopoietic Cell Transplantation City of Hope Duarte California USA
| | - Andrea Bacigalupo
- Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia Fondazione Policlinico Universitario A. Gemelli IRCCS Rome Italy
- Sezione di Ematologia, Dipartimento di Scienze Radiologiche ed Ematologiche Università Cattolica del Sacro Cuore Rome Italy
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McLornan DP, Hernandez-Boluda JC, Czerw T, Cross N, Joachim Deeg H, Ditschkowski M, Moonim MT, Polverelli N, Robin M, Aljurf M, Conneally E, Hayden P, Yakoub-Agha I. Allogeneic haematopoietic cell transplantation for myelofibrosis: proposed definitions and management strategies for graft failure, poor graft function and relapse: best practice recommendations of the EBMT Chronic Malignancies Working Party. Leukemia 2021; 35:2445-2459. [PMID: 34040148 DOI: 10.1038/s41375-021-01294-2] [Citation(s) in RCA: 36] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2021] [Revised: 05/04/2021] [Accepted: 05/07/2021] [Indexed: 01/31/2023]
Abstract
Allogeneic haematopoietic cell transplantation (allo-HCT) remains the only curative approach in myelofibrosis (MF). Despite advances over recent decades, relapse and non-relapse mortality rates remain significant. Relapse rates vary between 15 and 25% across retrospective studies and management strategies vary widely, ranging from palliation to adoptive immunotherapy and, in some cases, a second allo-HCT. Moreover, in allo-HCT, there is a higher incidence of poor graft function and graft failure due to splenomegaly and a hostile "pro-inflammatory" marrow niche. The Practice Harmonisation and Guidelines subcommittee of the Chronic Malignancies Working Party (CMWP) of EBMT convened an international panel consisting of transplant haematologists, histopathologists and molecular biologists to propose practical, clinically relevant definitions of graft failure, poor graft function and relapse as well as management strategies following allo-HCT. A systematic approach to molecular monitoring, histopathological assessment and chimerism testing is proposed. These proposed recommendations aim to increase the accuracy and uniformity of reporting and to thereby facilitate the development of more consistent approaches to these challenging issues. In addition, we propose management strategies for these complications.
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Affiliation(s)
- Donal P McLornan
- Department of Haematology, Guy's and St. Thomas' NHS Foundation Trust and University College Hospitals, London, UK.
| | | | - Tomasz Czerw
- Maria Sklodowska-Curie Institute, Gliwice, Poland
| | - Nicholas Cross
- National Genetics Reference Laboratory (Wessex), Salisbury District Hospital, Salisbury, UK
| | - H Joachim Deeg
- Fred Hutchinson Cancer Research Center and the University of Washington, Seattle, WA, USA
| | - Marcus Ditschkowski
- Department for Bone Marrow Transplantation, University of Essen, Essen, Germany
| | - Mufaddal T Moonim
- Department of Histopathology, Imperial College Healthcare NHS Trust, London, UK
| | - Nicola Polverelli
- Unit of Blood Diseases and Stem Cell Transplantation, Department of Clinical and Experimental Sciences-University of Brescia, ASST Spedali Civili, Brescia, Italy
| | - Marie Robin
- Hopital Saint-Louis, APHP, Université de Paris, Paris, France
| | - Mahmoud Aljurf
- Oncology Center, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
| | | | - Patrick Hayden
- Haematology Department, St. James Hospital, Dublin, Ireland
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Ho VT, Rambaldi A. Splenectomy before allogeneic hematopoietic stem-cell transplantation for myelofibrosis: Tumor burden matters! Am J Hematol 2021; 96:12-13. [PMID: 33219701 DOI: 10.1002/ajh.26054] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2020] [Accepted: 11/18/2020] [Indexed: 11/11/2022]
Affiliation(s)
- Vincent T. Ho
- Department of Medical Oncology, Division of Hematologic Malignancies, Dana‐Farber Cancer Institute Harvard Medical School Boston Massachusetts USA
| | - Alessandro Rambaldi
- Department of Oncology‐Hematology University of Milan and Azienda Socio Sanitaria Territoriale Papa Giovanni XXIII Bergamo Italy
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Tefferi A. Primary myelofibrosis: 2021 update on diagnosis, risk-stratification and management. Am J Hematol 2021; 96:145-162. [PMID: 33197049 DOI: 10.1002/ajh.26050] [Citation(s) in RCA: 171] [Impact Index Per Article: 57.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2020] [Accepted: 11/11/2020] [Indexed: 12/16/2022]
Abstract
DISEASE OVERVIEW Primary myelofibrosis (PMF) is a myeloproliferative neoplasm (MPN) characterized by stem cell-derived clonal myeloproliferation that is often but not always accompanied by JAK2, CALR, or MPL mutations. Additional disease features include bone marrow reticulin/collagen fibrosis, aberrant inflammatory cytokine expression, anemia, hepatosplenomegaly, extramedullary hematopoiesis (EMH), constitutional symptoms, cachexia, leukemic progression, and shortened survival. DIAGNOSIS Bone marrow morphology is the primary basis for diagnosis. Presence of JAK2, CALR, or MPL mutation, expected in around 90% of the patients, is supportive but not essential for diagnosis; these mutations are also prevalent in the closely related MPNs, namely polycythemia vera (PV) and essential thrombocythemia (ET). The 2016 World Health Organization classification system distinguishes "prefibrotic" from "overtly fibrotic" PMF; the former might mimic ET in its presentation. Furthermore, approximately 15% of patients with ET or PV might progress into a PMF-like phenotype (post-ET/PV MF) during their clinical course. ADVERSE MUTATIONS SRSF2, ASXL1, and U2AF1-Q157 mutations predict inferior survival in PMF, independent of each other and other risk factors. RAS/CBL mutations predicted resistance to ruxolitinib therapy. ADVERSE KARYOTYPE Very high risk abnormalities include -7, inv (3), i(17q), +21, +19, 12p-, and 11q-. RISK STRATIFICATION Two new prognostic systems for PMF have recently been introduced: GIPSS (genetically-inspired prognostic scoring system) and MIPSS70+ version 2.0 (MIPSSv2; mutation- and karyotype-enhanced international prognostic scoring system). GIPSS is based exclusively on mutations and karyotype. MIPSSv2 includes, in addition, clinical risk factors. GIPSS features four and MIPSSv2 five risk categories. RISK-ADAPTED THERAPY Observation alone is advised for MIPSSv2 "low" and "very low" risk disease (estimated 10-year survival 56%-92%); allogeneic hematopoietic stem cell transplant (AHSCT) is the preferred treatment for "very high" and "high" risk disease (estimated 10-year survival 0%-13%); treatment-requiring patients with intermediate-risk disease (estimated 10-year survival 30%) are best served by participating in clinical trials. In non-transplant candidates, conventional treatment for anemia includes androgens, prednisone, thalidomide, and danazol; for symptomatic splenomegaly, hydroxyurea and ruxolitinib; and for constitutional symptoms, ruxolitinib. Fedratinib, another JAK2 inhibitor, has now been FDA-approved for use in ruxolitinib failures. Splenectomy is considered for drug-refractory splenomegaly and involved field radiotherapy for non-hepatosplenic EMH and extremity bone pain. NEW DIRECTIONS A number of new agents, alone or in combination with ruxolitinib, are currently under investigation for MF treatment (ClinicalTrials.gov); preliminary results from some of these clinical trials were presented at the 2020 ASH annual meeting and highlighted in the current document.
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Affiliation(s)
- Ayalew Tefferi
- Division of Hematology, Department of Medicine Mayo Clinic Rochester Minnesota USA
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