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Goulart H, Masarova L, Mesa R, Harrison C, Kiladjian JJ, Pemmaraju N. Myeloproliferative neoplasms in the adolescent and young adult population: A comprehensive review of the literature. Br J Haematol 2024; 205:48-60. [PMID: 38853641 PMCID: PMC11245372 DOI: 10.1111/bjh.19557] [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: 03/21/2024] [Accepted: 05/14/2024] [Indexed: 06/11/2024]
Abstract
Myeloproliferative neoplasms (MPN) are characterized by a clonal proliferation of myeloid lineage cells within the bone marrow. The classical BCR-ABL negative MPNs are comprised of polycythaemia vera, essential thrombocythaemia and primary myelofibrosis. Historically, the majority of MPNs are diagnosed in adults older than 60 years of age; however, in recent years, there has been recognition of MPNs in the adolescent and young adult (AYA) population. AYAs with MPN, typically defined as between the ages of 15 and 39 years old, may comprise up to 20% of patients diagnosed with MPN. They demonstrate unique patterns of driver mutations and thrombotic events and remain at risk for progression to more aggressive disease states. Given the likely long length of time they will live with their disease, there is a significant unmet need in identifying well-tolerated and effective treatment options for these patients, particularly with the advent of disease modification. In this review, we provide a comprehensive overview of the clinical features, disease course and management of AYA patients with MPN and, in doing so, highlight key characteristics that distinguish them from their older counterparts.
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Affiliation(s)
- Hannah Goulart
- Division of Cancer Medicine, University of Texas, MD Anderson Cancer Center, Houston, TX, USA
| | - Lucia Masarova
- Department of Leukemia, University of Texas, MD Anderson Cancer Center, Houston, TX, USA
| | - Ruben Mesa
- Atrium Health Wake Forest Baptist Comprehensive Cancer Center, Winston-Salem, NC, USA
| | - Claire Harrison
- Department of Haematology, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | | | - Naveen Pemmaraju
- Department of Leukemia, University of Texas, MD Anderson Cancer Center, Houston, TX, USA
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Somay E, Topkan E, Kucuk A, Ozturk D, Ozkan EE, Ozdemir BS, Besen AA, Mertsoylu H, Pehlivan B, Selek U. Pre-chemoradiotherapy high platelet counts predict jaw osteoradionecrosis in locally advanced nasopharyngeal carcinoma patients. JOURNAL OF STOMATOLOGY, ORAL AND MAXILLOFACIAL SURGERY 2024; 125:101838. [PMID: 38518893 DOI: 10.1016/j.jormas.2024.101838] [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: 02/05/2024] [Revised: 03/15/2024] [Accepted: 03/18/2024] [Indexed: 03/24/2024]
Abstract
INTRODUCTION This retrospective study aimed to investigate if pretreatment platelet (PLT) levels can predict the risk of osteoradionecrosis of the jaw (ORNJ) in patients with locally advanced nasopharyngeal carcinoma (LA-NPC) who received concurrent chemoradiotherapy (CCRT). MATERIAL &METHODS ORNJ instances were identified from LA-NPC patients' pre- and post-CCRT oral exam records. All pretreatment PLT values were acquired on the first day of CCRT. Receiver operating characteristic curve analysis was used to determine the optimal PLT cutoff that divides patients into two subgroups with distinctive ORNJ rates. The primary outcome measure was the association between pretreatment PLT values and ORNJ incidence rates. RESULTS The incidence of ORNJ was 8.8 % among the 240 LA-NPC patients analyzed. The ideal pre-CCRT PLT cutoff which divided the patients into two significantly different ORNJ rate groups was 285,000 cells/µL (PLT ≤ 285,000 cells/µL (N = 175) vs. PLT > 285,000 cells/µL (N = 65)). A comparison of the two PLT groups revealed that the incidence of ORNJ was substantially higher in patients with PLT > 285,000 cells/L than in those with PLT≤285,000 cells/L (26.2% vs. 2.3 %; P < 0.001). The presence of pre-CCRT ≥3 tooth extractions, any post-CCRT tooth extractions, mean mandibular dose ≥ 34.1 Gy, mandibular V57.5 Gy ≥ 34.7 %, and post-CCRT tooth extractions > 9 months after CCRT completion were also associated with significantly increased ORNJ rates. A multivariate Cox regression analysis demonstrated that each characteristic had an independent significance on ORNJ rates after CCRT. CONCLUSION An affordable and easily accessible novel biomarker, PLT> 285,000 cells/L, may predict substantially higher ORNJ rates after definitive CCRT in individuals with LA-NPC.
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Affiliation(s)
- Efsun Somay
- Department of Oral and Maxillofacial Surgery, Faculty of Dentistry, Baskent University, Ankara, Turkey.
| | - Erkan Topkan
- Department of Radiation Oncology, Faculty of Medicine, Baskent University, Adana, Turkey
| | - Ahmet Kucuk
- Clinics of Radiation Oncology, Mersin City Education and Research Hospital, Mersin, Turkey
| | - Duriye Ozturk
- Department of Radiation Oncology, Faculty of Medicine, Afyonkarahisar Health Sciences University, Afyonkarahisar, Turkey
| | - Emine Elif Ozkan
- Department of Radiation Oncology, Faculty of Medicine, Suleyman Demirel University, Isparta, Turkey
| | | | - Ali Ayberk Besen
- Clinics of Medical Oncology, Istinye University, Adana Medical Park Hospital, Turkey
| | - Huseyin Mertsoylu
- Clinics of Medical Oncology, Istinye University, Adana Medical Park Hospital, Turkey
| | - Berrin Pehlivan
- Department of Radiation Oncology, Bahcesehir University, Istanbul, Turkey
| | - Ugur Selek
- Department of Radiation Oncology, School of Medicine, Koc University, Istanbul, Turkey
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Popova-Labachevska M, Cvetanoski M, Ridova N, Trajkova S, Stojanovska-Jakimovska S, Mojsovska T, Stojanoski Z, Pivkova-Veljanovska A, Panovska-Stavridis I. Effectiveness of Ropeginterferon Alfa-2B in High-Risk Patients with Philadelphia Chromosome Negative Myeloproliferative Neoplasms- Evaluation of Clinicohaematologic Response, and Safety Profile: Single Centre Experience. Pril (Makedon Akad Nauk Umet Odd Med Nauki) 2023; 44:57-62. [PMID: 38109450 DOI: 10.2478/prilozi-2023-0047] [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] [Indexed: 12/20/2023]
Abstract
Background: Treatment of Philadelphia chromosome negative myeloproliferative neoplasms (Ph - MPNs) requires individualized approach depending on multiple factors. Novel pegylated Interferon (IFN) formulations have become an attractive therapeutic option in young Ph- MPN patients associated with better patient compliance. Methods: In this retrospective observational study a total of 16 high-risk Ph- MPN patients treated off-label with ropeginterferon alfa-2b given twice monthly, were included. Median follow-up was 24 months. High-risk patients were defined using the IPSET score. Response to treatment was evaluated using ELN, IWG-MET EUMNET standardized criteria and occurrence of side effects was documented. Results: 11 patients were female (68.8%) and 5 male (31.2%); average age at diagnosis was 36 years (17-51); 12 patients (75%) had ET, one (6.2%) PV and three (18.8%) hypercellular phase of PMF. JAK2V617F mutation was detected in 10 patients (62.5%), CALR in three (18.8%), and three (18.7%) were triple-negative cases. In 7 patients (43.7%), ropeginterferon alfa-2b was used in first-line, and 9 (56.3%) were previously treated with HU and/or standard IFN. Among initially ropeginterferon alfa-2b treated patients, complete haematological response was observed in 4/7 (57.1%), partial in 2/7 (28.6%) and suboptimal in one (14.3%). Complete haematological response was observed in 8/9 (88.9%) among previously treated patients. Average time to blood count normalization was 8 weeks, at a dose ranging between 100mcg and 300mcg. Side effects were observed in one patient (6.2%). Conclusion: Our experience is in support of previous studies regarding ropeginterferon alfa-2b efficacy and safety profile in the treatment of young patients with Ph- MPNs.
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Affiliation(s)
- Marija Popova-Labachevska
- 1University clinic of hematology, Faculty of Medicine, Ss. Cyril and Methodius University in Skopje, RN Macedonia
| | - Milche Cvetanoski
- 1University clinic of hematology, Faculty of Medicine, Ss. Cyril and Methodius University in Skopje, RN Macedonia
| | - Nevenka Ridova
- 1University clinic of hematology, Faculty of Medicine, Ss. Cyril and Methodius University in Skopje, RN Macedonia
| | - Sanja Trajkova
- 1University clinic of hematology, Faculty of Medicine, Ss. Cyril and Methodius University in Skopje, RN Macedonia
| | | | - Tara Mojsovska
- 1University clinic of hematology, Faculty of Medicine, Ss. Cyril and Methodius University in Skopje, RN Macedonia
| | - Zlate Stojanoski
- 1University clinic of hematology, Faculty of Medicine, Ss. Cyril and Methodius University in Skopje, RN Macedonia
| | | | - Irina Panovska-Stavridis
- 1University clinic of hematology, Faculty of Medicine, Ss. Cyril and Methodius University in Skopje, RN Macedonia
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Ng ZY, Fuller KA, Mazza-Parton A, Erber WN. Morphology of myeloproliferative neoplasms. Int J Lab Hematol 2023. [PMID: 37211431 DOI: 10.1111/ijlh.14086] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2023] [Accepted: 04/27/2023] [Indexed: 05/23/2023]
Abstract
Myeloproliferative neoplasms (MPN) are a group of clonal haematological malignancies first described by Dameshek in 1957. The Philadelphia-negative MPN that will be described are polycythaemia vera (PV), essential thrombocythaemia (ET), pre-fibrotic myelofibrosis and primary myelofibrosis (PMF). The blood and bone marrow morphology are essential in diagnosis, for WHO classification, establishing a baseline, monitoring response to treatment and identifying changes that may indicate disease progression. The blood film changes may be in any of the cellular elements. The key bone marrow features are architecture and cellularity, relative complement of individual cell types, reticulin content and bony structure. Megakaryocytes are the most abnormal cell and key to classification, as their number, location, size and cytology are all disease-defining. Reticulin content and grade are integral to assignment of the diagnosis of myelofibrosis. Even with careful assessment of all these features, not all cases fit neatly into the diagnostic entities; there is frequent overlap reflecting the biological disease continuum rather than distinct entities. Notwithstanding this, an accurate morphologic diagnosis in MPN is crucial due to the significant differences in prognosis between different subtypes and the availability of different therapies in the era of novel agents. The distinction between "reactive" and MPN is also not always straightforward and caution needs to be exercised given the prevalence of "triple negative" MPN. Here we describe the morphology of MPN including comments on changes with disease evolution and with treatment.
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Affiliation(s)
- Zi Yun Ng
- School of Biomedical Sciences, The University of Western Australia, Perth, Western Australia, Australia
- Haematology Department, Royal Perth Hospital, Perth, Western Australia, Australia
| | - Kathryn A Fuller
- School of Biomedical Sciences, The University of Western Australia, Perth, Western Australia, Australia
| | - Allegra Mazza-Parton
- School of Biomedical Sciences, The University of Western Australia, Perth, Western Australia, Australia
| | - Wendy N Erber
- School of Biomedical Sciences, The University of Western Australia, Perth, Western Australia, Australia
- Department of Haematology, PathWest Laboratory Medicine, Nedlands, Western Australia, Australia
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Puglianini OC, Peker D, Zhang L, Papadantonakis N. Essential Thrombocythemia and Post-Essential Thrombocythemia Myelofibrosis: Updates on Diagnosis, Clinical Aspects, and Management. Lab Med 2023; 54:13-22. [PMID: 35960786 DOI: 10.1093/labmed/lmac074] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
Abstract
Although several decades have passed since the description of myeloproliferative neoplasms (MPN), many aspects of their pathophysiology have not been elucidated. In this review, we discuss the mutational landscape of patients with essential thrombocythemia (ET), prognostic scores and salient pathology, and clinical points. We discuss also the diagnostic challenges of differentiating ET from prefibrotic MF. We then focus on post-essential thrombocythemia myelofibrosis (post-ET MF), a rare subset of MPN that is usually studied in conjunction with post-polycythemia vera MF. The transition of ET to post-ET MF is not well studied on a molecular level, and we present available data. Patients with secondary MF could benefit from allogenic hematopoietic stem cell transplantation, and we present available data focusing on post-ET MF.
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Affiliation(s)
- Omar Castaneda Puglianini
- H. Lee Moffitt Cancer Center & Research Institute, Department of Blood & Marrow Transplant & Cellular Immunotherapy, Tampa, FL, USA
- Department of Oncologic Sciences, University of South Florida Morsani College of Medicine, Tampa, FL, USA
| | - Deniz Peker
- Department of Pathology and Laboratory Medicine, Emory University School of Medicine, Atlanta, GA, USA
| | - Linsheng Zhang
- Department of Pathology and Laboratory Medicine, Emory University School of Medicine, Atlanta, GA, USA
| | - Nikolaos Papadantonakis
- Winship Cancer Institute of Emory University, Department of Hematology and Medical Oncology, Atlanta, GA, USA
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Bieniaszewska M, Sobieralski P, Leszczyńska A, Dutka M. Anagrelide in essential thrombocythemia: Efficacy and long-term consequences in young patient population. Leuk Res 2022; 123:106962. [PMID: 36183610 DOI: 10.1016/j.leukres.2022.106962] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2022] [Revised: 09/03/2022] [Accepted: 09/19/2022] [Indexed: 10/14/2022]
Abstract
According to the current treatment recommendations, anagrelide, an oral antiplatelet agent, is recommended as a second-line therapy for patients with high-risk essential thrombocythemia experiencing intolerance or refractoriness to first-line approach, such as hydroxyurea or pegylated interferon alpha-2a. If there is a need for introduction of cytoreductive treatment in young patients with a perspective of lifelong exposure, both the efficacy and long-term outcomes should be known. We present the analysis of 48 young patients, diagnosed with essential thrombocythemia below the age of 60, who were exposed to anagrelide treatment for over 10 years. Our observations show that the highest proportion of complete remissions without adverse events and disease progression is seen in the JAK2-mutated patients. By evaluating the changes in hemoglobin concentration and serum erythropoietin throughout the study, we were able to reveal the development of progressive anemia, resulting from diminished susceptibility to erythropoietin and unrelated to bone marrow fibrosis, in patients harboring CALR mutation. Additionally, occurrence of new bone marrow fibrosis was confirmed in seven JAK2-unmutated patients at the end of the study. In summary, in young patient population, we recommend limiting the use of anagrelide to JAK2-mutated subgroup, reducing exposure time and underline the importance of periodic monitoring for the presence of bone marrow fibrosis.
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Affiliation(s)
- Maria Bieniaszewska
- Department of Hematology and Transplantology, Medical University of Gdańsk, Poland
| | - Patryk Sobieralski
- Department of Hematology and Transplantology, Medical University of Gdańsk, Poland.
| | | | - Magdalena Dutka
- Department of Hematology and Transplantology, Medical University of Gdańsk, Poland
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Pich A, Beggiato E, Godio L, Riera L, Francia di Celle P, Lanzarone G, Benevolo G. Bone marrow morphological features and therapy in patients with Philadelphia-negative neoplasms. Expert Rev Hematol 2021; 14:841-850. [PMID: 34384330 DOI: 10.1080/17474086.2021.1967138] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Introduction Chronic myeloproliferative neoplasm (MPNs) are clonal malignant bone marrow (BM) diseases, arising from a hematopoietic stem cell. All therapies for these neoplasms have peculiar effects on the bone marrow, but little evidence has been described in the literature.Areas covered This review examines BM morphological changes following the main treatments in Philadelphia-negative MPNs. Hydroxyurea can reduce the cellularity of the erythroid and megakaryocyte lineages but has minimal impact on fibrotic evolution. There is general agreement on its dysplastic effects, with a high incidence of acute myeloid leukemia and myelodysplastic syndrome. Interferon treatment can reduce or normalize BM cellularity, improve erythropoiesis, and reduce the number and atypicality of megakaryocytes. Most data describe reduction or complete resolution of marrow fibrosis; dysplastic effects are not reported. Anagrelide may induce an increase in the number of BM megakaryocytes, especially immature megakaryocytes or precursors, and a worsening of marrow fibrosis or increased transformation of essential thrombocythemia into myelofibrosis. Ruxolitinib can improve or stabilize BM fibrosis and reduces the frequency and dense clustering of megakaryocytes.Expert opinion Since previous therapy can modify BM features, it is essential to obtain information on previous or current therapies and to collect complete clinical information.
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Affiliation(s)
- Achille Pich
- Section of Pathology, Department of Molecular Biotechnology and Health Sciences, University of Turin, Turin, Italy
| | - Eloise Beggiato
- Hematology, AOU Città della Salute e della Scienza di Torino-Presidio Ospedaliero Molinette, Turin, Italy
| | - Laura Godio
- Pathology, AOU Città della Salute e della Scienza di Torino-Presidio Ospedaliero Molinette, Turin, Italy
| | - Ludovica Riera
- Pathology, AOU Città della Salute e della Scienza di Torino-Presidio Ospedaliero Molinette, Turin, Italy
| | - Paola Francia di Celle
- Pathology, AOU Città della Salute e della Scienza di Torino-Presidio Ospedaliero Molinette, Turin, Italy
| | - Giuseppe Lanzarone
- Hematology, AOU Città della Salute e della Scienza di Torino-Presidio Ospedaliero Molinette, Turin, Italy
| | - Giulia Benevolo
- Hematology, AOU Città della Salute e della Scienza di Torino-Presidio Ospedaliero Molinette, Turin, Italy
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The Use of Anagrelide in Myeloproliferative Neoplasms, with Focus on Essential Thrombocythemia. Curr Hematol Malig Rep 2017; 11:348-55. [PMID: 27497846 PMCID: PMC5031713 DOI: 10.1007/s11899-016-0335-0] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Anagrelide (ANA) is a drug with specific platelet-lowering activity, used primarily in ET, registered as a second-line drug in essential thrombocythemia (ET) in Europe and in some countries as first-line therapy, in USA licensed by FDA for thrombocythemia in myeloproliferative neoplasms (MPN). The platelet-lowering efficacy is similar to that of hydroxycarbamide (HC), around 70 % complete response and 90 % partial response. Side effects are common, especially headache and tachycardia, but usually subside or disappear within a few weeks. Around 20 % of patients stop ANA therapy due to side effects or insufficient response. Studies of treatment patterns in Europe show that ANA is preferentially given to younger patients, probably because of the concern for a possible leukemogenic effect of the common first-line drug, HC. Only two randomized studies have compared the efficacy of ANA and HC in preventing thrombosis and haemorrhage, the larger of them showing a slightly better efficacy of HC, the other showing non-inferiority of ANA to HC. A recent observational 5-year study of 3600 patients shows a low and basically similar efficacy of ANA and other cytoreductive therapies in ET. ANA does not appear to inhibit fibrosis development, and probably due to its anticoagulation properties, the combination of ASA and ANA produces an increased rate of haemorrhage. Combination of ANA with HC or interferon (IFN) is feasible and effective in patients with insufficient platelet response to mono-therapy.
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Sever C, Abbott CL, de Baca ME, Khoury JD, Perkins SL, Reichard KK, Taylor A, Terebelo HR, Colasacco C, Rumble RB, Thomas NE. Bone Marrow Synoptic Reporting for Hematologic Neoplasms: Guideline From the College of American Pathologists Pathology and Laboratory Quality Center. Arch Pathol Lab Med 2016; 140:932-49. [PMID: 26905483 DOI: 10.5858/arpa.2015-0450-sa] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
CONTEXT -There is ample evidence from the solid tumor literature that synoptic reporting improves accuracy and completeness of relevant data. No evidence-based guidelines currently exist for synoptic reporting for bone marrow samples. OBJECTIVE -To develop evidence-based recommendations to standardize the basic components of a synoptic report template for bone marrow samples. DESIGN -The College of American Pathologists Pathology and Laboratory Quality Center convened a panel of experts in hematopathology to develop recommendations. A systematic evidence review was conducted to address 5 key questions. Recommendations were derived from strength of evidence, open comment feedback, and expert panel consensus. RESULTS -Nine guideline statements were established to provide pathology laboratories with a framework by which to develop synoptic reporting templates for bone marrow samples. The guideline calls for specific data groups in the synoptic section of the pathology report; provides a list of evidence-based parameters for key, pertinent elements; and addresses ancillary testing. CONCLUSION -A framework for bone marrow synoptic reporting will improve completeness of the final report in a manner that is clear, succinct, and consistent among institutions.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | - Nicole E Thomas
- From the Department of Hematopathology, Pathology Associates of Albuquerque, Albuquerque, New Mexico (Dr Sever); the Department of Pathology, Berkshire Medical Center, Pittsfield, Massachusetts (Dr Abbott); Medical Laboratory Associates, Seattle, Washington (Dr de Baca); the Department of Pathology, University of Texas MD Anderson Cancer Center, Houston (Dr Khoury); the Department of Pathology, University of Utah, Salt Lake City (Dr Perkins); the Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota (Dr Reichard); Utah Pathology Services, Inc, Salt Lake City (Dr Taylor); the Department of Hematology/Medical Oncology, Newland Medical Associates, Novi, Michigan (Dr Terebelo); the Departments of Governance (Ms Colasacco) and Surveys (Ms Thomas), College of American Pathologists, Northfield, Illinois; and the Quality and Guidelines Department, American Society of Clinical Oncology, Alexandria, Virginia (Mr Rumble)
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Pozdnyakova O, Hasserjian RP, Verstovsek S, Orazi A. Impact of bone marrow pathology on the clinical management of Philadelphia chromosome-negative myeloproliferative neoplasms. CLINICAL LYMPHOMA, MYELOMA & LEUKEMIA 2015; 15:253-61. [PMID: 25515354 DOI: 10.1016/j.clml.2014.11.002] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/16/2014] [Accepted: 11/12/2014] [Indexed: 02/03/2023]
Abstract
Philadelphia chromosome-negative myeloproliferative neoplasms include primary myelofibrosis (PMF), polycythemia vera (PV), and essential thrombocythemia (ET). Although these 3 entities share many pathogenic characteristics, such as dysregulated Janus kinase (JAK)/signal transducer and activator of transcription signaling, they differ substantially regarding prognosis, progression to myelofibrosis (MF), risk of leukemic transformation, and specific medical needs. Accurate diagnosis and classification of myeloproliferative neoplasms are prerequisites for appropriate risk-based therapy and should be based on an integrated approach following the World Health Organization guidelines that, in addition to clinical, molecular, and cytogenetic evaluation, includes the examination of bone marrow morphology. Reticulin fibrosis at presentation in ET and PV is associated with increased risk of myelofibrotic transformation, and higher fibrosis grade in patients with MF is associated with worse prognosis. Additional assessment of collagen deposition and osteosclerosis may further increase diagnostic and prognostic precision. Moreover, the evaluation of bone marrow pathology has become very important in the new era of disease-modifying agents. In randomized controlled phase 3 studies, the JAK1/JAK2 inhibitor ruxolitinib provided rapid and lasting improvement in MF-related splenomegaly and symptom burden as well as a survival advantage compared with placebo or best available therapy. Follow-up for up to 5 years of patients who participated in a phase 1/2 study of ruxolitinib, revealed stabilization or reversal of bone marrow fibrosis in a proportion of patients with MF. Combinations of JAK inhibitors with other therapies, including agents with antifibrotic and/or anti-inflammatory properties, may possibly decrease bone marrow fibrosis further and favorably influence clinical outcomes.
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Affiliation(s)
| | | | | | - Attilio Orazi
- Weill Medical College of Cornell University, New York, NY.
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Vannucchi AM, Guglielmelli P, Pieri L, Antonioli E, Bosi A. Treatment options for essential thrombocythemia and polycythemia vera. Expert Rev Hematol 2014; 2:41-55. [DOI: 10.1586/17474086.2.1.41] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
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13
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Abstract
INTRODUCTION Two factors have deeply influenced the area of essential thrombocythemia (ET). A gain-of-function mutation in the pseudokinase region of the JAK2 gene, which partly explains the pathophysiology of myeloproliferative neoplasms (MPNs), was discovered in 2005 and is present in 50 - 60% of ET patients. Furthermore, the 2008 WHO MPN classification outlined criteria for the separation of ET and early or prefibrotic primary myelofibrosis (PMF). However, these and other new findings have not yet changed the pharmacotherapy of ET, which is based on risk stratification for thrombohemorrhagic risk and aims to reduce thrombosis and bleeding. AREAS COVERED Studies on the basis for and the validation of the WHO classification as well as studies on possible new risk factors are covered. The most important drugs for ET treatment and consensus recommendations for management of ET are also presented. EXPERT OPINION The new WHO classification should be used for both ET studies and clinical practice, since true ET has a different prognosis than early PMF. The management of patients should be based on risk stratification. Age > 60 years or previous throbosis (high risk) and platelet counts > 1500 × 10(9)/l warrant cytoreductive treatment, and high risk patients and selected low risk patients should be given anti-aggregation therapy.
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Affiliation(s)
- Gunnar Birgegård
- Uppsala University Hospital, Department of Haematology, 75185 Uppsala, Sweden.
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14
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Ejerblad E, Kvasnicka HM, Thiele J, Andreasson B, Björkholm M, Löfvenberg E, Markevärn B, Merup M, Nilssson L, Palmblad J, Samuelsson J, Birgegård G. Diagnosis according to World Health Organization determines the long-term prognosis in patients with myeloproliferative neoplasms treated with anagrelide: results of a prospective long-term follow-up. ACTA ACUST UNITED AC 2012; 18:8-13. [PMID: 22990042 DOI: 10.1179/1607845412y.0000000023] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
OBJECTIVES During long term follow-up of a cohort of patients with essential thrombocythemia (ET) and polycythemia vera (PV) a higher than expected incidence of myelofibrosis (MF) was noted. In order to test if the explanation could be found in the diagnostic criteria a re-evaluation of diagnosis using the 2008 WHO diagnostic criteria for ET and MF was performed. METHODS This prospective study of 60 patients with ET and PV was set up in 1998 to evaluate the long-term efficacy and tolerability of anagrelide treatment. Bone marrow trephine biopsies were requested from study start, after 2 and 7 years of follow-up. A blinded re-evaluation of the bone marrow trephines was performed. The 2008 WHO bone marrow criteria were used for diagnosis and fibrosis grading. RESULTS Of 40 patients with an initial diagnosis of ET, 21 were confirmed as 'true ET' whereas 17 were reclassified as primary myelofibrosis (PMF) (12 PMF-0, 3 PMF-1, 2 PMF-2) and 2 as myeloproliferative neoplasms of uncertain origin. After 7 years of follow-up, 19 of 21 patients with 'true ET' were alive, none had transformed to MF, leukemia, or myelodysplastic syndrome. In contrast, 4/17 patients reclassified as PMF had died, two patients transformed to myelodysplastic syndrome and 7 patients progressed to overt MF. DISCUSSION We conclude that a blinded re-evaluation of bone marrow trephines from study start and after 7 years of follow-up using 2008 World Health Organization criteria was able to differentiate between true ET and PMF with a marked difference in follow-up outcome.
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Reilly JT, McMullin MF, Beer PA, Butt N, Conneally E, Duncombe A, Green AR, Michaeel NG, Gilleece MH, Hall GW, Knapper S, Mead A, Mesa RA, Sekhar M, Wilkins B, Harrison CN. Guideline for the diagnosis and management of myelofibrosis. Br J Haematol 2012; 158:453-71. [DOI: 10.1111/j.1365-2141.2012.09179.x] [Citation(s) in RCA: 83] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2012] [Accepted: 05/02/2012] [Indexed: 01/09/2023]
Affiliation(s)
- John T. Reilly
- Sheffield Teaching Hospitals NHS Foundation Trust; Sheffield; UK
| | | | - Philip A. Beer
- Terry Fox Laboratory; BC Cancer Agency; Vancouver; BC; Canada
| | - Nauman Butt
- Wirral University Teaching Hospital; Wirral; UK
| | | | - Andrew Duncombe
- University Hospital Southampton NHS Foundation Trust; Southampton; UK
| | | | | | | | | | | | - Adam Mead
- Oxford University Hospitals NHS Trust; Oxford; UK
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Abstract
Since the discovery of mutant Janus Kinase 2 (JAK2), JAK2 V617F, in a major proportion of myeloproliferative neoplasm (MPN) patients, there has been a flurry of activity in the development of JAK2 inhibitors. Pan-JAK, predominantly JAK2 and off-target JAK2 inhibitors have been developed in the short span of the past 5 years. These compounds have since been tested to varying success in both in vitro and in vivo settings with several proceeding on to advanced clinical trials. Although it was hoped that these inhibitors would be the silver bullet in the manner than imatinib was to chronic myeloid leukemia, it is becoming apparent that this is not the case for various reasons, chief of which is that a significant reduction of the underlying pathogenic clone is not achieved. In fact, the very notion that the target of JAK2 inhibitors (be it pan-JAK or JAK2 specific) is the mutant JAK2 V617F is being challenged with findings from several clinical trials showing a poor correlation between the reduction in JAK2 V617F mutant allele burden and clinical response. In view of this, it is not surprising that several groups are now investigating combinations of JAK2 inhibitors and other agents in MPN. Although much knowledge has been added in this short span of time, it is apparent that our understanding of the role of JAK2 inhibitors in the treatment scheme of MPN is only beginning.
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Affiliation(s)
- Daniel Chan
- Department of Hematology—Oncology, National University Hospital, Singapore and Hematology/Oncology, Cedars-Sinai Medical Center, Los Angeles CA, USA
| | - Maya Koren-Michowitz
- Department of Hematology—Oncology, National University Hospital, Singapore and Hematology/Oncology, Cedars-Sinai Medical Center, Los Angeles CA, USA
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Harrison CN, Bareford D, Butt N, Campbell P, Conneally E, Drummond M, Erber W, Everington T, Green AR, Hall GW, Hunt BJ, Ludlam CA, Murrin R, Nelson-Piercy C, Radia DH, Reilly JT, Van der Walt J, Wilkins B, McMullin MF. Guideline for investigation and management of adults and children presenting with a thrombocytosis. Br J Haematol 2010; 149:352-75. [PMID: 20331456 DOI: 10.1111/j.1365-2141.2010.08122.x] [Citation(s) in RCA: 194] [Impact Index Per Article: 13.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
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Bone marrow hyaluronan and reticulin in patients with malignant disorders. Med Oncol 2009; 27:618-23. [DOI: 10.1007/s12032-009-9257-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2009] [Accepted: 06/08/2009] [Indexed: 11/25/2022]
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Campbell PJ, Bareford D, Erber WN, Wilkins BS, Wright P, Buck G, Wheatley K, Harrison CN, Green AR. Reticulin accumulation in essential thrombocythemia: prognostic significance and relationship to therapy. J Clin Oncol 2009; 27:2991-9. [PMID: 19364963 PMCID: PMC3398138 DOI: 10.1200/jco.2008.20.3174] [Citation(s) in RCA: 89] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE Essential thrombocythemia (ET) manifests substantial interpatient heterogeneity in rates of thrombosis, hemorrhage, and disease transformation. Bone marrow histology reflects underlying disease activity in ET but many morphological features show poor reproducibility. PATIENTS AND METHODS We evaluated the clinical significance of bone marrow reticulin, a measure previously shown to have relatively high interobserver reliability, in a large, prospectively-studied cohort of ET patients. RESULTS Reticulin grade positively correlated with white blood cell (P = .05) and platelet counts (P = .0001) at diagnosis. Elevated reticulin levels at presentation predicted higher rates of arterial thrombosis (hazard ratio [HR], 1.8; 95% CI, 1.1 to 2.9; P = .01), major hemorrhage (HR, 2.0; 95% CI, 1.0 to 3.9; P = .05), and myelofibrotic transformation (HR, 5.5; 95% CI, 1.7 to 18.4; P = .0007) independently of known risk factors. Higher reticulin levels at diagnosis were associated with greater subsequent falls in hemoglobin levels in patients treated with anagrelide (P < .0001), but not in those receiving hydroxyurea (P = .9). Moreover, serial trephine specimens in patients randomly assigned to anagrelide showed significantly greater increases in reticulin grade compared with those allocated to hydroxyurea (P = .0003), and four patients who developed increased bone marrow reticulin on anagrelide showed regression of fibrosis when switched to hydroxyurea. These data suggest that patients receiving anagrelide therapy should undergo surveillance bone marrow biopsy every 2 to 3 years and that those who show substantially increasing reticulin levels are at risk of myelofibrotic transformation and may benefit from changing therapy before adverse clinical features develop. CONCLUSION Our results demonstrate that bone marrow reticulin grade at diagnosis represents an independent prognostic marker in ET, reflecting activity and/or duration of disease, with implications for the monitoring of patients receiving anagrelide.
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Affiliation(s)
- Peter J Campbell
- Department of Haematology, Cambridge Institute for Medical Research, University of Cambridge, Cambridge, UK
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