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Oh ST, Verstovsek S, Gupta V, Platzbecker U, Devos T, Kiladjian J, McLornan DP, Perkins A, Fox ML, McMullin MF, Mead AJ, Egyed M, Mayer J, Sacha T, Kawashima J, Huang M, Strouse B, Mesa R. Changes in bone marrow fibrosis during momelotinib or ruxolitinib therapy do not correlate with efficacy outcomes in patients with myelofibrosis. EJHAEM 2024; 5:105-116. [PMID: 38406514 PMCID: PMC10887367 DOI: 10.1002/jha2.854] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 12/18/2023] [Accepted: 12/19/2023] [Indexed: 02/27/2024]
Abstract
Bone marrow fibrosis (BMF) is a pathological feature of myelofibrosis, with higher grades associated with poor prognosis. Limited data exist on the association between outcomes and BMF changes. We present BMF data from Janus kinase (JAK) inhibitor-naive patients from SIMPLIFY-1 (NCT01969838), a double-blind, randomized, phase 3 study of momelotinib vs ruxolitinib. Baseline and week 24 bone marrow biopsies were graded from 0 to 3 as per World Health Organization criteria. Other assessments included Total Symptom Score, spleen volume, transfusion independence status, and hemoglobin levels. Paired samples were available from 144 and 160 patients randomized to momelotinib and ruxolitinib. With momelotinib and ruxolitinib, transfusion independence was achieved by 87% and 44% of patients with BMF improvement of ≥1 grade and 76% and 56% of those with stable/worsening BMF; there was no association between BMF changes and transfusion independence for either arm (momelotinib, p = .350; ruxolitinib, p = .096). Regardless of BMF changes, hemoglobin levels also generally increased on momelotinib but decreased on ruxolitinib. In addition, no associations between BMF changes and spleen (momelotinib, p = .126; ruxolitinib, p = .407)/symptom (momelotinib, p = .617; ruxolitinib, p = .833) outcomes were noted, and no improvement in overall survival was observed with ≥1-grade BMF improvement (momelotinib, p = .395; ruxolitinib, p = .407). These data suggest that the anemia benefit of momelotinib is not linked to BMF changes, and question the use of BMF assessment as a surrogate marker for clinical benefit with JAK inhibitors.
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Affiliation(s)
- Stephen T. Oh
- Division of HematologyWashington University School of MedicineSt. LouisMissouriUSA
| | - Srdan Verstovsek
- Department of LeukemiaThe University of Texas MD Anderson Cancer CenterHoustonTexasUSA
| | - Vikas Gupta
- Department of Medicine, Princess Margaret Cancer CentreUniversity of TorontoTorontoCanada
| | - Uwe Platzbecker
- Clinic of Hematology, Cellular Therapy, and HemostaseologyUniversity of Leipzig Medical CenterLeipzigGermany
| | - Timothy Devos
- Microbiology, and Immunology, Laboratory of Molecular Immunology (Rega Institute)Department of Hematology, University Hospitals Leuven and Department of Microbiology and Immunology, Laboratory of Molecular Immunology (Rega Institute), KU LeuvenLeuvenBelgium
| | - Jean‐Jacques Kiladjian
- Université Paris Cité, AP‐HP, Hôpital Saint‐Louis, Centre d’Investigations CliniquesParisFrance
| | - Donal P. McLornan
- Department of HaematologyGuy's and St Thomas’ NHS Foundation Trust and University College HospitalLondonUK
| | - Andrew Perkins
- Australian Centre for Blood DiseasesMonash UniversityMelbourneAustralia
| | - Maria Laura Fox
- Department of HaematologyVall d'Hebron University HospitalBarcelonaSpain
| | | | - Adam J. Mead
- MRC Molecular Haematology UnitMRC Weatherall Institute of Molecular MedicineNIHR Biomedical Research CentreUniversity of OxfordOxfordUK
| | - Miklos Egyed
- Department of HematologySomogy County Kaposi Mór General HospitalKaposvárHungary
| | - Jiri Mayer
- Department of Internal Medicine, Hematology and OncologyMasaryk University and University Hospital BrnoBrnoCzech Republic
| | - Tomasz Sacha
- Department of HematologyJagiellonian University HospitalKrakówPoland
| | - Jun Kawashima
- Sierra Oncology, a GSK companySan MateoCaliforniaUSA
| | - Mei Huang
- Sierra Oncology, a GSK companySan MateoCaliforniaUSA
| | - Bryan Strouse
- Sierra Oncology, a GSK companySan MateoCaliforniaUSA
| | - Ruben Mesa
- Atrium Health Wake Forest Baptist Comprehensive Cancer CenterWake Forest University School of MedicineWinston‐SalemNorth CarolinaUSA
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Verstovsek S, Foltz L, Gupta V, Hasserjian R, Manshouri T, Mascarenhas J, Mesa R, Pozdnyakova O, Ritchie E, Veletic I, Gamel K, Hamidi H, Han L, Higgins B, Trunzer K, Uguen M, Wang D, El-Galaly TC, Todorov B, Gotlib J. Safety and efficacy of zinpentraxin alfa as monotherapy or in combination with ruxolitinib in myelofibrosis: stage I of a phase II trial. Haematologica 2023; 108:2730-2742. [PMID: 37165840 PMCID: PMC10543197 DOI: 10.3324/haematol.2022.282411] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2022] [Accepted: 05/03/2023] [Indexed: 05/12/2023] Open
Abstract
Pentraxin 2 (PTX-2; serum amyloid P component), a circulating endogenous regulator of the inflammatory response to tissue injury and fibrosis, is reduced in patients with myelofibrosis (MF). Zinpentraxin alfa (RO7490677, PRM-151) is a recombinant form of PTX-2 that has shown preclinical antifibrotic activity and no dose-limiting toxicities in phase I trials. We report results from stage 1 of a phase II trial of zinpentraxin alfa in patients with intermediate-1/2 or high-risk MF. Patients (n=27) received intravenous zinpentraxin α weekly (QW) or every 4 weeks (Q4W), as monotherapy or an additional therapy for patients on stable-dose ruxolitinib. The primary endpoint was overall response rate (ORR; investigatorassessed) adapted from International Working Group-Myeloproliferative Neoplasms Research and Treatment criteria. Secondary endpoints included modified Myeloproliferative Neoplasm-Symptom Assessment Form Total Symptom Score (MPN-SAF TSS) change, bone marrow (BM) MF grade reduction, pharmacokinetics, and safety. ORR at week 24 was 33% (n=9/27) and varied across individual cohorts (QW: 38% [3/8]; Q4W: 14% [1/7]; QW+ruxolitinib: 33% [2/6]; Q4W+ruxolitinib: 50% [3/6]). Five of 18 evaluable patients (28%) experienced a ≥50% reduction in MPN-SAF TSS, and six of 17 evaluable patients (35%) had a ≥1 grade improvement from baseline in BM fibrosis at week 24. Most treatment-emergent adverse events (AE) were grade 1-2, most commonly fatigue. Among others, anemia and thrombocytopenia were infrequent (n=3 and n=1, respectively). Treatment-related serious AE occurred in four patients (15%). Overall, zinpentraxin alfa showed evidence of clinical activity and tolerable safety as monotherapy and in combination with ruxolitinib in this open-label, non-randomized trial (clinicaltrials gov. Identifier: NCT01981850).
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Affiliation(s)
- Srdan Verstovsek
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX.
| | - Lynda Foltz
- St Paul's Hospital, University of British Columbia, Vancouver
| | - Vikas Gupta
- Princess Margaret Cancer Centre, University of Toronto, Toronto
| | | | - Taghi Manshouri
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - John Mascarenhas
- Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Ruben Mesa
- Mays Cancer Center at UT Health San Antonio MD Anderson, San Antonio, TX
| | - Olga Pozdnyakova
- Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | | | - Ivo Veletic
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX
| | | | | | | | | | | | | | - Dao Wang
- F. Hoffmann-La Roche, Ltd., Basel
| | - Tarec Christoffer El-Galaly
- F. Hoffmann-La Roche, Ltd., Basel, Switzerland; Current affiliation: Department of Hematology, Aalborg University Hospital, Aalborg
| | | | - Jason Gotlib
- Stanford Cancer Institute/Stanford University School of Medicine, Stanford, CA
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Ryou H, Sirinukunwattana K, Aberdeen A, Grindstaff G, Stolz BJ, Byrne H, Harrington HA, Sousos N, Godfrey AL, Harrison CN, Psaila B, Mead AJ, Rees G, Turner GDH, Rittscher J, Royston D. Continuous Indexing of Fibrosis (CIF): improving the assessment and classification of MPN patients. Leukemia 2023; 37:348-358. [PMID: 36470992 PMCID: PMC9898027 DOI: 10.1038/s41375-022-01773-0] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2022] [Revised: 11/17/2022] [Accepted: 11/21/2022] [Indexed: 12/09/2022]
Abstract
The grading of fibrosis in myeloproliferative neoplasms (MPN) is an important component of disease classification, prognostication and monitoring. However, current fibrosis grading systems are only semi-quantitative and fail to fully capture sample heterogeneity. To improve the quantitation of reticulin fibrosis, we developed a machine learning approach using bone marrow trephine (BMT) samples (n = 107) from patients diagnosed with MPN or a reactive marrow. The resulting Continuous Indexing of Fibrosis (CIF) enhances the detection and monitoring of fibrosis within BMTs, and aids MPN subtyping. When combined with megakaryocyte feature analysis, CIF discriminates between the frequently challenging differential diagnosis of essential thrombocythemia (ET) and pre-fibrotic myelofibrosis with high predictive accuracy [area under the curve = 0.94]. CIF also shows promise in the identification of MPN patients at risk of disease progression; analysis of samples from 35 patients diagnosed with ET and enrolled in the Primary Thrombocythemia-1 trial identified features predictive of post-ET myelofibrosis (area under the curve = 0.77). In addition to these clinical applications, automated analysis of fibrosis has clear potential to further refine disease classification boundaries and inform future studies of the micro-environmental factors driving disease initiation and progression in MPN and other stem cell disorders.
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Affiliation(s)
- Hosuk Ryou
- Nuffield Division of Clinical Laboratory Sciences, Radcliffe Department of Medicine, University of Oxford, Oxford, UK
| | - Korsuk Sirinukunwattana
- Institute of Biomedical Engineering (IBME), Department of Engineering Science, University of Oxford, Oxford, UK
- Big Data Institute/Li Ka Shing Centre for Health Information and Discovery, University of Oxford, Oxford, UK
- Ground Truth Labs, Oxford, UK
- Oxford NIHR Biomedical Research Centre, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | | | - Gillian Grindstaff
- Department of Mathematics, University of California, Los Angeles, CA, USA
| | - Bernadette J Stolz
- Mathematical Institute, University of Oxford, Oxford, UK
- Laboratory for Topology and Neuroscience, École Polytechnique Fédérale de Lausanne, Lausanne, Switzerland
| | - Helen Byrne
- Mathematical Institute, University of Oxford, Oxford, UK
- Ludwig Institute for Cancer Research, University of Oxford, Oxford, UK
| | - Heather A Harrington
- Mathematical Institute, University of Oxford, Oxford, UK
- Wellcome Centre for Human Genetics, University of Oxford, Oxford, UK
| | - Nikolaos Sousos
- Oxford NIHR Biomedical Research Centre, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
- Department of Haematology, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
- MRC Weatherall Institute of Molecular Medicine, Radcliffe Department of Medicine, University of Oxford, Oxford, UK
| | - Anna L Godfrey
- Haematopathology & Oncology Diagnostics Service, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Claire N Harrison
- Department of Haematology, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Bethan Psaila
- Oxford NIHR Biomedical Research Centre, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
- Department of Haematology, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
- MRC Weatherall Institute of Molecular Medicine, Radcliffe Department of Medicine, University of Oxford, Oxford, UK
| | - Adam J Mead
- Oxford NIHR Biomedical Research Centre, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
- Department of Haematology, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
- MRC Weatherall Institute of Molecular Medicine, Radcliffe Department of Medicine, University of Oxford, Oxford, UK
| | - Gabrielle Rees
- Department of Pathology, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Gareth D H Turner
- Department of Pathology, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Jens Rittscher
- Institute of Biomedical Engineering (IBME), Department of Engineering Science, University of Oxford, Oxford, UK
- Big Data Institute/Li Ka Shing Centre for Health Information and Discovery, University of Oxford, Oxford, UK
- Ground Truth Labs, Oxford, UK
- Oxford NIHR Biomedical Research Centre, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
- Ludwig Institute for Cancer Research, University of Oxford, Oxford, UK
| | - Daniel Royston
- Nuffield Division of Clinical Laboratory Sciences, Radcliffe Department of Medicine, University of Oxford, Oxford, UK.
- Department of Pathology, Oxford University Hospitals NHS Foundation Trust, Oxford, UK.
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Thiele J, Kvasnicka HM, Orazi A, Gianelli U, Gangat N, Vannucchi AM, Barbui T, Arber DA, Tefferi A. The international consensus classification of myeloid neoplasms and acute Leukemias: myeloproliferative neoplasms. Am J Hematol 2023; 98:166-179. [PMID: 36200127 DOI: 10.1002/ajh.26751] [Citation(s) in RCA: 23] [Impact Index Per Article: 23.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2022] [Revised: 09/30/2022] [Accepted: 10/02/2022] [Indexed: 02/04/2023]
Abstract
A group of international experts, including hematopathologists, oncologists, and geneticists were recently summoned (September 2021, Chicago, IL, USA) to update the 2016/17 World Health Organization classification system for hematopoietic tumors. After careful deliberation, the group introduced the new International Consensus Classification (ICC) for Myeloid Neoplasms and Acute Leukemias. This current in-depth review focuses on the ICC-2022 category of JAK2 mutation-prevalent myeloproliferative neoplasms (MPNs): essential thrombocythemia, polycythemia vera, primary myelofibrosis, and MPN, unclassifiable. The ICC MPN subcommittee chose to preserve the primary role of bone marrow morphology in disease classification and diagnostics, while also acknowledging the complementary role of genetic markers for establishing clonality, facilitating MPN subtype designation, and disease prognostication.
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Affiliation(s)
- Jürgen Thiele
- Institute of Pathology, University of Cologne, Cologne, Germany
| | | | - Attilio Orazi
- Department of Pathology, Texas Tech University Health Sciences Center, El Paso, Texas, USA
| | - Umberto Gianelli
- Department of Health Sciences and S.C. Anatomia Patologica, ASST Santi Paolo e Carlo, University of Milan, Milan, Italy
| | - Naseema Gangat
- Division of Hematology, Department of Internal Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Alessandro M Vannucchi
- CRIMM-Centro Ricerca e Innovazione delle Malattie Mieloproliferative, Azienda Ospedaliera-Universitaria Careggi, Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
| | - Tiziano Barbui
- FROM Research Foundation, Papa Giovanni XXIII Hospital, Bergamo, Italy
| | - Daniel A Arber
- Department of Pathology, University of Chicago, Chicago, Illinois, USA
| | - Ayalew Tefferi
- Division of Hematology, Department of Internal Medicine, Mayo Clinic, Rochester, Minnesota, USA
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Manshouri T, Veletic I, Li P, Yin CC, Post SM, Verstovsek S, Estrov Z. GLI1 activates pro-fibrotic pathways in myelofibrosis fibrocytes. Cell Death Dis 2022; 13:481. [PMID: 35595725 PMCID: PMC9122946 DOI: 10.1038/s41419-022-04932-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2021] [Revised: 05/05/2022] [Accepted: 05/09/2022] [Indexed: 12/14/2022]
Abstract
Bone marrow (BM) fibrosis was thought to be induced exclusively by mesenchymal stromal cells (MSCs). However, we and others found that neoplastic fibrocytes induce BM fibrosis in myelofibrosis (MF). Because glioma-associated oncogene-1 (GLI1), an effector of the Hedgehog pathway, plays a role in the induction of BM fibrosis, we wondered whether GLI1 affects fibrocyte-induced BM fibrosis in MF. Multiplexed fluorescence immunohistochemistry analysis of MF patients' BM detected high levels of GLI1 in MF fibrocytes compared to MSCs or normal fibrocytes. Immunostaining, RNA in situ hybridization, gene expression analysis, and western immunoblotting detected high levels of GLI1 and GLI1-induced matrix metalloproteases (MMP) 2 and 9 in MF patients BM-derived cultured fibrocytes. Similarly, MF patients' BM-derived GLI1+ fibrocytes were found in BMs and spleens of MF xenograft mice. GLI1 silencing reduced the levels of MMP2/9, phosphorylated SMAD2/3, and procollagen-I, and knockdown or inhibition of GLI1 decreased fibrocyte formation and induced apoptosis of both fibrocytes and fibrocyte progenitors. Because Janus kinase (JAK)2-induced STAT3 is constitutively activated in MF and because STAT3 induces GLI1 expression, we sought to determine whether STAT3 activates GLI1 in MF fibrocytes. Imaging analysis detected phosphotyrosine STAT3 in MF patients' BM fibrocytes, and transfection of fibrocytes with STAT3-siRNA or treatment with a JAK1/2 inhibitor ruxolitinib reduced GLI1 and MMP2/9 levels. Chromatin immunoprecipitation and a luciferase assay revealed that STAT3 induced the expression of the GLI1 gene in both MF BM fibrocytes and fibrocyte progenitors. Together, our data suggest that STAT3-activated GLI1 contributes to the induction of BM fibrosis in MF.
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Affiliation(s)
- Taghi Manshouri
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Ivo Veletic
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Ping Li
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - C Cameron Yin
- Department of Hematopathology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Sean M Post
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Srdan Verstovsek
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Zeev Estrov
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA.
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6
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Coltro G, Loscocco GG, Vannucchi AM. Classical Philadelphia-negative myeloproliferative neoplasms (MPNs): A continuum of different disease entities. INTERNATIONAL REVIEW OF CELL AND MOLECULAR BIOLOGY 2021; 365:1-69. [PMID: 34756241 DOI: 10.1016/bs.ircmb.2021.09.001] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Classical Philadelphia-negative myeloproliferative neoplasms (MPNs) are clonal hematopoietic stem cell-derived disorders characterized by uncontrolled proliferation of differentiated myeloid cells and close pathobiologic and clinical features. According to the 2016 World Health Organization (WHO) classification, MPNs include polycythemia vera (PV), essential thrombocythemia (ET), and primary myelofibrosis (PMF). The 2016 revision aimed in particular at strengthening the distinction between masked PV and JAK2-mutated ET, and between prefibrotic/early (pre-PMF) and overt PMF. Clinical manifestations in MPNs include constitutional symptoms, microvascular disorders, thrombosis and bleeding, splenomegaly secondary to extramedullary hematopoiesis, cytopenia-related symptoms, and progression to overt MF and acute leukemia. A dysregulation of the JAK/STAT pathway is the unifying mechanistic hallmark of MPNs, and is guided by somatic mutations in driver genes including JAK2, CALR and MPL. Additional mutations in myeloid neoplasm-associated genes have been also identified, with established prognostic relevance, particularly in PMF. Prognostication of MPN patients relies on disease-specific clinical models. The increasing knowledge of MPN biology led to the development of integrated clinical and molecular prognostic scores that allow a more refined stratification. Recently, the therapeutic landscape of MPNs has been revolutionized by the introduction of potent, selective JAK inhibitors (ruxolitinib, fedratinib), that proved effective in controlling disease-related symptoms and splenomegaly, yet leaving unmet critical needs, owing the lack of disease-modifying activity. In this review, we will deal with molecular, clinical, and therapeutic aspects of the three classical MPNs aiming at highlighting either shared characteristics, that overall define a continuum within a single disease family, and uniqueness, at the same time.
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Affiliation(s)
- Giacomo Coltro
- CRIMM, Center for Research and Innovation of Myeloproliferative Neoplasms, AOU Careggi, Florence, Italy; Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
| | - Giuseppe G Loscocco
- CRIMM, Center for Research and Innovation of Myeloproliferative Neoplasms, AOU Careggi, Florence, Italy; Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
| | - Alessandro M Vannucchi
- CRIMM, Center for Research and Innovation of Myeloproliferative Neoplasms, AOU Careggi, Florence, Italy; Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy.
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7
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Insufficiency of non-canonical PRC1 synergizes with JAK2V617F in the development of myelofibrosis. Leukemia 2021; 36:452-463. [PMID: 34497325 DOI: 10.1038/s41375-021-01402-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2021] [Revised: 08/19/2021] [Accepted: 08/26/2021] [Indexed: 12/22/2022]
Abstract
Insufficiency of polycomb repressive complex 2 (PRC2), which trimethylates histone H3 at lysine 27, is frequently found in primary myelofibrosis and promotes the development of JAK2V617F-induced myelofibrosis in mice by enhancing the production of dysplastic megakaryocytes. Polycomb group ring finger protein 1 (Pcgf1) is a component of PRC1.1, a non-canonical PRC1 that monoubiquitylates H2A at lysine 119 (H2AK119ub1). We herein investigated the impact of PRC1.1 insufficiency on myelofibrosis. The deletion of Pcgf1 in JAK2V617F mice strongly promoted the development of lethal myelofibrosis accompanied by a block in erythroid differentiation. Transcriptome and chromatin immunoprecipitation sequence analyses showed the de-repression of PRC1.1 target genes in Pcgf1-deficient JAK2V617F hematopoietic progenitors and revealed Hoxa cluster genes as direct targets. The deletion of Pcgf1 in JAK2V617F hematopoietic stem and progenitor cells (HSPCs), as well as the overexpression of Hoxa9, restored the attenuated proliferation of JAK2V617F progenitors. The overexpression of Hoxa9 also enhanced JAK2V617F-mediated myelofibrosis. The expression of PRC2 target genes identified in PRC2-insufficient JAK2V617F HSPCs was not largely altered in Pcgf1-deleted JAK2V617F HSPCs. The present results revealed a tumor suppressor function for PRC1.1 in myelofibrosis and suggest that PRC1.1 insufficiency has a different impact from that of PRC2 insufficiency on the pathogenesis of myelofibrosis.
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8
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Lee SS, Verstovsek S, Pemmaraju N. Novel Therapies in Myeloproliferative Neoplasms: Beyond JAK Inhibitor Monotherapy. JOURNAL OF IMMUNOTHERAPY AND PRECISION ONCOLOGY 2021; 4:117-128. [PMID: 35663101 PMCID: PMC9138435 DOI: 10.36401/jipo-20-35] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/14/2020] [Revised: 02/24/2021] [Accepted: 04/16/2021] [Indexed: 06/15/2023]
Abstract
Myeloproliferative neoplasms (MPNs) are clonal hematopoietic disorders that consist classically of polycythemia vera (PV), essential thrombocythemia (ET), and myelofibrosis (MF). Janus kinase (JAK) inhibitors have become the standard of therapy in treating patients with intermediate- to higher-risk MF. However, JAK inhibitor (JAKi) treatment can be associated with development of resistance, suboptimal response, relapse, or treatment-related adverse effects. With no approved therapies beyond the JAKi class, the estimated median survival, post JAKi failure, is approximately two years or less; therefore, novel therapies are urgently needed in the MF field. In this review, we discuss ruxolitinib use in MPNs as well as causes of ruxolitinib failure or discontinuation. In addition, we review novel therapies being investigated alone or in combination with JAKi administration. We summarize concepts and mechanisms behind emerging novel therapies being studied for MPNs. This review of emerging novel therapies outlines several novel mechanisms of agents, including via promotion of apoptosis, alteration of the microenvironment, activation or inactivation of various pathways, targeting fibrosis, and telomerase inhibition.
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Affiliation(s)
- Sophia S. Lee
- Department of Internal Medicine, The University of Texas School of Health Sciences at Houston, Houston, TX, USA
| | - Srdan Verstovsek
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Naveen Pemmaraju
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
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9
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Genthon A, Killian M, Mertz P, Cathebras P, Gimenez De Mestral S, Guyotat D, Chalayer E. [Myelofibrosis: A review]. Rev Med Interne 2020; 42:101-109. [PMID: 33243417 DOI: 10.1016/j.revmed.2020.08.018] [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: 01/19/2020] [Revised: 08/28/2020] [Accepted: 08/30/2020] [Indexed: 11/28/2022]
Abstract
Myelofibrosis is a BCR-ABL1-negative chronic myeloproliferative neoplasm that includes primary myelofibrosis, post-polycythemia vera myelofibrosis, and post-essential thrombocythemia myelofibrosis. It is characterized by stem cell-derived clonal proliferation that is often, but not always, accompanied by somatic mutations, which are classified into driver mutations (JAK2, CALR, or MPL), subclonal mutations and fibrosis on bone marrow biopsy. Myelofibrosis commonly demonstrates splenomegaly, constitutional symptoms, anemia, thrombocytosis, or thrombocytopenia. Patients may also be asymptomatic. Complications as thromboembolic or hemorrhagic events can reveal the disease. Primary myelofibrosis is the least common myeloproliferative neoplasm but is associated with poor survival and acute leukemic transformation. In contrast to the significant progress made in understanding the disease's pathogenesis, treatment for myelofibrosis remains largely palliative. The JAK2 inhibitor, ruxolitinib is not sufficient in eliminating the underlying myeloid progenitor clone, as disease inevitably returns with therapy discontinuation. Allogeneic hematopoietic stem cell transplantation is the only therapeutic option that offers potential cure. The development of novel treatment strategies aimed at slowing or even reversing disease progression, prolonging patient survival and preventing evolution to blast-phase are still lacking.
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Affiliation(s)
- A Genthon
- Service d'hématologie clinique et de thérapie cellulaire, hôpital Saint-Antoine, AP-HP, Paris, France; Médecine Sorbonne université, Paris, France
| | - M Killian
- Service de médecine interne, hôpital Nord, CHU de Saint-Étienne, 42055 Saint-Étienne cedex 02, France
| | - P Mertz
- Service de rhumatologie, hôpitaux universitaires de Strasbourg, Strasbourg, France; Inserm UMR_S1109, laboratoire d'immunorhumatologie moléculaire, Centre national de référence des maladies systémiques et autoimmunes rares Est Sud-Ouest (RESO), université de Strasbourg, 67000 Strasbourg, France
| | - P Cathebras
- Service de médecine interne, hôpital Nord, CHU de Saint-Étienne, 42055 Saint-Étienne cedex 02, France
| | - S Gimenez De Mestral
- Pathology department, Sorbonne université, hôpital Saint-Antoine, AP-HP, 75012 Paris, France
| | - D Guyotat
- Département d'hématologie et thérapie cellulaire, institut de cancérologie Lucien-Neuwirth, Saint-Étienne, France
| | - E Chalayer
- Département d'hématologie et thérapie cellulaire, institut de cancérologie Lucien-Neuwirth, Saint-Étienne, France; Inserm, SAINBIOSE, U1059, dysfonction vasculaire et hémostase, université Jean-Monnet, Saint-Étienne, France.
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Kimawaha P, Jusakul A, Junsawang P, Loilome W, Khuntikeo N, Techasen A. Circulating TGF-β1 as the potential epithelial mesenchymal transition-biomarker for diagnosis of cholangiocarcinoma. J Gastrointest Oncol 2020; 11:304-318. [PMID: 32399272 DOI: 10.21037/jgo.2019.01.03] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
Background Cholangiocarcinoma (CCA) is a malignant tumor arising from bile duct epithelium. The oncogenic risk factor is infection by the liver fluke, Opisthorchis viverrini (Ov). One of key mechanism in the development of CCA is epithelial mesenchymal transition (EMT). We aimed to investigate the expression of EMT-related proteins namely, E-cadherin, TGF-β1 and BMP-7 in CCA tissues, to determine the level of candidate EMT-related protein, and to examine whether there were significant correlations with clinicopathological data in sera of CCA patients compared with normal groups. Methods The expression of E-cadherin, TGF-β1 and BMP-7 was analyzed in human CCA tissues by immunohistochemistry and altered expressions compared to clinicopathological data were analyzed to identify the potential candidate EMT-biomarker. Subsequently, the level of candidate marker was determined in sera of CCA patients compared with normal and inflammatory-related diseases groups by enzyme-linked immunosorbent assay (ELISA). Results Immunohistochemical analysis showed that E-cadherin was expressed at a low level whereas TGF-β1 and BMP-7 showed high expression in CCA tissues when compared with liver from cadaveric donor. Interestingly, only high TGF-β1 expression in CCA tissues was significantly correlated with lymph node metastasis, severe cancer stage, intrahepatic CCA type and shorter survival time of CCA patients (P<0.05). Consequently, TGF-β1 was selected to determine the level in serum of CCA patients using ELISA. The results showed that serum TGF-β1 level was elevated in CCA patients compared to the normal group. Patients with high TGF-β1 levels were significantly correlated with metastasis status (P=0.03). Furthermore, receiver operating characteristic (ROC) analysis showed that serum TGF-β1 level is effective in distinguishing CCA patients from normal at the cut-off of 38.54 ng/mL with high sensitivity (71.1%) and specificity (68.9%) and from inflammatory-related diseases group at the cut-off of 38.67 ng/mL with effective sensitivity (68.0%) and specificity (71.1%). Furthermore, TGF-β1 could serve as a novel metastatic biomarker in CCA to diagnose the disease with 48.95 ng/mL as the cut-off along with the desired sensitivity and specificity (48.2% and 88.9% respectively). Conclusions The results of this study show that TGF-β1 could be a potential EMT-biomarker for diagnosis and prognosis of CCA.
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Affiliation(s)
- Phongsaran Kimawaha
- Faculty of Associated Medical Sciences, Khon Kaen University, Khon Kaen, Thailand.,Cholangiocarcinoma Research Institute, Khon Kaen University, Khon Kaen, Thailand
| | - Apinya Jusakul
- Faculty of Associated Medical Sciences, Khon Kaen University, Khon Kaen, Thailand.,Cholangiocarcinoma Research Institute, Khon Kaen University, Khon Kaen, Thailand
| | - Prem Junsawang
- Department of Statistics, Faculty of Science, Khon Kaen University, Khon Kaen, Thailand
| | - Watcharin Loilome
- Cholangiocarcinoma Research Institute, Khon Kaen University, Khon Kaen, Thailand.,Department of Biochemistry, Faculty of Medicine, Khon Kaen University, Khon Kaen, Thailand
| | - Narong Khuntikeo
- Cholangiocarcinoma Research Institute, Khon Kaen University, Khon Kaen, Thailand.,Department of Surgery, Faculty of Medicine, Khon Kaen University, Khon Kaen, Thailand
| | - Anchalee Techasen
- Faculty of Associated Medical Sciences, Khon Kaen University, Khon Kaen, Thailand.,Cholangiocarcinoma Research Institute, Khon Kaen University, Khon Kaen, Thailand
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11
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Mora B, Guglielmelli P, Rumi E, Maffioli M, Barraco D, Rambaldi A, Caramella M, Komrokji RS, Kiladjian J, Gotlib J, Iurlo A, Cervantes F, Devos T, Palandri F, De Stefano V, Ruggeri M, Silver RT, Albano F, Benevolo G, Cavalloni C, Uccella S, Accetta R, Siracusa C, Agnoli S, Merli M, Barbui T, Bertù L, Cazzola M, Vannucchi AM, Passamonti F. Impact of bone marrow fibrosis grade in post-polycythemia vera and post-essential thrombocythemia myelofibrosis: A study of the MYSEC group. Am J Hematol 2020; 95:E1-E3. [PMID: 31588594 DOI: 10.1002/ajh.25644] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2019] [Revised: 09/16/2019] [Accepted: 09/20/2019] [Indexed: 11/11/2022]
Affiliation(s)
- Barbara Mora
- HematologyOspedale di Circolo, ASST Sette Laghi Varese Italy
| | - Paola Guglielmelli
- CRIMM; Center Research and Innovation of Myeloproliferative NeoplasmsUniversity of Florence Florence Italy
| | - Elisa Rumi
- Hematology, Department of Molecular Medicine, Fondazione IRCCS Policlinico San MatteoUniversity of Pavia Pavia Italy
| | | | - Daniela Barraco
- HematologyOspedale di Circolo, ASST Sette Laghi Varese Italy
| | - Alessandro Rambaldi
- Hematology and Bone Marrow Transplant UnitASST Papa Giovanni XXIII Bergamo Italy
| | | | - Rami S. Komrokji
- Malignant Hematology DepartmentBlood and Marrow Transplantation, H. Lee Moffitt Cancer Center and Research Institute Tampa Florida
| | | | - Jason Gotlib
- Divisions of HematologyStanford Cancer Institute, Stanford University School of Medicine Stanford California
| | - Alessandra Iurlo
- UOC Oncoematologia, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico Milan Italy
| | - Francisco Cervantes
- Hematology DepartmentHospital Clinic, IDIBAPS, University of Barcelona Barcelona Spain
| | - Timothy Devos
- Department of HematologyUniversity Hospitals Leuven (UZ Leuven) Leuven Belgium
| | - Francesca Palandri
- Institute of HematologyAzienda Ospedaliero‐Universitaria S.Orsola‐Malpighi di Bologna Bologna Italy
| | - Valerio De Stefano
- HematologyFondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore Rome Italy
| | - Marco Ruggeri
- Hematology DepartmentSan Bortolo Hospital Vicenza Italy
| | - Richard T. Silver
- Richard T. Silver Myeloproliferative Neoplasms CenterWeill Cornell Medical Center New York New York
| | - Francesco Albano
- Hematology ‐ Dept. of Emergency and Organ TransplantationUniversity of Bari Bari Italy
| | - Giulia Benevolo
- Struttura Complessa (S.C.) di Ematologia, Presidio Molinette Azienda Universitario‐Ospedaliera (A.O.U) Città della Salute e della Scienza di Torino Torino Italy
| | - Chiara Cavalloni
- Hematology, Department of Molecular Medicine, Fondazione IRCCS Policlinico San MatteoUniversity of Pavia Pavia Italy
| | - Silvia Uccella
- Department of Surgical and Morphological SciencesOspedale di Circolo e Fondazione Macchi, ASST Sette Laghi, University of Insubria Varese Italy
| | - Raffaella Accetta
- Laboratory of Medicine, Service of cytogenetics and medical geneticsOspedale di Circolo, ASST Sette Laghi Varese Italy
| | - Claudia Siracusa
- Laboratory of Medicine, Service of cytogenetics and medical geneticsOspedale di Circolo, ASST Sette Laghi Varese Italy
| | - Stefania Agnoli
- HematologyOspedale di Circolo, ASST Sette Laghi Varese Italy
| | - Michele Merli
- HematologyOspedale di Circolo, ASST Sette Laghi Varese Italy
| | - Tiziano Barbui
- FROM Research FoundationASST Papa Giovanni XXIII Bergamo Italy
| | - Lorenza Bertù
- Department of Medicine and SurgeryUniversity of Insubria Varese Italy
| | - Mario Cazzola
- Hematology, Department of Molecular Medicine, Fondazione IRCCS Policlinico San MatteoUniversity of Pavia Pavia Italy
| | - Alessandro M. Vannucchi
- CRIMM; Center Research and Innovation of Myeloproliferative NeoplasmsUniversity of Florence Florence Italy
| | - Francesco Passamonti
- HematologyOspedale di Circolo, ASST Sette Laghi Varese Italy
- Department of Medicine and SurgeryUniversity of Insubria Varese Italy
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12
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Manshouri T, Verstovsek S, Harris DM, Veletic I, Zhang X, Post SM, Bueso-Ramos CE, Estrov Z. Primary myelofibrosis marrow-derived CD14+/CD34- monocytes induce myelofibrosis-like phenotype in immunodeficient mice and give rise to megakaryocytes. PLoS One 2019; 14:e0222912. [PMID: 31569199 PMCID: PMC6768666 DOI: 10.1371/journal.pone.0222912] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2019] [Accepted: 09/10/2019] [Indexed: 01/08/2023] Open
Abstract
To confirm that neoplastic monocyte-derived collagen- and fibronectin-producing fibrocytes induce bone marrow (BM) fibrosis in primary myelofibrosis (PMF), we injected PMF BM-derived fibrocyte-precursor CD14+/CD34- monocytes into the tail vein of NOD-SCID-γ (NSG) mice. PMF BM-derived CD14+/CD34- monocytes engrafted and induced a PMF-like phenotype with splenomegaly, myeloid hyperplasia with clusters of atypical megakaryocytes, persistence of the JAK2V617F mutation, and BM and spleen fibrosis. As control we used normal human BM-derived CD14+/CD34- monocytes. These monocytes also engrafted and gave rise to normal megakaryocytes that, like PMF CD14+/CD34--derived megakaryocytes, expressed HLA-ABC and human CD42b antigens. Using 2 clonogenic assays we confirmed that PMF and normal BM-derived CD14+/CD34- monocytes give rise to megakaryocyte colony-forming cells, suggesting that a subpopulation BM monocytes harbors megakaryocyte progenitor capacity. Taken together, our data suggest that PMF monocytes induce myelofibrosis-like phenotype in immunodeficient mice and that PMF and normal BM-derived CD14+/CD34- monocytes give rise to megakaryocyte progenitor cells.
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Affiliation(s)
- Taghi Manshouri
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX, United States of America
| | - Srdan Verstovsek
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX, United States of America
| | - David M. Harris
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX, United States of America
| | - Ivo Veletic
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX, United States of America
| | - Xiaorui Zhang
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX, United States of America
| | - Sean M. Post
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX, United States of America
| | - Carlos E. Bueso-Ramos
- Department of Hematopathology, The University of Texas MD Anderson Cancer Center, Houston, TX, United States of America
| | - Zeev Estrov
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX, United States of America
- * E-mail:
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Novel Therapies in Myeloproliferative Neoplasms (MPN): Beyond JAK Inhibitors. Curr Hematol Malig Rep 2019; 14:460-468. [DOI: 10.1007/s11899-019-00538-4] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
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14
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Cooke A, Montante-Montes D, Zúñiga-Tamayo D, Rivera M, Bourlon C, Aguayo Á, Demichelis-Gómez R. Bone marrow fibrosis as prognostic marker in adult patients with acute lymphoblastic leukemia. J Hematop 2019. [DOI: 10.1007/s12308-019-00353-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
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15
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Myelofibrosis osteoclasts are clonal and functionally impaired. Blood 2019; 133:2320-2324. [PMID: 30745304 DOI: 10.1182/blood-2018-10-878926] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2018] [Accepted: 02/06/2019] [Indexed: 12/19/2022] Open
Abstract
Bone marrow (BM) sclerosis is commonly found in patients with late-stage myelofibrosis (MF). Because osteoclasts (OCs) and osteoblasts play a key role in bone remodeling, and MF monocytes, the OC precursors, are derived from the neoplastic clone, we wondered whether decreased OC numbers or impairment in their osteolytic function affects the development of osteosclerosis. Analysis of BM biopsies from 50 MF patients showed increased numbers of multinucleated tartrate-resistant acid phosphatase (TRAP)/cathepsin K+ OCs expressing phosphorylated Janus kinase 2 (JAK2). Randomly microdissected TRAP+ OCs from 16 MF patients harbored JAK2 or calreticulin (CALR) mutations, confirming MF OCs are clonal. To study OC function, CD14+ monocytes from MF patients and healthy individuals were cultured and differentiated into OCs. Unlike normal OCs, MF OCs appeared small and round, with few protrusions, and carried the mutations and chromosomal abnormalities of neoplastic clones. In addition, MF OCs lacked F-actin-rich ring-like structures and had fewer nuclei and reduced colocalization signals, compatible with decreased fusion events, and their mineral resorption capacity was significantly reduced, indicating impaired osteolytic function. Taken together, our data suggest that, although the numbers of MF OCs are increased, their impaired osteolytic activity distorts bone remodeling and contributes to the induction of osteosclerosis.
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16
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Veletic I, Manshouri T, Newberry KJ, Garnett J, Verstovsek S, Estrov Z. Pentraxin-3 plasma levels correlate with tumour burden and overall survival in patients with primary myelofibrosis. Br J Haematol 2018; 185:382-386. [PMID: 30074241 DOI: 10.1111/bjh.15528] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- Ivo Veletic
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Taghi Manshouri
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Kate J Newberry
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Jeannine Garnett
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Srdan Verstovsek
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Zeev Estrov
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
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17
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LSD1 Inhibition Prolongs Survival in Mouse Models of MPN by Selectively Targeting the Disease Clone. Hemasphere 2018; 2:e54. [PMID: 31723778 PMCID: PMC6745991 DOI: 10.1097/hs9.0000000000000054] [Citation(s) in RCA: 69] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2018] [Accepted: 04/27/2018] [Indexed: 12/27/2022] Open
Abstract
Supplemental Digital Content is available in the text Despite recent advances, the myeloproliferative neoplasms (MPNs) are attended by considerable morbidity and mortality. Janus kinase (Jak) inhibitors such as ruxolitinib manage symptoms but do not substantially change the natural history of the disease. In this report, we show the effects of IMG-7289, an irreversible inhibitor of the epigenetically active lysine-specific demethylase 1 (LSD1) in mouse models of MPN. Once-daily treatment with IMG-7289 normalized or improved blood cell counts, reduced spleen volumes, restored normal splenic architecture, and reduced bone marrow fibrosis. Most importantly, LSD1 inhibition lowered mutant allele burden and improved survival. IMG-7289 selectively inhibited proliferation and induced apoptosis of JAK2V617F cells by concomitantly increasing expression and methylation of p53, and, independently, the pro-apoptotic factor PUMA and by decreasing the levels of its antiapoptotic antagonist BCLXL. These data provide a molecular understanding of the disease-modifying activity of the LSD1 inhibitor IMG-7289 that is currently undergoing clinical evaluation in patients with high-risk myelofibrosis. Moreover, low doses of IMG-7289 and ruxolitinib synergize in normalizing the MPN phenotype in mice, offering a rationale for investigating combination therapy.
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18
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Association of bone marrow fibrosis with inferior survival outcomes in chronic myelomonocytic leukemia. Ann Hematol 2018; 97:1183-1191. [PMID: 29557496 DOI: 10.1007/s00277-018-3289-6] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2017] [Accepted: 02/26/2018] [Indexed: 10/17/2022]
Abstract
The impact of bone marrow fibrosis grade on the prognosis of patients with chronic myelomonocytic leukemia (CMML) remains controversial. Therefore, we examined the records of 82 patients diagnosed with CMML at our institution and summarized baseline characteristics and molecular profiles by subgroups of absent or mild (grades 0/1) and moderate (grade 2) fibrosis. Cox proportional hazards models were constructed to assess the prognostic significance of fibrosis grade. Grade 2 fibrosis was identified in 63 patients (76.8%), grade 1 in 16 patients (19.5%), and grade 0 in 3 patients (3.7%). Grade 2 fibrosis was associated with reduced hemoglobin levels (median 9.75 vs 11.0 g/dL in grade 0/1; p = 0.04) and increased percentages of ringed sideroblasts (7.5 vs 0%; p = 0.008). In multivariable analysis, grade 2 fibrosis was an independent predictor of poor overall survival (OS; 95% CI 1.32-6.35; HR 2.90; p = 0.008), but not event-free survival (EFS; 95% CI 0.62-2.67; HR 1.28; p = 0.50). Absolute neutrophil count (ANC) was found to impact OS (95% CI 1.01-1.09; HR 1.05; p = 0.009), while both ANC (95% CI 1.00-1.07; HR 1.04; p = 0.04) and peripheral blood blast percentage (95% CI 1.02-1.32; HR 1.16; p = 0.02) impacted EFS. These results implicate fibrosis grade is an important indicator of prognosis, with high-grade fibrosis predicting inferior survival. Given the prevalence of marrow fibrosis in CMML, fibrosis grading should be incorporated into prognostic assessment and therapeutic decision-making.
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19
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Kvasnicka HM, Thiele J, Bueso-Ramos CE, Sun W, Cortes J, Kantarjian HM, Verstovsek S. Long-term effects of ruxolitinib versus best available therapy on bone marrow fibrosis in patients with myelofibrosis. J Hematol Oncol 2018; 11:42. [PMID: 29544547 PMCID: PMC5856218 DOI: 10.1186/s13045-018-0585-5] [Citation(s) in RCA: 62] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2017] [Accepted: 03/01/2018] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Myelofibrosis (MF) is a life-shortening complication of myeloproliferative neoplasms associated with ineffective hematopoiesis, splenomegaly, and progressive bone marrow (BM) fibrosis. The oral Janus kinase (JAK) 1/JAK2 inhibitor ruxolitinib has been shown to improve splenomegaly, symptom burden, and overall survival in patients with intermediate-2 or high-risk MF compared with placebo or best available therapy (BAT). METHODS The effects of ruxolitinib therapy for up to 66 months on BM morphology in 68 patients with advanced MF with variable BM fibrosis grade were compared with those in 192 matching patients treated with BAT. Available trephine biopsies underwent independent, blinded review by three hematopathologists for consensus-based adjudication of grades for reticulin fibrosis, collagen deposition, and osteosclerosis. RESULTS Ruxolitinib treatment versus BAT was associated with greater odds of BM fibrosis improvement or stabilization and decreased odds of BM fibrosis worsening based on changes from baseline in reticulin fibrosis grade. Generally, these changes were accompanied by a sustained higher level of individual spleen size reduction and regression of leukoerythroblastosis. Patients with more advanced baseline fibrosis showed lower spleen size response. CONCLUSIONS The finding that long-term ruxolitinib therapy may reverse or markedly delay BM fibrosis progression in advanced MF suggests that sustained JAK inhibition may be disease-modifying. TRIAL REGISTRATION INCB18424-251, ClinicalTrials.gov identifier NCT00509899 .
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Affiliation(s)
- Hans Michael Kvasnicka
- Senckenberg Institute of Pathology, University of Frankfurt, Theodor-Stern-Kai 7, 60590, Frankfurt, Germany.
| | | | - Carlos E Bueso-Ramos
- Department of Hematopathology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | | | - Jorge Cortes
- Department of Hematopathology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Hagop M Kantarjian
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Srdan Verstovsek
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
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Barbui T, Thiele J, Gisslinger H, Kvasnicka HM, Vannucchi AM, Guglielmelli P, Orazi A, Tefferi A. The 2016 WHO classification and diagnostic criteria for myeloproliferative neoplasms: document summary and in-depth discussion. Blood Cancer J 2018. [PMID: 29426921 DOI: 10.1038/s41408-018-0054-y.pmid:29426921;pmcid:pmc5807384] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/09/2023] Open
Abstract
The new edition of the 2016 World Health Organization (WHO) classification system for tumors of the hematopoietic and lymphoid tissues was published in September 2017. Under the category of myeloproliferative neoplasms (MPNs), the revised document includes seven subcategories: chronic myeloid leukemia, chronic neutrophilic leukemia, polycythemia vera (PV), primary myelofibrosis (PMF), essential thrombocythemia (ET), chronic eosinophilic leukemia-not otherwise specified and MPN, unclassifiable (MPN-U); of note, mastocytosis is no longer classified under the MPN category. In the current review, we focus on the diagnostic criteria for JAK2/CALR/MPL mutation-related MPNs: PV, ET, and PMF. In this regard, the 2016 changes were aimed at facilitating the distinction between masked PV and JAK2-mutated ET and between prefibrotic/early and overtly fibrotic PMF. In the current communication, we (i) provide practically useful resource tables and graphs on the new diagnostic criteria including outcome, (ii) elaborate on the rationale for the 2016 changes, (iii) discuss the complementary role of mutation screening, (iv) address ongoing controversies and propose solutions, (v) attend to the challenges of applying WHO criteria in routine clinical practice, and (vi) outline future directions from the perspectives of the clinical pathologist.
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Affiliation(s)
- Tiziano Barbui
- FROM Research Foundation, Papa Giovanni XXIII Hospital, Bergamo, Italy.
| | - Jürgen Thiele
- Institute of Pathology, University of Cologne, Cologne, Germany
| | | | | | | | - Paola Guglielmelli
- CRIMM-Centro Ricerca e Innovazione delle Malattie Mieloproliferative, Azienda Ospedaliera-Universitaria Careggi, Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
| | - Attilio Orazi
- Department of Pathology and Laboratory Medicine, Weill Cornell Medical College, New York, NY, USA
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Barbui T, Thiele J, Gisslinger H, Kvasnicka HM, Vannucchi AM, Guglielmelli P, Orazi A, Tefferi A. The 2016 WHO classification and diagnostic criteria for myeloproliferative neoplasms: document summary and in-depth discussion. Blood Cancer J 2018; 8:15. [PMID: 29426921 PMCID: PMC5807384 DOI: 10.1038/s41408-018-0054-y] [Citation(s) in RCA: 353] [Impact Index Per Article: 58.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2017] [Revised: 11/24/2017] [Accepted: 12/05/2017] [Indexed: 12/17/2022] Open
Abstract
The new edition of the 2016 World Health Organization (WHO) classification system for tumors of the hematopoietic and lymphoid tissues was published in September 2017. Under the category of myeloproliferative neoplasms (MPNs), the revised document includes seven subcategories: chronic myeloid leukemia, chronic neutrophilic leukemia, polycythemia vera (PV), primary myelofibrosis (PMF), essential thrombocythemia (ET), chronic eosinophilic leukemia-not otherwise specified and MPN, unclassifiable (MPN-U); of note, mastocytosis is no longer classified under the MPN category. In the current review, we focus on the diagnostic criteria for JAK2/CALR/MPL mutation-related MPNs: PV, ET, and PMF. In this regard, the 2016 changes were aimed at facilitating the distinction between masked PV and JAK2-mutated ET and between prefibrotic/early and overtly fibrotic PMF. In the current communication, we (i) provide practically useful resource tables and graphs on the new diagnostic criteria including outcome, (ii) elaborate on the rationale for the 2016 changes, (iii) discuss the complementary role of mutation screening, (iv) address ongoing controversies and propose solutions, (v) attend to the challenges of applying WHO criteria in routine clinical practice, and (vi) outline future directions from the perspectives of the clinical pathologist.
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Affiliation(s)
- Tiziano Barbui
- FROM Research Foundation, Papa Giovanni XXIII Hospital, Bergamo, Italy.
| | - Jürgen Thiele
- Institute of Pathology, University of Cologne, Cologne, Germany
| | | | | | | | - Paola Guglielmelli
- CRIMM-Centro Ricerca e Innovazione delle Malattie Mieloproliferative, Azienda Ospedaliera-Universitaria Careggi, Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
| | - Attilio Orazi
- Department of Pathology and Laboratory Medicine, Weill Cornell Medical College, New York, NY, USA
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23
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Gianelli U, Fiori S, Cattaneo D, Bossi A, Cortinovis I, Bonometti A, Ercoli G, Bucelli C, Orofino N, Bulfamante G, Iurlo A. Prognostic significance of a comprehensive histological evaluation of reticulin fibrosis, collagen deposition and osteosclerosis in primary myelofibrosis patients. Histopathology 2017; 71:897-908. [PMID: 28710830 DOI: 10.1111/his.13309] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2017] [Accepted: 07/12/2017] [Indexed: 01/25/2023]
Abstract
AIMS To evaluate whether a comprehensive histological evaluation of reticulin fibrosis, collagen deposition and osteosclerosis in bone marrow trephine biopsies (BMBs) of primary myelofibrosis (PMF) patients may have prognostic implications. METHODS AND RESULTS Reticulin fibrosis, collagen deposition and osteosclerosis were graded from 0 to 3 in a series of 122 baseline BMBs. Then, we assigned to each case a comprehensive score [reticulin, collagen, osteosclerosis (RCO) score, ranging from 0 to 9] that allowed us to distinguish two groups of patients, with low-grade (RCO score 0-4) and high-grade (RCO score 5-9) stromal changes. Of 122 patients, 88 displayed a low-grade and 34 a high-grade RCO score. The latter was associated more frequently with anaemia, thrombocytopenia, peripheral blood blasts and increased lactate dehydrogenase levels. The RCO score was correlated strictly with overall mortality (P = 0.013) and International Prognostic Scoring System (IPSS) risk categories, and was able to discriminate the overall survival of both low- and high-grade patients (log-rank test: P < 0.001). Moreover, it proved to be more accurate than the European Consensus on Grading of Bone Marrow Fibrosis (ECGMF grade) in identifying high-risk patients with poor prognosis. Finally, a combined analysis of RCO scores and IPSS risk categories in an integrated clinical-pathological evaluation was able to increase the positive predictive value (PPV) for mortality in high-risk patients. CONCLUSION The comprehensive RCO score, obtained by histological evaluation of reticulin fibrosis, collagen deposition and osteosclerosis was prognostically significant and more accurate than ECGMF grade in identifying high-risk patients and improved PPV when applied in addition to IPSS.
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Affiliation(s)
- Umberto Gianelli
- Division of Pathology, Department of Pathophysiology and Transplantation, University of Milan and IRCCS Ca' Granda, Maggiore Policlinico Hospital Foundation, Milan, Italy
| | - Stefano Fiori
- Division of Pathology, Department of Pathophysiology and Transplantation, University of Milan and IRCCS Ca' Granda, Maggiore Policlinico Hospital Foundation, Milan, Italy
| | - Daniele Cattaneo
- Hematology Division, IRCCS Ca' Granda, Maggiore Policlinico Hospital Foundation, Milan, Italy.,Department of Oncology and Hemato-oncology, University of Milan, Milan, Italy
| | - Anna Bossi
- Laboratory GA Maccacaro, Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
| | - Ivan Cortinovis
- Laboratory GA Maccacaro, Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
| | - Arturo Bonometti
- Division of Pathology, Department of Pathophysiology and Transplantation, University of Milan and IRCCS Ca' Granda, Maggiore Policlinico Hospital Foundation, Milan, Italy
| | - Giulia Ercoli
- Division of Pathology, Department of Pathophysiology and Transplantation, University of Milan and IRCCS Ca' Granda, Maggiore Policlinico Hospital Foundation, Milan, Italy
| | - Cristina Bucelli
- Hematology Division, IRCCS Ca' Granda, Maggiore Policlinico Hospital Foundation, Milan, Italy.,Department of Oncology and Hemato-oncology, University of Milan, Milan, Italy
| | - Nicola Orofino
- Hematology Division, IRCCS Ca' Granda, Maggiore Policlinico Hospital Foundation, Milan, Italy.,Department of Oncology and Hemato-oncology, University of Milan, Milan, Italy
| | - Gaetano Bulfamante
- Division of Pathology, Department of Health Sciences, University of Milan and San Paolo Hospital, Milan, Italy
| | - Alessandra Iurlo
- Hematology Division, IRCCS Ca' Granda, Maggiore Policlinico Hospital Foundation, Milan, Italy.,Department of Oncology and Hemato-oncology, University of Milan, Milan, Italy
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24
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Jeryczynski G, Thiele J, Gisslinger B, Wölfler A, Schalling M, Gleiß A, Burgstaller S, Buxhofer-Ausch V, Sliwa T, Schlögl E, Geissler K, Krauth MT, Nader A, Vesely M, Simonitsch-Klupp I, Müllauer L, Beham-Schmid C, Gisslinger H. Pre-fibrotic/early primary myelofibrosis vs. WHO-defined essential thrombocythemia: The impact of minor clinical diagnostic criteria on the outcome of the disease. Am J Hematol 2017; 92:885-891. [PMID: 28543356 DOI: 10.1002/ajh.24788] [Citation(s) in RCA: 37] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2017] [Revised: 05/05/2017] [Accepted: 05/08/2017] [Indexed: 01/01/2023]
Abstract
The 2016 revised WHO criteria for the diagnosis of pre-fibrotic/early primary myelofibrosis (pre-PMF) require at least one of the following four borderline expressed minor clinical criteria: anemia, leukocytosis, elevated lactate dehydrogenase and splenomegaly. In this study, we evaluated the relative frequency of these four criteria in a group of 170 pre-PMF patients and compared them to 225 ET cases. More than 91% of pre-PMF cases showed one or more of these features required for diagnosis, by contrast with only 48% of ET patients. According to clinical data the cumulative risk of progression to advanced/overt PMF in pre-PMF was 36.9% after 15 years. After fitting cox regression models to analyze the impact of the minor criteria on overall survival, only leukocytosis remained as a significant predictor of survival in both pre-PMF and ET. Molecular characterization showed differences in survival in pre-PMF but not ET, with CALR being a more favorable mutation than JAK2. The different outcome of pre-PMF versus ET and associated molecular genetic data supports the concept of two different entities, rather than a continuum of the same disease. Although slightly less than 50% of ET patients also show one or more minor clinical criteria, accurate distinction between ET and pre-PMF is possible by following an integrated approach including histomorphological diagnosis and presence of minor clinical criteria.
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Affiliation(s)
- Georg Jeryczynski
- Department of Internal Medicine I, Division of Hematology and Hemostaseology; Medical University of Vienna; Vienna Austria
| | - Jürgen Thiele
- Institute of Pathology, University of Cologne; Cologne Germany
| | - Bettina Gisslinger
- Department of Internal Medicine I, Division of Hematology and Hemostaseology; Medical University of Vienna; Vienna Austria
| | - Albert Wölfler
- Division of Hematology, Department of Internal Medicine; Medical University of Graz; Graz Austria
| | - Martin Schalling
- Department of Internal Medicine I, Division of Hematology and Hemostaseology; Medical University of Vienna; Vienna Austria
| | - Andreas Gleiß
- Center for Medical Statistics, Informatics, and Intelligent Systems, Medical University of Vienna; Vienna Austria
| | - Sonja Burgstaller
- Department of Internal Medicine IV; Klinikum Wels-Grieskirchen; Wels Austria
| | | | - Thamer Sliwa
- Department of Internal Medicine 3; Hanusch Hospital; Vienna Austria
| | - Ernst Schlögl
- Department of Internal Medicine 3; Hanusch Hospital; Vienna Austria
| | - Klaus Geissler
- 5th Medical Department for Hematology and Oncology; Hospital Hietzing; Vienna Austria
| | - Maria-Theresa Krauth
- Department of Internal Medicine I, Division of Hematology and Hemostaseology; Medical University of Vienna; Vienna Austria
| | - Alexander Nader
- Institute of Pathology and Microbiology, Hanusch Hospital; Vienna Austria
| | - Michael Vesely
- Institute of Pathology, Hospital Hietzing Vienna; Austria
| | | | - Leonhard Müllauer
- Clinical Institute of Pathology, Medical University of Vienna; Vienna Austria
| | | | - Heinz Gisslinger
- Department of Internal Medicine I, Division of Hematology and Hemostaseology; Medical University of Vienna; Vienna Austria
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25
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Rethinking the usefulness of bone marrow biopsy on treatment decision in CLL patients at diagnosis. Ann Hematol 2017; 96:1315-1321. [PMID: 28435987 DOI: 10.1007/s00277-017-2997-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2016] [Accepted: 04/10/2017] [Indexed: 12/22/2022]
Abstract
We aimed to investigate the role of bone marrow infiltration pattern (BMIP) and bone marrow reticulin fibrosis (BMRF) in determining treatment demand in patients with diagnosis of chronic lymphocytic leukemia (CLL). We retrospectively evaluated the data of 65 patients, who were followed with the diagnosis of CLL at Istanbul Training and Research Hospital, Department of Hematology, between July 2007 and June 2016. The median age of the patients was 64 years (range, 32-83). Twenty-three (35.4%) patients were female, and 42 (64.6%) were male. Early/mild grade BMRF was observed in 46 (70.8%) patients and advanced grade BMRF in 19 (29.2%) patients. Eleven (23.9%) of 46 patients with early/mild grade BMRF and 10 (52.9%) of 19 patients with advanced grade BMRF required treatment during follow-up (p = 0.04). According to the BMIP, 14 (21.5%) patients had diffuse and 51 (78.5%) patients had non-diffuse BMIP. Eleven (78.6%) of 14 patients with diffuse BMIP and 10 (19.6%) of 51 patients with non-diffuse BMIP required treatment during follow-up (p < 0.001). In univariate analysis, both advanced grade BMRF and diffuse BMIP had an impact on occurrence of treatment demand (p = 0.028, HR = 3.535 vs. p < 0.01 HR = 15.033). Multivariate analysis also revealed diffuse BMIP to be effective (p < 0.001, HR 13.089), while advanced grade BMRF failed to significantly influence treatment demand (p = 0.140, HR 2.664). In conclusion, in the light of our findings, it is reasonable to consider that bone marrow biopsy at the time of diagnosis might provide a preliminary information about treatment demand in patients with CLL.
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26
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Presentation and outcome of patients with 2016 WHO diagnosis of prefibrotic and overt primary myelofibrosis. Blood 2017; 129:3227-3236. [PMID: 28351937 DOI: 10.1182/blood-2017-01-761999] [Citation(s) in RCA: 120] [Impact Index Per Article: 17.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2017] [Accepted: 03/22/2017] [Indexed: 01/14/2023] Open
Abstract
The 2016 revision of the World Health Organization (WHO) classification of myeloproliferative neoplasms defines 2 stages of primary myelofibrosis (PMF): prefibrotic/early (pre-PMF) and overt fibrotic (overt PMF) phase. In this work, we studied the clinical and molecular features of patients belonging to these categories of PMF. The diagnosis of 661 PMF patients with a bone marrow biopsy at presentation was revised according to modern criteria; clinical information and annotation of somatic mutations in both driver and selected nondriver myeloid genes were available for all patients. Compared with pre-PMF, overt PMF was enriched in patients with anemia, thrombocytopenia, leukopenia, higher blast count, symptoms, large splenomegaly, and unfavorable karyotype. The different types of driver mutations were similarly distributed between the 2 categories, whereas selected mutations comprising the high mutation risk (HMR) category (any mutations in ASXL1, SRSF2, IDH1/2, EZH2) were more represented in overt PMF. More patients with overt PMF were in higher International Prognostic Scoring System risk categories at diagnosis, and the frequency increased during follow-up, suggesting greater propensity to disease progression compared with pre-PMF. Median survival was significantly shortened in overt PMF (7.2 vs 17.6 years), with triple negativity for driver mutations and presence of HMR mutations representing independent predictors of unfavorable outcome. The findings of this "real-life" study indicate that adherence to 2016 WHO criteria allows for identification of 2 distinct categories of patients with PMF where increased grades of fibrosis are associated with more pronounced disease manifestations, adverse mutation profile, and worse outcome, overall suggesting they might represent a phenotypic continuum.
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27
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Verstovsek S, Savona MR, Mesa RA, Dong H, Maltzman JD, Sharma S, Silverman J, Oh ST, Gotlib J. A phase 2 study of simtuzumab in patients with primary, post-polycythaemia vera or post-essential thrombocythaemia myelofibrosis. Br J Haematol 2017; 176:939-949. [DOI: 10.1111/bjh.14501] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2016] [Accepted: 10/25/2016] [Indexed: 12/18/2022]
Affiliation(s)
- Srdan Verstovsek
- The University of Texas MD Anderson Cancer Center; Houston TX USA
| | | | | | - Hua Dong
- Gilead Sciences, Inc.; Foster City CA USA
| | | | | | | | - Stephen T. Oh
- Washington University School of Medicine; St. Louis MO USA
| | - Jason Gotlib
- Stanford University School of Medicine/Stanford Cancer Institute; Stanford CA USA
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28
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Leiva O, Ng SK, Chitalia S, Balduini A, Matsuura S, Ravid K. The role of the extracellular matrix in primary myelofibrosis. Blood Cancer J 2017; 7:e525. [PMID: 28157219 PMCID: PMC5386340 DOI: 10.1038/bcj.2017.6] [Citation(s) in RCA: 39] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2016] [Accepted: 12/20/2016] [Indexed: 02/06/2023] Open
Abstract
Primary myelofibrosis (PMF) is a myeloproliferative neoplasm that arises from clonal proliferation of hematopoietic stem cells and leads to progressive bone marrow (BM) fibrosis. While cellular mutations involved in the development of PMF have been heavily investigated, noteworthy is the important role the extracellular matrix (ECM) plays in the progression of BM fibrosis. This review surveys ECM proteins contributors of PMF, and highlights how better understanding of the control of the ECM within the BM niche may lead to combined therapeutic options in PMF.
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Affiliation(s)
- O Leiva
- Department of Medicine and Whitaker Cardiovascular Institute, Boston University School of Medicine, Boston, MA, USA
| | - S K Ng
- Department of Medicine and Whitaker Cardiovascular Institute, Boston University School of Medicine, Boston, MA, USA
| | - S Chitalia
- Department of Medicine and Whitaker Cardiovascular Institute, Boston University School of Medicine, Boston, MA, USA
| | - A Balduini
- Department of Molecular Medicine, University of Pavia, Pavia, Italy.,Laboratory of Biotechnology, IRCCS San Matteo Foundation, Pavia, Italy
| | - S Matsuura
- Department of Medicine and Whitaker Cardiovascular Institute, Boston University School of Medicine, Boston, MA, USA
| | - K Ravid
- Department of Medicine and Whitaker Cardiovascular Institute, Boston University School of Medicine, Boston, MA, USA
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29
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Guglielmelli P, Rotunno G, Pacilli A, Rumi E, Rosti V, Delaini F, Maffioli M, Fanelli T, Pancrazzi A, Pieri L, Fjerza R, Pietra D, Cilloni D, Sant'Antonio E, Salmoiraghi S, Passamonti F, Rambaldi A, Barosi G, Barbui T, Cazzola M, Vannucchi AM. Prognostic impact of bone marrow fibrosis in primary myelofibrosis. A study of the AGIMM group on 490 patients. Am J Hematol 2016; 91:918-22. [PMID: 27264006 DOI: 10.1002/ajh.24442] [Citation(s) in RCA: 47] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2016] [Revised: 05/31/2016] [Accepted: 06/01/2016] [Indexed: 01/24/2023]
Abstract
The prognostic significance of bone marrow (BM) fibrosis grade in patients with primary myelofibrosis (PMF) is still debated. A fibrosis grade greater than 1 was shown to associate with higher risk of death, and addition of fibrosis grade to IPSS score resulted in a more accurate prediction of survival. The aim of this study was to analyze the prognostic impact of BM fibrosis in 490 patients with PMF, evaluated at diagnosis, molecularly annotated and with extensive follow-up information. We found that fibrosis grade 2 and greater on a 0-3 scale was associated with clinical characteristics indicative of a more advanced disease, such as anemia, leukopenia, thrombocytopenia, constitutional symptoms, larger splenomegaly and a higher IPSS risk category. Patients with higher grade of fibrosis were also more likely to have additional somatic mutations in ASXL1 and EZH2, that are prognostically adverse. Median survival was significantly reduced in patients with grade 2 and 3 fibrosis as compared with grade 1; this effect was maintained when analysis was restricted to younger patients. In multivariate analysis, fibrosis grade independently predicted for survival regardless of IPSS variables and mutational status; the adverse impact of fibrosis was noticeable especially in lower IPSS risk categories. Overall, results indicate that higher grades of fibrosis correlate with unique clinical and molecular aspects and represent an independent adverse variable in patients with PMF; these observations deserve confirmation in prospectively designed series of patients. Am. J. Hematol. 91:918-922, 2016. © 2016 Wiley Periodicals, Inc.
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Affiliation(s)
- Paola Guglielmelli
- Department of Experimental and Clinical Medicine and DENOTHE Excellence Center; CRIMM-Center for Research and Innovation of Myeloproliferative Neoplasms, AOU Careggi, University of Florence; Florence Italy
| | - Giada Rotunno
- Department of Experimental and Clinical Medicine and DENOTHE Excellence Center; CRIMM-Center for Research and Innovation of Myeloproliferative Neoplasms, AOU Careggi, University of Florence; Florence Italy
| | - Annalisa Pacilli
- Department of Experimental and Clinical Medicine and DENOTHE Excellence Center; CRIMM-Center for Research and Innovation of Myeloproliferative Neoplasms, AOU Careggi, University of Florence; Florence Italy
| | - Elisa Rumi
- Department of Hematology Oncology; Fondazione IRCCS Policlinico San Matteo; Pavia Italy
- Department of Molecular Medicine; University of Pavia; Pavia Italy
| | - Vittorio Rosti
- Center for the Study of Myelofibrosis, Research Lab of Biotechnology, IRCCS Policlinico San Matteo Foundation; Pavia Italy
| | - Federica Delaini
- Hematology and BMT Unit; ASST Papa Giovanni XXIII; Bergamo Italy
| | - Margherita Maffioli
- Ospedale Di Circolo; Fondazione Macchi Università Degli Studi Dell'Insubria; Varese Viale Borri 57 Varese Italia
| | - Tiziana Fanelli
- Department of Experimental and Clinical Medicine and DENOTHE Excellence Center; CRIMM-Center for Research and Innovation of Myeloproliferative Neoplasms, AOU Careggi, University of Florence; Florence Italy
- University of Siena; Italy
| | - Alessandro Pancrazzi
- Department of Experimental and Clinical Medicine and DENOTHE Excellence Center; CRIMM-Center for Research and Innovation of Myeloproliferative Neoplasms, AOU Careggi, University of Florence; Florence Italy
| | - Lisa Pieri
- Department of Experimental and Clinical Medicine and DENOTHE Excellence Center; CRIMM-Center for Research and Innovation of Myeloproliferative Neoplasms, AOU Careggi, University of Florence; Florence Italy
| | - Rajmonda Fjerza
- Department of Experimental and Clinical Medicine and DENOTHE Excellence Center; CRIMM-Center for Research and Innovation of Myeloproliferative Neoplasms, AOU Careggi, University of Florence; Florence Italy
| | - Daniela Pietra
- Department of Hematology Oncology; Fondazione IRCCS Policlinico San Matteo; Pavia Italy
| | - Daniela Cilloni
- Department of Clinical and Biological Sciences University of Turin; San Luigi Hospital Turin; Italy
| | - Emanuela Sant'Antonio
- Department of Experimental and Clinical Medicine and DENOTHE Excellence Center; CRIMM-Center for Research and Innovation of Myeloproliferative Neoplasms, AOU Careggi, University of Florence; Florence Italy
| | | | - Francesco Passamonti
- Ospedale Di Circolo; Fondazione Macchi Università Degli Studi Dell'Insubria; Varese Viale Borri 57 Varese Italia
| | | | - Giovanni Barosi
- Center for the Study of Myelofibrosis, Research Lab of Biotechnology, IRCCS Policlinico San Matteo Foundation; Pavia Italy
| | - Tiziano Barbui
- Research Foundation; Ospedale Papa Giovanni XXIII; Bergamo Italy
| | - Mario Cazzola
- Department of Hematology Oncology; Fondazione IRCCS Policlinico San Matteo; Pavia Italy
- Department of Molecular Medicine; University of Pavia; Pavia Italy
| | - Alessandro M. Vannucchi
- Department of Experimental and Clinical Medicine and DENOTHE Excellence Center; CRIMM-Center for Research and Innovation of Myeloproliferative Neoplasms, AOU Careggi, University of Florence; Florence Italy
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30
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Verstovsek S, Manshouri T, Pilling D, Bueso-Ramos CE, Newberry KJ, Prijic S, Knez L, Bozinovic K, Harris DM, Spaeth EL, Post SM, Multani AS, Rampal RK, Ahn J, Levine RL, Creighton CJ, Kantarjian HM, Estrov Z. Role of neoplastic monocyte-derived fibrocytes in primary myelofibrosis. J Exp Med 2016; 213:1723-40. [PMID: 27481130 PMCID: PMC4995084 DOI: 10.1084/jem.20160283] [Citation(s) in RCA: 112] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2016] [Accepted: 06/22/2016] [Indexed: 01/02/2023] Open
Abstract
Estrov and collaborators examine the role of fibrocytes in primary myelofibrosis and propose a novel therapeutic approach. Primary myelofibrosis (PMF) is a fatal neoplastic disease characterized by clonal myeloproliferation and progressive bone marrow (BM) fibrosis thought to be induced by mesenchymal stromal cells stimulated by overproduced growth factors. However, tissue fibrosis in other diseases is associated with monocyte-derived fibrocytes. Therefore, we sought to determine whether fibrocytes play a role in the induction of BM fibrosis in PMF. In this study, we show that BM from patients with PMF harbors an abundance of clonal, neoplastic collagen- and fibronectin-producing fibrocytes. Immunodeficient mice transplanted with myelofibrosis patients’ BM cells developed a lethal myelofibrosis-like phenotype. Treatment of the xenograft mice with the fibrocyte inhibitor serum amyloid P (SAP; pentraxin-2) significantly prolonged survival and slowed the development of BM fibrosis. Collectively, our data suggest that neoplastic fibrocytes contribute to the induction of BM fibrosis in PMF, and inhibiting fibrocyte differentiation with SAP may interfere with this process.
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Affiliation(s)
- Srdan Verstovsek
- Department of Leukemia, University of Texas MD Anderson Cancer Center, Houston, TX 77030
| | - Taghi Manshouri
- Department of Leukemia, University of Texas MD Anderson Cancer Center, Houston, TX 77030
| | - Darrell Pilling
- Department of Biology, Texas A&M University, College Station, TX 77433
| | - Carlos E Bueso-Ramos
- Department of Hematopathology, University of Texas MD Anderson Cancer Center, Houston, TX 77030
| | - Kate J Newberry
- Department of Leukemia, University of Texas MD Anderson Cancer Center, Houston, TX 77030
| | - Sanja Prijic
- Department of Leukemia, University of Texas MD Anderson Cancer Center, Houston, TX 77030
| | - Liza Knez
- Department of Leukemia, University of Texas MD Anderson Cancer Center, Houston, TX 77030
| | - Ksenija Bozinovic
- Department of Leukemia, University of Texas MD Anderson Cancer Center, Houston, TX 77030
| | - David M Harris
- Department of Leukemia, University of Texas MD Anderson Cancer Center, Houston, TX 77030
| | - Erika L Spaeth
- Department of Leukemia, University of Texas MD Anderson Cancer Center, Houston, TX 77030
| | - Sean M Post
- Department of Leukemia, University of Texas MD Anderson Cancer Center, Houston, TX 77030
| | - Asha S Multani
- Department of Genetics, University of Texas MD Anderson Cancer Center, Houston, TX 77030
| | - Raajit K Rampal
- Leukemia Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY 10065
| | - Jihae Ahn
- Human Oncology and Pathogenesis Program, Gerstner Sloan Kettering School of Biomedical Sciences, New York, NY 10065
| | - Ross L Levine
- Leukemia Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY 10065
| | - Chad J Creighton
- Division of Biostatistics, Dan L. Duncan Cancer Center, Baylor College of Medicine, Houston, TX 77030
| | - Hagop M Kantarjian
- Department of Leukemia, University of Texas MD Anderson Cancer Center, Houston, TX 77030
| | - Zeev Estrov
- Department of Leukemia, University of Texas MD Anderson Cancer Center, Houston, TX 77030
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31
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Verstovsek S, Talpaz M, Ritchie E, Wadleigh M, Odenike O, Jamieson C, Stein B, Uno T, Mesa RA. A phase I, open-label, dose-escalation, multicenter study of the JAK2 inhibitor NS-018 in patients with myelofibrosis. Leukemia 2016; 31:393-402. [PMID: 27479177 PMCID: PMC5292677 DOI: 10.1038/leu.2016.215] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2016] [Revised: 06/24/2016] [Accepted: 07/04/2016] [Indexed: 12/13/2022]
Abstract
NS-018 is a Janus-activated kinase 2 (JAK2)-selective inhibitor, targeting the JAK–signal transducer and activator of transcription (STAT) pathway that is deregulated in myelofibrosis. In this phase I, dose-escalation portion of a phase I/II study, patients with myelofibrosis received oral NS-018 in continuous 28-day cycles. The primary study objective was to evaluate safety, tolerability and clinically active dose of NS-018. Forty-eight patients were treated; 23 (48%) had previously received a JAK inhibitor (JAKi). The most common drug-related adverse events were thrombocytopenia (27%)/anemia (15%) for hematologic events, and dizziness (23%)/nausea (19%) for non-hematologic events. Once daily NS-018 at 300 mg was chosen as the phase II study dose based on improved tolerability compared with higher doses. A ⩾50% reduction in palpable spleen size was achieved in 56% of patients (47% of patients with prior JAKi treatment), and improvements were observed in myelofibrosis-associated symptoms. Bone marrow fibrosis grade (local assessment) improved from baseline in 11/30 evaluable patients (37%) after 3 cycles of NS-018. JAK2 allele burden was largely unchanged. Changes in cytokine/protein levels were noted after 4 weeks of treatment. NS-018 reached peak plasma concentration in 1–2 h and did not accumulate with multiple dosing. NS-018 will be assessed in patients with previous JAKi exposure in the phase II portion.
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Affiliation(s)
- S Verstovsek
- Department of Leukemia, University of Texas, MD Anderson Cancer Center, Houston, TX, USA
| | - M Talpaz
- Comprehensive Cancer Center, University of Michigan, Ann Arbor, MI, USA
| | - E Ritchie
- Division of Hematology and Medical Oncology, Cornell University, New York, NY, USA
| | - M Wadleigh
- Dana-Farber Cancer Institute, Boston, MA, USA
| | - O Odenike
- University of Chicago Medical Center, Chicago, IL, USA
| | - C Jamieson
- Moores Cancer Center, University of California, San Diego, CA, USA
| | - B Stein
- Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - T Uno
- NS Pharma Inc., Paramus, NJ, USA
| | - R A Mesa
- Mayo Clinic, Scottsdale, AZ, USA
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32
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The 2016 revision of WHO classification of myeloproliferative neoplasms: Clinical and molecular advances. Blood Rev 2016; 30:453-459. [PMID: 27341755 DOI: 10.1016/j.blre.2016.06.001] [Citation(s) in RCA: 81] [Impact Index Per Article: 10.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2016] [Revised: 05/26/2016] [Accepted: 06/06/2016] [Indexed: 12/18/2022]
Abstract
Clinical evidence supports the need of changing the diagnostic criteria of the 2008 updated WHO classification for polycythemia vera (PV), essential thrombocythemia (ET) and primary myelofibrosis (PMF). In JAK2-mutated patients who show characteristic bone marrow (BM) morphology, clinical studies demonstrated that a hemoglobin level of 16.5g/dL in men and 16.0g/dl for women or a hematocrit value of 49% in men and 48% in women are the optimal cut off levels for distinguishing JAK2-mutated ET from "masked/prodromal" PV. Therefore BM morphology was upgraded to a major diagnostic criterion. Regarding ET the key issue was to improve standardization of prominent BM features enhancing differentiation between "true" ET and prefibrotic/early primary myelofibrosis (prePMF). These two entities have shown a different epidemiology and clinical outcomes. Concerning prePMF a more explicit clinical characterization of minor criteria is mandated for an improved distinction from ET and overt PMF and accurate diagnosis and outcome prediction.
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33
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Barbui T, Thiele J, Vannucchi AM, Tefferi A. Myeloproliferative neoplasms: Morphology and clinical practice. Am J Hematol 2016; 91:430-3. [PMID: 26718907 DOI: 10.1002/ajh.24288] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2015] [Accepted: 12/22/2015] [Indexed: 12/26/2022]
Abstract
In myeloproliferative neoplasms (MPNs), controversy persists regarding the usefulness and reproducibility of bone marrow (BM) features. Disagreements concerning the WHO classification are mainly focused on the discrimination between essential thrombocythemia (ET) and prefibrotic/early primary myelofibrosis (prePMF) and prodromal polycythemia vera (PV). Criticism mostly refers to lack of standardization of distinctive BM features precluding correct morphological pattern recognition. The distinction between WHO-defined ET and prePMF is not trivial because outcome is significantly worse in prePMF. Morphology was generally considered to be non-specific for the diagnosis of PV. Recent studies have revealed under-diagnosis of morphologically and biologically consistent PV.
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Affiliation(s)
- Tiziano Barbui
- Research Foundation, Papa Giovanni XXIII Hospital; Bergamo Italy
| | - Jürgen Thiele
- Institute of pathology, University of Cologne; Cologne Germany
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34
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Cervantes F, Correa JG, Hernandez-Boluda JC. Alleviating anemia and thrombocytopenia in myelofibrosis patients. Expert Rev Hematol 2016; 9:489-96. [DOI: 10.1586/17474086.2016.1154452] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
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35
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Clinical impact of bone marrow morphology for the diagnosis of essential thrombocythemia: comparison between the BCSH and the WHO criteria. Leukemia 2015; 30:1126-32. [PMID: 26710883 PMCID: PMC4858583 DOI: 10.1038/leu.2015.360] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2015] [Revised: 11/12/2015] [Accepted: 12/14/2015] [Indexed: 02/08/2023]
Abstract
Essential thrombocythemia (ET) is currently diagnosed either by the British Committee of Standards in Haematology (BCSH) criteria that are predominantly based on exclusion and not necessarily on bone marrow (BM) morphology, or the World Health Organization (WHO) criteria that require BM examination as essential criterion. We studied the morphological and clinical features in patients diagnosed according either to the BCSH (n=238) or the WHO guidelines (n=232). The BCSH-defined ET cohort was re-evaluated by applying the WHO classification. At presentation, patients of the BCSH group showed significantly higher values of serum lactate dehydrogenase and had palpable splenomegaly more frequently. Following the WHO criteria, the re-evaluation of the BCSH-diagnosed ET cohort displayed a heterogeneous population with 141 (59.2%) ET, 77 (32.4%) prefibrotic primary myelofibrosis (prePMF), 16 (6.7%) polycythemia vera and 4 (1.7%) primary myelofibrosis. Contrasting WHO-confirmed ET, the BCSH cohort revealed a significant worsening of fibrosis-free survival and prognosis. As demonstrated by the clinical data and different outcomes between WHO-diagnosed ET and prePMF, these adverse features were generated by the inadvertent inclusion of prePMF to the BCSH group. Taken together, the diagnosis of ET without a scrutinized examination of BM biopsy specimens will generate a heterogeneous cohort of patients impairing an appropriate clinical management.
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Kvasnicka HM, Beham-Schmid C, Bob R, Dirnhofer S, Hussein K, Kreipe H, Kremer M, Schmitt-Graeff A, Schwarz S, Thiele J, Werner M, Stein H. Problems and pitfalls in grading of bone marrow fibrosis, collagen deposition and osteosclerosis - a consensus-based study. Histopathology 2015; 68:905-15. [PMID: 26402166 DOI: 10.1111/his.12871] [Citation(s) in RCA: 57] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2015] [Accepted: 09/18/2015] [Indexed: 12/22/2022]
Abstract
AIMS In the era of potentially disease-modifying agents such as Janus kinase inhibitors, accurate grading and differentiation of bone marrow (BM) fibrosis has become more relevant to assess staging of disease and therapeutic effects. However, different fibrosis grading models have been used in the past without uniformity, including the proposal by the World Health Organization. Current scoring systems are based only on reticulin fibrosis. Therefore, additional assessment of collagen and the grade of osteosclerosis appear to be essential to discriminate all components of the complex BM fibrous matrix. METHODS AND RESULTS We evaluated problems and pitfalls regarding staining techniques and the interpretation of reticulin fibrosis on a total of 352 samples. Furthermore, we propose a minor modification of the current grading and separate scoring for collagen deposition and osteosclerosis. Reproducibility of gradings was tested among 11 haematopathologists in a blinded assessment. Overall, the inter-rater reliability of all three grading systems ranged between 0.898 and 0.926. CONCLUSIONS A standardized assessment of BM fibrosis with differentiation between reticulin, collagen and osteosclerosis is recommended to evaluate the various components of the fibrous matrix which may be delinked after therapy. In this regard, quality of staining and application of laboratory standards enable a highly reproducible scoring.
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Affiliation(s)
| | | | - Roshanak Bob
- Berlin Reference and Consultation Centre for Lymphoma and Hematopathology, Pathodiagnostik Berlin, Berlin, Germany
| | - Stephan Dirnhofer
- Institute of Pathology, University Hospital Basel, Basel, Switzerland
| | - Kais Hussein
- Institute of Pathology, Hannover Medical School, Hannover, Germany
| | - Hans Kreipe
- Institute of Pathology, Hannover Medical School, Hannover, Germany
| | - Marcus Kremer
- Institute of Pathology, Staedtisches Klinikum Muenchen, Muenchen, Germany
| | | | - Stephan Schwarz
- Department of Pathology, University Medical Centre Erlangen, Erlangen, Germany
| | - Juergen Thiele
- Institute of Pathology, University of Cologne, Cologne, Germany
| | - Martin Werner
- Institute of Surgical Pathology, University Hospital, Freiburg, Germany
| | - Harald Stein
- Berlin Reference and Consultation Centre for Lymphoma and Hematopathology, Pathodiagnostik Berlin, Berlin, Germany
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Jamieson C, Hasserjian R, Gotlib J, Cortes J, Stone R, Talpaz M, Thiele J, Rodig S, Pozdnyakova O. Effect of treatment with a JAK2-selective inhibitor, fedratinib, on bone marrow fibrosis in patients with myelofibrosis. J Transl Med 2015; 13:294. [PMID: 26357842 PMCID: PMC4566296 DOI: 10.1186/s12967-015-0644-4] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2015] [Accepted: 08/18/2015] [Indexed: 11/16/2022] Open
Abstract
Background Progressive bone marrow fibrosis (BMF) is a cardinal feature of many myeloproliferative neoplasms (MPNs) and there is a documented association between the severity of BMF and overall prognosis. We conducted an exploratory analysis of sequential BMF data from two phase I studies of long-term treatment with the Janus kinase 2 (JAK2) inhibitor fedratinib in patients with myelofibrosis. Methods Bone marrow samples were obtained at baseline and after every six cycles (24 weeks) of daily fedratinib treatment. Fibrosis was centrally assessed by three independent haematopathologists, who were blinded to the patients’ data, and graded according to European Consensus Myelofibrosis Grading Criteria. The analysis population comprised patients with a baseline BMF grade ≥1, and at least one post-baseline BMF grade assessment. Changes in BMF grade compared with baseline were classified as improvement (≥1 grade reduction), stabilisation (no change in any baseline BMF grade <3) or worsening (≥1 grade increase). Results Twenty-one patients were included in the analysis. A total of 153 bone marrow samples were analysed. Improvement or stabilisation of BMF from baseline was recorded in 15 of 18 (83 %) evaluable patients at cycle 6 and in four of nine (44 %) evaluable patients at cycle 30. Two patients achieved resolution of their BMF (grade = 0) by cycle 12. Conclusions This exploratory analysis indicates that improvement or even resolution of BMF may be achievable with JAK2 inhibitor therapy in some patients with MPNs and myelofibrosis. Electronic supplementary material The online version of this article (doi:10.1186/s12967-015-0644-4) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Catriona Jamieson
- Moores UC San Diego Cancer Centre, 3855 Health Sciences Drive, La Jolla, CA, 92093-0820, USA.
| | - Robert Hasserjian
- Department of Pathology, Massachusetts General Hospital, 55 Fruit Street, Boston, MA, 02114, USA.
| | - Jason Gotlib
- Division of Hematology, Stanford University School of Medicine/Stanford Cancer Institute, 875 Blake Wilbur Drive, Room 2324, Stanford, CA, 94305, USA.
| | - Jorge Cortes
- Division of Cancer Medicine, Department of Leukemia, University of Texas MD Anderson Cancer Center, Faculty Center Building on Floors 3 and 4, 1515 Holcombe Blvd., Houston, TX, 77030, USA.
| | - Richard Stone
- Dana-Farber Cancer Institute, 450 Brookline Avenue, Boston, MA, 02215, USA.
| | - Moshe Talpaz
- The University of Michigan Hospital and Health Systems, Comprehensive Cancer Center, 1500 East Medical Center Drive, Ann Arbor, MI, 48109, USA.
| | - Jürgen Thiele
- Institute of Pathology, University of Cologne, Kerpener Str. 62, 50924, Cologne, Germany.
| | - Scott Rodig
- Department of Pathology, Brigham and Women's Hospital, 75 Francis Street, Boston, MA, 02115, USA.
| | - Olga Pozdnyakova
- Department of Pathology, Brigham and Women's Hospital, 75 Francis Street, Boston, MA, 02115, USA.
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Nazha A, Khoury JD, Rampal RK, Daver N. Fibrogenesis in Primary Myelofibrosis: Diagnostic, Clinical, and Therapeutic Implications. Oncologist 2015; 20:1154-60. [PMID: 26304912 DOI: 10.1634/theoncologist.2015-0094] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2015] [Accepted: 06/22/2015] [Indexed: 01/28/2023] Open
Abstract
Primary myelofibrosis is a stem cell-derived clonal malignancy characterized by unchecked proliferation of myeloid cells, resulting in bone marrow fibrosis, osteosclerosis, and pathologic angiogenesis. Bone marrow fibrosis (BMF) plays a central role in the pathophysiology of the disease. This review describes current issues regarding BMF in primary myelofibrosis, including the pathophysiology and impact of abnormal deposition of excess collagen and reticulin fibers in bone marrow spaces, the modified Bauermeister and the European Consensus grading systems of BMF, and the prognostic impact of BMF on the overall outcome of patients with primary myelofibrosis. The impact of novel therapeutic strategies, including JAK-STAT inhibitors and allogeneic stem cell transplant, on BMF is discussed.
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Affiliation(s)
- Aziz Nazha
- Leukemia Program, Department of Hematology and Medical Oncology, Taussig Cancer Institute, Cleveland, Ohio USA; Department of Hematopathology, and Leukemia Department, The University of Texas MD Anderson Cancer Center, Houston, Texas USA; Leukemia Service, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Joseph D Khoury
- Leukemia Program, Department of Hematology and Medical Oncology, Taussig Cancer Institute, Cleveland, Ohio USA; Department of Hematopathology, and Leukemia Department, The University of Texas MD Anderson Cancer Center, Houston, Texas USA; Leukemia Service, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Raajit K Rampal
- Leukemia Program, Department of Hematology and Medical Oncology, Taussig Cancer Institute, Cleveland, Ohio USA; Department of Hematopathology, and Leukemia Department, The University of Texas MD Anderson Cancer Center, Houston, Texas USA; Leukemia Service, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Naval Daver
- Leukemia Program, Department of Hematology and Medical Oncology, Taussig Cancer Institute, Cleveland, Ohio USA; Department of Hematopathology, and Leukemia Department, The University of Texas MD Anderson Cancer Center, Houston, Texas USA; Leukemia Service, Memorial Sloan Kettering Cancer Center, New York, New York, USA
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Rationale for revision and proposed changes of the WHO diagnostic criteria for polycythemia vera, essential thrombocythemia and primary myelofibrosis. Blood Cancer J 2015; 5:e337. [PMID: 26832847 PMCID: PMC4558589 DOI: 10.1038/bcj.2015.64] [Citation(s) in RCA: 81] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2015] [Accepted: 06/30/2015] [Indexed: 12/19/2022] Open
Abstract
The 2001/2008 World Health Organization (WHO)-based diagnostic criteria for polycythemia vera (PV), essential thrombocythemia (ET) and primary myelofibrosis (PMF) were recently revised to accomodate new information on disease-specific mutations and underscore distinguishing morphologic features. In this context, it seems to be reasonable to compare first major diagnostic criteria of the former WHO classifications for myeloproliferative neoplasm (MPN) and then to focus on details that have been discussed and will be proposed for the upcoming revision of diagnostic guidelines. In PV, a characteristic bone marrow (BM) morphology was added as one of three major diagnostic criteria, which allowed lowering of the hemoglobin/hematocrit threshold for diagnosis, which is another major criterion, to 16.5 g/dl/49% in men and 16 g/dl/48% in women. The presence of a JAK2 mutation remains the third major diagnostic criterion in PV. Subnormal serum erythropoietin level is now the only minor criterion in PV and is used to capture JAK2-unmutated cases. In ET and PMF, mutations that are considered to confirm clonality and specific diagnosis now include CALR, in addition to JAK2 and MPL. Also in the 2015 discussed revision, overtly fibrotic PMF is clearly distinguished from early/prefibrotic PMF and each PMF variant now includes a separate list of diagnostic criteria. The main rationale for these changes was to enhance the distinction between so-called masked PV and JAK2-mutated ET and between ET and prefibrotic early PMF. The proposed changes also underscore the complementary role, as well as limitations of mutation analysis in morphologic diagnosis. On the other hand, discovery of new biological markers may probably be expected in the future to enhance discrimination of the different MPN subtypes in accordance with the histological BM patterns and corresponding clinical features.
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Madelung AB, Bondo H, Stamp I, Løvgreen P, Nielsen SL, Falensteen A, Knudsen H, Svendsen KD, Lange T, Ralfkiaer E, Nielsen K, Hasselbalch H, Thiele J. WHO classification 2008 of myeloproliferative neoplasms: a workshop learning effect--the Danish experience. APMIS 2015. [PMID: 26200697 DOI: 10.1111/apm.12417] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
We examined the learning effect of a workshop for Danish hematopathologists led by an international expert regarding histological subtyping of myeloproliferative neoplasms (MPN). Six hematopathologists evaluated 43 bone marrow (BM) biopsies according to the WHO description (2008), blinded to clinical data. All panelists then participated in the workshop. The case biopsies - mixed with 251 other MPN BM biopsies - were reviewed again. Consensus regarding the histological subtype was significantly improved; from 49% to 72% (Fleiss kappa value 0.302 pre-workshop, 0.474 post-workshop; p = 0.004). There was no significant effect on the isolated morphological characteristics. Agreement between cases with histological consensus and clinical diagnosis was 86% without significant change during workshop sessions. Our study demonstrates that experienced hematopathologists can significantly improve their diagnostic ability by a workshop led by an international expert; not by improving the evaluation of individual histological parameters but by weighting these in their conclusive diagnosis.
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Affiliation(s)
- Ann B Madelung
- Department of Pathology, Naestved and Slagelse Hospitals, Naestved, Denmark
| | - Henrik Bondo
- Department of Pathology, Naestved and Slagelse Hospitals, Naestved, Denmark
| | - Inger Stamp
- Department of Pathology, Naestved and Slagelse Hospitals, Naestved, Denmark
| | - Preben Løvgreen
- Department of Pathology, Roskilde and Køge Hospitals, Roskilde, Denmark
| | | | | | - Helle Knudsen
- Department of Pathology, Herlev Hospital, Herlev, Denmark
| | - Kira D Svendsen
- Department of Biostatistics, University of Copenhagen, Copenhagen, Denmark
| | - Theis Lange
- Department of Biostatistics, University of Copenhagen, Copenhagen, Denmark
| | - Elisabeth Ralfkiaer
- Department of Pathology, Copenhagen University Hospital, Denmark, Copenhagen, Denmark
| | - Karsten Nielsen
- Department of Pathology, Naestved and Slagelse Hospitals, Naestved, Denmark
| | - Hans Hasselbalch
- Department of Haematology, Roskilde and Køge Hospitals, Roskilde, Denmark
| | - Jürgen Thiele
- Institute of Pathology, University of Cologne, Cologne, Germany
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High concordance in grading reticulin fibrosis and cellularity in patients with myeloproliferative neoplasms. Mod Pathol 2014; 27:1447-54. [PMID: 24762543 DOI: 10.1038/modpathol.2014.69] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2014] [Revised: 03/12/2014] [Accepted: 03/13/2014] [Indexed: 11/09/2022]
Abstract
The myeloproliferative neoplasms primary myelofibrosis, polycythemia vera, and, rarely, essential thrombocythemia are characterized by variable degrees of bone marrow fibrosis, either at presentation or upon progression. The increasing use of emerging therapies that may alter disease biology and morphology demands accurate and reproducible assessment of fibrosis grade. To assess concordance of hematopoietic cellularity and fibrosis grading, three hematopathologists independently evaluated a total of 728 bone marrow biopsies from 261 patients with myeloproliferative neoplasms on three clinical trials using fedratinib (SAR302503), a JAK2 inhibitor, including 249 taken at baseline and 479 on therapy. Concordance between the pathologists was evaluated by Pearson correlation coefficient (cellularity) and unweighted kappa statistic (fibrosis grade). There was high correlation of cellularity assessment (r=0.92) and fibrosis grading (kappa=0.83) between the three pathologists. Concordance with World Health Organization (WHO) grade 3 samples was higher compared with grades 0, 1, and 2. Concordance of fibrosis grading in pretreatment samples was superior to that of post-treatment samples (kappa=0.83 and 0.79, respectively, P=0.023). Our analysis suggests that the updated 2008 WHO reticulin fibrosis grading system is highly reproducible, even in patients undergoing JAK2 inhibitor therapy. This system is practically applicable to establish baseline fibrosis grade as well as changes in fibrosis in subsequent samples on therapy.
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The importance of central pathology review in international trials: a comparison of local versus central bone marrow reticulin grading. Leukemia 2014; 29:241-4. [PMID: 25183285 DOI: 10.1038/leu.2014.262] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
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Mascarenhas J. Rationale for combination therapy in myelofibrosis. Best Pract Res Clin Haematol 2014; 27:197-208. [PMID: 25189730 DOI: 10.1016/j.beha.2014.07.009] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2014] [Accepted: 07/11/2014] [Indexed: 12/18/2022]
Abstract
Agents targeting the JAK-STAT pathway have dominated the investigational therapeutic portfolio over the last five years resulting in the first and only approved agent for the treatment of patients with myelofibrosis (MF). However, chromatin modifying agents, anti-fibrosing agents, and other signaling pathway inhibitors have also demonstrated activity and offer the potential to improve upon the clinical success of JAK2 inhibition. Due to the complex pathobiological mechanisms underlying MF, it is likely that a combination of biologically active therapies will be required to target the MF hematopoietic stem cell in order to achieve significant disease course modification. Ruxolitinib in partnership with panobinostat, decitabine, and LDE225 are being evaluated in current combination therapy trials based on pre-clinical studies that provide strong scientific rationale. The rationale of combination of danazol or lenalidomide with ruxolitinib is mainly based on mitigation of anti-JAK2-mediated myelosuppression. Combination trials of ruxolitinib and novel anti-fibrosing agents such as PRM-151 represent an attempt to address therapeutic limitations of JAK2 inhibitors such as reversal of bone marrow fibrosis. Ruxolitinib is also being incorporated in novel treatment strategies in the setting of hematopoietic stem cell transplantation for MF. As the pathogenetic mechanisms are better understood, potential drug combinations in MF will increase dramatically and demonstration of biologic activity in effective preclinical models will be required to efficiently evaluate the most active combinations with least toxicity in future trials. This manuscript will address the proposed goals of combination therapy approach and review the state of the art in combination experimental therapy for MF.
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Affiliation(s)
- John Mascarenhas
- Myeloproliferative Disorder Program, Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, One Gustave L Levy Place, Box 1079, New York, NY, USA.
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Chalayer E, Ffrench M, Cathébras P. Bone marrow fibrosis as a feature of systemic lupus erythematosus: a case report and literature review. SPRINGERPLUS 2014; 3:349. [PMID: 25045617 PMCID: PMC4101126 DOI: 10.1186/2193-1801-3-349] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 06/20/2014] [Accepted: 06/26/2014] [Indexed: 11/21/2022]
Abstract
Introduction Peripheral cytopenias are common in systemic lupus erythematosus (SLE), but bone marrow involvement is rarely reported. Myelofibrosis is a rare disorder characterized by reticulin fibrosis of the bone marrow, which usually occurs in response to clonal proliferation of hematopoietic stem cells in myeloproliferative disorders. However, bone marrow fibrosis has also been described in association with auto-immune diseases, especially SLE. Method We will report here a new case of bone marrow fibrosis associated with SLE. We also reviewed the 27 cases published in the English language literature, and will discuss the clinical presentation, outcome, treatment, and pathophysiology of bone marrow fibrosis occurring in association with SLE. Results Over one half of patients were diagnosed concomitantly with bone marrow fibrosis and SLE. Epidemiological, clinical and biological features of lupus were unremarkable. Except for the presence of reticulin fibrosis, the findings from the bone marrow biopsies proved highly variable. Overall mortality was about 14% but corticosteroid-based therapy lead to clinical improvement and reverted bone marrow fibrosis in most cases. Data on the usefulness of other immunomodulatory therapies are inconclusive. Conclusions SLE may be complicated by bone marrow involvement, of a likely autoimmune origin. Bone marrow fibrosis occurring with SLE is probably similar to “primary autoimmune myelofibrosis” and may respond to steroid and immunomodulatory therapies. Further studies with standardised proofreading of bone marrow aspirations and biopsies are needed to delineate the clinical and biological features of this rare complication of SLE.
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Affiliation(s)
- Emilie Chalayer
- Service de médecine interne, Hôpital Nord, CHU de Saint-Étienne, Saint-Étienne, Cedex 2, 42055 France
| | - Martine Ffrench
- Laboratoire d'hématologie, Centre Hospitalier Lyon Sud, 165 Chemin du Grand Revoyet, 69495 Pierre Bénite, France
| | - Pascal Cathébras
- Service de médecine interne, Hôpital Nord, CHU de Saint-Étienne, Saint-Étienne, Cedex 2, 42055 France
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Kröger N, Zabelina T, Alchalby H, Stübig T, Wolschke C, Ayuk F, von Hünerbein N, Kvasnicka HM, Thiele J, Kreipe HH, Büsche G. Dynamic of Bone Marrow Fibrosis Regression Predicts Survival after Allogeneic Stem Cell Transplantation for Myelofibrosis. Biol Blood Marrow Transplant 2014; 20:812-5. [DOI: 10.1016/j.bbmt.2014.02.019] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2014] [Accepted: 02/21/2014] [Indexed: 11/26/2022]
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Abstract
Although the revised World Health Organization (WHO) criteria for the diagnosis and classification of myeloproliferative neoplasms (MPN) were defined by a panel of expert hematopathologists and clinicians, controversy has been repeatedly expressed questioning the clinical usefulness and reproducibility of these diagnostic guidelines. In particular, the distinction between essential thrombocythemia (ET), early/prefibrotic primary myelofibrosis (PMF) and initial stages of polycythemia vera (PV) is still a matter of debate. In this context, it has been argued that clinical correlations with histological features were not firmly substantiated. On the other hand, recently published data from independently performed studies have repeatedly validated the reproducibility of the WHO criteria and provided persuasive evidence that discrimination of early/prefibrotic PMF has a significant impact on the risk of myelofibrotic and leukemic transformation. However, as has been explicitly required, the WHO concept is based on the recognition of characteristic bone marrow patterns and a consensus of clinical and molecular data.
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Contribution of comorbidities and grade of bone marrow fibrosis to the prognosis of survival in patients with primary myelofibrosis. Med Oncol 2014; 31:869. [DOI: 10.1007/s12032-014-0869-8] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2013] [Accepted: 01/27/2014] [Indexed: 11/26/2022]
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48
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Madelung AB, Bondo H, Stamp I, Loevgreen P, Nielsen SL, Falensteen A, Knudsen H, Ehinger M, Dahl-Sørensen R, Mortensen NB, Svendsen KD, Lange T, Ralfkiaer E, Nielsen K, Hasselbalch HC, Thiele J. World Health Organization-defined classification of myeloproliferative neoplasms: morphological reproducibility and clinical correlations--the Danish experience. Am J Hematol 2013; 88:1012-6. [PMID: 23897670 DOI: 10.1002/ajh.23554] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2013] [Accepted: 07/16/2013] [Indexed: 12/16/2022]
Abstract
We examined inter- and intraobserver reproducibility and concordance between histological diagnosis and independently collected clinical findings in a large series of patients with the major subtypes of myeloproliferative neoplasms (MPNs) and controls. Seven hematopathologists reviewed 272 bone marrow biopsies including 43 controls. Diagnoses were determined according to the 2008 criteria of the World Health Organization (WHO). The participants were blinded to all clinical data except patient age. After initial evaluation all hematopathologists participated in a 3-day meeting with a leading clinician chaired by an expert hematopathologists. In cases with lack of consensus on fiber grading (n = 57), a new evaluation was performed. In cases with discordance on morphological diagnosis (n = 129), an additional nonblinded evaluation taking clinical data into consideration was carried out. For remaining cases with a lack of concordance between morphological diagnosis and clinical diagnosis (n = 33), a similar nonblinded evaluation was performed. Consensus on final histological diagnosis and concordance with clinical diagnosis were determined. Blinded histological evaluation resulted in a 53% consensus rate. After re-evaluation of fiber content, consensus was reached in 60% of cases. Adding clinical data increased the histological consensus to 83%. For cases with a histological consensus, we found a concordance of 71% with the clinician's diagnoses. This is the first study to present a larger cohort of MPN patients mimicking the diagnostic challenges that hematopathologists face in their daily practice. The results support the postulates of the WHO that both morphological and clinical findings are essential for a valid diagnosis
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Fu B, OK CY, Goswami M, Xei W, Jaso JM, Muzzafar T, Bueso-Ramos C, Verstovsek S, Garcia-Manero G, Medeiros LJ, Wang SA. The clinical importance of moderate/severe bone marrow fibrosis in patients with therapy-related myelodysplastic syndromes. Ann Hematol 2013; 92:1335-43. [PMID: 23660629 PMCID: PMC4190057 DOI: 10.1007/s00277-013-1776-3] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2013] [Accepted: 04/23/2013] [Indexed: 02/07/2023]
Abstract
The presence of moderate to severe bone marrow (BM) fibrosis has been shown to be an adverse feature in patients with primary myelodysplastic syndromes (MDS). However, the clinical importance of BM fibrosis is not clear in therapy-related MDS. We retrieved all therapy-related MDS (t-MDS) cases (n = 266) diagnosed at our hospital over a 10-year period (2003-2012). Reticulin and trichrome stains were performed in cases in which BM fibrosis was suspected on initial evaluation of hematoxylin and eosin-stained slide. BM fibrosis was graded according to European consensus guidelines, and a score of MF2/MF3 was defined as moderate/severe fibrosis. Moderate/severe BM fibrosis was found in 47 (17%) patients. Compared to 219 patients with no/mild BM fibrosis, the patients with moderate/severe fibrosis presented with severer thrombocytopenia (p = 0.039) and higher numbers of circulating blasts (p = 0.051) but with similar degrees of anemia and neutropenia, transfusion requirements, and similar incidences of hepatosplenomegaly and constitutional symptoms. Histological examination revealed a comparable BM cellularity and BM blast percentage, but markedly increased megakaryocytes (p < 0.001) in the fibrotic group. Although the risk distribution of cytogenetic data was similar according to the New Comprehensive Cytogenetic Scoring criteria, -5 and -17 were more frequently observed in t-MDS with moderate/severe BM fibrosis (p = 0.031 and p = 0.043, respectively). With a median follow-up of 11.5 months, patients with moderate/severe BM fibrosis showed a similar risk of acute myeloid leukemia transformation and a comparable overall survival in univariate and multivariate analyses. Moderate/severe BM fibrosis in patients with t-MDS is associated with certain clinicopathological and genetic features. However, unlike the situation in patients with primary MDS, moderate/severe BM fibrosis does not add additional risk to patients with therapy-related MDS.
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Affiliation(s)
- Bin Fu
- Department of Hematopathology, The University of Texas M.D. Anderson Cancer Center, Houston, TX, USA
| | - Chi Young OK
- Department of Hematopathology, The University of Texas M.D. Anderson Cancer Center, Houston, TX, USA
| | - Maitrayee Goswami
- Department of Hematopathology, The University of Texas M.D. Anderson Cancer Center, Houston, TX, USA
| | - Wei Xei
- Department of Hematopathology, The University of Texas M.D. Anderson Cancer Center, Houston, TX, USA
| | - Jesse M Jaso
- Department of Hematopathology, The University of Texas M.D. Anderson Cancer Center, Houston, TX, USA
| | - Tariq Muzzafar
- Department of Hematopathology, The University of Texas M.D. Anderson Cancer Center, Houston, TX, USA
| | - Carlos Bueso-Ramos
- Department of Hematopathology, The University of Texas M.D. Anderson Cancer Center, Houston, TX, USA
| | - Srdan Verstovsek
- Department of Leukemia, The University of Texas M.D. Anderson Cancer Center, Houston, TX, USA
| | - Guillermo Garcia-Manero
- Department of Leukemia, The University of Texas M.D. Anderson Cancer Center, Houston, TX, USA
| | - L. Jeffrey Medeiros
- Department of Hematopathology, The University of Texas M.D. Anderson Cancer Center, Houston, TX, USA
| | - Sa A. Wang
- Department of Hematopathology, The University of Texas M.D. Anderson Cancer Center, Houston, TX, USA
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Mascarenhas J, Li T, Sandy L, Newsom C, Petersen B, Godbold J, Hoffman R. Anti-transforming growth factor-β therapy in patients with myelofibrosis. Leuk Lymphoma 2013; 55:450-2. [PMID: 23682558 DOI: 10.3109/10428194.2013.805329] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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