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Kewan T, Stahl M, Bewersdorf JP, Zeidan AM. Treatment of Myelodysplastic Syndromes for Older Patients: Current State of Science, Challenges, and Opportunities. Curr Hematol Malig Rep 2024; 19:138-150. [PMID: 38632155 DOI: 10.1007/s11899-024-00733-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/20/2024] [Indexed: 04/19/2024]
Abstract
PURPOSE OF REVIEW Myelodysplastic syndromes/neoplasms (MDS) represent a diverse group of pathologically distinct diseases with varying prognoses and risks of leukemia progression. This review aims to discuss current treatment options for elderly patients with MDS, focusing on patients ineligible for intensive chemotherapy or allogenic hematopoietic stem cell transplantation (HSCT). The challenges associated with treatment in this population and emerging therapeutic prospects are also explored. RECENT FINDINGS Recent advancements in molecular diagnostics have enhanced risk stratification by incorporating genetic mutations, notably through the molecular International Prognostic Scoring System (IPSS-M). Lower-risk MDS (LR-MDS) treatment ranges from observation to supportive measures and erythropoiesis-stimulating agents (ESAs), with emerging therapies like luspatercept showing promise. High-risk MDS (HR-MDS) is treated with hypomethylating agents (HMAs) or allogenic HSCT, but outcomes remain poor. Elderly MDS patients, often diagnosed after 70, pose challenges in treatment decision-making. The IPSS-M aids risk stratification, guiding therapeutic choices. For LR-MDS, supportive care, ESAs, and novel agents like luspatercept are considered. Treatment of HR-MDS involves HMAs or allogenic HSCT. Emerging treatments, including oral HMAs and novel agents targeting FLT3, and IDH 1/2 mutations, show promise. Future research should refine treatment strategies for this elderly population focusing on quality-of-life improvement.
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Affiliation(s)
- Tariq Kewan
- Section of Hematology, Department of Internal Medicine, Yale School of Medicine, and Yale Comprehensive Cancer Center, Yale University, New Haven, CT, USA
| | - Maximillian Stahl
- Department of Medical Oncology, Dana-Farber Cancer Institute and Harvard Medical School, Boston, MA, USA
| | - Jan Philipp Bewersdorf
- Department of Medicine, Leukemia Service, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Amer M Zeidan
- Section of Hematology, Department of Internal Medicine, Yale School of Medicine, and Yale Comprehensive Cancer Center, Yale University, New Haven, CT, USA.
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Jing Q, Zhou C, Zhang J, Zhang P, Wu Y, Zhou J, Tong X, Li Y, Du J, Wang Y. Role of reactive oxygen species in myelodysplastic syndromes. Cell Mol Biol Lett 2024; 29:53. [PMID: 38616283 PMCID: PMC11017617 DOI: 10.1186/s11658-024-00570-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2023] [Accepted: 03/27/2024] [Indexed: 04/16/2024] Open
Abstract
Reactive oxygen species (ROS) serve as typical metabolic byproducts of aerobic life and play a pivotal role in redox reactions and signal transduction pathways. Contingent upon their concentration, ROS production not only initiates or stimulates tumorigenesis but also causes oxidative stress (OS) and triggers cellular apoptosis. Mounting literature supports the view that ROS are closely interwoven with the pathogenesis of a cluster of diseases, particularly those involving cell proliferation and differentiation, such as myelodysplastic syndromes (MDS) and chronic/acute myeloid leukemia (CML/AML). OS caused by excessive ROS at physiological levels is likely to affect the functions of hematopoietic stem cells, such as cell growth and self-renewal, which may contribute to defective hematopoiesis. We review herein the eminent role of ROS in the hematological niche and their profound influence on the progress of MDS. We also highlight that targeting ROS is a practical and reliable tactic for MDS therapy.
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Affiliation(s)
- Qiangan Jing
- Laboratory Medicine Center, Department of Clinical Laboratory, Zhejiang Provincial People's Hospital (Affiliated People's Hospital), Hangzhou Medical College, Hangzhou, 310014, Zhejiang, China
- HEALTH BioMed Research & Development Center, Health BioMed Co., Ltd, Ningbo, 315803, Zhejiang, China
| | - Chaoting Zhou
- Laboratory Medicine Center, Department of Clinical Laboratory, Zhejiang Provincial People's Hospital (Affiliated People's Hospital), Hangzhou Medical College, Hangzhou, 310014, Zhejiang, China
| | - Junyu Zhang
- Department of Hematology, Lishui Central Hospital, Lishui, 323000, Zhejiang, China
| | - Ping Zhang
- Laboratory Medicine Center, Department of Clinical Laboratory, Zhejiang Provincial People's Hospital (Affiliated People's Hospital), Hangzhou Medical College, Hangzhou, 310014, Zhejiang, China
| | - Yunyi Wu
- Laboratory Medicine Center, Department of Clinical Laboratory, Zhejiang Provincial People's Hospital (Affiliated People's Hospital), Hangzhou Medical College, Hangzhou, 310014, Zhejiang, China
| | - Junyu Zhou
- Laboratory Medicine Center, Department of Clinical Laboratory, Zhejiang Provincial People's Hospital (Affiliated People's Hospital), Hangzhou Medical College, Hangzhou, 310014, Zhejiang, China
| | - Xiangmin Tong
- Department of Central Laboratory, Affiliated Hangzhou First People's Hospital, School of Medicine, Westlake University, Hangzhou, 310006, Zhejiang, China
| | - Yanchun Li
- Department of Central Laboratory, Affiliated Hangzhou First People's Hospital, School of Medicine, Westlake University, Hangzhou, 310006, Zhejiang, China.
| | - Jing Du
- Laboratory Medicine Center, Department of Clinical Laboratory, Zhejiang Provincial People's Hospital (Affiliated People's Hospital), Hangzhou Medical College, Hangzhou, 310014, Zhejiang, China.
| | - Ying Wang
- Department of Central Laboratory, Affiliated Hangzhou First People's Hospital, School of Medicine, Westlake University, Hangzhou, 310006, Zhejiang, China.
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Awidi A, Alzu'bi M, Odeh N, Alrawabdeh J, Al Zyoud M, Hamadneh Y, Bawa'neh H, Magableh A, Alshorman A, Al-Fararjeh F, Aladily T, Zeidan AM. Myelodysplastic Syndromes and Myelodysplastic Syndromes/Myeloproliferative Neoplasms: A Real-World Experience From a Developing Country. JCO Glob Oncol 2024; 10:e2300281. [PMID: 38422464 PMCID: PMC10914245 DOI: 10.1200/go.23.00281] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2023] [Revised: 11/10/2023] [Accepted: 12/11/2023] [Indexed: 03/02/2024] Open
Abstract
PURPOSE Myelodysplastic syndromes (MDS) include a heterogeneous group of clonal bone marrow disorders characterized by ineffective hematopoiesis. They manifest as dysplasia in bone marrow hemopoietic elements associated with peripheral cytopenias with variable risk of AML transformation. PATIENTS AND METHODS We analyzed retrospectively registry data collected prospectively from patients with primary MDS and patients with MDS/myeloproliferative neoplasm (MPN) in the Jordan University Hospital between January 2007 and September 2021. The registry captured epidemiologic information such as date of diagnosis, age, gender, date of AML transformation, cytogenetics, MDS subtype, risk group according to Revised International Prognostic Scoring System, and survival. The registry also captured baseline ferritin, B12, and lactate dehydrogenase levels. RESULTS A total of 112 patients with MDS and MDS/MPN were included in the registry. Median age at diagnosis was 59 years. The male-to-female ratio was about 1.2. In a multivariate cox regression model, baseline serum ferritin significantly affected survival as patients with levels exceeding 1,000 μg/L had a risk of death three times higher compared with those with <1,000 μg/L levels (P < .05). CONCLUSION To our knowledge, our study is the first comprehensive study examining the epidemiology and prognostic factors in patients with MDS and patients with MDS/MPN in Jordan. Our results show that MDS and MDS/MPN epidemiology in Jordan is different compared with Western countries. Our results also show that baseline serum ferritin levels can be used as a prognostic marker for patients with MDS.
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Affiliation(s)
- Abdalla Awidi
- Medical School, University of Jordan, Amman, Jordan
- Jordan University Hospital, Amman, Jordan
- Cell Therapy Center, University of Jordan, Amman, Jordan
| | | | - Nada Odeh
- Medical School, University of Jordan, Amman, Jordan
| | | | | | | | | | | | - Alaa Alshorman
- Jordan University Hospital, Amman, Jordan
- Al-Basheer Hospital, Ministry of Health, Amman, Jordan
| | - Feras Al-Fararjeh
- Medical School, University of Jordan, Amman, Jordan
- Jordan University Hospital, Amman, Jordan
| | - Tariq Aladily
- Medical School, University of Jordan, Amman, Jordan
- Jordan University Hospital, Amman, Jordan
| | - Amer M. Zeidan
- Yale Cancer Center and Smilow Cancer Hospital, Yale University School of Medicine, New Haven, CT
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Holbein BE, Lehmann C. Dysregulated Iron Homeostasis as Common Disease Etiology and Promising Therapeutic Target. Antioxidants (Basel) 2023; 12:antiox12030671. [PMID: 36978919 PMCID: PMC10045916 DOI: 10.3390/antiox12030671] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2023] [Revised: 03/02/2023] [Accepted: 03/07/2023] [Indexed: 03/11/2023] Open
Abstract
Iron is irreplaceably required for animal and human cells as it provides the activity center for a wide variety of essential enzymes needed for energy production, nucleic acid synthesis, carbon metabolism and cellular defense. However, iron is toxic when present in excess and its uptake and storage must, therefore, be tightly regulated to avoid damage. A growing body of evidence indicates that iron dysregulation leading to excess quantities of free reactive iron is responsible for a wide range of otherwise discrete diseases. Iron excess can promote proliferative diseases such as infections and cancer by supplying iron to pathogens or cancer cells. Toxicity from reactive iron plays roles in the pathogenesis of various metabolic, neurological and inflammatory diseases. Interestingly, a common underlying aspect of these conditions is availability of excess reactive iron. This underpinning aspect provides a potential new therapeutic avenue. Existing hematologically used iron chelators to take up excess iron have shown serious limitations for use but new purpose-designed chelators in development show promise for suppressing microbial pathogen and cancer cell growth, and also for relieving iron-induced toxicity in neurological and other diseases. Hepcidin and hepcidin agonists are also showing promise for relieving iron dysregulation. Harnessing iron-driven reactive oxygen species (ROS) generation with ferroptosis has shown promise for selective destruction of cancer cells. We review biological iron requirements, iron regulation and the nature of iron dysregulation in various diseases. Current results pertaining to potential new therapies are also reviewed.
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Affiliation(s)
- Bruce E. Holbein
- Department of Microbiology and Immunology, Dalhousie University, Halifax, NS B3H 1X5, Canada
| | - Christian Lehmann
- Department of Anesthesia, Pain Management and Perioperative Medicine, Dalhousie University, Halifax, NS B3H 1X5, Canada
- Correspondence:
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How I Manage Transplant Ineligible Patients with Myelodysplastic Neoplasms. Clin Hematol Int 2022; 5:8-20. [PMID: 36574201 PMCID: PMC10063738 DOI: 10.1007/s44228-022-00024-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2022] [Accepted: 11/14/2022] [Indexed: 12/28/2022] Open
Abstract
AbstractMyelodysplastic neoplasms, formerly known as myelodysplastic syndromes (MDS), represent a group of clonal disorders characterized by a high degree of clinical and molecular heterogeneity, and an invariable tendency to progress to acute myeloid leukemia. MDS typically present in the elderly with cytopenias of different degrees and bone marrow dysplasia, the hallmarks of the disease. Allogeneic hematopoietic stem cell transplant is the sole curative approach to date. Nonetheless, given the disease’s demographics, only a minority of patients can benefit from this procedure. Currently used prognostic schemes such as the Revised International Prognostic Scoring System (R-IPSS), and most recently the molecular IPSS (IPSS-M), guide clinical management by dividing MDS into two big categories: lower- and higher-risk cases, based on a cut-off score of 3.5. The main clinical problem of the lower-risk group is represented by the management of cytopenias, whereas the prevention of secondary leukemia progression is the goal for the latter. Herein, we discuss the non-transplant treatment of MDS, focusing on current practice and available therapeutic options, while also presenting new investigational agents potentially entering the MDS therapeutic arsenal in the near future.
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Rozema J, van Asten I, Kwant B, Kibbelaar RE, Veeger NJGM, de Wit H, van Roon EN, Hoogendoorn M. Clinical view versus guideline adherence in ferritin monitoring and initiating iron chelation therapy in patients with myelodysplastic syndromes. Eur J Haematol Suppl 2022; 109:772-778. [PMID: 36130872 PMCID: PMC9828450 DOI: 10.1111/ejh.13865] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2022] [Revised: 09/03/2022] [Accepted: 09/08/2022] [Indexed: 01/12/2023]
Abstract
OBJECTIVES In patients with myelodysplastic syndromes (MDS) with >20 transfusions and ferritin levels >1000 μg/L, international guidelines recommend iron chelation therapy (ICT). The study's objective was to determine guideline adherence and the intensity of ferritin monitoring in clinical practice. METHODS We performed an observational population-based study using the HemoBase Registry, which contains data of all MDS patients diagnosed since 2005 in Friesland, the Netherlands. Clinical information on transfusions, ferritin measurements, ICT, and clinical performance as defined by age ≤ 80 years, Charlson Comorbidity Index <2 and lower-risk MDS was collected from health records. RESULTS Two hundred and thirty seven of 292 patients (81.1%) received ≥1 transfusion, and 121 (41.4%) received >20 transfusions. In 57 of these 121 patients (47.1%), ferritin measurements were performed at least once. Clinical performance was significantly associated with monitoring ferritin around the 20th transfusion (RR: 2.49, p = .016). Clinical performance was also associated with initiating ICT (RR: 5.99, p < .001). ICT was offered to 22.3% (n = 25) of eligible patients. CONCLUSIONS In this population-based study, ferritin levels were measured in <50% of MDS patients who received >20 transfusions, and clinical performance was significantly associated with measuring ferritin. Our study suggests that in heavily transfused MDS patients, ferritin monitoring is primarily based on patients' clinical performance rather than guideline recommendations.
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Affiliation(s)
- Johanne Rozema
- Unit of Pharmacotherapy, Epidemiology and Economics, Department of PharmacyUniversity of GroningenGroningenThe Netherlands,Department of Clinical Pharmacy & PharmacologyMedical Centre LeeuwardenLeeuwardenThe Netherlands
| | - Ivar van Asten
- Certe Medical Diagnostics & Advicelocation Medical Centre LeeuwardenLeeuwardenThe Netherlands
| | - Beau Kwant
- Unit of Pharmacotherapy, Epidemiology and Economics, Department of PharmacyUniversity of GroningenGroningenThe Netherlands
| | | | - Nic J. G. M. Veeger
- MCL Academy, Medical Centre LeeuwardenLeeuwardenThe Netherlands,Department of EpidemiologyUniversity of Groningen, University Medical Centre GroningenGroningenThe Netherlands
| | - Harry de Wit
- Certe Medical Diagnostics & Advicelocation Medical Centre LeeuwardenLeeuwardenThe Netherlands
| | - Eric N. van Roon
- Unit of Pharmacotherapy, Epidemiology and Economics, Department of PharmacyUniversity of GroningenGroningenThe Netherlands,Department of Clinical Pharmacy & PharmacologyMedical Centre LeeuwardenLeeuwardenThe Netherlands
| | - Mels Hoogendoorn
- Department of Internal MedicineMedical Centre LeeuwardenLeeuwardenThe Netherlands
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Li J, Zhang W. From iron chelation to overload as a therapeutic strategy to induce ferroptosis in hematologic malignancies. HEMATOLOGY (AMSTERDAM, NETHERLANDS) 2022; 27:1163-1170. [PMID: 36222350 DOI: 10.1080/16078454.2022.2132362] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
OBJECTIVES Ferroptosis is an iron-dependent, non-apoptotic mode of cell death characterized by excessive accumulation of reactive oxygen species (ROS). It plays an important role in the occurrence, development and treatment of various cancers, but little is known regarding the role of ferroptosis in hematologic malignancies. This review elaborates the regulatory mechanism of ferroptosis and the treatment opportunities for targeting ferroptosis in hematologic malignancies. METHODS A systematic literature review through PubMed was conducted to summarize the published evidence on the therapeutic potential of targeting ferroptosis in hematological malignant tumors. Literature sources published in English were searched, using the terms ferroptosis, leukemia, myelodysplastic syndrome, lymphoma and multiple myeloma. RESULTS More and more small molecules have been found to induce ferroptosis in hematologic malignancies through targeted iron metabolism and lipid peroxidation, and some ferroptosis inducers have been proved to have synergistic effect with other chemotherapeutic drugs. CONCLUSION This paper discusses the significance of ferroptosis in hematologic malignancies and provides a new way for the treatment of hematologic malignancies, and more experimental studies should be conducted in future.
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Affiliation(s)
- Jiaojiao Li
- Department of Hematology, General Hospital of Tianjin Medical University, Tianjin, People's Republic of China
| | - Wei Zhang
- Department of Hematology, General Hospital of Tianjin Medical University, Tianjin, People's Republic of China
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Huang L, Tian M, Liu Z, Liu C, Fu R. Deferasirox combination with eltrombopag shows anti-myelodysplastic syndrome effects by enhancing iron deprivation-related apoptosis. J Investig Med 2021; 70:953-962. [PMID: 34921125 DOI: 10.1136/jim-2021-002147] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/09/2021] [Indexed: 11/04/2022]
Abstract
Iron overload (IO) affected the survival of patients with myelodysplastic syndrome (MDS). Deferasirox (DFX) is widely used in patients with MDS for iron chelation therapy, but is not suitable for MDS patients with severe thrombocytopenia. Eltrombopag (ELT) is a type of thrombopoietin receptor (TPOR) analog used in the treatment of thrombocytopenia. Therefore, we sought to explore the synergistic effects and possible mechanisms of DFX combination with ELT in MDS cells. In our study, the combination of DFX with ELT synergistically inhibited proliferation, induced apoptosis and arrested cell cycle of MDS cells. Through the RNA-sequence and gene set enrichment analysis (GSEA), iron metabolism-related pathway played important roles in apoptosis of SKM-1 cells treated with DFX plus ELT. Transferrin receptor (TFRC) was significantly highly expressed in combination group than that in single agent groups, without affecting TPOR. Furthermore, the apoptosis of the combination group MDS cells could be partially reversed by ferric ammonium citrate (FAC), accompanied with decreased expression of TFRC. These results suggested that the combination of DFX and ELT synergistically induced apoptosis of MDS cells by enhancing iron deprivation-related pathway.
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Affiliation(s)
- Lei Huang
- Hematology, Tianjin Medical University General Hospital, Tianjin, China
| | - Mengyue Tian
- Hematology, Tianjin Medical University General Hospital, Tianjin, China
| | - Zhaoyun Liu
- Hematology, Tianjin Medical University General Hospital, Tianjin, China
| | - Chunyan Liu
- Hematology, Tianjin Medical University General Hospital, Tianjin, China
| | - Rong Fu
- Hematology, Tianjin Medical University General Hospital, Tianjin, China
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Parisi S, Finelli C. Prognostic Factors and Clinical Considerations for Iron Chelation Therapy in Myelodysplastic Syndrome Patients. J Blood Med 2021; 12:1019-1030. [PMID: 34887690 PMCID: PMC8651046 DOI: 10.2147/jbm.s287876] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2021] [Accepted: 09/15/2021] [Indexed: 01/19/2023] Open
Abstract
Iron chelation therapy (ICT) is an important tool in the treatment of transfusion-dependent lower-risk myelodysplastic syndrome (MDS) patients. ICT is effective in decreasing iron overload and consequently in limiting its detrimental effects on several organs, such as the heart, liver, and endocrine glands. Besides this effect, ICT also proved to be effective in improving peripheral cytopenia in a significant number of MDS patients, thus further increasing the clinical interest of this therapeutic tool. In the first part of the review, we will analyze the toxic effect of iron overload and its mechanism. Subsequently, we will revise the clinical role of ICT in various subsets of MDS patients (low, intermediate, and high risk MDS, patients who are candidates for allogeneic stem cell transplantation).
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Affiliation(s)
- Sarah Parisi
- IRCCS Azienda Ospedaliero-Universitaria di Bologna, Istituto di Ematologia “Seràgnoli”, Dipartimento di Medicina Specialistica, Diagnostica e Sperimentale, Università di Bologna, Bologna, Italy
| | - Carlo Finelli
- IRCCS Azienda Ospedaliero-Universitaria di Bologna, Istituto di Ematologia “Seràgnoli”, Bologna, Italy
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Palumbo GA, Galimberti S, Barcellini W, Cilloni D, Di Renzo N, Elli EM, Finelli C, Maurillo L, Ricco A, Musto P, Russo R, Latagliata R. From Biology to Clinical Practice: Iron Chelation Therapy With Deferasirox. Front Oncol 2021; 11:752192. [PMID: 34692534 PMCID: PMC8527180 DOI: 10.3389/fonc.2021.752192] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2021] [Accepted: 09/08/2021] [Indexed: 01/19/2023] Open
Abstract
Iron chelation therapy (ICT) has become a mainstay in heavily transfused hematological patients, with the aim to reduce iron overload (IOL) and prevent organ damage. This therapeutic approach is already widely used in thalassemic patients and in low-risk Myelodysplastic Syndrome (MDS) patients. More recently, ICT has been proposed for high-risk MDS, especially when an allogeneic bone marrow transplantation has been planned. Furthermore, other hematological and hereditary disorders, characterized by considerable transfusion support to manage anemia, could benefit from this therapy. Meanwhile, data accumulated on how iron toxicity could exacerbate anemia and other clinical comorbidities due to oxidative stress radical oxygen species (ROS) mediated by free iron species. Taking all into consideration, together with the availability of approved oral iron chelators, we envision a larger use of ICT in the near future. The aim of this review is to better identify those non-thalassemic patients who can benefit from ICT and give practical tips for management of this therapeutic strategy.
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Affiliation(s)
- Giuseppe A Palumbo
- Department of Scienze Mediche Chirurgiche e Tecnologie Avanzate "G.F. Ingrassia, " University of Catania, Catania, Italy
| | - Sara Galimberti
- Section of Hematology, Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Wilma Barcellini
- Hematology, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Ca' Granda Ospedale Maggiore Policlinico di Milano and University of Milan, Milan, Italy
| | - Daniela Cilloni
- Department of Clinical and Biological Sciences, University of Turin, Turin, Italy
| | - Nicola Di Renzo
- Hematology and Transplant Unit, Ospedale Vito Fazzi, Lecce, Italy
| | - Elena Maria Elli
- Division of Hematology and Bone Marrow Unit, Ospedale San Gerardo, Aziende Socio Sanitarie Territoriali (ASST), Monza, Italy
| | - Carlo Finelli
- IRCCS Azienda Ospedaliero-Universitaria di Bologna, Istituto di Ematologia "Seràgnoli", Bologna, Italy
| | - Luca Maurillo
- Department of Onco-hematology, Fondazione Policlinico Tor Vergata, Rome, Italy
| | - Alessandra Ricco
- Unit of Hematology and Stem Cell Transplantation, Azienda Ospedaliera Universitaria (AOU) Consorziale Policlinico, Bari, Italy
| | - Pellegrino Musto
- Unit of Hematology and Stem Cell Transplantation, Azienda Ospedaliera Universitaria (AOU) Consorziale Policlinico, Bari, Italy.,Department of Emergency and Organ Transplantation, "Aldo Moro" University School of Medicine, Bari, Italy
| | - Rodolfo Russo
- Clinica Nefrologica, Dialisi e Trapianto, Department of Integrated Medicine with the Territory, IRCCS Ospedale Policlinico San Martino, Genoa, Italy
| | - Roberto Latagliata
- Unità Operativa Complessa (UOC) Ematologia, Ospedale Belcolle, Viterbo and Division of Cellular Biotechnology and Hematology, Sapienza University, Rome, Italy
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Shallis RM, Zeidan AM. Management of the Older Patient with Myelodysplastic Syndrome. Drugs Aging 2021; 38:751-767. [PMID: 34342860 DOI: 10.1007/s40266-021-00881-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/11/2021] [Indexed: 01/19/2023]
Abstract
No two diagnoses of myelodysplastic syndrome are genuinely alike, owing to differing and dynamic mutational topography and epigenetic aberrancy. Consequently, no two patients with myelodysplastic syndrome are identical and disease-specific and patient-specific factors are considered in formulating the optimal treatment, which includes few that are disease modifying. Age itself should not be an absolute contraindication to therapy, including intensive therapy such as allogeneic hematopoietic stem cell transplantation, which is the only curative therapy. However, age associates with an increased prevalence of frailty and comorbidities that must be considered and may preclude a path to cure. Palliative therapies are the mainstay for many patients with myelodysplastic syndrome, which is a disease of older adults with the majority of patients diagnosed at age ≥ 75 years. The older patient requires heightened attention to end organ function/reserve and drug-drug interactions as well as insurance, income, cost, and socioeconomic and psychosocial issues that influence management. Many prior studies have included relatively younger populations or have not specifically performed high-quality subgroup analyses of older patients. In this review, we discuss the available standard-of-care therapies for myelodysplastic syndrome as they specifically relate to the older population and assess the emerging therapeutics that may further the pursuit for personalized treatment and improve both the outcomes and quality of life of the older patient with myelodysplastic syndrome.
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Affiliation(s)
- Rory M Shallis
- Section of Hematology, Department of Internal Medicine, Yale University School of Medicine and Yale Cancer Center, Yale University, 333 Cedar Street, PO Box 208028, New Haven, CT, 06520-8028, USA
| | - Amer M Zeidan
- Section of Hematology, Department of Internal Medicine, Yale University School of Medicine and Yale Cancer Center, Yale University, 333 Cedar Street, PO Box 208028, New Haven, CT, 06520-8028, USA.
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Myelodysplastic Syndromes in the Postgenomic Era and Future Perspectives for Precision Medicine. Cancers (Basel) 2021; 13:cancers13133296. [PMID: 34209457 PMCID: PMC8267785 DOI: 10.3390/cancers13133296] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2021] [Revised: 06/18/2021] [Accepted: 06/21/2021] [Indexed: 12/19/2022] Open
Abstract
Simple Summary With demographic ageing, improved cancer survivorship and increased diagnostic sensitivity, incident cases of patients with Myelodysplastic Syndromes (MDS) are continuously rising, leading to a relevant impact on health care resources. Disease heterogeneity and various comorbidities are challenges for the management of the generally elderly patients. Therefore, experienced physicians and multidisciplinary teams should be involved in the establishment of the correct diagnosis, risk-assessment and personalized treatment plan. Next-generation sequencing allows for early detection of clonal hematopoiesis and monitoring of clonal evolution, but also poses new challenges for its appropriate use. At present, allogeneic hematopoietic stem cell transplantation remains the only curative treatment option for a minority of fit MDS patients. All others receive palliative treatment and will eventually progress, having an unmet need for novel therapies. Targeting compounds are in prospect for precision medicine, however, abrogation of clonal evolution to acute myeloid leukemia remains actually out of reach. Abstract Myelodysplastic syndromes (MDS) represent a heterogeneous group of clonal disorders caused by sequential accumulation of somatic driver mutations in hematopoietic stem and progenitor cells (HSPCs). MDS is characterized by ineffective hematopoiesis with cytopenia, dysplasia, inflammation, and a variable risk of transformation into secondary acute myeloid leukemia. The advent of next-generation sequencing has revolutionized our understanding of the genetic basis of the disease. Nevertheless, the biology of clonal evolution remains poorly understood, and the stochastic genetic drift with sequential accumulation of genetic hits in HSPCs is individual, highly dynamic and hardly predictable. These continuously moving genetic targets pose substantial challenges for the implementation of precision medicine, which aims to maximize efficacy with minimal toxicity of treatments. In the current postgenomic era, allogeneic hematopoietic stem cell transplantation remains the only curative option for younger and fit MDS patients. For all unfit patients, regeneration of HSPCs stays out of reach and all available therapies remain palliative, which will eventually lead to refractoriness and progression. In this review, we summarize the recent advances in our understanding of MDS pathophysiology and its impact on diagnosis, risk-assessment and disease monitoring. Moreover, we present ongoing clinical trials with targeting compounds and highlight future perspectives for precision medicine.
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Ma L, Gholam Azad M, Dharmasivam M, Richardson V, Quinn RJ, Feng Y, Pountney DL, Tonissen KF, Mellick GD, Yanatori I, Richardson DR. Parkinson's disease: Alterations in iron and redox biology as a key to unlock therapeutic strategies. Redox Biol 2021; 41:101896. [PMID: 33799121 PMCID: PMC8044696 DOI: 10.1016/j.redox.2021.101896] [Citation(s) in RCA: 56] [Impact Index Per Article: 18.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2020] [Revised: 02/05/2021] [Accepted: 02/09/2021] [Indexed: 12/13/2022] Open
Abstract
A plethora of studies indicate that iron metabolism is dysregulated in Parkinson's disease (PD). The literature reveals well-documented alterations consistent with established dogma, but also intriguing paradoxical observations requiring mechanistic dissection. An important fact is the iron loading in dopaminergic neurons of the substantia nigra pars compacta (SNpc), which are the cells primarily affected in PD. Assessment of these changes reveal increased expression of proteins critical for iron uptake, namely transferrin receptor 1 and the divalent metal transporter 1 (DMT1), and decreased expression of the iron exporter, ferroportin-1 (FPN1). Consistent with this is the activation of iron regulator protein (IRP) RNA-binding activity, which is an important regulator of iron homeostasis, with its activation indicating cytosolic iron deficiency. In fact, IRPs bind to iron-responsive elements (IREs) in the 3ꞌ untranslated region (UTR) of certain mRNAs to stabilize their half-life, while binding to the 5ꞌ UTR prevents translation. Iron loading of dopaminergic neurons in PD may occur through these mechanisms, leading to increased neuronal iron and iron-mediated reactive oxygen species (ROS) generation. The "gold standard" histological marker of PD, Lewy bodies, are mainly composed of α-synuclein, the expression of which is markedly increased in PD. Of note, an atypical IRE exists in the α-synuclein 5ꞌ UTR that may explain its up-regulation by increased iron. This dysregulation could be impacted by the unique autonomous pacemaking of dopaminergic neurons of the SNpc that engages L-type Ca+2 channels, which imparts a bioenergetic energy deficit and mitochondrial redox stress. This dysfunction could then drive alterations in iron trafficking that attempt to rescue energy deficits such as the increased iron uptake to provide iron for key electron transport proteins. Considering the increased iron-loading in PD brains, therapies utilizing limited iron chelation have shown success. Greater therapeutic advancements should be possible once the exact molecular pathways of iron processing are dissected.
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Affiliation(s)
- L Ma
- School of Environment and Science, Griffith University Nathan, Brisbane, Queensland, Australia; Griffith Institute for Drug Discovery, Griffith University, Nathan, Brisbane, Queensland, Australia
| | - M Gholam Azad
- School of Environment and Science, Griffith University Nathan, Brisbane, Queensland, Australia; Griffith Institute for Drug Discovery, Griffith University, Nathan, Brisbane, Queensland, Australia; Centre for Cancer Cell Biology and Drug Discovery, Griffith Institute for Drug Discovery, Griffith University, Nathan, Brisbane, Queensland, Australia
| | - M Dharmasivam
- School of Environment and Science, Griffith University Nathan, Brisbane, Queensland, Australia; Griffith Institute for Drug Discovery, Griffith University, Nathan, Brisbane, Queensland, Australia; Centre for Cancer Cell Biology and Drug Discovery, Griffith Institute for Drug Discovery, Griffith University, Nathan, Brisbane, Queensland, Australia
| | - V Richardson
- School of Environment and Science, Griffith University Nathan, Brisbane, Queensland, Australia; Griffith Institute for Drug Discovery, Griffith University, Nathan, Brisbane, Queensland, Australia; Centre for Cancer Cell Biology and Drug Discovery, Griffith Institute for Drug Discovery, Griffith University, Nathan, Brisbane, Queensland, Australia
| | - R J Quinn
- Griffith Institute for Drug Discovery, Griffith University, Nathan, Brisbane, Queensland, Australia
| | - Y Feng
- School of Environment and Science, Griffith University Nathan, Brisbane, Queensland, Australia; Griffith Institute for Drug Discovery, Griffith University, Nathan, Brisbane, Queensland, Australia
| | - D L Pountney
- School of Medical Science, Griffith University, Gold Coast, Queensland, Australia
| | - K F Tonissen
- School of Environment and Science, Griffith University Nathan, Brisbane, Queensland, Australia; Griffith Institute for Drug Discovery, Griffith University, Nathan, Brisbane, Queensland, Australia
| | - G D Mellick
- School of Environment and Science, Griffith University Nathan, Brisbane, Queensland, Australia; Griffith Institute for Drug Discovery, Griffith University, Nathan, Brisbane, Queensland, Australia
| | - I Yanatori
- Department of Pathology and Biological Responses, Nagoya University Graduate School of Medicine, Nagoya, 466-8550, Japan
| | - D R Richardson
- School of Environment and Science, Griffith University Nathan, Brisbane, Queensland, Australia; Griffith Institute for Drug Discovery, Griffith University, Nathan, Brisbane, Queensland, Australia; Centre for Cancer Cell Biology and Drug Discovery, Griffith Institute for Drug Discovery, Griffith University, Nathan, Brisbane, Queensland, Australia; Department of Pathology and Biological Responses, Nagoya University Graduate School of Medicine, Nagoya, 466-8550, Japan.
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Lewis R, Bewersdorf JP, Zeidan AM. Clinical Management of Anemia in Patients with Myelodysplastic Syndromes: An Update on Emerging Therapeutic Options. Cancer Manag Res 2021; 13:645-657. [PMID: 33531837 PMCID: PMC7846829 DOI: 10.2147/cmar.s240600] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2020] [Accepted: 01/13/2021] [Indexed: 12/18/2022] Open
Abstract
For the majority of patients with lower-risk myelodysplastic syndrome (LR-MDS), one of the primary clinical goals is to alleviate the symptoms associated with the resultant cytopenias and to minimize the transfusion burden. While supportive red blood cell (RBC) transfusions and erythropoiesis-stimulating agents (ESAs) may lead to clinical improvement, frequent transfusions are often complicated by iron overload and decreased quality of life; furthermore, most patients either do not respond to ESAs or will eventually develop resistance. As such, there is a great need for further therapeutic options in the management of anemia related to MDS. Several additional therapeutics are now available in select patients with LR-MDS and symptomatic anemia including luspatercept, lenalidomide, and immunosuppressive therapy. Furthermore, several novel agents are currently in development to address this area of clinical need such as imetelstat and roxadustat. In this article, we review the currently available therapeutic options for symptomatic anemia in LR-MDS as well as review the therapeutic agents in development.
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Affiliation(s)
- Russell Lewis
- Department of Medicine, Section of Hematology, Yale University, New Haven, CT, USA
| | | | - Amer M Zeidan
- Department of Medicine, Section of Hematology, Yale University, New Haven, CT, USA
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15
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Holbein BE, Ang MTC, Allan DS, Chen W, Lehmann C. Iron-withdrawing anti-infectives for new host-directed therapies based on iron dependence, the Achilles' heel of antibiotic-resistant microbes. ENVIRONMENTAL CHEMISTRY LETTERS 2021; 19:2789-2808. [PMID: 33907538 PMCID: PMC8062846 DOI: 10.1007/s10311-021-01242-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/23/2021] [Accepted: 04/13/2021] [Indexed: 05/02/2023]
Abstract
The iron dependence of antibiotic-resistant microbes represents an Achilles' heel that can be exploited broadly. The growing global problem of antibiotic resistance of microbial pathogens wherein microbes become resistant to the very antibiotics used against them during infection is linked not only to our health uses but also to agribusiness practices and the changing environment. Here we review mechanisms of microbial iron acquisition and host iron withdrawal defense, and the influence of iron withdrawal on the antimicrobial activity of antibiotics. Antibiotic-resistant microbes are unaltered in their iron requirements, but iron withdrawal from microbes enhances the activities of various antibiotics and importantly suppresses outgrowth of antibiotic-exposed resistant microbial survivors. Of the three therapeutic approaches available to exploit microbial iron susceptibility, including (1) use of gallium as a non-functional iron analogue, (2) Trojan horse conjugates of microbial siderophores carrying antibiotics, and (3) new generation iron chelators, purposely designed as anti-microbials, the latter offers various advantages. For instance, these novel anti-microbial chelators overcome the limitations of conventional clinically-used hematological chelators which display host toxicity and are not useful antimicrobials. 3-Hydroxypyridin-4-one-containing polymeric chelators appear to have the highest potential. DIBI (developmental code name) is a well-developed lead candidate, being a low molecular weight, water-soluble copolymer with enhanced iron binding characteristics, strong anti-microbial and anti-inflammatory activities, low toxicity for animals and demonstrated freedom from microbial resistance development. DIBI has been shown to enhance antibiotic efficacy for antibiotic-resistant microbes during infection, and it also prevents recovery growth and resistance development during microbe exposure to various antibiotics. Because DIBI bolsters innate iron withdrawal defenses of the infected host, it has potential to provide a host-directed anti-infective therapy.
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Affiliation(s)
- Bruce E. Holbein
- Chelation Partners Inc., #58, The Labs at Innovacorp, Life Sciences Research Institute, 1344 Summer Street, Halifax, NS B3H OA8 Canada
- Department of Microbiology and Immunology, Dalhousie University, 5859 College St., Halifax, NS B3H 1X5 Canada
| | - M. Trisha C. Ang
- Chelation Partners Inc., #58, The Labs at Innovacorp, Life Sciences Research Institute, 1344 Summer Street, Halifax, NS B3H OA8 Canada
| | - David S. Allan
- Chelation Partners Inc., #58, The Labs at Innovacorp, Life Sciences Research Institute, 1344 Summer Street, Halifax, NS B3H OA8 Canada
| | - Wangxue Chen
- Human Health Therapeutics Research Center, National Research Council Canada, 100 Sussex Drive, Ottawa, ON K1A 0R6 Canada
| | - Christian Lehmann
- Department of Microbiology and Immunology, Dalhousie University, 5859 College St., Halifax, NS B3H 1X5 Canada
- Department of Anesthesia, Pain Management and Perioperative Medicine, Dalhousie University, Halifax, NS Canada
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Carraway HE, Saygin C. Therapy for lower-risk MDS. HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2020; 2020:426-433. [PMID: 33275714 PMCID: PMC7727572 DOI: 10.1182/hematology.2020000127] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/09/2023]
Abstract
Lower-risk myelodysplastic syndromes (MDS) are characterized by the presence of dysplasia, low bone marrow blast percentage, low number and depth of cytopenia(s), and relatively good-risk karyotpic and molecular abnormalities. A score of ≤3.5 on the Revised International Prognostic Scoring System classifies patients as lower-risk MDS. Information from a mutational profile of the MDS at time of diagnosis (and over serial time points) can be reassuring for predicted behavior of lower-risk MDS compared with one expected to progress more rapidly (higher-risk MDS). Supportive care continues to be the crux of treatment, although the options to reduce transfusion needs have improved in 2020. Erythropoiesis stimulating agents, lenalidomide, and luspatercept address the most frequent (and symptomatic) cytopenia (anemia) and are started only when patients are transfusion dependent. Patients can derive long-term benefits (years) from these approaches but will often progress to higher-risk MDS. Interestingly, some patients with lower-risk MDS can present with an isolated thrombocytopenia for which thrombopoietin receptor analogs such as romiplostim and eltrombopag are options (as long as blast counts are low). The presence of pancytopenia and or intensifying and unremitting clinical symptoms are often treated with hypomethylating agents or (anti-thymocyte globulin if hypocellular MDS is of concern). Targeted therapies are emerging for small subsets of MDS patients with specific somatic mutations (ie, TP53, IDH1/2, FLT3), although currently, there are no approved, mutation-directed medications to treat MDS.
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Affiliation(s)
- Hetty E. Carraway
- Leukemia Program, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH; and
| | - Caner Saygin
- Wexner Medical Center, The Ohio State University, Cleveland, OH
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Calabrese C, Panuzzo C, Stanga S, Andreani G, Ravera S, Maglione A, Pironi L, Petiti J, Shahzad Ali M, Scaravaglio P, Napoli F, Fava C, De Gobbi M, Frassoni F, Saglio G, Bracco E, Pergolizzi B, Cilloni D. Deferasirox-Dependent Iron Chelation Enhances Mitochondrial Dysfunction and Restores p53 Signaling by Stabilization of p53 Family Members in Leukemic Cells. Int J Mol Sci 2020; 21:ijms21207674. [PMID: 33081324 PMCID: PMC7589297 DOI: 10.3390/ijms21207674] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2020] [Revised: 10/02/2020] [Accepted: 10/10/2020] [Indexed: 12/11/2022] Open
Abstract
Iron is crucial to satisfy several mitochondrial functions including energy metabolism and oxidative phosphorylation. Patients affected by Myelodysplastic Syndromes (MDS) and acute myeloid leukemia (AML) are frequently characterized by iron overload (IOL), due to continuous red blood cell (RBC) transfusions. This event impacts the overall survival (OS) and it is associated with increased mortality in lower-risk MDS patients. Accordingly, the oral iron chelator Deferasirox (DFX) has been reported to improve the OS and delay leukemic transformation. However, the molecular players and the biological mechanisms laying behind remain currently mostly undefined. The aim of this study has been to investigate the potential anti-leukemic effect of DFX, by functionally and molecularly analyzing its effects in three different leukemia cell lines, harboring or not p53 mutations, and in human primary cells derived from 15 MDS/AML patients. Our findings indicated that DFX can lead to apoptosis, impairment of cell growth only in a context of IOL, and can induce a significant alteration of mitochondria network, with a sharp reduction in mitochondrial activity. Moreover, through a remarkable reduction of Murine Double Minute 2 (MDM2), known to regulate the stability of p53 and p73 proteins, we observed an enhancement of p53 transcriptional activity after DFX. Interestingly, this iron depletion-triggered signaling is enabled by p73, in the absence of p53, or in the presence of a p53 mutant form. In conclusion, we propose a mechanism by which the increased p53 family transcriptional activity and protein stability could explain the potential benefits of iron chelation therapy in terms of improving OS and delaying leukemic transformation.
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Affiliation(s)
- Chiara Calabrese
- Department of Clinical and Biological Sciences, University of Turin, 10043 Turin, Italy; (C.C.); (G.A.); (A.M.); (L.P.); (J.P.); (M.S.A.); (P.S.); (C.F.); (M.D.G.); (F.F.); (G.S.); (B.P.); (D.C.)
| | - Cristina Panuzzo
- Department of Clinical and Biological Sciences, University of Turin, 10043 Turin, Italy; (C.C.); (G.A.); (A.M.); (L.P.); (J.P.); (M.S.A.); (P.S.); (C.F.); (M.D.G.); (F.F.); (G.S.); (B.P.); (D.C.)
- Correspondence:
| | - Serena Stanga
- Department of Neuroscience Rita Levi Montalcini, Neuroscience Institute Cavalieri Ottolenghi, University of Turin, 10126 Turin, Italy;
| | - Giacomo Andreani
- Department of Clinical and Biological Sciences, University of Turin, 10043 Turin, Italy; (C.C.); (G.A.); (A.M.); (L.P.); (J.P.); (M.S.A.); (P.S.); (C.F.); (M.D.G.); (F.F.); (G.S.); (B.P.); (D.C.)
| | - Silvia Ravera
- Human Anatomy Section, Department of Experimental Medicine, University of Genoa, 16132 Genova, Italy;
| | - Alessandro Maglione
- Department of Clinical and Biological Sciences, University of Turin, 10043 Turin, Italy; (C.C.); (G.A.); (A.M.); (L.P.); (J.P.); (M.S.A.); (P.S.); (C.F.); (M.D.G.); (F.F.); (G.S.); (B.P.); (D.C.)
| | - Lucrezia Pironi
- Department of Clinical and Biological Sciences, University of Turin, 10043 Turin, Italy; (C.C.); (G.A.); (A.M.); (L.P.); (J.P.); (M.S.A.); (P.S.); (C.F.); (M.D.G.); (F.F.); (G.S.); (B.P.); (D.C.)
| | - Jessica Petiti
- Department of Clinical and Biological Sciences, University of Turin, 10043 Turin, Italy; (C.C.); (G.A.); (A.M.); (L.P.); (J.P.); (M.S.A.); (P.S.); (C.F.); (M.D.G.); (F.F.); (G.S.); (B.P.); (D.C.)
| | - Muhammad Shahzad Ali
- Department of Clinical and Biological Sciences, University of Turin, 10043 Turin, Italy; (C.C.); (G.A.); (A.M.); (L.P.); (J.P.); (M.S.A.); (P.S.); (C.F.); (M.D.G.); (F.F.); (G.S.); (B.P.); (D.C.)
| | - Patrizia Scaravaglio
- Department of Clinical and Biological Sciences, University of Turin, 10043 Turin, Italy; (C.C.); (G.A.); (A.M.); (L.P.); (J.P.); (M.S.A.); (P.S.); (C.F.); (M.D.G.); (F.F.); (G.S.); (B.P.); (D.C.)
| | - Francesca Napoli
- Department of Oncology, University of Turin, 10043 Turin, Italy; (F.N.); (E.B.)
| | - Carmen Fava
- Department of Clinical and Biological Sciences, University of Turin, 10043 Turin, Italy; (C.C.); (G.A.); (A.M.); (L.P.); (J.P.); (M.S.A.); (P.S.); (C.F.); (M.D.G.); (F.F.); (G.S.); (B.P.); (D.C.)
| | - Marco De Gobbi
- Department of Clinical and Biological Sciences, University of Turin, 10043 Turin, Italy; (C.C.); (G.A.); (A.M.); (L.P.); (J.P.); (M.S.A.); (P.S.); (C.F.); (M.D.G.); (F.F.); (G.S.); (B.P.); (D.C.)
| | - Francesco Frassoni
- Department of Clinical and Biological Sciences, University of Turin, 10043 Turin, Italy; (C.C.); (G.A.); (A.M.); (L.P.); (J.P.); (M.S.A.); (P.S.); (C.F.); (M.D.G.); (F.F.); (G.S.); (B.P.); (D.C.)
| | - Giuseppe Saglio
- Department of Clinical and Biological Sciences, University of Turin, 10043 Turin, Italy; (C.C.); (G.A.); (A.M.); (L.P.); (J.P.); (M.S.A.); (P.S.); (C.F.); (M.D.G.); (F.F.); (G.S.); (B.P.); (D.C.)
| | - Enrico Bracco
- Department of Oncology, University of Turin, 10043 Turin, Italy; (F.N.); (E.B.)
| | - Barbara Pergolizzi
- Department of Clinical and Biological Sciences, University of Turin, 10043 Turin, Italy; (C.C.); (G.A.); (A.M.); (L.P.); (J.P.); (M.S.A.); (P.S.); (C.F.); (M.D.G.); (F.F.); (G.S.); (B.P.); (D.C.)
| | - Daniela Cilloni
- Department of Clinical and Biological Sciences, University of Turin, 10043 Turin, Italy; (C.C.); (G.A.); (A.M.); (L.P.); (J.P.); (M.S.A.); (P.S.); (C.F.); (M.D.G.); (F.F.); (G.S.); (B.P.); (D.C.)
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Controversies on the Consequences of Iron Overload and Chelation in MDS. Hemasphere 2020; 4:e357. [PMID: 32647792 PMCID: PMC7306315 DOI: 10.1097/hs9.0000000000000357] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2019] [Accepted: 02/17/2020] [Indexed: 12/15/2022] Open
Abstract
Many patients with MDS are prone to develop systemic and tissue iron overload in part as a consequence of disease-immanent ineffective erythropoiesis. However, chronic red blood cell transfusions, which are part of the supportive care regimen to correct anemia, are the major source of iron overload in MDS. Increased systemic iron levels eventually lead to the saturation of the physiological systemic iron carrier transferrin and the occurrence of non-transferrin-bound iron (NTBI) together with its reactive fraction, the labile plasma iron (LPI). NTBI/LPI-mediated toxicity and tissue iron overload may exert multiple detrimental effects that contribute to the pathogenesis, complications and eventually evolution of MDS. Until recently, the evidence supporting the use of iron chelation in MDS was based on anecdotal reports, uncontrolled clinical trials or prospective registries. Despite not fully conclusive, these and more recent studies, including the TELESTO trial, unravel an overall adverse action of iron overload and therapeutic benefit of chelation, ranging from improved hematological outcome, reduced transfusion dependence and superior survival of iron-loaded MDS patients. The still limited and somehow controversial experimental and clinical data available from preclinical studies and randomized trials highlight the need for further investigation to fully elucidate the mechanisms underlying the pathological impact of iron overload-mediated toxicity as well as the effect of classic and novel iron restriction approaches in MDS. This review aims at providing an overview of the current clinical and translational debated landscape about the consequences of iron overload and chelation in the setting of MDS.
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Angelucci E, Li J, Greenberg P, Wu D, Hou M, Montano Figueroa EH, Rodriguez MG, Dong X, Ghosh J, Izquierdo M, Garcia-Manero G. Iron Chelation in Transfusion-Dependent Patients With Low- to Intermediate-1-Risk Myelodysplastic Syndromes: A Randomized Trial. Ann Intern Med 2020; 172:513-522. [PMID: 32203980 DOI: 10.7326/m19-0916] [Citation(s) in RCA: 68] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Iron chelation therapy (ICT) in patients with lower-risk myelodysplastic syndromes (MDS) has not been evaluated in randomized studies. OBJECTIVE To evaluate event-free survival (EFS) and safety of ICT in iron-overloaded patients with low- or intermediate-1-risk MDS. DESIGN Multicenter, randomized, double-blind, placebo-controlled trial (TELESTO). (ClinicalTrials.gov: NCT00940602). SETTING 60 centers in 16 countries. PARTICIPANTS 225 patients with serum ferritin levels greater than 2247 pmol/L; prior receipt of 15 to 75 packed red blood cell units; and no severe cardiac, liver, or renal abnormalities. INTERVENTION Deferasirox dispersible tablets (10 to 40 mg/kg per day) (n = 149) or matching placebo (n = 76). MEASUREMENTS The primary end point was EFS, defined as time from date of randomization to first documented nonfatal event (related to cardiac or liver dysfunction and transformation to acute myeloid leukemia) or death, whichever occurred first. RESULTS Median time on treatment was 1.6 years (interquartile range [IQR], 0.5 to 3.1 years) in the deferasirox group and 1.0 year (IQR, 0.6 to 2.0 years) in the placebo group. Median EFS was prolonged by approximately 1 year with deferasirox versus placebo (3.9 years [95% CI, 3.2 to 4.3 years] vs. 3.0 years [CI, 2.2 to 3.7 years], respectively; hazard ratio, 0.64 [CI, 0.42 to 0.96]). Adverse events occurred in 97.3% of deferasirox recipients and 90.8% of placebo recipients. Exposure-adjusted incidence rates of adverse events (≥15 events per 100 patient treatment-years) in deferasirox versus placebo recipients, respectively, were 24.7 versus 23.9 for diarrhea, 21.8 versus 18.7 for pyrexia, 16.7 versus 22.7 for upper respiratory tract infection, and 15.9 versus 0.9 for increased serum creatinine concentration. LIMITATIONS The protocol was amended from a phase 3 to a phase 2 study, with a reduced target sample size from 630 to 210 participants. There was differential follow-up between treatment groups. CONCLUSION The findings support ICT in iron-overloaded patients with low- to intermediate-1-risk MDS, with longer EFS compared with placebo and a clinically manageable safety profile. Therefore, ICT may be considered in these patients. PRIMARY FUNDING SOURCE Novartis Pharma AG.
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Affiliation(s)
- Emanuele Angelucci
- Hematology and Transplant Center, IRCCS Ospedale Policlinico San Martino, Genova, Italy (E.A.)
| | - Junmin Li
- Ruijin Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China (J.L.)
| | - Peter Greenberg
- Stanford University Medical Center, Stanford, California (P.G.)
| | - Depei Wu
- Jiangsu Institute of Hematology, First Affiliated Hospital of Soochow University, Suzhou, China (D.W.)
| | - Ming Hou
- Department of Hematology, Qilu Hospital, Shandong University, Jinan, China (M.H.)
| | | | - Maria Guadalupe Rodriguez
- Department of Hematology, Hospital de Especialidades, Centro Médico Nacional La Raza, IMSS, Mexico City, Mexico (M.G.R.)
| | - Xunwei Dong
- Novartis Pharmaceuticals Corporation, East Hanover, New Jersey (X.D., J.G.)
| | - Jagannath Ghosh
- Novartis Pharmaceuticals Corporation, East Hanover, New Jersey (X.D., J.G.)
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Evolving therapies for lower-risk myelodysplastic syndromes. Ann Hematol 2020; 99:677-692. [PMID: 32078008 DOI: 10.1007/s00277-020-03963-1] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2020] [Accepted: 02/10/2020] [Indexed: 12/16/2022]
Abstract
The development in the therapeutic landscape of myelodysplastic syndromes (MDS) has substantially lagged behind other hematologic malignancies with no new drug approvals for MDS for 13 years since the approval of decitabine in the United States in 2006. While therapeutic concepts for MDS patients continue to be primarily defined by clinical-pathologic risk stratification tools such as the International Prognostic Scoring System (IPSS) and its revised version IPSS-R, our understanding of the genetic landscape and the molecular pathogenesis of MDS has greatly evolved over the last decade. It is expected that the therapeutic approach to MDS patients will become increasingly individualized based on prognostic and predictive genetic features and other biomarkers. Herein, we review the current treatment of lower-risk MDS patients and discuss promising agents in advanced clinical testing for the treatment of symptomatic anemia in lower-risk MDS patients such as luspatercept and imetelstat. Lastly, we review the clinical development of new agents and the implications of the wider availability of mutational analysis for the management of individual MDS patients.
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21
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Liu H, Yang N, Meng S, Zhang Y, Zhang H, Zhang W. Iron chelation therapy for myelodysplastic syndrome: a systematic review and meta-analysis. Clin Exp Med 2020; 20:1-9. [PMID: 31712933 DOI: 10.1007/s10238-019-00592-5] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2019] [Accepted: 10/30/2019] [Indexed: 01/19/2023]
Abstract
Iron overload remains a concern in myelodysplastic syndrome (MDS) patients especially those requiring recurrent blood transfusions. Whether iron chelating therapy (ICT) is beneficial to the long-term survival of myelodysplastic syndrome is still a controversial issue. Therefore, we conducted a systematic review and meta-analysis to clarify the relationship between ICT and long-term survival in patients with MDS. A total of 14 studies involving 7242 participants were identified; the outcomes revealed that for patients with MDS, ICT resulted in a lower risk of mortality compared to those with no ICT (HR 0.57; 95% CI 0.44-0.70; P < 0.001); what is more, ICT led to a lower risk of leukemia transformation (HR 0.70; 95% CI 0.52-0.93; P = 0.016). Results of subgroup analyses based on adequate ICT or any ICT, low/int-1 IPSS or unclassified IPSS and study types indicated that the ICT had a beneficial role in all these groups of patients.
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Affiliation(s)
- Hailing Liu
- Department of Clinical Hematology, Second Affiliated Hospital of Xi'an Jiaotong University, West Five Road, No. 157, Xi'an, 710004, Shaanxi Province, China
| | - Nan Yang
- Department of Clinical Hematology, Second Affiliated Hospital of Xi'an Jiaotong University, West Five Road, No. 157, Xi'an, 710004, Shaanxi Province, China
| | - Shan Meng
- Department of Clinical Hematology, Second Affiliated Hospital of Xi'an Jiaotong University, West Five Road, No. 157, Xi'an, 710004, Shaanxi Province, China
| | - Yang Zhang
- Department of Clinical Hematology, Second Affiliated Hospital of Xi'an Jiaotong University, West Five Road, No. 157, Xi'an, 710004, Shaanxi Province, China
| | - Hui Zhang
- Department of Clinical Hematology, Second Affiliated Hospital of Xi'an Jiaotong University, West Five Road, No. 157, Xi'an, 710004, Shaanxi Province, China
| | - Wanggang Zhang
- Department of Clinical Hematology, Second Affiliated Hospital of Xi'an Jiaotong University, West Five Road, No. 157, Xi'an, 710004, Shaanxi Province, China.
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Roatsch M, Hoffmann I, Abboud MI, Hancock RL, Tarhonskaya H, Hsu KF, Wilkins SE, Yeh TL, Lippl K, Serrer K, Moneke I, Ahrens TD, Robaa D, Wenzler S, Barthes NPF, Franz H, Sippl W, Lassmann S, Diederichs S, Schleicher E, Schofield CJ, Kawamura A, Schüle R, Jung M. The Clinically Used Iron Chelator Deferasirox Is an Inhibitor of Epigenetic JumonjiC Domain-Containing Histone Demethylases. ACS Chem Biol 2019; 14:1737-1750. [PMID: 31287655 DOI: 10.1021/acschembio.9b00289] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Fe(II)- and 2-oxoglutarate (2OG)-dependent JumonjiC domain-containing histone demethylases (JmjC KDMs) are "epigenetic eraser" enzymes involved in the regulation of gene expression and are emerging drug targets in oncology. We screened a set of clinically used iron chelators and report that they potently inhibit JMJD2A (KDM4A) in vitro. Mode of action investigations revealed that one compound, deferasirox, is a bona fide active site-binding inhibitor as shown by kinetic and spectroscopic studies. Synthesis of derivatives with improved cell permeability resulted in significant upregulation of histone trimethylation and potent cancer cell growth inhibition. Deferasirox was also found to inhibit human 2OG-dependent hypoxia inducible factor prolyl hydroxylase activity. Therapeutic effects of clinically used deferasirox may thus involve transcriptional regulation through 2OG oxygenase inhibition. Deferasirox might provide a useful starting point for the development of novel anticancer drugs targeting 2OG oxygenases and a valuable tool compound for investigations of KDM function.
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Affiliation(s)
- Martin Roatsch
- Institute of Pharmaceutical Sciences , Albert-Ludwigs-Universität Freiburg , Albertstraße 25 , 79104 Freiburg i.Br. , Germany
| | - Inga Hoffmann
- Institute of Pharmaceutical Sciences , Albert-Ludwigs-Universität Freiburg , Albertstraße 25 , 79104 Freiburg i.Br. , Germany
| | - Martine I Abboud
- Chemistry Research Laboratory , University of Oxford , 12 Mansfield Road , Oxford OX1 3TA , United Kingdom
| | - Rebecca L Hancock
- Chemistry Research Laboratory , University of Oxford , 12 Mansfield Road , Oxford OX1 3TA , United Kingdom
| | - Hanna Tarhonskaya
- Chemistry Research Laboratory , University of Oxford , 12 Mansfield Road , Oxford OX1 3TA , United Kingdom
| | - Kuo-Feng Hsu
- Chemistry Research Laboratory , University of Oxford , 12 Mansfield Road , Oxford OX1 3TA , United Kingdom
| | - Sarah E Wilkins
- Chemistry Research Laboratory , University of Oxford , 12 Mansfield Road , Oxford OX1 3TA , United Kingdom
| | - Tzu-Lan Yeh
- Chemistry Research Laboratory , University of Oxford , 12 Mansfield Road , Oxford OX1 3TA , United Kingdom
| | - Kerstin Lippl
- Chemistry Research Laboratory , University of Oxford , 12 Mansfield Road , Oxford OX1 3TA , United Kingdom
| | - Kerstin Serrer
- Institute of Physical Chemistry , Albert-Ludwigs-Universität Freiburg , Albertstraße 21 , 79104 Freiburg i.Br. , Germany
| | - Isabelle Moneke
- Division of Cancer Research, Department of Thoracic Surgery, Medical Center-University of Freiburg, Faculty of Medicine , University of Freiburg , German Cancer Consortium (DKTK)-Partner Site Freiburg, Breisacher Straße 115 , 79106 Freiburg i.Br. , Germany
| | - Theresa D Ahrens
- Institute for Surgical Pathology, Medical Center and Faculty of Medicine , University of Freiburg , Breisacher Straße 115a , 79106 Freiburg i.Br. , Germany
| | - Dina Robaa
- Institute of Pharmacy , Martin-Luther-University Halle-Wittenberg , Wolfgang-Langenbeck-Straße 4 , 06120 Halle (Saale) , Germany
| | - Sandra Wenzler
- Institute of Pharmaceutical Sciences , Albert-Ludwigs-Universität Freiburg , Albertstraße 25 , 79104 Freiburg i.Br. , Germany
| | - Nicolas P F Barthes
- Institute of Pharmaceutical Sciences , Albert-Ludwigs-Universität Freiburg , Albertstraße 25 , 79104 Freiburg i.Br. , Germany
| | - Henriette Franz
- Central Clinical Research, Medical Center and Faculty of Medicine , University of Freiburg , Breisacher Straße 66 , 79106 Freiburg i.Br. , Germany
| | - Wolfgang Sippl
- Institute of Pharmacy , Martin-Luther-University Halle-Wittenberg , Wolfgang-Langenbeck-Straße 4 , 06120 Halle (Saale) , Germany
| | - Silke Lassmann
- Institute for Surgical Pathology, Medical Center and Faculty of Medicine , University of Freiburg , Breisacher Straße 115a , 79106 Freiburg i.Br. , Germany
| | - Sven Diederichs
- Division of Cancer Research, Department of Thoracic Surgery, Medical Center-University of Freiburg, Faculty of Medicine , University of Freiburg , German Cancer Consortium (DKTK)-Partner Site Freiburg, Breisacher Straße 115 , 79106 Freiburg i.Br. , Germany
- Division of RNA Biology & Cancer , German Cancer Research Center (DKFZ) , Im Neuenheimer Feld 280 , 69120 Heidelberg , Germany
| | - Erik Schleicher
- Institute of Physical Chemistry , Albert-Ludwigs-Universität Freiburg , Albertstraße 21 , 79104 Freiburg i.Br. , Germany
| | - Christopher J Schofield
- Chemistry Research Laboratory , University of Oxford , 12 Mansfield Road , Oxford OX1 3TA , United Kingdom
| | - Akane Kawamura
- Chemistry Research Laboratory , University of Oxford , 12 Mansfield Road , Oxford OX1 3TA , United Kingdom
| | - Roland Schüle
- Central Clinical Research, Medical Center and Faculty of Medicine , University of Freiburg , Breisacher Straße 66 , 79106 Freiburg i.Br. , Germany
| | - Manfred Jung
- Institute of Pharmaceutical Sciences , Albert-Ludwigs-Universität Freiburg , Albertstraße 25 , 79104 Freiburg i.Br. , Germany
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23
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Zhao X, Yin H, Li N, Zhu Y, Shen W, Qian S, He G, Li J, Wang X. An Integrated Regulatory Network Based on Comprehensive Analysis of mRNA Expression, Gene Methylation and Expression of Long Non-coding RNAs (lncRNAs) in Myelodysplastic Syndromes. Front Oncol 2019; 9:200. [PMID: 30984623 PMCID: PMC6450213 DOI: 10.3389/fonc.2019.00200] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2018] [Accepted: 03/08/2019] [Indexed: 12/12/2022] Open
Abstract
Myelodysplastic syndromes (MDS) are a heterogeneous group of disorders characterized by ineffective hematopoiesis, defective differentiation of hematopoietic precursors, and expansion of the abnormal clones. The prevalence of MDS has raised great concerns worldwide, but its pathogenetic mechanisms remain elusive. To provide insights on novel biomarkers for the diagnosis and therapy of MDS, we performed high-throughput genome-wide mRNA expression profiling, DNA methylation analysis, and long non-coding RNAs (lncRNA) analysis on bone marrows from four MDS patients and four age-matched healthy controls. We identified 1,937 differentially expressed genes (DEGs), 515 methylated genes, and 214 lncRNA that showed statistically significant differences. As the most significant module-related DEGs, TCL1A, PTGS2, and MME were revealed to be enriched in regulation of cell differentiation and cell death pathways. In addition, the GeneGo pathway maps identified by top DEGs were shown to converge on cancer, immunoregulation, apoptosis and regulation of actin cytoskeleton, most of which are known contributors in MDS etiology and pathogenesis. Notably, as potential biomarkers for diagnosis of MDS, four specific genes (ABAT, FADD, DAPP1, and SMPD3) were further subjected to detailed pathway analysis. Our integrative analysis on mRNA expression, gene methylation and lncRNAs profiling facilitates further understanding of the pathogenesis of MDS, and may promote the diagnosis and novel therapeutics for this disease.
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Affiliation(s)
- Xiaoli Zhao
- Key Laboratory of Hematology, Department of Hematology, Collaborative Innovation Center for Cancer Personalized Medicine, The First Affiliated Hospital of Nanjing Medical University, Jiangsu Province Hospital, Nanjing Medical University, Nanjing, China.,Department of Haematology, Huashan Hospital, Fudan University, Shanghai, China
| | - Hua Yin
- Key Laboratory of Hematology, Department of Hematology, Collaborative Innovation Center for Cancer Personalized Medicine, The First Affiliated Hospital of Nanjing Medical University, Jiangsu Province Hospital, Nanjing Medical University, Nanjing, China
| | - Nianyi Li
- Department of Haematology, Huashan Hospital, Fudan University, Shanghai, China
| | - Yu Zhu
- Key Laboratory of Hematology, Department of Hematology, Collaborative Innovation Center for Cancer Personalized Medicine, The First Affiliated Hospital of Nanjing Medical University, Jiangsu Province Hospital, Nanjing Medical University, Nanjing, China
| | - Wenyi Shen
- Key Laboratory of Hematology, Department of Hematology, Collaborative Innovation Center for Cancer Personalized Medicine, The First Affiliated Hospital of Nanjing Medical University, Jiangsu Province Hospital, Nanjing Medical University, Nanjing, China
| | - Sixuan Qian
- Key Laboratory of Hematology, Department of Hematology, Collaborative Innovation Center for Cancer Personalized Medicine, The First Affiliated Hospital of Nanjing Medical University, Jiangsu Province Hospital, Nanjing Medical University, Nanjing, China
| | - Guangsheng He
- Key Laboratory of Hematology, Department of Hematology, Collaborative Innovation Center for Cancer Personalized Medicine, The First Affiliated Hospital of Nanjing Medical University, Jiangsu Province Hospital, Nanjing Medical University, Nanjing, China
| | - Jianyong Li
- Key Laboratory of Hematology, Department of Hematology, Collaborative Innovation Center for Cancer Personalized Medicine, The First Affiliated Hospital of Nanjing Medical University, Jiangsu Province Hospital, Nanjing Medical University, Nanjing, China
| | - Xiaoqin Wang
- Department of Haematology, Huashan Hospital, Fudan University, Shanghai, China
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24
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Zeidan AM, Shallis RM, Wang R, Davidoff A, Ma X. Epidemiology of myelodysplastic syndromes: Why characterizing the beast is a prerequisite to taming it. Blood Rev 2019; 34:1-15. [DOI: 10.1016/j.blre.2018.09.001] [Citation(s) in RCA: 75] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2018] [Revised: 09/01/2018] [Accepted: 09/17/2018] [Indexed: 02/08/2023]
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