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Tremblay D, Mascarenhas J. Pharmacotherapeutic advances for splenomegaly in myelofibrosis. Expert Opin Pharmacother 2023; 24:577-585. [PMID: 36922391 DOI: 10.1080/14656566.2023.2192350] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/18/2023]
Abstract
INTRODUCTION Myelofibrosis is a hematologic malignancy with a variety of clinical manifestations including splenomegaly, which is present in approximately 80% of newly diagnosed patients. JAK inhibitors are the mainstay of pharmacologic treatment for splenomegaly in myelofibrosis, although spleen size reduction is not universal, and the duration of benefit is only moderately durable. AREAS COVERED We first discuss the pathobiology of splenomegaly in myelofibrosis before detailing approved and novel pharmacotherapies that can reduce spleen size while also highlighting non-pharmacologic approaches. In this review, efficacy of these treatments is measured solely by spleen volume reduction, acknowledging that other outcome measures such as symptom improvement and survival are also critical. EXPERT OPINION Currently, ruxolitinib can be administered to the majority of frontline patients although those with severe thrombocytopenia should receive pacritinib to address spleen burden. Momelotinib may be particularly well suited for patients with significant anemia and novel combination treatments in clinical development may improve the depth and duration of spleen responses. After frontline treatment failure, fedratinib, or pacritinib are commercial options for patients with persistent symptomatic splenomegaly. Novel agents given alone or in combination with a JAK inhibitor are being explored in trials, which may ameliorate splenomegaly and ultimately improve disease progression.
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Affiliation(s)
- Douglas Tremblay
- Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - John Mascarenhas
- Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
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Thrombocytopenia in Patients With Myelofibrosis: A Practical Management Guide. CLINICAL LYMPHOMA, MYELOMA & LEUKEMIA 2022; 22:e1067-e1074. [PMID: 36117043 DOI: 10.1016/j.clml.2022.08.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/16/2022] [Revised: 08/17/2022] [Accepted: 08/18/2022] [Indexed: 01/26/2023]
Abstract
Patients with myelofibrosis (MF) frequently develop thrombocytopenia as a consequence of bone marrow fibrosis, splenic sequestration, and myelosuppression from an inflammatory microenvironmental milieu. Thrombocytopenia occurs frequently at diagnosis, worsens with disease progression, is an independent adverse prognostic factor, and limits effective dosing of JAK2 inhibitors. Recently, pacritinib was approved for patients with MF and extreme thrombocytopenia. However, this JAK2/IRAK1 inhibitor is not primarily used to attain improvement in platelet count. In this narrative review, we discuss strategies to specifically address thrombocytopenia in MF patients including immunomodulatory drugs, synthetic androgens, hypomethylating agents and splenectomy, all of which have only modest efficacy in alleviating thrombocytopenia. We also detail transfusion approaches, including diagnostic and therapeutic consideration for platelet transfusion refractoriness. We end by discussing novel therapies, including TGFβ traps and recombinant pentraxin-2, which may increase platelet counts in MF patients. Despite recent therapeutic advancements in MF, there remains a near paucity of agents that can effectively alleviate thrombocytopenia.
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Bossard J, Beuscart J, Robin M, Mohty M, Barraco F, Chevallier P, Marchand T, Rubio M, Charbonnier A, Blaise D, Bay J, Botella‐Garcia C, Damaj G, Beckerich F, Ceballos P, Cluzeau T, Cornillon J, Meunier M, Orvain C, Duhamel A, Garnier F, Kiladjian J, Yakoub‐Agha I. Splenectomy before allogeneic hematopoietic cell transplantation for myelofibrosis: A French nationwide study. Am J Hematol 2021; 96:80-88. [PMID: 33108024 DOI: 10.1002/ajh.26034] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2020] [Revised: 10/06/2020] [Accepted: 10/21/2020] [Indexed: 12/12/2022]
Abstract
The value of pretransplant splenectomy in patients with myelofibrosis (MF) is subject to debate, since the procedure may preclude subsequent allogeneic hematopoietic cell transplantation (allo-HCT). To determine the impact of pretransplant splenectomy on the incidence of allo-HCT, we conducted a comprehensive retrospective study of all patients with MF for whom an unrelated donor search had been initiated via the French bone marrow transplantation registry (RFGM) between 1 January 2008 and 1 January 2017. Additional data were collected from the patients' medical files and a database held by the French-Language Society for Bone Marrow Transplantation and Cell Therapy (SFGM-TC). We used a multistate model with four states ("RFGM registration"; "splenectomy"; "death before allo-HCT", and "allo-HCT") to evaluate the association between splenectomy and the incidence of allo-HCT. The study included 530 patients from 57 centers. With a median follow-up time of 6 years, we observed 81 splenectomies, 99 deaths before allo-HCT (90 without splenectomy and nine after), and 333 allo-HCTs (268 without splenectomy and 65 after). In a bivariable analysis, the hazard ratio [95% confidence interval (CI)] for the association of splenectomy with allo-HCT was 7.2 [5.1-10.3] in the first 4 months and 1.18 [0.69-2.03] thereafter. The hazard ratio [95% CI] for death associated with splenectomy was 1.58 [0.79-3.14]. These reassuring results suggest that splenectomy does not preclude allo-HCT in patients with MF.
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Affiliation(s)
- Jean‐Baptiste Bossard
- University of Lille, CHU Lille, ULR 2694 ‐ METRICS: Évaluation des technologies de santé et des pratiques médicales Lille France
- Department of Hematology CHU Lille Lille France
| | - Jean‐Baptiste Beuscart
- University of Lille, CHU Lille, ULR 2694 ‐ METRICS: Évaluation des technologies de santé et des pratiques médicales Lille France
| | - Marie Robin
- Hôpital Saint‐Louis, APHP Université Paris 7 Paris France
| | - Mohamad Mohty
- Hématologie Clinique Saint‐Antoine Hospital and University Pierre & Marie Curie Paris France
| | - Fiorenza Barraco
- Departement d'Hématologie, Centre Hospitalier Lyon Sud Hospices Civils de Lyon Lyon France
| | | | | | | | | | | | - Jacques‐Olivier Bay
- Hématologie Clinique Centre Hospitalier Universitaire de Clermont‐Ferrand Clermont Ferrand France
| | | | - Gandhi Damaj
- Hematology Institute University Hospital Caen France
| | - Florence Beckerich
- Henri Mondor & Assistance Publique‐Hôpitaux de Paris Université Paris‐Est Créteil Créteil France
| | - Patrice Ceballos
- Département d'Hématologie Clinique CHU Lapeyronie Montpellier France
| | | | - Jérôme Cornillon
- Department of Clinical Hematology Institut de Cancérologie Lucien Neuwirth Saint‐Priest‐en‐Jarez France
| | | | | | - Alain Duhamel
- University of Lille, CHU Lille, ULR 2694 ‐ METRICS: Évaluation des technologies de santé et des pratiques médicales Lille France
| | | | - Jean‐Jacques Kiladjian
- Centre d'investigations cliniques Hôpital Saint‐Louis Paris France
- Université de Paris Paris France
- Inserm CIC1427 Paris France
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Tremblay D, Schwartz M, Bakst R, Patel R, Schiano T, Kremyanskaya M, Hoffman R, Mascarenhas J. Modern management of splenomegaly in patients with myelofibrosis. Ann Hematol 2020; 99:1441-1451. [PMID: 32417942 DOI: 10.1007/s00277-020-04069-4] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2020] [Accepted: 04/28/2020] [Indexed: 12/17/2022]
Abstract
Myelofibrosis (MF) is a chronic myeloproliferative neoplasm which can lead to massive splenomegaly secondary to extramedullary hematopoiesis. Patients frequently exhibit debilitating symptoms including pain and early satiety, in addition to cellular sequestration causing severe cytopenias. JAK 1/2 inhibitors, such as ruxolitinib and fedratinib, are the mainstay of therapy and produce significant and durable reductions in spleen volume. However, many patients are not eligible for JAK 2 inhibitor therapy or become refractory to treatment over time. Novel therapies are in development that can reduce the degree of splenomegaly for some of these patients. However, splenectomy, splenic irradiation, and partial splenic artery embolization remain valuable therapeutic options in select patients. In this review, we will discuss currently available pharmacologic therapies and describe promising drugs currently in development. We will also delve into the efficacy and safety concerns of splenectomy, splenic irradiation, and partial splenic artery embolization. Finally, we will propose a treatment algorithm to help guide clinicians in the management of symptomatic splenomegaly in patients with MF.
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Affiliation(s)
- Douglas Tremblay
- Division of Hematology and Medical Oncology, Icahn School of Medicine at Mount Sinai, Tisch Cancer Institute, New York, NY, USA
| | - Myron Schwartz
- Recanati/Miller Transplantation Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Richard Bakst
- Department of Radiation of Oncology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Rahul Patel
- Division of Interventional Radiology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Thomas Schiano
- Recanati/Miller Transplantation Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Marina Kremyanskaya
- Division of Hematology and Medical Oncology, Icahn School of Medicine at Mount Sinai, Tisch Cancer Institute, New York, NY, USA
| | - Ronald Hoffman
- Division of Hematology and Medical Oncology, Icahn School of Medicine at Mount Sinai, Tisch Cancer Institute, New York, NY, USA
| | - John Mascarenhas
- Division of Hematology and Medical Oncology, Icahn School of Medicine at Mount Sinai, Tisch Cancer Institute, New York, NY, USA.
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Imetelstat, a telomerase inhibitor, is capable of depleting myelofibrosis stem and progenitor cells. Blood Adv 2019; 2:2378-2388. [PMID: 30242099 DOI: 10.1182/bloodadvances.2018022012] [Citation(s) in RCA: 36] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2018] [Accepted: 08/18/2018] [Indexed: 01/26/2023] Open
Abstract
Clinical trials of imetelstat therapy have indicated that this telomerase inhibitor might have disease-modifying effects in a subset of patients with myelofibrosis (MF). The mechanism by which imetelstat induces such clinical responses has not been clearly elucidated. Using in vitro hematopoietic progenitor cell (HPC) assays and in vivo hematopoietic stem cell (HSC) assays, we examined the effects of imetelstat on primary normal and MF HSCs/HPCs. Treatment of CD34+ cells with imetelstat reduced the numbers of MF but not cord blood HPCs (colony-forming unit-granulocyte/macrophage, burst-forming unit-erythroid, and colony-forming unit-granulocyte/erythroid/macrophage/megakaryocyte) as well as MF but not normal CD34+ALDH+ cells irrespective of the patient's mutational status. Moreover, imetelstat treatment resulted in depletion of mutated HPCs from JAK2V617F+ MF patients. Furthermore, treatment of immunodeficient mice that had been previously transplanted with MF splenic CD34+ cells with imetelstat at a dose of 15 mg/kg, 3 times per week for 4 weeks had a limited effect on the degree of chimerism achieved by normal severe combined immunodeficiency repopulating cells but resulted in a significant reduction in the degree of human MF cell chimerism as well as the proportion of mutated donor cells. These effects were sustained for at least 3 months after drug treatment was discontinued. These actions of imetelstat on MF HSCs/HPCs were associated with inhibition of telomerase activity and the induction of apoptosis. Our findings indicate that the effects of imetelstat therapy observed in MF patients are likely attributable to the greater sensitivity of imetelstat against MF as compared with normal HSCs/HPCs as well as the intensity of the imetelstat dose schedule.
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How I treat myelofibrosis after failure of JAK inhibitors. Blood 2018; 132:492-500. [PMID: 29866811 DOI: 10.1182/blood-2018-02-785923] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2018] [Accepted: 05/28/2018] [Indexed: 12/16/2022] Open
Abstract
The introduction of JAK inhibitors, leading to regulatory approval of ruxolitinib, represents a major therapeutic advance in myelofibrosis (MF). Most patients experience reduction in splenomegaly and improved quality of life from symptom improvement. It is a paradox, however, that, despite inhibition of signaling downstream of disease-related driver mutations, JAK inhibitor treatment is not associated with consistent molecular or pathologic responses in MF. Furthermore, there are important limitations to JAK inhibitor therapy including development of dose-limiting cytopenias and/or nonhematological toxicities such as neuropathy or opportunistic infections. Over half of the patients discontinue treatment within 3 years of starting treatment. Although data are sparse, clinical outcome after JAK inhibitor "failure" is likely poor; consequently, it is important to understand patterns of failure to select appropriate salvage treatment(s). An algorithmic approach, particularly one that incorporates cytogenetics/molecular data, is most helpful in selecting stem cell transplant candidates. Treatment of transplant-ineligible patients relies on a problem-based approach that includes use of investigational drugs, or consideration of splenectomy or radiotherapy. Data from early phase ruxolitinib combination studies, despite promising preclinical data, have not shown clear benefit over monotherapy thus far. Development of effective treatment strategies for MF patients failing JAK inhibitors remains a major unmet need.
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Zimran E, Tripodi J, Rampal R, Rappoport F, Zirkiev S, Hoffman R, Najfeld V. Genomic characterization of spleens in patients with myelofibrosis. Haematologica 2018; 103:e446-e449. [PMID: 29748436 DOI: 10.3324/haematol.2018.193763] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Affiliation(s)
- Eran Zimran
- Myeloproliferative Neoplasms Research Program, Department of Hematology and Oncology, Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, Rockefeller University, New York, NY, USA
| | - Joseph Tripodi
- Myeloproliferative Neoplasms Research Program, Department of Hematology and Oncology, Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, Rockefeller University, New York, NY, USA.,Tumor Cytogenomics Laboratory, Department of Pathology, Icahn School of Medicine at Mount Sinai, Rockefeller University, New York, NY, USA
| | - Raajit Rampal
- Human Oncology and Pathogenesis Program, Leukemia Service, Memorial Sloan-Kettering Cancer Center, Rockefeller University, New York, NY, USA
| | - Franck Rappoport
- Human Oncology and Pathogenesis Program, Leukemia Service, Memorial Sloan-Kettering Cancer Center, Rockefeller University, New York, NY, USA.,Center for Clinical and Translational Science, Rockefeller University, New York, NY, USA
| | - Sharon Zirkiev
- Tumor Cytogenomics Laboratory, Department of Pathology, Icahn School of Medicine at Mount Sinai, Rockefeller University, New York, NY, USA
| | - Ronald Hoffman
- Myeloproliferative Neoplasms Research Program, Department of Hematology and Oncology, Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, Rockefeller University, New York, NY, USA
| | - Vesna Najfeld
- Myeloproliferative Neoplasms Research Program, Department of Hematology and Oncology, Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, Rockefeller University, New York, NY, USA .,Tumor Cytogenomics Laboratory, Department of Pathology, Icahn School of Medicine at Mount Sinai, Rockefeller University, New York, NY, USA
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Zimran E, Hoffman R, Kremyanskaya M. Current approaches to challenging scenarios in myeloproliferative neoplasms. Expert Rev Anticancer Ther 2018; 18:567-578. [PMID: 29575945 DOI: 10.1080/14737140.2018.1457441] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
INTRODUCTION The Philadelphia chromosome-negative myeloproliferative neoplasms (MPNs) including polycythemia vera, essential thrombocythemia and primary myelofibrosis are clonal hematological malignancies that originate at the level of the hematopoietic stem cell, and are characterized by excessive proliferation of cells belonging to one or more of the myeloid lineages. Central to the pathogenesis of the MPNs is constitutive activation of the JAK/STAT signaling pathway due to a family of driver mutations affecting JAK2, CALR or MPL. These disorders share common clinical and laboratory features, a significant burden of systemic symptoms, increased risk of developing arterial and venous thrombotic events, and the potential to progress to myelofibrosis and acute leukemia. Areas covered: We identified four clinical situations which represent challenging management dilemmas for patients with MPNs. Our conclusions and recommendations are based on a literature search using MEDLINE and recent meeting abstracts using the keywords, focusing on publications directly addressing these scenarios and on recent contributions to the field. Expert commentary: Multi-center efforts to study large cohorts of MPN patients have led to more uniform and evidence-based approaches to key aspects in MPN management. However, treatment strategies to deal with specific clinical scenarios are lacking.
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Affiliation(s)
- Eran Zimran
- a Icahn School of Medicine at Mount Sinai , Tisch Cancer Institute , New York , NY , USA
| | - Ronald Hoffman
- a Icahn School of Medicine at Mount Sinai , Tisch Cancer Institute , New York , NY , USA
| | - Marina Kremyanskaya
- a Icahn School of Medicine at Mount Sinai , Tisch Cancer Institute , New York , NY , USA
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Greenfield G, McMullin MF. A spotlight on the management of complications associated with myeloproliferative neoplasms: a clinician's perspective. Expert Rev Hematol 2017; 11:25-35. [PMID: 29183180 DOI: 10.1080/17474086.2018.1410433] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
INTRODUCTION Myeloproliferative neoplasms (MPNs) are associated with a variety of symptoms and signs which cause major morbidity for the patients. The disorders are associated with increased incidence of thromboembolic and hemorrhagic events which can lead to complications and shortened life expectancy. Areas covered: Using systematic literature review and expert clinical and research experience the authors discuss strategies for the management of symptoms and signs including pruritus, fatigue, splenomegaly, and cytopenia. Cytoreduction including treatments to inhibit the JAK/STAT pathway are considered. Pathogenesis and prevention and treatment of thrombotic and hemorrhagic events and their management is addressed and the suggested management of the special situations such as surgery and pregnancy are discussed. Expert commentary: Management of disease has traditionally focused on symptom treatment and complication prevention but the discovery of driver mutations has led to treatments aiming to eliminate the clone, which should be the ultimate goal of therapy. A future challenge is to develop safe and effective MPN therapy and to personalize therapy.
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Casaccia M, Fornaro R, Frascio M, Palombo D, Stabilini C, Firpo E, Gianetta E. Peritoneal carcinomatosis-like implants of extramedullary hematopoiesis. An insolite occurrence during splenectomy for myelofibrosis. Int J Surg Case Rep 2017; 41:9-11. [PMID: 29024842 PMCID: PMC5742008 DOI: 10.1016/j.ijscr.2017.09.030] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2017] [Revised: 09/21/2017] [Accepted: 09/21/2017] [Indexed: 11/25/2022] Open
Abstract
INTRODUCTION Primary myelofibrosis (MF) is a myeloproliferative neoplasm that results in debilitating constitutional symptoms, splenomegaly, and cytopenias. In patients with symptomatic splenomegaly, splenectomy remains a viable treatment option for MF patients with medically refractory symptomatic splenomegaly that precludes the use of ruxolitinib. CASE PRESENTATION We present the clinical case of a patient who was admitted to our Department to perform a splenectomy in MF as a therapeutic step prior to an allogeneic stem cell transplantation (ASCT). A laparotomic splenectomy and excision of whitish wide-spread peritoneal and omental nodulations was performed. There were no operative complications and the surgery was completed with minimal blood loss. The histopathological exam revealed an extramedullary hematopoiesis in both spleen and peritoneal nodules. CONCLUSION In primary myelofibrosis it must always be kept in mind the possible presence of peritoneal implants of extramedullary hematopoiesis and ascites of reactive genesis. We report a rare case of peritoneal carcinomatosis-like implants of extramedullary hematopoiesis found at splenectomy for MF.
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Affiliation(s)
- Marco Casaccia
- Surgical Clinic Unit II Department of Surgical Sciences and Integrated Diagnostics (DISC), Genova, Italy
| | - Rosario Fornaro
- Surgical Clinic Unit II Department of Surgical Sciences and Integrated Diagnostics (DISC), Genova, Italy
| | - Marco Frascio
- Surgical Clinic Unit II Department of Surgical Sciences and Integrated Diagnostics (DISC), Genova, Italy
| | - Denise Palombo
- Surgical Clinic Unit II Department of Surgical Sciences and Integrated Diagnostics (DISC), Genova, Italy.
| | - Cesare Stabilini
- Surgical Clinic Unit II Department of Surgical Sciences and Integrated Diagnostics (DISC), Genova, Italy
| | - Emma Firpo
- Surgical Clinic Unit II Department of Surgical Sciences and Integrated Diagnostics (DISC), Genova, Italy
| | - Ezio Gianetta
- Surgical Clinic Unit II Department of Surgical Sciences and Integrated Diagnostics (DISC), Genova, Italy
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