1
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Smallbone P, Louw A, Purtill D. Laboratory methods of monitoring disease response after allogeneic haematopoietic stem cell transplantation for myelofibrosis. Pathology 2024; 56:24-32. [PMID: 38071159 DOI: 10.1016/j.pathol.2023.10.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2023] [Revised: 09/10/2023] [Accepted: 10/06/2023] [Indexed: 01/24/2024]
Abstract
The era of molecular prognostication in myelofibrosis has allowed comprehensive assessment of disease risk and informed decisions regarding allogeneic haematopoietic stem cell transplantation (HSCT). However, monitoring disease response after transplantation is difficult, and limited by disease and sample-related factors. The emergence of laboratory techniques sensitive enough to monitor measurable residual disease is promising in predicting molecular and haematological relapse and guiding management. This paper summarises the existing literature regarding methods for detecting and monitoring disease response after HSCT in myelofibrosis and explores the therapeutic use of measurable residual disease (MRD) assays in transplant recipients. Laboratory assessment of disease response in myelofibrosis post-allogeneic transplant is limited by disease and treatment characteristics and by the sensitivity of available conventional molecular assays. The identification of MRD has prognostic implications and may allow early intervention to prevent relapse. Further applicability is limited by mutation-specific assay variability, a lack of standardisation and sample considerations.
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Affiliation(s)
- Portia Smallbone
- Department of Haematology, Fiona Stanley Hospital, Perth, WA, Australia; PathWest, Fiona Stanley Hospital, Perth, WA, Australia.
| | - Alison Louw
- PathWest, Fiona Stanley Hospital, Perth, WA, Australia
| | - Duncan Purtill
- Department of Haematology, Fiona Stanley Hospital, Perth, WA, Australia; PathWest, Fiona Stanley Hospital, Perth, WA, Australia
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2
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Kröger N, Wolschke C, Gagelmann N. How I treat transplant-eligible patients with myelofibrosis. Blood 2023; 142:1683-1696. [PMID: 37647853 DOI: 10.1182/blood.2023021218] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2023] [Revised: 08/14/2023] [Accepted: 08/18/2023] [Indexed: 09/01/2023] Open
Abstract
Despite the approval of Janus kinase inhibitors and novel agents for patients with myelofibrosis (MF), disease-modifying responses remain limited, and hematopoietic stem cell transplantation (HSCT) remains the only potentially curative treatment option. The number of HSCTs for MF continues to increase worldwide, but its inherent therapy-related morbidity and mortality limit its use for many patients. Furthermore, patients with MF often present at an older age, with cytopenia, splenomegaly, and severe bone marrow fibrosis, posing challenges in managing them throughout the HSCT procedure. Although implementation of molecular analyses enabled improved understanding of disease mechanisms and subsequently sparked development of novel drugs with promising activity, prospective trials in the HSCT setting are often lacking, making an evidence-based decision process particularly difficult. To illustrate how we approach patients with MF with respect to HSCT, we present 3 different clinical scenarios to capture relevant aspects that influence our decision making regarding indication for, or against, HSCT. We describe how we perform HSCT according to different risk categories and, furthermore, discuss our up-to-date approach to reduce transplant-related complications. Last, we show how to harness graft-versus-MF effects, particularly in the posttransplant period to achieve the best possible outcomes for patients.
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Affiliation(s)
- Nicolaus Kröger
- Department of Stem Cell Transplantation, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Christine Wolschke
- Department of Stem Cell Transplantation, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Nico Gagelmann
- Department of Stem Cell Transplantation, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
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3
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Ryou H, Lomas O, Theissen H, Thomas E, Rittscher J, Royston D. Quantitative interpretation of bone marrow biopsies in MPN-What's the point in a molecular age? Br J Haematol 2023; 203:523-535. [PMID: 37858962 PMCID: PMC10952168 DOI: 10.1111/bjh.19154] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2023] [Revised: 09/20/2023] [Accepted: 09/30/2023] [Indexed: 10/21/2023]
Abstract
The diagnosis of myeloproliferative neoplasms (MPN) requires the integration of clinical, morphological, genetic and immunophenotypic findings. Recently, there has been a transformation in our understanding of the cellular and molecular mechanisms underlying disease initiation and progression in MPN. This has been accompanied by the widespread application of high-resolution quantitative molecular techniques. By contrast, microscopic interpretation of bone marrow biopsies by haematologists/haematopathologists remains subjective and qualitative. However, advances in tissue image analysis and artificial intelligence (AI) promise to transform haematopathology. Pioneering studies in bone marrow image analysis offer to refine our understanding of the boundaries between reactive samples and MPN subtypes and better capture the morphological correlates of high-risk disease. They also demonstrate potential to improve the evaluation of current and novel therapeutics for MPN and other blood cancers. With increased therapeutic targeting of diverse molecular, cellular and extra-cellular components of the marrow, these approaches can address the unmet need for improved objective and quantitative measures of disease modification in the context of clinical trials. This review focuses on the state-of-the-art in image analysis/AI of bone marrow tissue, with an emphasis on its potential to complement and inform future clinical studies and research in MPN.
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Affiliation(s)
- Hosuk Ryou
- Nuffield Division of Clinical Laboratory Sciences, Radcliffe Department of MedicineUniversity of OxfordOxfordUK
| | - Oliver Lomas
- Department of HaematologyOxford University Hospitals NHS Foundation TrustOxfordUK
| | - Helen Theissen
- Department of Engineering Science, Institute of Biomedical Engineering (IBME)University of OxfordOxfordUK
| | - Emily Thomas
- Department of Engineering Science, Institute of Biomedical Engineering (IBME)University of OxfordOxfordUK
| | - Jens Rittscher
- Department of Engineering Science, Institute of Biomedical Engineering (IBME)University of OxfordOxfordUK
- Ground Truth LabsOxfordUK
- Oxford NIHR Biomedical Research CentreOxford University Hospitals NHS Foundation TrustOxfordUK
- Ludwig Institute for Cancer ResearchUniversity of OxfordOxfordUK
| | - Daniel Royston
- Nuffield Division of Clinical Laboratory Sciences, Radcliffe Department of MedicineUniversity of OxfordOxfordUK
- Department of PathologyOxford University Hospitals NHS Foundation TrustOxfordUK
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4
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Perram J, Ross DM, McLornan D, Gowin K, Kröger N, Gupta V, Lewis C, Gagelmann N, Hamad N. Innovative strategies to improve hematopoietic stem cell transplant outcomes in myelofibrosis. Am J Hematol 2022; 97:1464-1477. [PMID: 35802782 PMCID: PMC9796730 DOI: 10.1002/ajh.26654] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2022] [Revised: 06/28/2022] [Accepted: 07/05/2022] [Indexed: 01/28/2023]
Abstract
Myelofibrosis (MF) is a clonal myeloproliferative neoplasm characterized by inflammation, marrow fibrosis, and an inherent risk of blastic transformation. Hematopoietic allogeneic stem cell transplant is the only potentially curative therapy for this disease, however, survival gains observed for other transplant indications over the past two decades have not been realized for MF. The role of transplantation may also evolve with the use of novel targeted agents. The chronic inflammatory state associated with MF necessitates pretransplantation assessment of end-organ function. Applying the transplant methodology employed for other myeloid disorders to patients with MF fails to acknowledge differences in the underlying disease pathophysiology. Limited understanding of the causes of poor transplant outcomes in this cohort has prevented refinement of transplant eligibility criteria in MF. There is increasing evidence of heterogeneity in molecular disease grade, beyond the clinical manifestations which have traditionally guided transplant timing. Exploring the physiological consequences of disease chronicity unique to MF, acknowledging the heterogeneity in disease grade, and using advanced prognostic models, molecular diagnostics and other organ function diagnostic tools, we present an innovative review of strategies with the potential to improve transplant outcomes in this disease. Larger, prospective studies which consider the impact of molecular-based disease grade are needed for MF transplantation.
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Affiliation(s)
- Jacinta Perram
- Department of Bone Marrow Transplantation and HaematologySt Vincent's HospitalDarlinghurstNew South WalesAustralia,School of Clinical Medicine, UNSW Medicine & HealthKensingtonNew South WalesAustralia
| | - David M. Ross
- Department of Haematology and Bone Marrow TransplantationRoyal Adelaide HospitalAdelaideSouth AustraliaAustralia,Centre for Cancer BiologySA Pathology and University of South AustraliaAdelaideSouth AustraliaAustralia
| | - Donal McLornan
- Department of Haematology and Stem Cell TransplantationUniversity College London Hospitals NHSLondonUK
| | - Krisstina Gowin
- Department of Hematology and OncologyBone Marrow Transplant and Cellular Therapy, University of ArizonaTucsonArizonaUSA
| | - Nicolas Kröger
- Department of Stem Cell TransplantationUniversity Medical Center Hamburg‐EppendorfHamburgGermany
| | - Vikas Gupta
- Medical Oncology and HaematologyPrincess Margaret Cancer CentreTorontoOntarioCanada
| | - Clinton Lewis
- Department of HaematologyAuckland City HospitalAucklandNew Zealand
| | - Nico Gagelmann
- Department of Stem Cell TransplantationUniversity Medical Center Hamburg‐EppendorfHamburgGermany
| | - Nada Hamad
- Department of Bone Marrow Transplantation and HaematologySt Vincent's HospitalDarlinghurstNew South WalesAustralia,School of Clinical Medicine, UNSW Medicine & HealthKensingtonNew South WalesAustralia,School of MedicineUniversity of Notre Dame AustraliaFremantleWestern AustraliaAustralia
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5
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Inhibition of proinflammatory signaling impairs fibrosis of bone marrow mesenchymal stromal cells in myeloproliferative neoplasms. Exp Mol Med 2022; 54:273-284. [PMID: 35288649 PMCID: PMC8980093 DOI: 10.1038/s12276-022-00742-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2021] [Revised: 11/04/2021] [Accepted: 12/21/2021] [Indexed: 12/03/2022] Open
Abstract
Although bone marrow-derived mesenchymal stromal cells (BM-MSCs) have been identified as a major cellular source of fibrosis, the exact molecular mechanism and signaling pathways involved have not been identified thus far. Here, we show that BM-MSCs contribute to fibrosis in myeloproliferative neoplasms (MPNs) by differentiating into αSMA-positive myofibroblasts. These cells display a dysregulated extracellular matrix with increased FN1 production and secretion of profibrotic MMP9 compared to healthy donor cells. Fibrogenic TGFβ and inflammatory JAK2/STAT3 and NFκB signaling pathway activity is increased in BM-MSCs of MPN patients. Moreover, coculture with mononuclear cells from MPN patients was sufficient to induce fibrosis in healthy BM-MSCs. Inhibition of JAK1/2, SMAD3 or NFκB significantly reduced the fibrotic phenotype of MPN BM-MSCs and was able to prevent the development of fibrosis induced by coculture of healthy BM-MSCs and MPN mononuclear cells with overly active JAK/STAT signaling, underlining their involvement in fibrosis. Combined treatment with JAK1/2 and SMAD3 inhibitors showed synergistic and the most favorable effects on αSMA and FN1 expression in BM-MSCs. These results support the combined inhibition of TGFβ and inflammatory signaling to extenuate fibrosis in MPN. The treatment of fibrosis in patients with rare bone marrow disorders could be improved with a combined therapy that targets inflammatory pathways. Myeloproliferative neoplasms (MPN) are a group of bone marrow disorders characterized by the over-production of blood cells, which can lead to fibrosis in the bone marrow. Vladan Čokić at the University of Belgrade, Serbia, and co-workers examined how stem cells known as mesenchymal stromal cells from the bone marrow contribute to MPN fibrosis. They found an increase in three pro-inflammatory signaling pathways in MPN patients, resulting in the stromal cells differentiating into cells with dysregulated extracellular matrices. The differentiated cells did not behave correctly nor degrade properly, triggering fibrosis. The team combined two drugs that target the inflammatory signaling pathways, and successfully inhibited the development of fibrosis in MPN cell cultures.
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6
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Lysenko V, Wildner-Verhey van Wijk N, Zimmermann K, Weller MC, Bühler M, Wildschut MHE, Schürch P, Fritz C, Wagner U, Calabresi L, Psaila B, Flavell RA, Vannucchi AM, Mead AJ, Wild PJ, Dirnhofer S, Manz MG, Theocharides APA. Enhanced engraftment of human myelofibrosis stem and progenitor cells in MISTRG mice. Blood Adv 2020; 4:2477-2488. [PMID: 32502268 PMCID: PMC7284099 DOI: 10.1182/bloodadvances.2019001364] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2019] [Accepted: 04/28/2020] [Indexed: 02/06/2023] Open
Abstract
The engraftment potential of myeloproliferative neoplasms in immunodeficient mice is low. We hypothesized that the physiological expression of human cytokines (macrophage colony-stimulating factor, interleukin-3, granulocyte-macrophage colony-stimulating factor, and thrombopoietin) combined with human signal regulatory protein α expression in Rag2-/-Il2rγ-/- (MISTRG) mice might provide a supportive microenvironment for the development and maintenance of hematopoietic stem and progenitor cells (HSPC) from patients with primary, post-polycythemia or post-essential thrombocythemia myelofibrosis (MF). We show that MISTRG mice, in contrast to standard immunodeficient NOD.Cg-PrkdcscidIl2rgtm1Wjl/SzJ and Rag2-/-Il2rγ-/- mice, supported engraftment of all patient samples investigated independent of MF disease stage or risk category. Moreover, MISTRG mice exhibited significantly higher human MF engraftment levels in the bone marrow, peripheral blood, and spleen and supported secondary repopulation. Bone marrow fibrosis development was limited to 3 of 14 patient samples investigated in MISTRG mice. Disease-driving mutations were identified in all xenografts, and targeted sequencing revealed maintenance of the primary patient sample clonal composition in 7 of 8 cases. Treatment of engrafted mice with the current standard-of-care Janus kinase inhibitor ruxolitinib led to a reduction in human chimerism. In conclusion, the established MF patient-derived xenograft model supports robust engraftment of MF HSPCs and maintains the genetic complexity observed in patients. The model is suited for further testing of novel therapeutic agents to expedite their transition into clinical trials.
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Affiliation(s)
- Veronika Lysenko
- Department of Medical Oncology and Hematology, University of Zurich and University Hospital Zurich, Zurich, Switzerland
| | | | - Kathrin Zimmermann
- Department of Medical Oncology and Hematology, University of Zurich and University Hospital Zurich, Zurich, Switzerland
| | - Marie-Christine Weller
- Department of Medical Oncology and Hematology, University of Zurich and University Hospital Zurich, Zurich, Switzerland
| | - Marco Bühler
- Institute of Pathology and Molecular Pathology, University Hospital Zurich, Zurich, Switzerland
| | - Mattheus H E Wildschut
- Department of Medical Oncology and Hematology, University of Zurich and University Hospital Zurich, Zurich, Switzerland
- Institute of Molecular Systems Biology, ETH Zurich, Zurich, Switzerland
| | - Patrick Schürch
- Department of Medical Oncology and Hematology, University of Zurich and University Hospital Zurich, Zurich, Switzerland
| | - Christine Fritz
- Institute of Pathology and Molecular Pathology, University Hospital Zurich, Zurich, Switzerland
| | - Ulrich Wagner
- Institute of Pathology and Molecular Pathology, University Hospital Zurich, Zurich, Switzerland
| | - Laura Calabresi
- Center for Research and Innovation of Myeloproliferative Neoplasms, Azienda Ospedaliero, Universitaria Careggi, University of Florence, Florence, Italy
| | - Bethan Psaila
- Haematopoietic Stem Cell Biology Laboratory, Medical Research Council Weatherall Institute of Molecular Medicine
- Medical Research Council Molecular Haematology Unit, Weatherall Institute of Molecular Medicine, and
- National Institute for Health Research Biomedical Research Centre, University of Oxford, Oxford, United Kingdom
| | | | - Alessandro M Vannucchi
- Center for Research and Innovation of Myeloproliferative Neoplasms, Azienda Ospedaliero, Universitaria Careggi, University of Florence, Florence, Italy
| | - Adam J Mead
- Haematopoietic Stem Cell Biology Laboratory, Medical Research Council Weatherall Institute of Molecular Medicine
- Medical Research Council Molecular Haematology Unit, Weatherall Institute of Molecular Medicine, and
- National Institute for Health Research Biomedical Research Centre, University of Oxford, Oxford, United Kingdom
| | - Peter J Wild
- Dr. Senckenberg Institute of Pathology, University Hospital Frankfurt, Frankfurt, Germany; and
| | - Stefan Dirnhofer
- Institute of Pathology, University Hospital, University of Basel, Basel, Switzerland
| | - Markus G Manz
- Department of Medical Oncology and Hematology, University of Zurich and University Hospital Zurich, Zurich, Switzerland
| | - Alexandre P A Theocharides
- Department of Medical Oncology and Hematology, University of Zurich and University Hospital Zurich, Zurich, Switzerland
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7
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Zhang L, Yang F, Feng S. Allogeneic hematopoietic stem-cell transplantation for myelofibrosis. Ther Adv Hematol 2020; 11:2040620720906002. [PMID: 32110286 PMCID: PMC7019406 DOI: 10.1177/2040620720906002] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2019] [Accepted: 01/09/2020] [Indexed: 12/22/2022] Open
Abstract
Myelofibrosis is one of the Philadelphia chromosome (Ph)-negative
myeloproliferative neoplasms with heterogeneous clinical course. Though many
treatment options, including Janus kinase (JAK) inhibitors, have provided
clinical benefits and improved survival, allogeneic hematopoietic stem-cell
transplantation (AHSCT) remains the only potentially curative therapy.
Considering the significant transplant-related morbidity and mortality, it is
crucial to decide who to proceed to AHSCT, and when. In this review, we discuss
recent updates in patient selection, prior splenectomy, conditioning regimen,
donor type, molecular mutation, and other factors affecting AHSCT outcomes.
Relapse is a major cause of treatment failure; we also describe recent data on
minimal residual disease monitoring and management of relapse. In addition,
emerging studies have reported pretransplant therapy with ruxolitinib for
myelofibrosis showing favorable results, and further research is needed to
explore its use in the post-transplant setting.
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Affiliation(s)
- Lining Zhang
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Institute of Hematology and Blood Diseases Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Tianjin, China
| | - Fan Yang
- Aerospace Center Hospital, Beijing, China
| | - Sizhou Feng
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Institute of Hematology and Blood Diseases Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, 288 Nanjing Road, Heping District, Tianjin, 300020, China
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8
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Daghia G, Zabelina T, Zeck G, von Pein U, Christopeit M, Wolschke C, Ayuk F, Kröger N. Allogeneic stem cell transplantation for myelofibrosis patients aged ≥65 years. Eur J Haematol 2019; 103:370-378. [DOI: 10.1111/ejh.13294] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2019] [Revised: 06/28/2019] [Accepted: 06/29/2019] [Indexed: 12/13/2022]
Affiliation(s)
- Giulia Daghia
- Department of Stem Cell Transplantation University Medical Center Hamburg‐Eppendorf Hamburg Germany
- Ospedale SM delle Croci, Sezione di Ematologia e Unità Trapianto Cellule Staminali Azienda Ospedaliera della Romagna Ravenna Italy
| | - Tatjana Zabelina
- Department of Stem Cell Transplantation University Medical Center Hamburg‐Eppendorf Hamburg Germany
| | - Gaby Zeck
- Department of Stem Cell Transplantation University Medical Center Hamburg‐Eppendorf Hamburg Germany
| | - Ute‐Marie von Pein
- Department of Stem Cell Transplantation University Medical Center Hamburg‐Eppendorf Hamburg Germany
| | - Maximilian Christopeit
- Department of Stem Cell Transplantation University Medical Center Hamburg‐Eppendorf Hamburg Germany
| | - Christine Wolschke
- Department of Stem Cell Transplantation University Medical Center Hamburg‐Eppendorf Hamburg Germany
| | - Francis Ayuk
- Department of Stem Cell Transplantation University Medical Center Hamburg‐Eppendorf Hamburg Germany
| | - Nicolaus Kröger
- Department of Stem Cell Transplantation University Medical Center Hamburg‐Eppendorf Hamburg Germany
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9
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Treating early-stage myelofibrosis. Ann Hematol 2018; 98:241-253. [DOI: 10.1007/s00277-018-3526-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2018] [Accepted: 10/12/2018] [Indexed: 01/03/2023]
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10
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Kvasnicka HM, Thiele J, Bueso-Ramos CE, Sun W, Cortes J, Kantarjian HM, Verstovsek S. Long-term effects of ruxolitinib versus best available therapy on bone marrow fibrosis in patients with myelofibrosis. J Hematol Oncol 2018; 11:42. [PMID: 29544547 PMCID: PMC5856218 DOI: 10.1186/s13045-018-0585-5] [Citation(s) in RCA: 62] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2017] [Accepted: 03/01/2018] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Myelofibrosis (MF) is a life-shortening complication of myeloproliferative neoplasms associated with ineffective hematopoiesis, splenomegaly, and progressive bone marrow (BM) fibrosis. The oral Janus kinase (JAK) 1/JAK2 inhibitor ruxolitinib has been shown to improve splenomegaly, symptom burden, and overall survival in patients with intermediate-2 or high-risk MF compared with placebo or best available therapy (BAT). METHODS The effects of ruxolitinib therapy for up to 66 months on BM morphology in 68 patients with advanced MF with variable BM fibrosis grade were compared with those in 192 matching patients treated with BAT. Available trephine biopsies underwent independent, blinded review by three hematopathologists for consensus-based adjudication of grades for reticulin fibrosis, collagen deposition, and osteosclerosis. RESULTS Ruxolitinib treatment versus BAT was associated with greater odds of BM fibrosis improvement or stabilization and decreased odds of BM fibrosis worsening based on changes from baseline in reticulin fibrosis grade. Generally, these changes were accompanied by a sustained higher level of individual spleen size reduction and regression of leukoerythroblastosis. Patients with more advanced baseline fibrosis showed lower spleen size response. CONCLUSIONS The finding that long-term ruxolitinib therapy may reverse or markedly delay BM fibrosis progression in advanced MF suggests that sustained JAK inhibition may be disease-modifying. TRIAL REGISTRATION INCB18424-251, ClinicalTrials.gov identifier NCT00509899 .
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Affiliation(s)
- Hans Michael Kvasnicka
- Senckenberg Institute of Pathology, University of Frankfurt, Theodor-Stern-Kai 7, 60590, Frankfurt, Germany.
| | | | - Carlos E Bueso-Ramos
- Department of Hematopathology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | | | - Jorge Cortes
- Department of Hematopathology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Hagop M Kantarjian
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Srdan Verstovsek
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
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11
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Leiva O, Leon C, Kah Ng S, Mangin P, Gachet C, Ravid K. The role of extracellular matrix stiffness in megakaryocyte and platelet development and function. Am J Hematol 2018; 93:430-441. [PMID: 29247535 DOI: 10.1002/ajh.25008] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2017] [Revised: 12/11/2017] [Accepted: 12/13/2017] [Indexed: 12/16/2022]
Abstract
The extracellular matrix (ECM) is a key acellular structure in constant remodeling to provide tissue cohesion and rigidity. Deregulation of the balance between matrix deposition, degradation, and crosslinking results in fibrosis. Bone marrow fibrosis (BMF) is associated with several malignant and nonmalignant pathologies severely affecting blood cell production. BMF results from abnormal deposition of collagen fibers and enhanced lysyl oxidase-mediated ECM crosslinking within the marrow, thereby increasing marrow stiffness. Bone marrow stiffness has been recently recognized as an important regulator of blood cell development, notably by modifying the fate and differentiation process of hematopoietic or mesenchymal stem cells. This review surveys the different components of the ECM and their influence on stem cell development, with a focus on the impact of the ECM composition and stiffness on the megakaryocytic lineage in health and disease. Megakaryocyte maturation and the biogenesis of their progeny, the platelets, are thought to respond to environmental mechanical forces through a number of mechanosensors, including integrins and mechanosensitive ion channels, reviewed here.
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Affiliation(s)
- Orly Leiva
- Department of Medicine; Whitaker Cardiovascular Institute, Boston University School of Medicine; Boston Massachusetts
| | - Catherine Leon
- Université de Strasbourg, INSERM, EFS Grand-Est, BPPS UMR-S 949, FMTS; Strasbourg F-67000 France
| | - Seng Kah Ng
- Department of Medicine; Whitaker Cardiovascular Institute, Boston University School of Medicine; Boston Massachusetts
| | - Pierre Mangin
- Université de Strasbourg, INSERM, EFS Grand-Est, BPPS UMR-S 949, FMTS; Strasbourg F-67000 France
| | - Christian Gachet
- Université de Strasbourg, INSERM, EFS Grand-Est, BPPS UMR-S 949, FMTS; Strasbourg F-67000 France
| | - Katya Ravid
- Department of Medicine; Whitaker Cardiovascular Institute, Boston University School of Medicine; Boston Massachusetts
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12
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Gianelli U, Fiori S, Cattaneo D, Bossi A, Cortinovis I, Bonometti A, Ercoli G, Bucelli C, Orofino N, Bulfamante G, Iurlo A. Prognostic significance of a comprehensive histological evaluation of reticulin fibrosis, collagen deposition and osteosclerosis in primary myelofibrosis patients. Histopathology 2017; 71:897-908. [PMID: 28710830 DOI: 10.1111/his.13309] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2017] [Accepted: 07/12/2017] [Indexed: 01/25/2023]
Abstract
AIMS To evaluate whether a comprehensive histological evaluation of reticulin fibrosis, collagen deposition and osteosclerosis in bone marrow trephine biopsies (BMBs) of primary myelofibrosis (PMF) patients may have prognostic implications. METHODS AND RESULTS Reticulin fibrosis, collagen deposition and osteosclerosis were graded from 0 to 3 in a series of 122 baseline BMBs. Then, we assigned to each case a comprehensive score [reticulin, collagen, osteosclerosis (RCO) score, ranging from 0 to 9] that allowed us to distinguish two groups of patients, with low-grade (RCO score 0-4) and high-grade (RCO score 5-9) stromal changes. Of 122 patients, 88 displayed a low-grade and 34 a high-grade RCO score. The latter was associated more frequently with anaemia, thrombocytopenia, peripheral blood blasts and increased lactate dehydrogenase levels. The RCO score was correlated strictly with overall mortality (P = 0.013) and International Prognostic Scoring System (IPSS) risk categories, and was able to discriminate the overall survival of both low- and high-grade patients (log-rank test: P < 0.001). Moreover, it proved to be more accurate than the European Consensus on Grading of Bone Marrow Fibrosis (ECGMF grade) in identifying high-risk patients with poor prognosis. Finally, a combined analysis of RCO scores and IPSS risk categories in an integrated clinical-pathological evaluation was able to increase the positive predictive value (PPV) for mortality in high-risk patients. CONCLUSION The comprehensive RCO score, obtained by histological evaluation of reticulin fibrosis, collagen deposition and osteosclerosis was prognostically significant and more accurate than ECGMF grade in identifying high-risk patients and improved PPV when applied in addition to IPSS.
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Affiliation(s)
- Umberto Gianelli
- Division of Pathology, Department of Pathophysiology and Transplantation, University of Milan and IRCCS Ca' Granda, Maggiore Policlinico Hospital Foundation, Milan, Italy
| | - Stefano Fiori
- Division of Pathology, Department of Pathophysiology and Transplantation, University of Milan and IRCCS Ca' Granda, Maggiore Policlinico Hospital Foundation, Milan, Italy
| | - Daniele Cattaneo
- Hematology Division, IRCCS Ca' Granda, Maggiore Policlinico Hospital Foundation, Milan, Italy.,Department of Oncology and Hemato-oncology, University of Milan, Milan, Italy
| | - Anna Bossi
- Laboratory GA Maccacaro, Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
| | - Ivan Cortinovis
- Laboratory GA Maccacaro, Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
| | - Arturo Bonometti
- Division of Pathology, Department of Pathophysiology and Transplantation, University of Milan and IRCCS Ca' Granda, Maggiore Policlinico Hospital Foundation, Milan, Italy
| | - Giulia Ercoli
- Division of Pathology, Department of Pathophysiology and Transplantation, University of Milan and IRCCS Ca' Granda, Maggiore Policlinico Hospital Foundation, Milan, Italy
| | - Cristina Bucelli
- Hematology Division, IRCCS Ca' Granda, Maggiore Policlinico Hospital Foundation, Milan, Italy.,Department of Oncology and Hemato-oncology, University of Milan, Milan, Italy
| | - Nicola Orofino
- Hematology Division, IRCCS Ca' Granda, Maggiore Policlinico Hospital Foundation, Milan, Italy.,Department of Oncology and Hemato-oncology, University of Milan, Milan, Italy
| | - Gaetano Bulfamante
- Division of Pathology, Department of Health Sciences, University of Milan and San Paolo Hospital, Milan, Italy
| | - Alessandra Iurlo
- Hematology Division, IRCCS Ca' Granda, Maggiore Policlinico Hospital Foundation, Milan, Italy.,Department of Oncology and Hemato-oncology, University of Milan, Milan, Italy
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13
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The effects of hematopoietic stem cell transplant on splenic extramedullary hematopoiesis in patients with myeloproliferative neoplasm-associated myelofibrosis. Hematol Oncol Stem Cell Ther 2016; 9:96-104. [DOI: 10.1016/j.hemonc.2016.07.002] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2016] [Revised: 06/15/2016] [Accepted: 07/03/2016] [Indexed: 11/23/2022] Open
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14
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Barbui T, Thiele J, Vannucchi AM, Tefferi A. Myeloproliferative neoplasms: Morphology and clinical practice. Am J Hematol 2016; 91:430-3. [PMID: 26718907 DOI: 10.1002/ajh.24288] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2015] [Accepted: 12/22/2015] [Indexed: 12/26/2022]
Abstract
In myeloproliferative neoplasms (MPNs), controversy persists regarding the usefulness and reproducibility of bone marrow (BM) features. Disagreements concerning the WHO classification are mainly focused on the discrimination between essential thrombocythemia (ET) and prefibrotic/early primary myelofibrosis (prePMF) and prodromal polycythemia vera (PV). Criticism mostly refers to lack of standardization of distinctive BM features precluding correct morphological pattern recognition. The distinction between WHO-defined ET and prePMF is not trivial because outcome is significantly worse in prePMF. Morphology was generally considered to be non-specific for the diagnosis of PV. Recent studies have revealed under-diagnosis of morphologically and biologically consistent PV.
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Affiliation(s)
- Tiziano Barbui
- Research Foundation, Papa Giovanni XXIII Hospital; Bergamo Italy
| | - Jürgen Thiele
- Institute of pathology, University of Cologne; Cologne Germany
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15
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Kekre N, Ho VT. Allogeneic hematopoietic stem cell transplantation for myelofibrosis and chronic myelomonocytic leukemia. Am J Hematol 2016; 91:123-30. [PMID: 26453238 DOI: 10.1002/ajh.24215] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2015] [Accepted: 10/07/2015] [Indexed: 12/17/2022]
Abstract
The efficacy of hematopoietic stem cell transplantation (HSCT) is not well established in Philadelphia chromosome negative myeloproliferative neoplasms (Ph- MPNs). Without randomized prospective trials comparing HSCT to non-HSCT options or comparing HSCT regimens, physicians must rely on prognostic scoring systems and clinical experience when making decisions about who and when to transplant patients with Ph- MPNs. These patients are vulnerable to hepatic toxicity and graft failure after HSCT because of their increased likelihood of portal hypertension, massive splenomegaly, and extensive bone marrow fibrosis related to their disease. In this review, we aim to outline the indications and modalities of HSCT as they pertain to the Ph- MPNs and CMML based on the currently available evidence. We will further highlight the challenges of HSCT in these diseases, including but not limited to the incorporation of JAK inhibitors into HSCT for myelofibrosis.
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Affiliation(s)
- Natasha Kekre
- Division of Hematologic Malignancies; Dana-Farber Cancer Institute; Boston Massachusetts
| | - Vincent T. Ho
- Division of Hematologic Malignancies; Dana-Farber Cancer Institute; Boston Massachusetts
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16
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Hussein K, Stucki-Koch A, Alchalby H, Triviai I, Kröger N, Kreipe H. Cytokine Expression Pattern in Bone Marrow Microenvironment after Allogeneic Stem Cell Transplantation in Primary Myelofibrosis. Biol Blood Marrow Transplant 2015; 22:644-650. [PMID: 26708839 DOI: 10.1016/j.bbmt.2015.12.006] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2015] [Accepted: 12/07/2015] [Indexed: 02/03/2023]
Abstract
The only curative therapy for primary myelofibrosis (PMF) is allogeneic stem cell transplantation (ASCT). However, although we know that patients can benefit from ASCT, we do not know the extent of the changes of the expression profile of cytokines and matrix modulation factors. In this first systematic analysis, we evaluated the expression profile of 103 factors before and after transplantation to identify potential biomarkers. The expression of fibrosis-, inflammation-, and angiogenesis-associated genes was analyzed in a total of 52 bone marrow biopsies: PMF patients (n = 14) before and after ASCT and, for control purposes, post-ASCT multiple myeloma patients (n = 14) and non-neoplastic hematopoiesis (n = 10). In post-ASCT PMF cases, decreased expression of tissue inhibitor of metalloproteinases (TIMP) and platelet-derived growth factor alpha (PDGFA) correlated with bone marrow remodeling and hematological remission. Expression of several other matrix factors remained at high levels and may contribute to post-ASCT remodeling. This is the first systematic analysis of cytokine expression in post-ASCT PMF bone marrow that shows that normalization of bone marrow microenvironment is paralleled by decreased expression of TIMP and PDGFA.
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Affiliation(s)
- Kais Hussein
- Institute of Pathology, Hannover Medical School, Hannover, Germany.
| | | | - Haefaa Alchalby
- Department of Stem Cell Transplantation, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Ioanna Triviai
- Department of Stem Cell Transplantation, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Nicolaus Kröger
- Department of Stem Cell Transplantation, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Hans Kreipe
- Institute of Pathology, Hannover Medical School, Hannover, Germany
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17
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Kvasnicka HM, Beham-Schmid C, Bob R, Dirnhofer S, Hussein K, Kreipe H, Kremer M, Schmitt-Graeff A, Schwarz S, Thiele J, Werner M, Stein H. Problems and pitfalls in grading of bone marrow fibrosis, collagen deposition and osteosclerosis - a consensus-based study. Histopathology 2015; 68:905-15. [PMID: 26402166 DOI: 10.1111/his.12871] [Citation(s) in RCA: 57] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2015] [Accepted: 09/18/2015] [Indexed: 12/22/2022]
Abstract
AIMS In the era of potentially disease-modifying agents such as Janus kinase inhibitors, accurate grading and differentiation of bone marrow (BM) fibrosis has become more relevant to assess staging of disease and therapeutic effects. However, different fibrosis grading models have been used in the past without uniformity, including the proposal by the World Health Organization. Current scoring systems are based only on reticulin fibrosis. Therefore, additional assessment of collagen and the grade of osteosclerosis appear to be essential to discriminate all components of the complex BM fibrous matrix. METHODS AND RESULTS We evaluated problems and pitfalls regarding staining techniques and the interpretation of reticulin fibrosis on a total of 352 samples. Furthermore, we propose a minor modification of the current grading and separate scoring for collagen deposition and osteosclerosis. Reproducibility of gradings was tested among 11 haematopathologists in a blinded assessment. Overall, the inter-rater reliability of all three grading systems ranged between 0.898 and 0.926. CONCLUSIONS A standardized assessment of BM fibrosis with differentiation between reticulin, collagen and osteosclerosis is recommended to evaluate the various components of the fibrous matrix which may be delinked after therapy. In this regard, quality of staining and application of laboratory standards enable a highly reproducible scoring.
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Affiliation(s)
| | | | - Roshanak Bob
- Berlin Reference and Consultation Centre for Lymphoma and Hematopathology, Pathodiagnostik Berlin, Berlin, Germany
| | - Stephan Dirnhofer
- Institute of Pathology, University Hospital Basel, Basel, Switzerland
| | - Kais Hussein
- Institute of Pathology, Hannover Medical School, Hannover, Germany
| | - Hans Kreipe
- Institute of Pathology, Hannover Medical School, Hannover, Germany
| | - Marcus Kremer
- Institute of Pathology, Staedtisches Klinikum Muenchen, Muenchen, Germany
| | | | - Stephan Schwarz
- Department of Pathology, University Medical Centre Erlangen, Erlangen, Germany
| | - Juergen Thiele
- Institute of Pathology, University of Cologne, Cologne, Germany
| | - Martin Werner
- Institute of Surgical Pathology, University Hospital, Freiburg, Germany
| | - Harald Stein
- Berlin Reference and Consultation Centre for Lymphoma and Hematopathology, Pathodiagnostik Berlin, Berlin, Germany
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18
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Nazha A, Khoury JD, Rampal RK, Daver N. Fibrogenesis in Primary Myelofibrosis: Diagnostic, Clinical, and Therapeutic Implications. Oncologist 2015; 20:1154-60. [PMID: 26304912 DOI: 10.1634/theoncologist.2015-0094] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2015] [Accepted: 06/22/2015] [Indexed: 01/28/2023] Open
Abstract
Primary myelofibrosis is a stem cell-derived clonal malignancy characterized by unchecked proliferation of myeloid cells, resulting in bone marrow fibrosis, osteosclerosis, and pathologic angiogenesis. Bone marrow fibrosis (BMF) plays a central role in the pathophysiology of the disease. This review describes current issues regarding BMF in primary myelofibrosis, including the pathophysiology and impact of abnormal deposition of excess collagen and reticulin fibers in bone marrow spaces, the modified Bauermeister and the European Consensus grading systems of BMF, and the prognostic impact of BMF on the overall outcome of patients with primary myelofibrosis. The impact of novel therapeutic strategies, including JAK-STAT inhibitors and allogeneic stem cell transplant, on BMF is discussed.
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Affiliation(s)
- Aziz Nazha
- Leukemia Program, Department of Hematology and Medical Oncology, Taussig Cancer Institute, Cleveland, Ohio USA; Department of Hematopathology, and Leukemia Department, The University of Texas MD Anderson Cancer Center, Houston, Texas USA; Leukemia Service, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Joseph D Khoury
- Leukemia Program, Department of Hematology and Medical Oncology, Taussig Cancer Institute, Cleveland, Ohio USA; Department of Hematopathology, and Leukemia Department, The University of Texas MD Anderson Cancer Center, Houston, Texas USA; Leukemia Service, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Raajit K Rampal
- Leukemia Program, Department of Hematology and Medical Oncology, Taussig Cancer Institute, Cleveland, Ohio USA; Department of Hematopathology, and Leukemia Department, The University of Texas MD Anderson Cancer Center, Houston, Texas USA; Leukemia Service, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Naval Daver
- Leukemia Program, Department of Hematology and Medical Oncology, Taussig Cancer Institute, Cleveland, Ohio USA; Department of Hematopathology, and Leukemia Department, The University of Texas MD Anderson Cancer Center, Houston, Texas USA; Leukemia Service, Memorial Sloan Kettering Cancer Center, New York, New York, USA
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19
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20
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Pozdnyakova O, Hasserjian RP, Verstovsek S, Orazi A. Impact of bone marrow pathology on the clinical management of Philadelphia chromosome-negative myeloproliferative neoplasms. CLINICAL LYMPHOMA, MYELOMA & LEUKEMIA 2015; 15:253-61. [PMID: 25515354 DOI: 10.1016/j.clml.2014.11.002] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/16/2014] [Accepted: 11/12/2014] [Indexed: 02/03/2023]
Abstract
Philadelphia chromosome-negative myeloproliferative neoplasms include primary myelofibrosis (PMF), polycythemia vera (PV), and essential thrombocythemia (ET). Although these 3 entities share many pathogenic characteristics, such as dysregulated Janus kinase (JAK)/signal transducer and activator of transcription signaling, they differ substantially regarding prognosis, progression to myelofibrosis (MF), risk of leukemic transformation, and specific medical needs. Accurate diagnosis and classification of myeloproliferative neoplasms are prerequisites for appropriate risk-based therapy and should be based on an integrated approach following the World Health Organization guidelines that, in addition to clinical, molecular, and cytogenetic evaluation, includes the examination of bone marrow morphology. Reticulin fibrosis at presentation in ET and PV is associated with increased risk of myelofibrotic transformation, and higher fibrosis grade in patients with MF is associated with worse prognosis. Additional assessment of collagen deposition and osteosclerosis may further increase diagnostic and prognostic precision. Moreover, the evaluation of bone marrow pathology has become very important in the new era of disease-modifying agents. In randomized controlled phase 3 studies, the JAK1/JAK2 inhibitor ruxolitinib provided rapid and lasting improvement in MF-related splenomegaly and symptom burden as well as a survival advantage compared with placebo or best available therapy. Follow-up for up to 5 years of patients who participated in a phase 1/2 study of ruxolitinib, revealed stabilization or reversal of bone marrow fibrosis in a proportion of patients with MF. Combinations of JAK inhibitors with other therapies, including agents with antifibrotic and/or anti-inflammatory properties, may possibly decrease bone marrow fibrosis further and favorably influence clinical outcomes.
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Affiliation(s)
| | | | | | - Attilio Orazi
- Weill Medical College of Cornell University, New York, NY.
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21
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Allogeneic haematopoietic stem cell transplantation for primary myelofibrosis and myelofibrosis evolved from other myeloproliferative neoplasms. Curr Opin Hematol 2015; 22:184-90. [DOI: 10.1097/moh.0000000000000121] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
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22
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Allo-SCT for myelofibrosis: reversing the chronic phase in the JAK inhibitor era? Bone Marrow Transplant 2015; 50:628-36. [PMID: 25665047 DOI: 10.1038/bmt.2014.323] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2014] [Revised: 11/16/2014] [Accepted: 11/17/2014] [Indexed: 01/30/2023]
Abstract
At present, allo-SCT is the only curative treatment for patients with myelofibrosis (MF). Unfortunately, a significant proportion of candidate patients are considered transplant ineligible due to their poor general condition and advanced age at the time of diagnosis. The approval of the first JAK inhibitor, ruxolitinib, for patients with advanced MF in 2011 has had a qualified impact on the treatment algorithm. The drug affords substantial improvement in MF-associated symptoms and splenomegaly but no major effect on the natural history. There has, therefore, been considerable support for assessing the drug's candidacy in the peritransplant period. The drug's precise impact on clinical outcome following allo-SCT is currently not known; nor are the drug's long-term efficacy and safety known. Considering the rarity of MF and the small proportion of patients who undergo allo-SCT, well designed collaborative efforts are required. In order to address some of the principal challenges, an expert panel of laboratory and clinical experts in this field was established, and an independent workshop held during the 54th American Society of Hematology Annual Meeting in New Orleans, USA on 6 December 2013, and the European Hematology Association's Annual Meeting in Milan, Italy on 13 June 2014. This document summarizes the results of these efforts.
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23
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Shanavas M, Gupta V. Controversies and dilemmas in allogeneic transplantation for myelofibrosis. Best Pract Res Clin Haematol 2014; 27:165-74. [PMID: 25189727 DOI: 10.1016/j.beha.2014.07.007] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2014] [Accepted: 07/11/2014] [Indexed: 01/10/2023]
Abstract
JAK1/2 inhibitors have broadened the therapeutic options in myelofibrosis. Though not curative, they result in a meaningful clinical benefit with relatively fewer side effects. In contrast, allogeneic hematopoietic cell transplantation (HCT) is a potentially curative option, but is associated with significant morbidity and mortality. Hence, an important question is the optimal timing of HCT in the era of JAK inhibitors. Timing of HCT is a crucial decision, and need to be individualized based on the personal preferences and goals of therapy; in addition to patient, disease, and transplant related factors. Risk stratification by the currently established prognostic scoring systems need to be further refined by incorporation of prognostically significant mutations to guide the treatment choices better. Data on use of JAK inhibitors prior to HCT have just started to emerge. We discuss some of the current controversies and dilemmas in transplantation for myelofibrosis based on a few real life scenarios.
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Affiliation(s)
- Mohamed Shanavas
- Allogeneic Blood and Marrow Transplant Program, Princess Margaret Cancer Center and University of Toronto, 610 University Avenue, Toronto, Ontario, M5G 2M9, Canada
| | - Vikas Gupta
- Allogeneic Blood and Marrow Transplant Program, Princess Margaret Cancer Center and University of Toronto, 610 University Avenue, Toronto, Ontario, M5G 2M9, Canada.
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24
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Kröger N, Zabelina T, Alchalby H, Stübig T, Wolschke C, Ayuk F, von Hünerbein N, Kvasnicka HM, Thiele J, Kreipe HH, Büsche G. Dynamic of Bone Marrow Fibrosis Regression Predicts Survival after Allogeneic Stem Cell Transplantation for Myelofibrosis. Biol Blood Marrow Transplant 2014; 20:812-5. [DOI: 10.1016/j.bbmt.2014.02.019] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2014] [Accepted: 02/21/2014] [Indexed: 11/26/2022]
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25
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Kröger N, Kvasnicka M, Thiele J. Replacement of hematopoietic system by allogeneic stem cell transplantation in myelofibrosis patients induces rapid regression of bone marrow fibrosis. FIBROGENESIS & TISSUE REPAIR 2012; 5:S25. [PMID: 23259545 PMCID: PMC3368753 DOI: 10.1186/1755-1536-5-s1-s25] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
Bone marrow fibrosis is a hallmark of primary and post ET/PV myelofibrosis. To investigated the impact of replacement of the hematopoietic system in myelofibrosis patients by allogeneic stem cell transplantation on bone marrow fibrosis, we studied bone marrow fibrosis on bone marrow samples from 24 patients with myelofibrosis before and after dose-reduced conditioning followed by allogeneic stem cell transplantation from related or unrelated donor. Using the European Consensus on Grading Bone Marrow Fibrosis, before allografting all patients had advanced fibrosis MF-2 (n = 13) or MF-3 (n = 11). After transplantation, a complete (MF-0) or nearly complete (MF-1) regression of bone marrow fibrosis was seen in 59 % at day +100, in 90 % at day +180, and in 100 % at day +360. No correlation between occurrence of acute graft-versus-host disease, and fibrosis regression on day +180 was seen. We conclude that dose-reduced conditioning, followed by allogeneic stem cell transplantation, resulted in a rapid resolution of bone-marrow fibrosis suggesting the bone marrow fibrogenesis is a highly dynamic rather than static process in patients with myelofibrosis.
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Affiliation(s)
- Nicolaus Kröger
- Dept. of Stem Cell Transplantation, University Hospital Hamburg, Germany
| | | | - Jürgen Thiele
- Institute for Pathology, University Hospital Cologne, Germany
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26
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Nagi W, Lim Z, Krishnamurthy P, Potter V, Tindell V, Reiff-Zall L, Abdullah A, Lea N, Kenyon M, Marsh J, Ho A, Mufti G, Pagliuca A. Alemtuzumab based reduced intensity conditioning allogeneic haematopoietic stem cell transplantation for myelofibrosis. Leuk Res 2011; 35:998-1000. [DOI: 10.1016/j.leukres.2011.02.012] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2011] [Revised: 02/10/2011] [Accepted: 02/14/2011] [Indexed: 11/17/2022]
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27
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Samuelson S, Sandmaier BM, Heslop HE, Popat U, Carrum G, Champlin RE, Storb R, Prchal JT, Gooley TA, Deeg HJ. Allogeneic haematopoietic cell transplantation for myelofibrosis in 30 patients 60-78 years of age. Br J Haematol 2011; 153:76-82. [PMID: 21323890 DOI: 10.1111/j.1365-2141.2011.08582.x] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
We analysed the results of haematopoietic cell transplantation (HCT) in 30 patients aged 60-78 (median 65) years, with primary myelofibrosis or myelofibrosis evolving from antecedent polycythaemia vera or essential thrombocythaemia. Donors were human leucocyte antigen (HLA)-identical siblings (N = 15) or unrelated individuals (N = 15). Various conditioning regimens were used, ranging from very low intensity (fludarabine plus 2 Gy total body irradiation) to high dose (busulfan plus cyclophosphamide). Stem cell sources were granulocyte colony-stimulating factor mobilized peripheral blood progenitor cells in 29 patients and marrow in one patient. Sustained engraftment was documented in 27 of 30 patients. Day -100 mortality was 13%. With a median follow-up of 22 (range 0·5 - 69) months, 3-year overall survival and progression-free survival were 45% and 40%, respectively. Currently, 13 patients are surviving. Seven patients died with disease progression at 0·5 -22 months, and 10 patients died from other causes at 1·5 -37.5 months after HCT. While the selection of older patients for transplantation was probably biased, the present results are encouraging. Motivated older patients with myelofibrosis without substantial comorbid conditions should be offered the option of allogeneic HCT.
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Affiliation(s)
- Scott Samuelson
- University of Utah, Department of Medicine, Salt Lake City, UT, USA
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28
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Suyanı E, Akı SZ, Yegin ZA, Ozkurt ZN, Altındal S, Akyürek N, Yaǧcı M, Sucak GT. The impact of bone marrow fibrosis on the outcome of hematopoietic stem cell transplantation. Transplant Proc 2010; 42:2713-9. [PMID: 20832575 DOI: 10.1016/j.transproceed.2010.05.150] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2009] [Accepted: 05/12/2010] [Indexed: 12/01/2022]
Abstract
We retrospectively analyzed the data of 175 patients who underwent autologous (n = 69) or allogeneic hematopoietic stem cell transplantation (HCT) (n = 106) including 19 (27.5%) and 38 (35.8%) recipients who had bone marrow fibrosis (BMF) prior to transplantation, respectively. We investigated the effects of BMF on engraftment, graft-versus-host disease (GVHD), early posttransplant complications, and survival. Pretransplantation BMF did not delay engraftment and showed no impact either on early posttransplant complications or on the development of acute and/or chronic GVHD. Probability of 1-year overall survival (OS) and progression-free survival (PFS) of autologous HCT recipients were similar, namely 76.7% versus 88.6% (P > .005) and 26.33% versus 16.5% (P > .05) among patients with versus without fibrosis, respectively. In allogeneic HCT recipients, the probability of 1-year OS was 35.2% among patients with versus 48.9% among those without fibrosis (P = .004) PFS at 1 year was inferior among allogeneic HCT recipients with BMF: 27.8% versus 51.2% (P = .0008). Cox regression analysis revealed BMF to be independently associated with age, Sorror comorbidity index, primary disease, and disease status during HCT (P = .045).
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Affiliation(s)
- E Suyanı
- Department of Hematology, Gazi University, Ankara, Turkey
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29
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Kröger N, Bacher U, Bader P, Böttcher S, Borowitz MJ, Dreger P, Khouri I, Olavarria E, Radich J, Stock W, Vose JM, Weisdorf D, Willasch A, Giralt S, Bishop MR, Wayne AS. NCI first international workshop on the biology, prevention, and treatment of relapse after allogeneic hematopoietic stem cell transplantation: report from the committee on disease-specific methods and strategies for monitoring relapse following allogeneic stem cell transplantation. part II: chronic leukemias, myeloproliferative neoplasms, and lymphoid malignancies. Biol Blood Marrow Transplant 2010; 16:1325-46. [PMID: 20637879 DOI: 10.1016/j.bbmt.2010.07.001] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2010] [Accepted: 07/06/2010] [Indexed: 12/31/2022]
Abstract
Relapse has become the major cause of treatment failure after allogeneic hematopoietic stem cell transplantation. Outcome of patients with clinical relapse after transplantation generally remains poor, but intervention prior to florid relapse improves outcome for certain hematologic malignancies. To detect early relapse or minimal residual disease, sensitive methods such as molecular genetics, tumor-specific molecular primers, fluorescence in situ hybridization (FISH), and multiparameter flow cytometry (MFC) are commonly used after allogeneic stem cell transplantation to monitor patients, but not all of them are included in the commonly employed disease-specific response criteria. The highest sensitivity and specificity can be achieved by molecular monitoring of tumor- or patient-specific markers measured by polymerase chain reaction-based techniques, but not all diseases have such targets for monitoring. Similar high sensitivity can be achieved by determination of recipient-donor chimerism, but its specificity regarding detection of relapse is low and differs substantially among diseases. Here, we summarize the current knowledge about the utilization of such sensitive monitoring techniques in chronic leukemias, myeloproliferative neoplasms, and lymphoid malignancies based on tumor-specific markers and cell chimerism and how these methods might augment the standard definitions of posttransplant remission, persistence, progression, relapse, and the prediction of relapse. Critically important is the need for standardization of the different residual disease techniques and to assess the clinical relevance of minimal residual disease and chimerism surveillance in individual diseases, which in turn must be followed by studies to assess the potential impact of specific interventional strategies.
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Affiliation(s)
- Nicolaus Kröger
- Department for Stem Cell Transplantation, University Medical Center Hamburg-Eppendorf, Germany.
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30
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Outcome of allogeneic stem cell transplantation following reduced-intensity conditioninig regimen in patients with idiopathic myelofibrosis: the g.I.T.m.o. Experience. Mediterr J Hematol Infect Dis 2010; 2:e2010010. [PMID: 21415963 PMCID: PMC3033132 DOI: 10.4084/mjhid.2010.010] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2010] [Accepted: 05/03/2010] [Indexed: 11/14/2022] Open
Abstract
Background: Allogeneic stem cell transplantation (SCT) is a potentially curative treatment for myelofibrosis (MI), though limited by a high rate of transplant-related mortality (TRM). In the present study we evaluate the outcome of MI patients undergoing an allogenic SCT after reduced intensity conditioning (RIC) regimens, and the impact of prognostic factors. Design and methods: Fifty two patients were transplanted in 26 Italian centres between 1998 and 2006. We analyzed the influence of patient and disease clinical features before SCT and of transplant procedures on TRM and overall survival (OS) by means of univariate and multivariate analyses. Results: At SCT, median age was 52,5 years (32–68) and 89% of the patients had an intermediate or high Dupriez score. Conditioning regimens were based on fludarabine plus busulphan in 27% of patients, thiotepa plus cyclophosphamide in 46% and miscellaneous drug combinations in the other 27% of cases. Stem cells came from matched sibling donors for 75% of the patients and mismatched sibling or unrelated donors for the remaining 25%. The cumulative incidence of engraftment at day 90 after transplant was 83% (95% CI, 0.87–0.97). The estimated 1-year TRM was 30%. The estimated 3-year event-free-survival (EFS) and OS after hematopoietic SCT was 44% and 38% respectively. In multivariate analysis, an higher leukocyte count and circulating blasts in the peripheral blood before SCT significantly reduced EFS and OS respectively. Interpretation and conclusions: We conclude that the extension of the disease before transplantation based on the presence of circulating blasts and high leukocyte counts significantly affected the outcome after HSCT
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31
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Rambaldi A. Therapy of myelofibrosis (excluding JAK2 inhibitors). Int J Hematol 2010; 91:180-8. [PMID: 20178012 DOI: 10.1007/s12185-010-0532-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2010] [Accepted: 02/07/2010] [Indexed: 10/19/2022]
Abstract
Myelofibrosis shows a progressive clinical course and usually a poor, lethal prognosis. Allogeneic transplantation is an effective, potentially curable treatment approach although only a minority of patients may currently benefit from it. New effective treatment strategies are becoming available for this disease, including not only JAK2 inhibitors, but also other innovative drugs, targeting more general oncogenic mechanisms and the epigenetic control of cell proliferation and differentiation.
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Affiliation(s)
- Alessandro Rambaldi
- Divisione di Ematologia, Ospedali Riuniti, Largo Barozzi 1, 24100 Bergamo, Italy.
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The role of allogeneic SCT in primary myelofibrosis: a British Society for Blood and Marrow Transplantation study. Bone Marrow Transplant 2010; 45:1587-93. [PMID: 20154739 DOI: 10.1038/bmt.2010.14] [Citation(s) in RCA: 59] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
Fifty-one patients with primary myelofibrosis (PMF) received allogeneic haematopoietic stem cell transplants from related (n=33) or unrelated (n=18) donors. Twenty-seven patients, 19-54 years old, were prepared with myeloablative regimens including CY plus BU (n=4) or TBI (n=23). Twenty-four patients, 40-64 years old, received reduced-intensity conditioning (RIC) regimens. All RIC regimens contained fludarabine, combined with melphalan (n=19) or BU (n=5), and alemtuzumab or anti-thymocyte globulin (ATG) in the majority (n=19). Four patients (17%) in the RIC group had primary graft failure. Previous splenectomy reduced time to engraftment in the RIC group (13 versus 20 days; P=0.008). For MA and RIC groups, respectively, at 3 years, overall survival rates were 44 and 31% (P=0.67), progression-free survival 44 and 24% (P=0.87), and actuarial relapse rates 15 and 46% (P=0.06). Non-relapse mortality at 3 years was 41% for the myeloablative and 32% for the RIC group. Acute GVHD occurred in 29 and 38% of patients in the myeloablative and RIC groups, respectively. Extensive chronic GVHD developed in 30 and 35% of evaluable patients, respectively.
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Ramakrishnan A, Sandmaier BM. Optimizing reduced-intensity conditioning regimens for myeloproliferative neoplasms. Expert Rev Hematol 2010; 3:23-33. [PMID: 20383269 PMCID: PMC2850074 DOI: 10.1586/ehm.09.73] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
The myeloproliferative neoplasms (MPNs) are a group of clonal disorders that arise from a pluripotent hematopoietic stem cell and are characterized by excess cellular proliferation. These disorders tend to be chronic in nature and can terminate over time into a bone marrow failure syndrome characterized by marrow fibrosis or transform into a leukemic phase. MPNs are predominantly diseases of the elderly and this is one reason why until very recently the standard treatment was supportive care. The only curative modality for these disorders is allogeneic hematopoietic cell transplantation. The introduction of reduced-intensity conditioning regimens now allows this life-saving therapy to be offered to elderly patients who were previously considered ineligible for high-dose conditioning owing to age or comorbidity. In this review, we will summarize the current strategies and future directions regarding the use of reduced-intensity conditioning regimens in the treatment of MPNs.
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Affiliation(s)
- Aravind Ramakrishnan
- Associate in Clinical Research, Fred Hutchinson Cancer Research Center, Acting Instructor, University of Washington School of Medicine, 1100 Fairview Avenue N, D1-100, PO Box 19024, Seattle, WA 98109-1024, USA, Tel.: +1 206 667 2908, Fax: +1 206 667 6124,
| | - Brenda M Sandmaier
- Member, Clinical Research Division, Fred Hutchinson Cancer Research Center, Professor, University of Washington School of Medicine, 1100 Fairview Avenue N, D1-100, PO Box 19024, Seattle, WA 98109-1024, USA, Tel.: +1 206 667 4961, Fax: +1 206 667 6124
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Schmitt-Graeff AH. [Chronic myeloid neoplasms. Diagnostic criteria and current therapeutic concepts]. DER PATHOLOGE 2010; 31:29-41. [PMID: 20076959 DOI: 10.1007/s00292-009-1261-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Myeloproliferative neoplasms (MPNs) and related chronic disorders constitute a subgroup of myeloid malignancies which are defined according to clinical, morphological and molecular features by the actual World Health Organization classification of tumors of the haematopietic system. Screening procedures for a BCR-ABL fusion gene, JAK2, thrombopoietin receptor and KIT mutations are formally included in the diagnostic approach. Myelodysplastic/MPN overlap syndromes include rare entities such as refractory anemia with ringed sideroblasts characterized by a high proportion of JAK2V617F mutated cases. The paradigm of targeted treatment of chronic myeloid leukemia with imatinib has now been extended to eosinophilia-associated myeloid neoplasms with PDGFRA, PDGFRB or FGFR1 gene mutations. Pegylated interferon-alpha has convincingly been proved to reduce the JAK2 allele burden. JAK2 inhibitor drugs are currently being tested in clinical trials. The development of pathogenesis-targeted diagnostic and therapeutic approaches to the various MPNs will continue in the future.
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Affiliation(s)
- A H Schmitt-Graeff
- Institut für Pathologie, Universitätsklinikum Freiburg, Breisacherstrasse 115a, Freiburg.
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Allogeneic stem cell transplantation after reduced-intensity conditioning in patients with myelofibrosis: a prospective, multicenter study of the Chronic Leukemia Working Party of the European Group for Blood and Marrow Transplantation. Blood 2009; 114:5264-70. [PMID: 19812383 DOI: 10.1182/blood-2009-07-234880] [Citation(s) in RCA: 278] [Impact Index Per Article: 18.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
From 2002 to 2007, 103 patients with primary myelofibrosis or postessential thrombocythemia and polycythemia vera myelofibrosis and a median age of 55 years (range, 32-68 years) were included in a prospective multicenter phase 2 trial to determine efficacy of a busulfan (10 mg/kg)/fludarabine (180 mg/m(2))-based reduced-intensity conditioning regimen followed by allogeneic stem cell transplantation from related (n = 33) or unrelated donors (n = 70). All but 2 patients (2%) showed leukocyte and platelet engraftment after a median of 18 and 22 days, respectively. Acute graft-versus-host disease grade 2 to 4 occurred in 27% and chronic graft-versus-host disease in 43% of the patients. Cumulative incidence of nonrelapse mortality at 1 year was 16% (95% confidence interval, 9%-23%) and significantly lower for patients with a completely matched donor (12% vs 38%; P = .003). The cumulative incidence of relapse at 3 years was 22% (95% confidence interval, 13%-31%) and was influenced by Lille risk profile (low, 14%; intermediate, 22%; and high, 34%; P = .02). The estimated 5-year event-free and overall survival was 51% and 67%, respectively. In a multivariate analysis, age older than 55 years (hazard ratio = 2.70; P = .02) and human leukocyte antigen-mismatched donor (hazard ratio = 3.04; P = .006) remained significant factors for survival. The study was registered at www.clinicaltrials.gov as #NCT 00599547.
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Onida F. Factors affecting prognosis in myelofibrosis. F1000 MEDICINE REPORTS 2009; 1. [PMID: 20948725 PMCID: PMC2948309 DOI: 10.3410/m1-55] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
Studies investigating factors affecting prognosis in primary myelofibrosis have been numerous over the years because of the high heterogeneity with regard to its natural clinical course. Recently, the increasing application of reduced-intensity conditioning with allogeneic hematopoietic stem cell transplantation as well as the ongoing rapid development of new experimental agents, such as JAK2 inhibitors, have made the requirement for simple and accurate scoring systems to select individual patients for the most appropriate treatment strategy even more critical. This short report summarizes the state of the art and the most recent advances in this area.
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Affiliation(s)
- Francesco Onida
- Hematology I - Bone Marrow Transplantation Center, Fondazione IRCCS Ospedale Maggiore Policlinico, Mangiagalli e Regina Elena, University of Milan Via Francesco Sforza 35, 20122 Milan Italy
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Abstract
PURPOSE OF REVIEW Hematopoietic cell transplantation (HCT) offers potentially curative therapy for patients with myelofibrosis. What is the current status? RECENT FINDINGS Changes in transplant strategies allow offering HCT to patients who, because of age or comorbid conditions, were not considered transplant candidates in the past. The omission of high-dose total body irradiation, adjusting doses of busulfan to achieve defined target levels, using fludarabine instead of cyclophosphamide as an immunosuppressive agent, the addition of melphalan, and the incorporation of antithymocyte globulin all appear to have contributed to better tolerability of new regimens. Reduced-intensity conditioning regimens are associated with a decrease in nonrelapse mortality and allow for successful HCT, even in patients 60-70 years of age. Some 50-75% of patients are cured by HCT. Emerging concepts include new prognostic scoring systems and novel molecular markers such as Janus kinase 2 mutations, which may aid in making treatment decisions and assessing remission status. SUMMARY Modifications of transplant-conditioning regimens have reduced transplant-related mortality and allow carrying out successful HCT in increasingly older patients. The selection of patients who should be transplanted, the optimal timing for transplantation, and pretransplant and posttransplant strategies remain challenging problems.
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Affiliation(s)
- Dae Young Zang
- Hallym University Medical Center and the Hallym University College of Medicine, Anyang, South Korea
| | - H. Joachim Deeg
- Fred Hutchinson Cancer Research Center and the University of Washington, Seattle, WA, USA
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Perz JB, Hegenbart U, Kroeger N, Otto G, Ho AD, Dreger P. Successful unrelated donor stem cell transplantation for advanced myelofibrosis in an adult patient with history of orthotopic liver transplantation. Haematologica 2009; 94:594-6. [PMID: 19229047 DOI: 10.3324/haematol.2008.002923] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
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Benjamini O, Koren-Michowitz M, Amariglio N, Kroger N, Nagler A, Shimoni A. Relapse of postpolycythemia myelofibrosis after allogeneic stem cell transplantation in a polycythemic phase: successful treatment with donor lymphocyte infusion directed by quantitative PCR test for V617F-JAK2 mutation. Leukemia 2008; 22:1961-3. [PMID: 18685610 DOI: 10.1038/leu.2008.215] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
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George B, Kerridge I, Gottlieb D, Huang G, Hertzberg M, Svennilson J, Bradstock K. A reduced intensity conditioning protocol associated with excellent survival in patients with myelofibrosis. Bone Marrow Transplant 2008; 42:567-8. [PMID: 18660841 DOI: 10.1038/bmt.2008.219] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
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Minimal residual disease diagnostics in myeloid malignancies in the post transplant period. Bone Marrow Transplant 2008; 42:145-57. [PMID: 18587431 DOI: 10.1038/bmt.2008.185] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
Allogeneic SCT is important in myelodysplastic syndrome, the BCR-ABL-negative chronic myeloproliferative diseases (CMPDs) and in poor-risk AML. Techniques to monitor the minimal residual disease, for example, by PCR or immunophenotyping gain increasing importance in the post transplantation period as basis for improved and earlier therapeutic interventions in impending relapse. Recent markers such as the NPM1 mutations in AML or the JAK2V617F mutation in the CMPD can be exactly quantified by real-time PCR and were evaluated for their prognostic value in the post transplantation phase and for their utility to plan adoptive immunotherapy in case of molecular relapse. With respect to chimerism, new and very sensitive methods were introduced, for example, quantitative assessment of genetic polymorphisms by real-time PCR, but also methods here are still highly individualized. Only in CML, where SCT focuses now on poor-risk cases or cases of tyrosine kinase inhibitor failure, follow-up schedules are standardized. Standardization of the different diagnostic techniques and of the intervals in the post transplantation period is urgently needed also in other myeloid malignancies and should be focus of future studies.
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Rambaldi A, Barbui T, Barosi G. From palliation to epigenetic therapy in myelofibrosis. HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2008; 2008:83-91. [PMID: 19074063 DOI: 10.1182/asheducation-2008.1.83] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/27/2023]
Abstract
Myelofibrosis shows a progressive clinical course and usually a poor, lethal prognosis. The molecular pathogenesis of this disease largely remains to be fully understood but the identification of the JAK2V617F mutation in more than half of patients was a major improvement in our understanding of the disease biology and may represent the first biologic marker useful for risk stratification, independently from conventional clinical predictors. After many elusive efforts, new effective treatment strategies are becoming available for this disease. Allogeneic transplantation following reduced-intensity conditioning programs, at least in some patients, may induce not only a hematologic response but also a molecular remission, thus supporting the hope of a possible, definitive eradication of the disease. Moreover, new innovative drugs, targeting either the JAK2V617F mutation or more general oncogenic mechanisms, may provide widely applicable, effective treatments to many patients for whom allogeneic transplantation is not feasible.
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Affiliation(s)
- Alessandro Rambaldi
- Unit of Hematology, Ospedali Riuniti Bergamo, Istituto di Ricovero e Cura a Carattere Scientifico, Policlinico S., Matteo Foundation, Pavia, Italy.
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