1
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Pardanani A. Systemic mastocytosis in adults: 2023 update on diagnosis, risk stratification and management. Am J Hematol 2023; 98:1097-1116. [PMID: 37309222 DOI: 10.1002/ajh.26962] [Citation(s) in RCA: 12] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2023] [Revised: 04/29/2023] [Accepted: 05/02/2023] [Indexed: 06/14/2023]
Abstract
OVERVIEW Systemic mastocytosis (SM) results from clonal proliferation of mast cells (MC) in extracutaneous organs. DIAGNOSIS The major criterion is presence of multifocal MC clusters in the bone marrow and/or extracutaneous organs. Minor diagnostic criteria include elevated serum tryptase level, MC CD25/CD2/CD30 expression, and presence of activating KIT mutations. RISK STRATIFICATION Establishing SM subtype as per the International Consensus Classification/World Health Organization classification systems is an important first step. Patients either have indolent/smoldering SM (ISM/SSM) or advanced SM, including aggressive SM (ASM), SM with associated myeloid neoplasm (SM-AMN), and mast cell leukemia. Identification of poor-risk mutations (i.e., ASXL1, RUNX1, SRSF2, NRAS) further refines the risk stratification. Several risk models are available to help assign prognosis in SM patients. MANAGEMENT Treatment goals for ISM patients are primarily directed toward anaphylaxis prevention/symptom control/osteoporosis treatment. Patients with advanced SM frequently need MC cytoreductive therapy to reverse disease-related organ dysfunction. Tyrosine kinase inhibitors (TKI) (midostaurin, avapritinib) have changed the treatment landscape in SM. While deep biochemical, histological and molecular responses have been documented with avapritinib treatment, its efficacy as monotherapy against a multimutated AMN disease component in SM-AMN patients remains unclear. Cladribine continues to have a role for MC debulking, whereas interferon-α has a diminishing role in the TKI era. Treatment of SM-AMN primarily targets the AMN component, particularly if an aggressive disease such as acute leukemia is present. Allogeneic stem cell transplant has a role in such patients. Imatinib has a therapeutic role only in the rare patient with an imatinib-sensitive KIT mutation.
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Affiliation(s)
- Animesh Pardanani
- Division of Hematology, Department of Medicine, Mayo Clinic, Rochester, Minnesota, USA
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2
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Parente R, Giudice V, Cardamone C, Serio B, Selleri C, Triggiani M. Secretory and Membrane-Associated Biomarkers of Mast Cell Activation and Proliferation. Int J Mol Sci 2023; 24:ijms24087071. [PMID: 37108232 PMCID: PMC10139107 DOI: 10.3390/ijms24087071] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2023] [Revised: 04/05/2023] [Accepted: 04/06/2023] [Indexed: 04/29/2023] Open
Abstract
Mast cells (MCs) are immune cells distributed in many organs and tissues and involved in the pathogenesis of allergic and inflammatory diseases as a major source of pro-inflammatory and vasoactive mediators. MC-related disorders are heterogeneous conditions characterized by the proliferation of MC within tissues and/or MC hyper-reactivity that leads to the uncontrolled release of mediators. MC disorders include mastocytosis, a clonal disease characterized by tissue MC proliferation, and MC activation syndromes that can be primary (clonal), secondary (related to allergic disorders), or idiopathic. Diagnosis of MC disorders is difficult because symptoms are transient, unpredictable, and unspecific, and because these conditions mimic many other diseases. Validation of markers of MC activation in vivo will be useful to allow faster diagnosis and better management of MC disorders. Tryptase, being the most specific MC product, is a widely used biomarker of proliferation and activation. Other mediators, such as histamine, cysteinyl leukotrienes, and prostaglandin D2, are unstable molecules and have limitations in their assays. Surface MC markers, detected by flow cytometry, are useful for the identification of neoplastic MC in mastocytosis but, so far, none of them has been validated as a biomarker of MC activation. Further studies are needed to identify useful biomarkers of MC activation in vivo.
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Affiliation(s)
- Roberta Parente
- Division of Allergy and Clinical Immunology, University of Salerno, 84081 Baronissi, Italy
| | - Valentina Giudice
- Division of Hematology and Transplant Center, University of Salerno, 84081 Baronissi, Italy
| | - Chiara Cardamone
- Division of Allergy and Clinical Immunology, University of Salerno, 84081 Baronissi, Italy
| | - Bianca Serio
- Division of Hematology and Transplant Center, University of Salerno, 84081 Baronissi, Italy
| | - Carmine Selleri
- Division of Hematology and Transplant Center, University of Salerno, 84081 Baronissi, Italy
| | - Massimo Triggiani
- Division of Allergy and Clinical Immunology, University of Salerno, 84081 Baronissi, Italy
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3
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Flow-based allergen testing: can mast cells beat basophils? Clin Chim Acta 2022; 532:64-71. [DOI: 10.1016/j.cca.2022.05.014] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2022] [Revised: 05/17/2022] [Accepted: 05/18/2022] [Indexed: 12/15/2022]
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4
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Pardanani A. Systemic mastocytosis in adults: 2021 Update on diagnosis, risk stratification and management. Am J Hematol 2021; 96:508-525. [PMID: 33524167 DOI: 10.1002/ajh.26118] [Citation(s) in RCA: 90] [Impact Index Per Article: 30.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2021] [Accepted: 01/08/2021] [Indexed: 12/16/2022]
Abstract
OVERVIEW Systemic mastocytosis (SM) results from a clonal proliferation of abnormal mast cells (MC) in extra-cutaneous organs. DIAGNOSIS The major criterion is presence of multifocal clusters of spindled MC in the bone marrow. Minor diagnostic criteria include elevated serum tryptase level, abnormal MC CD25 expression, and presence of KITD816V mutation. RISK STRATIFICATION Establishing SM subtype as per the World Health Organization classification system is an important first step. Broadly, patients either have indolent/smoldering SM (ISM/SSM) or advanced SM, the latter includes aggressive SM (ASM), SM with associated hematological neoplasm (SM-AHN), and mast cell leukemia (MCL). Identification of poor-risk mutations (ie, ASXL1, RUNX1, SRSF2, NRAS) further refines the risk stratification. Recently, clinical and hybrid clinical-molecular risk models have been developed to more accurately assign prognosis in SM patients. MANAGEMENT Treatment goals for ISM patients are primarily directed towards anaphylaxis prevention/symptom control/osteoporosis treatment. Patients with advanced SM frequently need MC cytoreductive therapy to ameliorate disease-related organ dysfunction. High response rates have been seen with small-molecule inhibitors that target mutant-KIT, including midostaurin (Food and Drug Administration approved) or avapritinib (investigational). Other options for MC cytoreduction include cladribine or interferon-α, although head-to-head comparisons are lacking. Treatment of SM-AHN primarily targets the AHN component, particularly if an aggressive disease such as acute myeloid leukemia is present. Allogeneic stem cell transplant can be considered in such patients, or in those with relapsed/refractory advanced SM. Imatinib has a limited therapeutic role in SM; effective cytoreduction is limited to those with imatinib-sensitive KIT mutations.
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Affiliation(s)
- Animesh Pardanani
- Division of Hematology, Department of Medicine Mayo Clinic Rochester Minnesota
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5
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Identification and Immunophenotypic Characterization of Normal and Pathological Mast Cells. Methods Mol Biol 2020; 2163:331-353. [PMID: 32766988 DOI: 10.1007/978-1-0716-0696-4_27] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
Mast cells (MCs) are secretory cells that are central players in human allergic disease and immune responses. With the exception of a few pathological situations, MCs are usually present at relatively low frequencies in most tissues. Since their first description, MCs in tissues were identified mostly using their morphological characteristics and their typical coloration when stained with aniline dyes. However, increasing availability of highly specific antibodies now permits the use of fluorescence-based flow cytometry as the method of choice for the quantification, characterization, and purification of cells in suspension. This technique allows for a rapid analysis of thousands of events and for the identification of cells present at frequencies as low as one event in 106 unwanted cells. This method also permits for simultaneous characterization of multiple antigens at a single cell level, which is ideal in order to study rare populations of cells like MCs. Here we describe the basis of flow cytometry-based immunophenotyping applied to the study of MC. The protocol focuses on the study of human MCs present in body fluids (mainly bone marrow) but can easily be adapted to studying MCs from other tissues and species.
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Valent P, Orazi A, Savona MR, Patnaik MM, Onida F, van de Loosdrecht AA, Haase D, Haferlach T, Elena C, Pleyer L, Kern W, Pemovska T, Vladimer GI, Schanz J, Keller A, Lübbert M, Lion T, Sotlar K, Reiter A, De Witte T, Pfeilstöcker M, Geissler K, Padron E, Deininger M, Orfao A, Horny HP, Greenberg PL, Arber DA, Malcovati L, Bennett JM. Proposed diagnostic criteria for classical chronic myelomonocytic leukemia (CMML), CMML variants and pre-CMML conditions. Haematologica 2019; 104:1935-1949. [PMID: 31048353 PMCID: PMC6886439 DOI: 10.3324/haematol.2019.222059] [Citation(s) in RCA: 88] [Impact Index Per Article: 17.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2019] [Accepted: 04/29/2019] [Indexed: 12/15/2022] Open
Abstract
Chronic myelomonocytic leukemia (CMML) is a myeloid neoplasm characterized by dysplasia, abnormal production and accumulation of monocytic cells and an elevated risk of transforming into acute leukemia. Over the past two decades, our knowledge about the pathogenesis and molecular mechanisms in CMML has increased substantially. In parallel, better diagnostic criteria and therapeutic strategies have been developed. However, many questions remain regarding prognostication and optimal therapy. In addition, there is a need to define potential pre-phases of CMML and special CMML variants, and to separate these entities from each other and from conditions mimicking CMML. To address these unmet needs, an international consensus group met in a Working Conference in August 2018 and discussed open questions and issues around CMML, its variants, and pre-CMML conditions. The outcomes of this meeting are summarized herein and include diag nostic criteria and a proposed classification of pre-CMML conditions as well as refined minimal diagnostic criteria for classical CMML and special CMML variants, including oligomonocytic CMML and CMML associated with systemic mastocytosis. Moreover, we propose diagnostic standards and tools to distinguish between 'normal', pre-CMML and CMML entities. These criteria and standards should facilitate diagnostic and prognostic evaluations in daily practice and clinical studies in applied hematology.
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Affiliation(s)
- Peter Valent
- Department of Internal Medicine I, Division of Hematology & Hemostaseology, Medical University of Vienna, Vienna, Austria .,Ludwig Boltzmann Institute for Hematology & Oncology, Vienna, Austria
| | - Attilio Orazi
- Department of Pathology, Texas Tech University Health Sciences Center, El Paso, TX, USA
| | - Michael R Savona
- Department of Medicine, Vanderbilt University School of Medicine, Vanderbilt-Ingram Cancer Center, Nashville, TN, USA
| | - Mrinal M Patnaik
- Division of Hematology, Department of Medicine, Mayo Clinic, Rochester, MN, USA
| | - Francesco Onida
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, University of Milan, Milan, Italy
| | - Arjan A van de Loosdrecht
- Department of Hematology, Amsterdam UMC, location VU University Medical Center, Cancer Center Amsterdam, the Netherlands
| | - Detlef Haase
- Clinic of Hematology and Medical Oncology, University Medical Center Göttingen, Göttingen, Germany
| | | | - Chiara Elena
- Department of Molecular Medicine, University of Pavia, Pavia, Italy
| | - Lisa Pleyer
- 3 Medical Department with Hematology and Medical Oncology, Hemostaseology, Rheumatology and Infectious Diseases, Paracelsus Medical University, Salzburg, Austria
| | | | - Tea Pemovska
- CeMM Research Center for Molecular Medicine of the Austrian Academy of Sciences, Vienna, Austria
| | - Gregory I Vladimer
- CeMM Research Center for Molecular Medicine of the Austrian Academy of Sciences, Vienna, Austria
| | - Julie Schanz
- Clinic of Hematology and Medical Oncology, University Medical Center Göttingen, Göttingen, Germany
| | - Alexandra Keller
- Department of Internal Medicine I, Division of Hematology & Hemostaseology, Medical University of Vienna, Vienna, Austria
| | - Michael Lübbert
- Department of Medicine I, Medical Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Thomas Lion
- Children's Cancer Research Institute and Department of Pediatrics, Medical University of Vienna, Vienna, Austria
| | - Karl Sotlar
- Institute of Pathology, Paracelsus Medical University, Salzburg, Austria
| | - Andreas Reiter
- Department of Hematology and Oncology, University Hospital Mannheim, University of Heidelberg, Mannheim, Germany
| | - Theo De Witte
- Department of Tumor Immunology-Nijmegen Center for Molecular Life Sciences, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Michael Pfeilstöcker
- Ludwig Boltzmann Institute for Hematology & Oncology, Vienna, Austria.,3 Medical Department, Hanusch Hospital, Vienna, Vienna, Austria
| | | | - Eric Padron
- Malignant Hematology Department, H. Lee Moffitt Cancer Center & Research Institute, Tampa, FL, USA
| | - Michael Deininger
- Huntsman Cancer Institute & Division of Hematology and Hematologic Malignancies, University of Utah, Salt Lake City, UT, USA
| | - Alberto Orfao
- Servicio Central de Citometría, Centro de Investigación del Cáncer (IBMCC, CSIC-USAL), CIBERONC and IBSAL, Universidad de Salamanca, Salamanca, Spain
| | - Hans-Peter Horny
- Institute of Pathology, Ludwig-Maximilians University, Munich, Germany
| | | | - Daniel A Arber
- Department of Pathology, University of Chicago, Chicago, IL, USA
| | - Luca Malcovati
- Department of Molecular Medicine, University of Pavia, Pavia, Italy
| | - John M Bennett
- Department of Pathology, Hematopathology Unit and James P Wilmot Cancer Institute, University of Rochester Medical Center, Rochester, NY, USA
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7
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Abstract
Mast cell disorders comprise a heterogeneous group of rare diseases, the diagnosis of which still remains a challenge. Bone marrow analysis constitutes the most appropriate site for screening systemic involvement in mastocytosis. Morphologic, immunohistochemical, flow cytometric immunophenotyping, and molecular studies should be routinely performed for diagnostic/prognostic purposes in experienced reference centers during the diagnostic workup in suspected systemic mastocytosis. The authors review the most relevant characteristics of bone marrow expression of mast cell disorders as well as the different methodological approaches to be applied to perform an objective and reproducible diagnosis and classification of mastocytosis and other mast cell disorders.
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8
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Metcalfe DD, Mekori YA. Pathogenesis and Pathology of Mastocytosis. ANNUAL REVIEW OF PATHOLOGY-MECHANISMS OF DISEASE 2017; 12:487-514. [PMID: 28135563 DOI: 10.1146/annurev-pathol-052016-100312] [Citation(s) in RCA: 42] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Systemic mastocytosis is a clonal disorder of mast cells that may variably present with characteristic skin lesions, episodes of mast cell mediator release, and disturbances of hematopoiesis. No curative therapy presently exists. Conventional management has relied on agents that antagonize mediators released by mast cells, inhibit mediator secretion, or modulate mast cell proliferation. Recent advances in the molecular understanding of the pathophysiology of systemic mastocytosis have provided new therapeutic considerations, including new and novel tyrosine kinase inhibitors.
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Affiliation(s)
- Dean D Metcalfe
- Laboratory of Allergic Diseases, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland 20892;
| | - Yoseph A Mekori
- Tel Hai College, Upper Galilee, 1220800 Israel; .,Meir Medical Center, Kfar Saba 44281, Israel.,Sackler School of Medicine, Tel Aviv University, Tel Aviv 6997801, Israel
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9
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Van den Poel B, Kochuyt AM, Del Biondo E, Dewaele B, Lierman E, Tousseyn T, de Hertogh G, Vandenberghe P, Boeckx N. Highly sensitive assays are mandatory for the differential diagnosis of patients presenting with symptoms of mast cell activation: diagnostic work-up of 38 patients. Acta Clin Belg 2017; 72:123-129. [PMID: 28262030 DOI: 10.1080/17843286.2017.1293312] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Mastocytosis is a heterogeneous disease caused by excessive mast cell (MC) proliferation. Diagnosis of systemic mastocytosis (SM) is based on the presence of major and minor criteria defined by the World Health Organization. Symptoms of MC activation can also occur in patients without SM or without allergic or inflammatory disease. These MC activation syndromes (MCAS) can be divided into primary (monoclonal) MCAS (MMAS) vs. secondary and idiopathic MCAS. In this single center study, the diagnostic work-up of 38 patients with a clinical suspicion of SM and/or with elevated basic tryptase levels is presented. Clinical symptoms, biochemical parameters, results of bone marrow investigation, flow cytometric immunophenotyping, and molecular analysis were retrospectively reviewed. Twenty-three patients were found to have a monoclonal MC disorder of which 19 were diagnosed with SM and 4 with MMAS. In 13/19 SM patients, multifocal MC infiltrates in the bone marrow were found (major criterion), while in 6 the diagnosis was based on the presence of ≥3 minor criteria. Flow cytometric analysis of bone marrow showed CD25 expression of MCs in all patients with SM and MMAS (range: 0.002-0.3% of cells). In bone marrow, the KIT D816V mutation was detected in all SM patients but in only 2 patients with MMAS (range: 0.007-9% mutated cells). Basic tryptase elevation was demonstrated in 16/19 patients with SM but also in 9/19 patients without SM. Our study reveals the heterogeneity of primary MC disorders and the importance of sensitive assays in patients suspected of having SM.
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Affiliation(s)
- Bea Van den Poel
- Department of Laboratory Medicine, University Hospitals Leuven, Leuven, Belgium
| | - Anne-Marie Kochuyt
- Clinical Department of Allergy and Clinical Immunology, University Hospitals Leuven, Leuven, Belgium
| | - Elke Del Biondo
- Department of Laboratory Medicine, University Hospitals Leuven, Leuven, Belgium
| | | | - Els Lierman
- Center for Human Genetics, KU Leuven, Leuven, Belgium
| | - Thomas Tousseyn
- Department of Pathology, University Hospitals Leuven, Leuven, Belgium
- Translational Cell and Tissue Research, KU Leuven, Leuven, Belgium
| | - Gert de Hertogh
- Department of Morphology and Molecular Pathology, University Hospitals Leuven, Leuven, Belgium
| | | | - Nancy Boeckx
- Department of Laboratory Medicine, University Hospitals Leuven, Leuven, Belgium
- Department of Oncology, KU Leuven, Leuven, Belgium
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10
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Pardanani A. Systemic mastocytosis in adults: 2017 update on diagnosis, risk stratification and management. Am J Hematol 2016; 91:1146-1159. [PMID: 27762455 DOI: 10.1002/ajh.24553] [Citation(s) in RCA: 71] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2016] [Accepted: 09/12/2016] [Indexed: 12/17/2022]
Abstract
Disease overview:Systemic mastocytosis (SM) results from a clonal proliferation of abnormal mast cells (MC) in one or more extra-cutaneous organs. DIAGNOSIS The major criterion is presence of multifocal clusters of morphologically abnormal MC in the bone marrow. Minor diagnostic criteria include elevated serum tryptase level, abnormal MC expression of CD25 and/or CD2, and presence of KITD816V. Risk stratification: The 2008 World Health Organization (WHO) classification of SM has been shown to be prognostically relevant. Classification of SM patients into indolent (SM), aggressive SM (ASM), SM associated with a clonal non-MC lineage disease (SM-AHNMD) and mast cell leukemia (MCL) subgroups is a useful first step in establishing prognosis. MANAGEMENT SM treatment is generally palliative. ISM patients have a normal life expectancy and receive symptom-directed therapy; infrequently, cytoreductive therapy may be indicated for refractory symptoms. ASM patients have disease-related organ dysfunction; interferon-α (±corticosteroids) can control dermatological, hematological, gastrointestinal, skeletal and mediator-release symptoms, but is hampered by poor tolerability. Similarly, cladribine has broad therapeutic activity, with particular utility when rapid MC debulking is indicated; the main toxicity is myelosuppression. Imatinib has a therapeutic role in the presence of an imatinib-sensitive KIT mutation or in KITD816-unmutated patients. Treatment of SM-AHNMD is governed primarily by the non-MC neoplasm; hydroxyurea has modest utility in this setting; there is a role for allogeneic stem cell transplantation in select cases. Investigational drugs: Recent data confirms midostaurin's significant anti-MC activity in patients with advanced SM. Am. J. Hematol. 91:1147-1159, 2016. © 2016 Wiley Periodicals, Inc.
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Affiliation(s)
- Animesh Pardanani
- Division of Hematology Department of Medicine; Mayo Clinic; Rochester Minnesota
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11
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Cherian S, McCullouch V, Miller V, Dougherty K, Fromm JR, Wood BL. Expression of CD2 and CD25 on mast cell populations can be seen outside the setting of systemic mastocytosis. CYTOMETRY PART B-CLINICAL CYTOMETRY 2015; 90:387-92. [DOI: 10.1002/cyto.b.21336] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/08/2015] [Revised: 10/16/2015] [Accepted: 10/29/2015] [Indexed: 11/07/2022]
Affiliation(s)
- Sindhu Cherian
- Department of Laboratory Medicine; University of Washington; Seattle Washington
| | - Vivian McCullouch
- Department of Laboratory Medicine; University of Washington; Seattle Washington
| | - Valerie Miller
- Department of Laboratory Medicine; University of Washington; Seattle Washington
| | - Katy Dougherty
- Department of Laboratory Medicine; University of Washington; Seattle Washington
| | - Jonathan R. Fromm
- Department of Laboratory Medicine; University of Washington; Seattle Washington
| | - Brent L. Wood
- Department of Laboratory Medicine; University of Washington; Seattle Washington
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12
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Detection of the KIT D816V mutation in peripheral blood of systemic mastocytosis: diagnostic implications. Mod Pathol 2015; 28:1138-49. [PMID: 26067933 DOI: 10.1038/modpathol.2015.72] [Citation(s) in RCA: 72] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2015] [Accepted: 05/05/2015] [Indexed: 01/08/2023]
Abstract
Recent studies have found the KIT D816V mutation in peripheral blood of virtually all adult systemic mastocytosis patients once highly sensitive PCR techniques were used; thus, detection of the KIT D816V mutation in peripheral blood has been proposed to be included in the diagnostic work-up of systemic mastocytosis algorithms. However, the precise frequency of the mutation, the biological significance of peripheral blood-mutated cells and their potential association with involvement of bone marrow hematopoietic cells other than mast cells still remain to be investigated. Here, we determined the frequency of peripheral blood involvement by the KIT D816V mutation, as assessed by two highly sensitive PCR methods, and investigated its relationship with multilineage involvement of bone marrow hematopoiesis. Overall, our results confirmed the presence of the KIT D816V mutation in peripheral blood of most systemic mastocytosis cases (161/190; 85%)--with an increasing frequency from indolent systemic mastocytosis without skin lesions (29/44; 66%) to indolent systemic mastocytosis with skin involvement (124/135; 92%), and more aggressive disease subtypes (11/11; 100%)--as assessed by the allele-specific oligonucleotide-qPCR method, which was more sensitive (P<.0001) than the peptide nucleic acid-mediated PCR approach (84/190; 44%). Although the presence of the KIT mutation in peripheral blood, as assessed by the allele-specific oligonucleotide-qPCR technique, did not accurately predict for multilineage bone marrow involvement of hematopoiesis, the allele-specific oligonucleotide-qPCR allele burden and the peptide nucleic acid-mediated-PCR approach did. These results suggest that both methods provide clinically useful and complementary information through the identification and/or quantification of the KIT D816V mutation in peripheral blood of patients suspected of systemic mastocytosis.
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13
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Chisholm KM, Merker JD, Gotlib JR, Gitana G, Lefterova M, Zehnder JL, George TI, Arber DA, Ohgami RS. Mast cells in systemic mastocytosis have distinctly brighter CD45 expression by flow cytometry. Am J Clin Pathol 2015; 143:527-34. [PMID: 25780004 DOI: 10.1309/ajcpz3j4geeyirra] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
OBJECTIVES We sought to determine the significance of bright CD45 expression on mast cells in cases of systemic mastocytosis vs mast cells in bone marrows uninvolved by systemic mastocytosis and compare this CD45 expression with CD25 and CD2 expression on mast cells. METHODS Multiparameter flow cytometry was performed on 31 cases of systemic mastocytosis and 70 bone marrow cases that were not involved by systemic mastocytosis. Bright expression of CD45 was defined as more than 20% of CD117+ mast cells showing brighter CD45 expression than the average expression level of lymphocytes. RESULTS Mast cells with bright CD45 expression were seen in 26 systemic mastocytosis cases and three bone marrows uninvolved by systemic mastocytosis (sensitivity, 84%; specificity, 96%). CD25 alone had a greater sensitivity (100%) but lower specificity (93%) compared with bright CD45 for identifying abnormal mast cells, while CD2 alone had lower sensitivity but higher specificity. To reach a specificity of 100%, CD25 together with bright CD45 on mast cells was the optimal combination to detect cases of systemic mastocytosis. CONCLUSIONS A combination of bright CD45 and CD25 appears to specifically identify abnormal mast cells in cases of systemic mastocytosis. Further studies will be necessary to confirm these results.
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Affiliation(s)
- Karen M. Chisholm
- Department of Pathology, Stanford University School of Medicine, Stanford, CA
| | - Jason D. Merker
- Department of Pathology, Stanford University School of Medicine, Stanford, CA
| | - Jason R. Gotlib
- Department of Medicine, Stanford University School of Medicine, Stanford, CA
| | - Gary Gitana
- Department of Pathology, Stanford University School of Medicine, Stanford, CA
| | - Martina Lefterova
- Department of Pathology, Stanford University School of Medicine, Stanford, CA
| | - James L. Zehnder
- Department of Pathology, Stanford University School of Medicine, Stanford, CA
| | - Tracy I. George
- Department of Pathology, University of New Mexico School of Medicine, Albuquerque
| | - Daniel A. Arber
- Department of Pathology, Stanford University School of Medicine, Stanford, CA
| | - Robert S. Ohgami
- Department of Pathology, Stanford University School of Medicine, Stanford, CA
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14
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Pardanani A. Systemic mastocytosis in adults: 2015 update on diagnosis, risk stratification, and management. Am J Hematol 2015; 90:250-62. [PMID: 25688753 DOI: 10.1002/ajh.23931] [Citation(s) in RCA: 70] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2014] [Accepted: 12/24/2014] [Indexed: 12/20/2022]
Abstract
DISEASE OVERVIEW Systemic mastocytosis (SM) results from a clonal proliferation of abnormal mast cells (MC) in one or more extracutaneous organs. DIAGNOSIS The major criterion is presence of multifocal clusters of morphologically abnormal MC in the bone marrow. Minor diagnostic criteria include elevated serum tryptase level, abnormal MC expression of CD25 and/or CD2, and presence of KITD816V. RISK STRATIFICATION The 2008 World Health Organization classification of SM has been shown to be prognostically relevant. Classification of SM patients into indolent SM (ISM), aggressive SM (ASM), SM associated with a clonal non-MC lineage disease (SM-AHNMD), and mast cell leukemia (MCL) subgroups is a useful first step in establishing prognosis. MANAGEMENT SM treatment is generally palliative. ISM patients have a normal life expectancy and receive symptom-directed therapy; infrequently, cytoreductive therapy may be indicated for refractory symptoms. ASM patients have disease-related organ dysfunction; interferon-α (+/-corticosteroids) can control dermatological, hematological, gastrointestinal, skeletal, and mediator-release symptoms, but is hampered by poor tolerability. Similarly, cladribine has broad therapeutic activity, with particular utility when rapid MC debulking is indicated; the main toxicity is myelosuppression. Imatinib has a therapeutic role in the presence of an imatinib-sensitive KIT mutation or in KITD816-unmutated patients. Treatment of SM-AHNMD is governed primarily by the non-MC neoplasm; hydroxyurea has modest utility in this setting; there is a role for allogeneic stem cell transplantation in select cases. Investigational Drugs: Recent data confirms midostaurin's significant anti-MC activity in patients with advanced SM.
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Affiliation(s)
- Animesh Pardanani
- Division of Hematology; Mayo Clinic; Rochester Minnesota
- Department of Medicine; Mayo Clinic; Rochester Minnesota
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Teodosio C, Mayado A, Sánchez-Muñoz L, Morgado JM, Jara-Acevedo M, Álvarez-Twose I, García-Montero AC, Matito A, Caldas C, Escribano L, Orfao A. The immunophenotype of mast cells and its utility in the diagnostic work-up of systemic mastocytosis. J Leukoc Biol 2014; 97:49-59. [PMID: 25381388 DOI: 10.1189/jlb.5ru0614-296r] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
SM comprises a heterogeneous group of disorders, characterized by an abnormal accumulation of clonal MCs in 1 or more tissues, frequently involving the skin and BM. Despite the fact that most adult patients (>90%) carry the same genetic lesion (D816V KIT mutation), the disease presents with multiple variants with very distinct clinical and biologic features, a diverse prognosis, and different therapeutic requirements. Recent advances in the standardization of the study of BM MC by MFC allowed reproducible identification and characterization of normal/reactive MCs and their precursors, as well as the establishment of the normal MC maturational profiles. Analysis of large groups of patients versus normal/reactive samples has highlighted the existence of aberrant MC phenotypes in SM, which are essential for the diagnosis of the disease. In turn, 3 clearly distinct and altered maturation-associated immunophenotypic profiles have been reported recently in SM, which provide criteria for the distinction between ISM patients with MC-restricted and multilineage KIT mutation; thus, immunphenotyping also contributes to prognostic stratification of ISM, particularly when analysis of the KIT mutation on highly purified BM cells is not routinely available in the diagnostic work-up of the disease.
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Affiliation(s)
- Cristina Teodosio
- *Servicio General de Citometría, Centro de Investigación del Cáncer (Instituto de Biologia Molecular y Celular del Cancer-Consejo Superior de Investigaciones Cientificas/University of Salamanca and Instituto de Investigación Biomédica de Salamanca) and Departamento de Medicina, Universidad de Salamanca, Salamanca, Spain; and Centro de Estudios de Mastocitosis de Castilla La Mancha, Hospital Virgen del Valle, Toledo, Spain
| | - Andrea Mayado
- *Servicio General de Citometría, Centro de Investigación del Cáncer (Instituto de Biologia Molecular y Celular del Cancer-Consejo Superior de Investigaciones Cientificas/University of Salamanca and Instituto de Investigación Biomédica de Salamanca) and Departamento de Medicina, Universidad de Salamanca, Salamanca, Spain; and Centro de Estudios de Mastocitosis de Castilla La Mancha, Hospital Virgen del Valle, Toledo, Spain
| | - Laura Sánchez-Muñoz
- *Servicio General de Citometría, Centro de Investigación del Cáncer (Instituto de Biologia Molecular y Celular del Cancer-Consejo Superior de Investigaciones Cientificas/University of Salamanca and Instituto de Investigación Biomédica de Salamanca) and Departamento de Medicina, Universidad de Salamanca, Salamanca, Spain; and Centro de Estudios de Mastocitosis de Castilla La Mancha, Hospital Virgen del Valle, Toledo, Spain
| | - José M Morgado
- *Servicio General de Citometría, Centro de Investigación del Cáncer (Instituto de Biologia Molecular y Celular del Cancer-Consejo Superior de Investigaciones Cientificas/University of Salamanca and Instituto de Investigación Biomédica de Salamanca) and Departamento de Medicina, Universidad de Salamanca, Salamanca, Spain; and Centro de Estudios de Mastocitosis de Castilla La Mancha, Hospital Virgen del Valle, Toledo, Spain
| | - María Jara-Acevedo
- *Servicio General de Citometría, Centro de Investigación del Cáncer (Instituto de Biologia Molecular y Celular del Cancer-Consejo Superior de Investigaciones Cientificas/University of Salamanca and Instituto de Investigación Biomédica de Salamanca) and Departamento de Medicina, Universidad de Salamanca, Salamanca, Spain; and Centro de Estudios de Mastocitosis de Castilla La Mancha, Hospital Virgen del Valle, Toledo, Spain
| | - Ivan Álvarez-Twose
- *Servicio General de Citometría, Centro de Investigación del Cáncer (Instituto de Biologia Molecular y Celular del Cancer-Consejo Superior de Investigaciones Cientificas/University of Salamanca and Instituto de Investigación Biomédica de Salamanca) and Departamento de Medicina, Universidad de Salamanca, Salamanca, Spain; and Centro de Estudios de Mastocitosis de Castilla La Mancha, Hospital Virgen del Valle, Toledo, Spain
| | - Andrés C García-Montero
- *Servicio General de Citometría, Centro de Investigación del Cáncer (Instituto de Biologia Molecular y Celular del Cancer-Consejo Superior de Investigaciones Cientificas/University of Salamanca and Instituto de Investigación Biomédica de Salamanca) and Departamento de Medicina, Universidad de Salamanca, Salamanca, Spain; and Centro de Estudios de Mastocitosis de Castilla La Mancha, Hospital Virgen del Valle, Toledo, Spain
| | - Almudena Matito
- *Servicio General de Citometría, Centro de Investigación del Cáncer (Instituto de Biologia Molecular y Celular del Cancer-Consejo Superior de Investigaciones Cientificas/University of Salamanca and Instituto de Investigación Biomédica de Salamanca) and Departamento de Medicina, Universidad de Salamanca, Salamanca, Spain; and Centro de Estudios de Mastocitosis de Castilla La Mancha, Hospital Virgen del Valle, Toledo, Spain
| | - Caldas Caldas
- *Servicio General de Citometría, Centro de Investigación del Cáncer (Instituto de Biologia Molecular y Celular del Cancer-Consejo Superior de Investigaciones Cientificas/University of Salamanca and Instituto de Investigación Biomédica de Salamanca) and Departamento de Medicina, Universidad de Salamanca, Salamanca, Spain; and Centro de Estudios de Mastocitosis de Castilla La Mancha, Hospital Virgen del Valle, Toledo, Spain
| | - Luis Escribano
- *Servicio General de Citometría, Centro de Investigación del Cáncer (Instituto de Biologia Molecular y Celular del Cancer-Consejo Superior de Investigaciones Cientificas/University of Salamanca and Instituto de Investigación Biomédica de Salamanca) and Departamento de Medicina, Universidad de Salamanca, Salamanca, Spain; and Centro de Estudios de Mastocitosis de Castilla La Mancha, Hospital Virgen del Valle, Toledo, Spain
| | - Alberto Orfao
- *Servicio General de Citometría, Centro de Investigación del Cáncer (Instituto de Biologia Molecular y Celular del Cancer-Consejo Superior de Investigaciones Cientificas/University of Salamanca and Instituto de Investigación Biomédica de Salamanca) and Departamento de Medicina, Universidad de Salamanca, Salamanca, Spain; and Centro de Estudios de Mastocitosis de Castilla La Mancha, Hospital Virgen del Valle, Toledo, Spain
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Jabbar KJ, Medeiros LJ, Wang SA, Miranda RN, Johnson MR, Verstovsek S, Jorgensen JL. Flow cytometric immunophenotypic analysis of systemic mastocytosis involving bone marrow. Arch Pathol Lab Med 2014; 138:1210-4. [PMID: 25171703 DOI: 10.5858/arpa.2013-0537-oa] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
CONTEXT Mast cells of systemic mastocytosis (SM) have aberrant immunophenotypes that are useful for their detection by flow cytometry immunophenotyping. OBJECTIVES To assess the usefulness of CD2, CD25, and other antigens for establishing the diagnosis of SM in bone marrow using flow cytometry immunophenotyping. DESIGN We studied 50 bone marrow aspirates of patients with SM using flow cytometry immunophenotyping. The bone marrow aspirates were stained with antibodies specific for CD2, CD25, CD35, CD59, CD63, and CD69. For the detection of CD2 and CD25, antibodies conjugated with phycoerythrin (PE) or fluorescein isothiocyanate (FITC) were compared. CD45-PerCP and CD117-APC were used for gating. Data were acquired on FACS Calibur cytometers and analyzed using CellQuest software. RESULTS CD2 and CD25 were positive in 41 of 50 (82%) and 45 of 50 (90%) SM cases, respectively. For CD2, the PE-conjugated antibody yielded better sensitivity than the FITC-conjugated antibody (31 of 40 [78%] versus 28 of 40 [70%]). For CD25, PE-conjugated and FITC-conjugated antibodies showed similar detection sensitivity, although the intensity of expression was brighter with CD25-PE. Compared with immunohistochemistry, flow cytometry immunophenotyping was superior for detecting CD2 (14 of 23 [61%] versus 9 of 23 [39%]). Other antigens frequently overexpressed in SM were CD35 (43 of 50 [86%]), CD59 (46 of 50 [92%]), CD63 (43 of 49 [88%]), and CD69 (39 of 48 [81%]). CONCLUSIONS Flow cytometry immunophenotyping is a rapid and sensitive technique for characterizing mast cells in bone marrow aspirate specimens. The use of PE-conjugated antibodies for CD2 and CD25 improves the detection rate (CD2) or facilitates analysis (CD25); therefore, PE-conjugated antibodies are suggested. Antibodies reactive with CD35, CD59, CD63, and CD69 are also helpful in detecting SM in bone marrow.
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Affiliation(s)
- Kausar J Jabbar
- From the Department of Hematopathology, The University of Texas MD Anderson Cancer Center, Houston
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17
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Sánchez-Muñoz L, Teodosio C, Morgado JMT, Perbellini O, Mayado A, Alvarez-Twose I, Matito A, Jara-Acevedo M, García-Montero AC, Orfao A, Escribano L. Flow Cytometry in Mastocytosis. Immunol Allergy Clin North Am 2014; 34:297-313. [DOI: 10.1016/j.iac.2014.01.008] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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18
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Morgado JM, Sánchez-Muñoz L, Teodósio C, Escribano L. Identification and immunophenotypic characterization of normal and pathological mast cells. Methods Mol Biol 2014; 1192:205-226. [PMID: 25149495 DOI: 10.1007/978-1-4939-1173-8_16] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
Mast cells (MCs) are secretory cells that are central players in human allergic disease and immune responses. With the exception of a few pathological situations, MCs are usually present at relatively low frequencies in most tissues. Since their first description, MCs in tissues were identified mostly using their morphological characteristics and their typical coloration when stained with aniline dyes. However, increasing availability of highly specific antibodies now permits the use of fluorescence-based flow cytometry as the method of choice for the quantification, characterization, and purification of cells in suspension. This technique allows for a rapid analysis of thousands of events and for the identification of cells present at frequencies as low as one event in 10(6) unwanted cells. This method also permits for simultaneous characterization of multiple antigens at a single-cell level, which is ideal in order to study rare populations of cells like MCs. Here we describe the basis of flow cytometry-based immunophenotyping applied to the study of MC. The protocol focuses on the study of human MCs present in body fluids (mainly bone marrow) but can easily be adapted to study MCs from other tissues and species.
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Affiliation(s)
- José Mário Morgado
- Instituto de Estudios de Mastocitosis de Castilla La Mancha, Toledo, Spain
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19
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Pardanani A. Systemic mastocytosis in adults: 2013 update on diagnosis, risk stratification, and management. Am J Hematol 2013; 88:612-24. [PMID: 23720340 DOI: 10.1002/ajh.23459] [Citation(s) in RCA: 53] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2013] [Accepted: 04/04/2013] [Indexed: 12/20/2022]
Abstract
DISEASE OVERVIEW Systemic mastocytosis (SM) results from a clonal proliferation of abnormal mast cells (MC) in one or more extracutaneous organs. DIAGNOSIS The major criterion is presence of multifocal clusters of morphologically abnormal MC in the bone marrow. Minor diagnostic criteria include elevated serum tryptase level, abnormal MC expression of CD25 and/or CD2, and presence of KITD816V. RISK STRATIFICATION The 2008 World Health Organization (WHO) classification of SM has been shown to be prognostically relevant. Classification of SM patients into indolent (SM), aggressive SM (ASM), SM associated with a clonal non-MC lineage disease (SM-AHNMD) and mast cell leukemia (MCL) subgroups is a useful first step in establishing prognosis. MANAGEMENT SM treatment is generally palliative. ISM patients have a normal life expectancy and receive symptom-directed therapy; infrequently, cytoreductive therapy may be indicated for refractory symptoms. ASM patients have disease-related organ dysfunction; interferon-α (±corticosteroids) can control dermatological, hematological, gastrointestinal, skeletal, and mediator-release symptoms, but is hampered by poor tolerability. Similarly, cladribine has broad therapeutic activity, with particular utility when rapid MC debulking is indicated; the main toxicity is myelosuppression. Imatinib has a therapeutic role in the presence of an imatinib-sensitive KIT mutation or in KITD816-unmutated patients. Treatment of SM-AHNMD is governed primarily by the non-MC neoplasm; hydroxyurea has modest utility in this setting. INVESTIGATIONAL DRUGS Dasatinib's in vitro anti- KITD816V activity has not translated into significant therapeutic activity in most SM patients. In contrast, recently updated data confirms Midostaurin's significant anti-MC activity in patients with advanced SM.
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Affiliation(s)
- Animesh Pardanani
- Division of Hematology, Department of Medicine; Mayo Clinic; Rochester Minnesota
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20
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Varón de 67 años con dolor abdominal, esplenomegalia, adenopatías y alteraciones de la densidad ósea. Med Clin (Barc) 2012; 139:300-6. [DOI: 10.1016/j.medcli.2012.03.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2012] [Accepted: 03/29/2012] [Indexed: 11/18/2022]
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21
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ALVAREZ-TWOSE I, MORGADO JM, SÁNCHEZ-MUÑOZ L, GARCÍA-MONTERO A, MOLLEJO M, ORFAO A, ESCRIBANO L. Current state of biology and diagnosis of clonal mast cell diseases in adults. Int J Lab Hematol 2012; 34:445-60. [DOI: 10.1111/j.1751-553x.2012.01427.x] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
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22
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Pardanani A. Systemic mastocytosis in adults: 2012 Update on diagnosis, risk stratification, and management. Am J Hematol 2012; 87:401-11. [PMID: 22410759 DOI: 10.1002/ajh.23134] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
DISEASE OVERVIEW Systemic mastocytosis (SM) results from a clonal proliferation of abnormal mast cells (MC) in one or more extra-cutaneous organs. DIAGNOSIS The major criterion is presence of multifocal clusters of morphologically abnormal MC in the bone marrow. Minor diagnostic criteria include elevated serum tryptase level, abnormal MC expression of CD25 and/or CD2, and presence of KITD816V. RISK STRATIFICATION The prognostic relevance of the 2008 World Health Organization (WHO) classification of SM has recently been confirmed. Classification of SM patients into indolent (SM), aggressive SM (ASM), SM associated with a clonal non-MC lineage disease (SM-AHNMD) and mast cell leukemia (MCL) subgroups is a useful first step in establishing prognosis. MANAGEMENT SM treatment is generally palliative. ISM patients have a normal life expectancy and receive symptom-directed therapy; infrequently, cytoreductive therapy may be indicated for refractory symptoms. ASM patients have disease-related organ dysfunction; interferon-α (±corticosteroids) can control dermatological, hematological, gastrointestinal, skeletal, and mediator-release symptoms, but is hampered by poor tolerability. Similarly, cladribine has broad therapeutic activity, with particular utility when rapid MC debulking is indicated; the main toxicity is myelosuppression. Imatinib has a therapeutic role in the presence of an imatinib-sensitive KIT mutation or in KITD816-unmutated patients. Treatment of SM-AHNMD is governed primarily by the non-MC neoplasm; hydroxyurea has modest utility in this setting. INVESTIGATIONAL DRUGS Dasatinib's in vitro anti-KITD816V activity has not translated into significant therapeutic activity in most SM patients. In contrast, preliminary data suggest that Midostaurin may produce significant decreases in MC burden in some patients.
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Affiliation(s)
- Animesh Pardanani
- Division of Hematology, Department of Medicine, Mayo Clinic, Rochester, Minnesota, USA.
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23
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González-de-Olano D, Alvarez-Twose I, Vega A, Orfao A, Escribano L. Venom immunotherapy in patients with mastocytosis and hymenoptera venom anaphylaxis. Immunotherapy 2011; 3:637-51. [PMID: 21554093 DOI: 10.2217/imt.11.44] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Systemic mastocytosis (SM) is typically suspected in patients with cutaneous mastocytosis (CM). In recent years, the presence of clonal mast cells (MCs) in a subset of patients with systemic symptoms associated with MC activation in the absence of CM has been reported and termed monoclonal MC activation syndromes or clonal systemic MC activation syndromes. In these cases, bone marrow (BM) MC numbers are usually lower than in SM with CM, there are no detectable BM MC aggregates, and serum baseline tryptase is often <20 µg/l; thus, diagnosis of SM in these patients should be based on careful evaluation of other minor WHO criteria for SM in reference centers, where highly sensitive techniques for immunophenotypic analysis and investigation of KIT mutations on fluorescence-activated cell sorter-purified BM MCs are routinely performed. The prevalence of hymenoptera venom anaphylaxis (HVA) among SM patients is higher than among the normal population and it has been reported to be approximately 5%. In SM patients with IgE-mediated HVA, venom immunotherapy is safe and effective and it should be prescribed lifelong. Severe adverse reactions to hymenoptera stings or venom immunotherapy have been associated with increased serum baseline tryptase; however, presence of clonal MC has not been ruled out in most reports and thus both SM and clonal MC activation syndrome might be underdiagnosed in such patients. In fact, clonal BM MC appears to be a relevant risk factor for both HVA and severe reactions to venom immunotherapy, while the increase in serum baseline tryptase by itself should be considered as a powerful surrogate marker for anaphylaxis. The Spanish Network on Mastocytosis has developed a scoring system based on patient gender, the clinical symptoms observed during anaphylaxis and serum baseline tryptase to predict for the presence of both MC clonality and SM among individuals who suffer from anaphylaxis.
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24
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Perbellini O, Zamò A, Colarossi S, Zampieri F, Zoppi F, Bonadonna P, Schena D, Artuso A, Martinelli G, Chilosi M, Pizzolo G, Zanotti R. Primary role of multiparametric flow cytometry in the diagnostic work-up of indolent clonal mast cell disorders. CYTOMETRY PART B-CLINICAL CYTOMETRY 2011; 80:362-8. [PMID: 21656905 DOI: 10.1002/cyto.b.20606] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/17/2011] [Revised: 04/08/2011] [Accepted: 05/10/2011] [Indexed: 11/07/2022]
Abstract
BACKGROUND According to the World Health Organization (WHO) classification the diagnosis of systemic mastocytosis (SM) relies on bone marrow (BM) examination and is based on one major and four minor criteria. Herein, we used WHO criteria to compare flow cytometry (FC) with other available techniques in the diagnosis of SM after BM examination. METHODS We analyzed a cohort of 95 patients with suspect SM. All patients underwent comprehensive BM examination by using cytology, immunohistochemistry, FC and molecular study for mutation of c-Kit and serum tryptase dosage. FC evaluation was based on a combination of monoclonal antibodies, specifically CD25/CD2/CD45/CD34/CD117. RESULTS Seventy-four out of ninety-five patients were diagnosed with indolent SM (n = 59) or monoclonal mast cell activation syndrome (n = 15) because satisfying less than 3 minor criteria. Thirty-nine out of these seventy-four patients fulfilled the major histological criterion, whereas the presence of a minor criterion was assessed by FC, molecular study, cytology, and tryptase level in 70/74, 52/67, 56/74, and 42/74 patients, respectively. FC showed higher sensitivity than IHC in detection of CD25+ mast cells (MC) (92.9% vs. 73.8%; P = 0.019), especially in the absence of the major histological criterion (90.5% vs. 47.6%; P = 0.003). Moreover, CD2 expression was documented by FC and IHC in 97.1% and 35.3% of cases, respectively (P < 0.001). CONCLUSIONS FC showed the best sensitivity for identifying abnormal MC compared to other techniques, especially in cases with low MC burden. Therefore, we hope for a major role of FC in the diagnostic work-up of clonal MC disorders.
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Affiliation(s)
- Omar Perbellini
- Department of Medicine, Section of Hematology, Azienda Ospedaliera Universitaria Integrata and University of Verona, Italy.
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25
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Maric I, Calvo KR. Mastocytosis: the new differential diagnosis of CD30-positive neoplasms. Leuk Lymphoma 2011; 52:732-3. [DOI: 10.3109/10428194.2011.561389] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
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26
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Pardanani A. Systemic mastocytosis in adults: 2011 update on diagnosis, risk stratification, and management. Am J Hematol 2011; 86:362-71. [PMID: 21442641 DOI: 10.1002/ajh.21982] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
DISEASE OVERVIEW Systemic mastocytosis (SM) results from a clonal proliferation of abnormal mast cells (MC) in one or more extracutaneous organs. DIAGNOSIS The major criterion is presence of multifocal clusters of morphologically abnormal MC in the bone marrow. Minor diagnostic criteria include elevated serum tryptase level, abnormal MC expression of CD25 and/or CD2, and presence of KITD816V. RISK STRATIFICATION The prognostic relevance of the 2008 World Health Organization (WHO) classification of SM has recently been confirmed. Classification of SM patients into indolent (SM), aggressive SM (ASM), SM associated with a clonal non-MC lineage disease (SM-AHNMD), and mast cell leukemia (MCL) subgroups is a useful first step in establishing prognosis. RISK-ADAPTED THERAPY SM treatment is generally palliative. ISM patients have a normal life expectancy and receive symptom-directed therapy; infrequently, cytoreductive therapy may be indicated for refractory symptoms. ASM patients have disease-related organ dysfunction; interferon-α (±corticosteroids) can control dermatological, hematological, gastrointestinal, skeletal, and mediator-release symptoms, but is hampered by poor tolerability. Similarly, cladribine has broad therapeutic activity, with particular utility when rapid MC debulking is indicated; the main toxicity is myelosuppression. Imatinib has a therapeutic role in the presence of an imatinib-sensitive KIT mutation or in KITD816-unmutated patients. Treatment of SM-AHNMD is governed primarily by the non-MC neoplasm; hydroxyurea has modest utility in this setting. Dasatinib's in vitro anti- KITD816V activity has not translated into significant therapeutic activity in most SM patients. In contrast, preliminary data suggest that Midostaurin may produce significant decreases in MC burden in some patients.
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Affiliation(s)
- Animesh Pardanani
- Department of Medicine, Division of Hematology, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA.
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27
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Vardiman J, Hyjek E. World health organization classification, evaluation, and genetics of the myeloproliferative neoplasm variants. HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2011; 2011:250-256. [PMID: 22160042 DOI: 10.1182/asheducation-2011.1.250] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
Abstract
There is no single category in the fourth edition (2008) of the World Health Organization (WHO) classification of myeloid neoplasms that encompasses all of the diseases referred to by some authors as the myeloproliferative neoplasm (MPN) "variants." Instead, they are considered as distinct entities and are distributed among various subgroups of myeloid neoplasms in the classification scheme. These relatively uncommon neoplasms do not meet the criteria for any so-called "classical" MPN (chronic myelogenous leukemia, polycythemia vera, primary myelofibrosis, or essential thrombocythemia) and, although some exhibit myelodysplasia, none meets the criteria for any myelodysplastic syndrome (MDS). They are a diverse group of neoplasms ranging from fairly well-characterized disorders such as chronic myelomonocytic leukemia to rare and thus poorly characterized disorders such as chronic neutrophilic leukemia. Recently, however, there has been a surge of information regarding the genetic infrastructure of neoplastic cells in the MPN variants, allowing some to be molecularly defined. Nevertheless, in most cases, correlation of clinical, genetic, and morphologic findings is required for diagnosis and classification. The fourth edition of the WHO classification provides a framework to incorporate those neoplasms in which a genetic abnormality is a major defining criterion of the disease, such as those associated with eosinophilia and abnormalities of PDGFRA, PDGFRB, and FGFR1, as well as for those in which no specific genetic defect has yet been discovered and which remain clinically and pathologically defined. An understanding of the clinical, morphologic, and genetic features of the MPN variants will facilitate their diagnosis.
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Affiliation(s)
- James Vardiman
- Department of Pathology, University of Chicago, Chicago, IL 60637, USA.
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28
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Sánchez-Muñoz L, Teodósio C, Morgado JM, Escribano L. Immunophenotypic Characterization of Bone Marrow Mast Cells in Mastocytosis and Other Mast Cell Disorders. Methods Cell Biol 2011; 103:333-59. [DOI: 10.1016/b978-0-12-385493-3.00014-0] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
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29
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Rama TA, Côrte-Real I, Gomes PS, Escribano L, Fernandes MH. Mastocytosis: oral implications of a rare disease. J Oral Pathol Med 2010; 40:441-50. [DOI: 10.1111/j.1600-0714.2010.00996.x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Affiliation(s)
- T A Rama
- Laboratório de Farmacologia e Biocompatibilidade Celular, Faculdade de Medicina Dentária, Universidade do Porto, Portugal
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30
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Maluf LC, Barros JAD, Machado Filho CDADS. Mastocytosis. An Bras Dermatol 2010; 84:213-25. [PMID: 19668934 DOI: 10.1590/s0365-05962009000300002] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2009] [Accepted: 02/17/2009] [Indexed: 11/21/2022] Open
Abstract
Mastocytosis is characterized by pathologic accumulation and activation of mast cells in tissues and organs. Although the classification for mastocytosis and diagnostic criteria are well accepted, there remains a need to define standards for the application of diagnostic tests, clinical evaluations, and responses to treatment. The objective of this article was to make an extensive literature review, providing comprehensive knowledge about the etiopathological and pathophysiological mechanisms, with a special emphasis on diagnosis, classification and treatment of mastocytosis, promoting continued medical education.
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Affiliation(s)
- Luciana Cirillo Maluf
- Mestre em Ciências da Saúde pela Faculdade de Medicina do ABC, Preceptor da disciplina de Dermatologia da Faculdade de Medicina do ABC, Santo André (SP), Brazil.
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31
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Teodosio C, García-Montero AC, Jara-Acevedo M, Sánchez-Muñoz L, Alvarez-Twose I, Núñez R, Schwartz LB, Walls AF, Escribano L, Orfao A. Mast cells from different molecular and prognostic subtypes of systemic mastocytosis display distinct immunophenotypes. J Allergy Clin Immunol 2010; 125:719-26, 726.e1-726.e4. [PMID: 20061010 DOI: 10.1016/j.jaci.2009.10.020] [Citation(s) in RCA: 105] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2009] [Revised: 10/19/2009] [Accepted: 10/20/2009] [Indexed: 02/04/2023]
Abstract
BACKGROUND Systemic mastocytosis (SM) is a heterogeneous group of disorders with distinct clinical and biological behavior. Despite this, little is known about the immunophenotypic features of the distinct diagnostic categories of SM. OBJECTIVE To analyze the immunophenotypic characteristics of bone marrow (BM) mast cells (MCs) of different subtypes of SM. METHODS Bone marrow samples from 123 patients with different subtypes of SM and 92 controls were analyzed for a broad panel of immunophenotypic markers by flow cytometry. RESULTS Three clearly different maturation-associated immunophenotypic profiles were found for BMMCs in SM. These different profiles were associated with both genetic markers of the disease and its clinical behavior. BMMCs from poor-prognosis categories of SM (aggressive SM and MC leukemia) typically showed an immature phenotype with clonal involvement of all myeloid lineages by the D816V stem cell growth factor receptor gene (KIT) mutation. In turn, a mature activated versus resting BMMC immunophenotype was commonly found among patients with good-prognosis subtypes of SM depending on whether they carried (indolent SM and clonal MC activation disorders) or not (well differentiated SM) the D816V KIT mutation. CONCLUSION Bone marrow MCs from SM show 3 different maturation-related immunophenotypic profiles that are associated with both the genetic markers of the disease and its clinical behavior.
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Affiliation(s)
- Cristina Teodosio
- Servicio General de Citometría, Instituto de Biología Molecular y Celular del Cáncer, Centro de Investigación del Cáncer/IBMCC (CSIC-USAL) and Departamento de Medicina, Universidad de Salamanca, Salamanca, Spain
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Johnson MR, Verstovsek S, Jorgensen JL, Manshouri T, Luthra R, Jones DM, Bueso-Ramos CE, Medeiros LJ, Huh YO. Utility of the World Heath Organization classification criteria for the diagnosis of systemic mastocytosis in bone marrow. Mod Pathol 2009; 22:50-7. [PMID: 19116630 DOI: 10.1038/modpathol.2008.141] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
In the World Health Organization classification, one major and four minor criteria are specified for the diagnosis of systemic mastocytosis. We report our experience using these criteria to diagnose systemic mastocytosis involving bone marrow. A total of 59 patients with clinically suspected systemic mastocytosis underwent comprehensive bone marrow examination, including immunophenotyping by immunohistochemistry and/or flow cytometry and molecular studies for KIT exon 17 mutations. Serum tryptase levels were also assessed. Of these 59, 53 (90%) patients met the diagnostic criteria for systemic mastocytosis. In these patients, multifocal dense infiltrates of mast cells, the major criterion, was observed in 36 (68%) patients. Atypical mast cell morphology was observed in 53 (100%), an aberrant immunophenotype was identified in 50 of 52 (96%), KIT mutation was present in 33 of 44 (75%), and an elevated serum tryptase (>20 ng/ml) was detected in 44 of 52 (85%). In the six patients in which bone marrow examination could not confirm systemic mastocytosis, one had systemic mastocytosis involving spleen, one patient had chronic idiopathic myelofibrosis, and four had no specific diagnosis, but systemic mastocytosis was still considered most likely. Of these six patients, atypical mast cell morphology was identified in five, aberrant immunophenotype in five, KIT mutation in two, and elevated serum tryptase in two. None of these cases met the major criteria. We conclude that the World Health Organization criteria are useful for the diagnosis of systemic mastocytosis in bone marrow specimens. The results also show the relative values of traditional morphologic criteria (ie, major criterion) and the results of ancillary testing (ie, minor criteria). However, as illustrated by the case of splenic systemic mastocytosis as well as the patient with chronic idiopathic myelofibrosis, the current World Health Organization system is neither completely sensitive nor specific for systemic mastocytosis.
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Affiliation(s)
- Malisha R Johnson
- Department of Hematopathology, University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
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Abstract
Flow cytometric immunophenotyping remains an indispensable tool for the diagnosis, classification, staging, and monitoring of hematologic neoplasms. The last 10 years have seen advances in flow cytometry instrumentation and availability of an expanded range of antibodies and fluorochromes that have improved our ability to identify different normal cell populations and recognize phenotypic aberrancies, even when present in a small proportion of the cells analyzed. Phenotypically abnormal populations have been documented in many hematologic neoplasms, including lymphoma, chronic lymphoid leukemias, plasma cell neoplasms, acute leukemia, paroxysmal nocturnal hemoglobinuria, mast cell disease, myelodysplastic syndromes, and myeloproliferative disorders. The past decade has also seen refinement of the criteria used to identify distinct disease entities with widespread adoption of the 2001 World Health Organization (WHO) classification. This classification endorses a multiparametric approach to diagnosis and outlines the morphologic, immunophenotypic, and genotypic features characteristic of each disease entity. When should flow cytometric immunophenotyping be applied? The recent Bethesda International Consensus Conference on flow cytometric immunophenotypic analysis of hematolymphoid neoplasms made recommendations on the medical indications for flow cytometric testing. This review discusses how flow cytometric testing is currently applied in these clinical situations and how the information obtained can be used to direct other testing.
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Patnaik MM, Rindos M, Kouides PA, Tefferi A, Pardanani A. Systemic mastocytosis: a concise clinical and laboratory review. Arch Pathol Lab Med 2007; 131:784-91. [PMID: 17488167 DOI: 10.5858/2007-131-784-smacca] [Citation(s) in RCA: 46] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/24/2006] [Indexed: 11/06/2022]
Abstract
CONTEXT Systemic mastocytosis is characterized by abnormal growth and accumulation of neoplastic mast cells in various organs. The clinical presentation is varied and may include skin rash, symptoms related to release of mast cell mediators, and/or organopathy from involvement of bone, liver, spleen, bowel, or bone marrow. OBJECTIVE To concisely review pathogenesis, disease classification, clinical features, diagnosis, and treatment of mast cell disorders. DATA SOURCES Pertinent literature emerging during the last 20 years in the field of mast cell disorders. CONCLUSIONS The cornerstone of diagnosis is careful bone marrow histologic examination with appropriate immunohistochemical studies. Ancillary tests such as mast cell immunophenotyping, cytogenetic/molecular studies, and serum tryptase levels assist in confirming the diagnosis. Patients with cutaneous disease or with low systemic mast cell burden are generally managed symptomatically. In the patients requiring mast cell cytoreductive therapy, treatment decisions are increasingly being guided by results of molecular studies. Most patients carry the kit D816V mutation and are predicted to be resistant to imatinib mesylate (Gleevec) therapy. In contrast, patients carrying the FIP1L1-PDGFRA mutation achieve complete responses with low-dose imatinib therapy. Other therapeutic options include use of interferon-alpha, chemotherapy (2-chlorodeoxyadenosine), or novel small molecule tyrosine kinase inhibitors currently in clinical trials.
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Affiliation(s)
- Mrinal M Patnaik
- Department of Medicine, University of Minnesota, Minneapolis, USA
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