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Ferrone CK, McNaughton AJM, Rashedi I, Ring B, Buckstein R, Tsui H, Rauh MJ. A Lower Frequency of Spliceosome Mutations Distinguishes Clonal Cytopenias of Undetermined Significance From Low-Risk Myelodysplastic Syndromes, Despite Inherent Similarities in Genomic, Laboratory, and Clinical Features. Mod Pathol 2023; 36:100068. [PMID: 36788103 DOI: 10.1016/j.modpat.2022.100068] [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: 06/28/2022] [Revised: 11/23/2022] [Accepted: 12/06/2022] [Indexed: 01/11/2023]
Abstract
Clonal cytopenias of undetermined significance (CCUS) are associated with an increased risk of developing a myelodysplastic syndrome (MDS); however, the mechanism and factors associated with evolution remain unclear. We propose that next-generation sequencing (NGS) of cytopenic cases with equivocal morphologic dysplasia will improve patient clinical care and that serial sequencing of such equivocal cases could identify the factors that predict evolution to MDS. We performed targeted NGS of samples from 193 individuals with confirmed or suspected MDS or MDS/myeloproliferative neoplasm, including sequential investigation for 28 individuals at the time of diagnosis and during follow-up. NGS facilitated the diagnosis of all suspicious cases as myeloid neoplasm (21%), CCUS (34%), or idiopathic cytopenias of undetermined significance (45%) when no variants were detected. We found that there was no significant difference in most measured clinical features or clonal phenotypes, such as cell counts, number of variants, variant allele frequencies, and overall survival, between CCUS and International Prognostic Scoring System-Revised-defined low-risk MDS. However, there was a significant difference in the types of variants between CCUS and low-risk MDS, with a significantly lower number of splicing factor mutations in CCUS cases (P < .001). Moreover, we observed an increased probability of evolution to MDS of individuals with CCUS compared with that in those with idiopathic cytopenias of undetermined significance over the first 5 years (P = .045). Our analyses revealed no conclusive pattern associating clonal expansion or the number of variants with the evolution of CCUS to MDS, perhaps further supporting the similarity of these diseases and the clinical importance of recognizing and formally defining CCUS as a category of precursor myeloid disease state in the next revision of the World Health Organization guidelines.
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Affiliation(s)
- Christina K Ferrone
- Department of Pathology and Molecular Medicine, Queen's University, Kingston, Ontario, Canada
| | - Amy J M McNaughton
- Department of Pathology and Molecular Medicine, Queen's University, Kingston, Ontario, Canada
| | - Iran Rashedi
- Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, Ontario, Canada; Department of Laboratory Medicine and Molecular Diagnostics, Precision Diagnostics and Therapeutics Program, Sunnybrook Health Sciences Centre and Sunnybrook Research Institute, Toronto, Ontario, Canada
| | - Brooke Ring
- Department Medicine, Queen's University, Kingston, Ontario, Canada
| | - Rena Buckstein
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada; Division of Medical Oncology and Hematology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada; Odette Cancer Research Program, Sunnybrook Research Institute, Toronto, Ontario, Canada
| | - Hubert Tsui
- Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, Ontario, Canada; Department of Laboratory Medicine and Molecular Diagnostics, Precision Diagnostics and Therapeutics Program, Sunnybrook Health Sciences Centre and Sunnybrook Research Institute, Toronto, Ontario, Canada; Department of Immunology, University of Toronto, Toronto, Ontario, Canada
| | - Michael J Rauh
- Department of Pathology and Molecular Medicine, Queen's University, Kingston, Ontario, Canada.
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Zhang Y, Hao S, Xiao N, Zhang Y, Wang H, Li L, Fu R, Shao Z. Ferritin Light Chain: A Candidate Autoantigen in Immuno-Related Pancytopenia. Front Immunol 2022; 13:851096. [PMID: 35572557 PMCID: PMC9097271 DOI: 10.3389/fimmu.2022.851096] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2022] [Accepted: 03/29/2022] [Indexed: 11/19/2022] Open
Abstract
The characteristic feature of immune-related pancytopenia (IRP) is autoantibody-mediated bone marrow (BM) damage and peripheral blood cytopenia. We found that the potential antigen of IRP was Ferritin light chain (FTL) by SEREX (serological analysis of recombinant cDNA expression libraries) in the previous study. In this study, we tried to explore the antigenic epitopes of FTL and verify its antigenicity in IRP. We found the possible FTL epitope: VNLYLQASYTYLSLG by phage random peptide library. Through ELISPOT, it was found that peptide VNLYLQASYTYLSLG can significantly stimulate the production of interleukin-4 and cannot stimulate the production of interferon-γ, which suggested that the peptide can obviously activate Th2 cells. Peptide-major histocompatibility complex tetramer elicited antigen-specific T cell responses. The expression levels of FTL were significantly increased in the patients with untreated IRP (P < 0.05). In conclusion, we found that FTL is the target antigen for some patients with IRP. The peptide of VNLYLQASYTYLSLG is an epitope of the target antigen. The target antigen is abnormally overexpressed on the membrane of BM cells, especially on the surface of CD34+ BM cells of patients with IRP. In addition, it is related to the severity of disease. These results provide a possible new target for the treatment of IRP in the future.
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Affiliation(s)
| | | | | | | | | | | | | | - Zonghong Shao
- Department of Hematology, Tianjin Medical University General Hospital, Tianjin, China
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3
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Alvarez-Payares JC, Rivera-Arismendy S, Ruiz-Bravo P, Sánchez-Salazar SM, Manzur RA, Ramirez-Urrea SI, Puello A. Unexplained Anemia in the Elderly. Cureus 2021; 13:e19971. [PMID: 34984131 PMCID: PMC8714032 DOI: 10.7759/cureus.19971] [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] [Accepted: 11/28/2021] [Indexed: 11/18/2022] Open
Abstract
Anemia is frequently diagnosed in elderly patients, and it is a key indicator of many reactive and clonal conditions. Furthermore, the older age is the most common presenting age for myelodysplastic syndromes (MDS). Anemia in older age may be attributed to an inflammatory state due to senescence, comorbidities, nutritional deficiencies, or primary bone marrow conditions. As diagnostic possibilities and life expectancy increase, the prevalence of anemia of the elderly increases as well. The etiology has a direct impact on the treatment and quality of life of these patients, in whom is a usual clinical challenge as it may be due to a multifactorial origin. In a minority group, when no etiology is identified, it is classified as unexplained anemia (UA) or clonal cytopenia of unknown significance (CCUS). The underlying cause of anemia remains unexplained in 30% of cases, and a great part of unexplained cytopenia may account for myeloid neoplasms. Anemia in the elderly is associated with worse cognitive and functional outcomes and increased mortality.
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Katsumi A, Abe A, Tamura S, Matsushita T. Anemia in older adults as a geriatric syndrome: A review. Geriatr Gerontol Int 2021; 21:549-554. [PMID: 34085375 DOI: 10.1111/ggi.14183] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2021] [Revised: 04/08/2021] [Accepted: 04/28/2021] [Indexed: 12/11/2022]
Abstract
Anemia, a frequently occurring condition in older patients, has no standard definition; however, in most studies, it is defined as hemoglobin level <12 and <13 g/dL in women and men, respectively. Approximately 10% of older adults living in the community have anemia. The prevalence of anemia is significantly correlated with advanced age and male sex. Anemia is associated with falls, frailty and other negative outcomes, including early mortality. However, there remains little consensus regarding whether anemia treatment favorably affects these adverse outcomes. Therefore, this article reviews the prevalence of anemia, and provides updates on its common causes and treatments in older adults. While excluding well-established hematopoietic diseases, the etiology of anemia in older adults has been grouped into four categories: (i) nutritional deficiency; (ii) inflammation; (iii) clonal hematopoiesis; and (iv) "unexplained anemia," when there is no clear mechanism to account for the anemia. Recently, clonal leukocytes were detected in a considerable number of older individuals. The number of somatic mutations in blood leukocytes increases with age; however, single mutations of DNMT3A, TET2 and ASXL1 are not correlated with the presence of unexplained anemia in older adults. With an increased understanding of anemia etiology and the availability of innovative anti-anemic drugs, future studies that evaluate the causes and benefits of treatment are required. Geriatr Gerontol Int 2021; 21: 549-554.
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Affiliation(s)
- Akira Katsumi
- Department of Hematology, National Center for Geriatrics and Gerontology, Obu, Japan
| | - Akihiro Abe
- Department of Hematology, Fujita Health University, Toyoake, Japan
| | - Shogo Tamura
- Department of Pathophysiological Laboratory Science, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Tadashi Matsushita
- Department of Transfusion Medicine, Nagoya University Hospital, Nagoya, Japan
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5
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Zhang W, Fu R. [Progress in pre-myelodysplastic syndrome conditions]. ZHONGHUA XUE YE XUE ZA ZHI = ZHONGHUA XUEYEXUE ZAZHI 2021; 41:603-607. [PMID: 32810971 PMCID: PMC7449764 DOI: 10.3760/cma.j.issn.0253-2727.2020.07.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 12/03/2022]
Affiliation(s)
- W Zhang
- Department of Hematology, General Hospital, Tianjin Medical University, Tianjin 300052, China
| | - R Fu
- Department of Hematology, General Hospital, Tianjin Medical University, Tianjin 300052, China
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6
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Kawata E, Lazo-Langner A, Xenocostas A, Hsia CC, Howson-Jan K, Deotare U, Saini L, Yang P, Broadbent R, Levy M, Howlett C, Stuart A, Kerkhof J, Santos S, Lin H, Sadikovic B, Chin-Yee I. Clinical value of next-generation sequencing compared to cytogenetics in patients with suspected myelodysplastic syndrome. Br J Haematol 2020; 192:729-736. [PMID: 32588428 DOI: 10.1111/bjh.16891] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2020] [Accepted: 05/25/2020] [Indexed: 12/21/2022]
Abstract
Next-generation sequencing (NGS) increasingly influences diagnosis, prognosis and management of myelodysplastic syndrome (MDS). In addition to marrow morphology and flow cytometry, our institution performs cytogenetics (CG) and NGS-based testing routinely in patients with suspected MDS. We evaluated the relative value of NGS in the assessment of patients with suspected MDS. We initially compared the diagnostic and prognostic information derived from CG and NGS in 134 patients. NGS enhanced the diagnostic yield compared to CG for clonal myeloid disorders (sensitivity 77% vs. 42·2%; specificity 90·2% vs. 78%; positive predictive value 92·8% vs. 76%; and negative predictive value 70·8% vs. 45·5%). The identification of poor prognosis mutations by NGS altered risk category in 27/39 (69·2%) patients with MDS with good/intermediate risk CG. Subsequently, we prospectively evaluated 70 patients with suspected MDS using an 'NGS-first approach' with CG restricted to samples with morphological abnormalities. We rarely identified mutations or CG abnormalities in patients without dysplastic features. NGS has a superior diagnostic performance compared to CG in patients with suspected MDS. We estimate that by using an 'NGS-first approach' we could reduce karyotyping by approximately 30%.
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Affiliation(s)
- Eri Kawata
- Division of Hematology, Department of Medicine, London Health Sciences Centre, London, Ontario, Canada.,Department of Hematology, Matsushita Memorial Hospital, Moriguchi, Osaka, Japan.,Division of Hematology and Oncology, Department of Medicine, Kyoto Prefectural University of Medicine, Kyoto, Kyoto, Japan
| | - Alejandro Lazo-Langner
- Division of Hematology, Department of Medicine, London Health Sciences Centre, London, Ontario, Canada.,Division of Hematology, Department of Medicine, Schulish School of Medicine and Dentistry, Western University, London, Ontario, Canada
| | - Anargyros Xenocostas
- Division of Hematology, Department of Medicine, London Health Sciences Centre, London, Ontario, Canada.,Division of Hematology, Department of Medicine, Schulish School of Medicine and Dentistry, Western University, London, Ontario, Canada
| | - Cyrus C Hsia
- Division of Hematology, Department of Medicine, London Health Sciences Centre, London, Ontario, Canada.,Division of Hematology, Department of Medicine, Schulish School of Medicine and Dentistry, Western University, London, Ontario, Canada.,Department of Pathology & Laboratory Medicine, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada
| | - Kang Howson-Jan
- Division of Hematology, Department of Medicine, London Health Sciences Centre, London, Ontario, Canada.,Division of Hematology, Department of Medicine, Schulish School of Medicine and Dentistry, Western University, London, Ontario, Canada
| | - Uday Deotare
- Division of Hematology, Department of Medicine, London Health Sciences Centre, London, Ontario, Canada.,Division of Hematology, Department of Medicine, Schulish School of Medicine and Dentistry, Western University, London, Ontario, Canada
| | - Lalit Saini
- Division of Hematology, Department of Medicine, London Health Sciences Centre, London, Ontario, Canada.,Division of Hematology, Department of Medicine, Schulish School of Medicine and Dentistry, Western University, London, Ontario, Canada
| | - Ping Yang
- Department of Pathology & Laboratory Medicine, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada.,Cytogenetics Laboratory, London Health Sciences Centre, London, Ontario, Canada
| | - Robert Broadbent
- Cytogenetics Laboratory, London Health Sciences Centre, London, Ontario, Canada
| | - Michael Levy
- Department of Pathology & Laboratory Medicine, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada.,Molecular Genetics Laboratory, London Health Sciences Centre, London, Ontario, Canada
| | - Christopher Howlett
- Department of Pathology & Laboratory Medicine, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada.,Molecular Genetics Laboratory, London Health Sciences Centre, London, Ontario, Canada
| | - Alan Stuart
- Molecular Genetics Laboratory, London Health Sciences Centre, London, Ontario, Canada
| | - Jennifer Kerkhof
- Molecular Genetics Laboratory, London Health Sciences Centre, London, Ontario, Canada
| | - Stephanie Santos
- Molecular Genetics Laboratory, London Health Sciences Centre, London, Ontario, Canada
| | - Hanxin Lin
- Department of Pathology & Laboratory Medicine, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada.,Molecular Genetics Laboratory, London Health Sciences Centre, London, Ontario, Canada
| | - Bekim Sadikovic
- Department of Pathology & Laboratory Medicine, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada.,Molecular Genetics Laboratory, London Health Sciences Centre, London, Ontario, Canada
| | - Ian Chin-Yee
- Division of Hematology, Department of Medicine, London Health Sciences Centre, London, Ontario, Canada.,Division of Hematology, Department of Medicine, Schulish School of Medicine and Dentistry, Western University, London, Ontario, Canada.,Department of Pathology & Laboratory Medicine, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada
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7
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Kaner J, Desai P, Mencia-Trinchant N, Guzman ML, Roboz GJ, Hassane DC. Clonal Hematopoiesis and Premalignant Diseases. Cold Spring Harb Perspect Med 2020; 10:a035675. [PMID: 31615870 PMCID: PMC7117948 DOI: 10.1101/cshperspect.a035675] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Clonal hematopoiesis (CH) arises when mutations in the hematopoietic system confer a fitness advantage to specific clones, thereby favoring their disproportionate growth. The presence of CH increases with age and environmental exposures such as cytotoxic chemotherapy or radiotherapy. The most frequent mutations occur in epigenetic regulators, such as DNMT3A, TET2, and ASXL1, leading to dysregulation of tumor suppressor function, pathogen response, and inflammation. These dysregulated processes elevate risk of overall mortality, cardiovascular disease, and eventual hematologic malignancy (HM). CH is likely acting as an initiating event leading to HM when followed by cooperating mutations. However, further evidence suggests that CH exerts a bystander influence through its pro-inflammatory properties. Delineating the mechanisms that lead to the onset and expansion of CH as well as its contribution to risk of HM is crucial to defining a management and intervention strategy. In this review, we discuss the potential causes, consequences, technical considerations, and possible management strategies for CH in the context of HMs and pre-HMs.
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Affiliation(s)
- Justin Kaner
- Division of Hematology & Oncology, Weill Cornell Medical College, New York, New York 10065, USA
| | - Pinkal Desai
- Division of Hematology & Oncology, Weill Cornell Medical College, New York, New York 10065, USA
| | - Nuria Mencia-Trinchant
- Division of Hematology & Oncology, Weill Cornell Medical College, New York, New York 10065, USA
| | - Monica L Guzman
- Division of Hematology & Oncology, Weill Cornell Medical College, New York, New York 10065, USA
| | - Gail J Roboz
- Division of Hematology & Oncology, Weill Cornell Medical College, New York, New York 10065, USA
| | - Duane C Hassane
- Division of Hematology & Oncology, Weill Cornell Medical College, New York, New York 10065, USA
- Caryl and Israel Englander Institute for Precision Medicine, Weill Cornell Medical College, New York, New York 10065, USA
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8
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Effects of Epstein-Barr Virus Infection on CD19+ B Lymphocytes in Patients with Immunorelated Pancytopenia. J Immunol Res 2020; 2020:4098235. [PMID: 32149157 PMCID: PMC7048940 DOI: 10.1155/2020/4098235] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2019] [Accepted: 01/03/2020] [Indexed: 11/24/2022] Open
Abstract
Objectives To explore effects of Epstein-Barr virus (EBV) infection on CD19+ B lymphocytes in patients with immunorelated pancytopenia (IRP). Methods An enzyme-linked immunosorbent assay (ELISA) in vitro diagnostic kit was used to detect EBV capsid antigen- (CA-) IgG and VCA-IgM antibodies in the serum. We analyzed the EBV-DNA copies of CD19+ B lymphocyte by using real-time quantitative polymerase chain reaction (RT-qPCR). CD21, CD23, CD5, CD80, and CD86 receptors on the surfaces of CD19+ B cells were detected by flow cytometry (FCM). The correlation between these receptors and EBV-DNA copies were evaluated. Results The results revealed that the positive rate of EBVCA-IgM and CD19+ B lymphocyte EBV-DNA copy in the IRP group were significantly higher than those in the control group (P < 0.05). CD19+ B lymphocyte EBV-DNA copies were also more abundant in IRP patients than in control subjects (P < 0.05). CD19+ B lymphocyte EBV-DNA copies were also more abundant in IRP patients than in control subjects (P < 0.05). CD19+ B lymphocyte EBV-DNA copies were also more abundant in IRP patients than in control subjects ( Conclusions EBV infection may activate CD19+ B lymphocytes and further disrupt bone marrow hematopoiesis in IRP patients.
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Behbehani GK, Finck R, Samusik N, Sridhar K, Fantl WJ, Greenberg PL, Nolan GP. Profiling myelodysplastic syndromes by mass cytometry demonstrates abnormal progenitor cell phenotype and differentiation. CYTOMETRY PART B-CLINICAL CYTOMETRY 2020; 98:131-145. [PMID: 31917512 PMCID: PMC9292828 DOI: 10.1002/cyto.b.21860] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/29/2019] [Accepted: 12/02/2019] [Indexed: 11/25/2022]
Abstract
Background We sought to enhance the cytometric analysis of myelodysplastic syndromes (MDS) by performing a pilot study of a single cell mass cytometry (MCM) assay to more comprehensively analyze patterns of surface marker expression in patients with MDS. Methods Twenty‐three MDS and five healthy donor bone marrow samples were studied using a 34‐parameter mass cytometry panel utilizing barcoding and internal reference standards. The resulting data were analyzed by both traditional gating and high‐dimensional clustering. Results This high‐dimensional assay provided three major benefits relative to traditional cytometry approaches: First, MCM enabled detection of aberrant surface maker at high resolution, detecting aberrancies in 27/31 surface markers, encompassing almost every previously reported MDS surface marker aberrancy. Additionally, three previously unrecognized aberrancies in MDS were detected in multiple samples at least one developmental stage: increased CD321 and CD99; and decreased CD47. Second, analysis of the stem and progenitor cell compartment (HSPCs), demonstrated aberrant expression in 21 of the 23 MDS samples, which were not detected in three samples from patients with idiopathic cytopenia of undetermined significance. These immunophenotypically abnormal HSPCs were also the single most significant distinguishing feature between clinical risk groups. Third, unsupervised clustering of high‐parameter MCM data allowed identification of abnormal differentiation patterns associated with immunophenotypically aberrant myeloid cells similar to myeloid derived suppressor cells. Conclusions These results demonstrate that high‐parameter cytometry methods that enable simultaneous analysis of all bone marrow cell types could enhance the diagnostic utility of immunophenotypic analysis in MDS.
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Affiliation(s)
- Gregory K. Behbehani
- Baxter Laboratory for Stem Cell Biology, Department of Microbiology & ImmunologyStanford University School of Medicine Stanford California
- Department of Medicine, Division of HematologyStanford University School of Medicine Stanford California
- Stanford Cancer Institute Stanford California
| | - Rachel Finck
- Baxter Laboratory for Stem Cell Biology, Department of Microbiology & ImmunologyStanford University School of Medicine Stanford California
| | - Nikolay Samusik
- Baxter Laboratory for Stem Cell Biology, Department of Microbiology & ImmunologyStanford University School of Medicine Stanford California
| | - Kunju Sridhar
- Department of Medicine, Division of HematologyStanford University School of Medicine Stanford California
| | - Wendy J. Fantl
- Department of Obstetrics and Gynecology, Division of Gynecologic OncologyStanford University School of Medicine Stanford California
| | - Peter L. Greenberg
- Department of Medicine, Division of HematologyStanford University School of Medicine Stanford California
- Stanford Cancer Institute Stanford California
| | - Garry P. Nolan
- Baxter Laboratory for Stem Cell Biology, Department of Microbiology & ImmunologyStanford University School of Medicine Stanford California
- Stanford Cancer Institute Stanford California
- Department of Obstetrics and Gynecology, Division of Gynecologic OncologyStanford University School of Medicine Stanford California
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10
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Bewersdorf JP, Ardasheva A, Podoltsev NA, Singh A, Biancon G, Halene S, Zeidan AM. From clonal hematopoiesis to myeloid leukemia and what happens in between: Will improved understanding lead to new therapeutic and preventive opportunities? Blood Rev 2019; 37:100587. [DOI: 10.1016/j.blre.2019.100587] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2019] [Revised: 06/22/2019] [Accepted: 07/02/2019] [Indexed: 02/08/2023]
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11
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Valent P. ICUS, IDUS, CHIP and CCUS: Diagnostic Criteria, Separation from MDS and Clinical Implications. Pathobiology 2018; 86:30-38. [PMID: 29860246 DOI: 10.1159/000489042] [Citation(s) in RCA: 62] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2018] [Accepted: 04/09/2018] [Indexed: 01/28/2023] Open
Abstract
Various myeloid neoplasms, including the myelodysplastic syndromes (MDS), bear a certain risk of progression to secondary acute myeloid leukemia (sAML). The evolution from low-risk to high-risk MDS and finally to sAML suggests that leukemogenesis is a multistep process. However, even before an overt neoplasm, such as an MDS, develops, "prediagnostic" clonal conditions may be identified. With the advent of large-scale genomic screens, such conditions may be detected quite frequently and early in apparently healthy individuals. Recent data suggest that these conditions increase with age and are indeed associated with an increased risk of the occurrence of MDS or another myeloid neoplasm. In other patients, unexplained cytopenia may be detected and may precede MDS. More recently, diagnostic criteria for potential pre-MDS conditions, including idiopathic cytopenia of uncertain significance and clonal hematopoiesis with indeterminate potential, have been proposed. The current article provides an overview of pre-MDS states and related criteria through which these conditions can be discriminated from each other and from MDS. In addition, the clinical implications and management of pre-MDS states are discussed.
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Affiliation(s)
- Peter Valent
- Department of Internal Medicine I, Division of Hematology and Hemostaseology, Medical University of Vienna, Vienna, .,Ludwig Boltzmann Cluster Oncology, Medical University of Vienna, Vienna,
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12
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Anemia at older age: etiologies, clinical implications, and management. Blood 2018; 131:505-514. [DOI: 10.1182/blood-2017-07-746446] [Citation(s) in RCA: 167] [Impact Index Per Article: 27.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2017] [Accepted: 10/05/2017] [Indexed: 12/29/2022] Open
Abstract
Abstract
Anemia is quite frequently diagnosed in older individuals and is a key indicator of various reactive and clonal conditions. Many underlying diseases, like myelodysplastic syndrome (MDS), develop preferentially in elderly individuals. The prevalence of anemia at older age is increasing, and this is mainly attributable to more frequently applied diagnostics and demographic changes in our societies. The etiology of anemia at older age is complex and ranges from bone marrow failure syndromes to chronic kidney disease, and from nutritional deficiencies to inflammatory processes including inflammaging in immunosenescence. In a smaller number of cases, no clear-cut etiology is identified. These patients are referred to as unexplained anemia or idiopathic cytopenia of unknown significance. In others, somatic mutations in leukocytes are found, but diagnostic criteria for MDS or other hematologic diseases are not fulfilled, a condition termed clonal cytopenia of undetermined significance. Management of anemias at older age depends on (1) the severity of the anemia, (2) underlying condition(s), and (3) patient-related factors, including comorbidities. Even a mild anemia may substantially affect physical and cognitive capacities and quality of life. An underestimated aspect is that because of age-related changes, organ function such as erythropoietin production in the kidney may become suboptimal. Management and treatment of anemia in older patients often require a multidisciplinary approach and detailed investigations of organ function. In this article, we review current concepts around anemias at older age, with special emphasis on etiologies, clinical implications, and innovative concepts in the management of these patients.
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Parisi S, Ratti S, Mongiorgi S, Suh PG, Manzoli L, McCubrey JA, Cocco L, Follo MY, Finelli C. Current therapy and new drugs: a road to personalized treatment of myelodysplastic syndromes. EXPERT REVIEW OF PRECISION MEDICINE AND DRUG DEVELOPMENT 2018. [DOI: 10.1080/23808993.2018.1419820] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Affiliation(s)
- Sarah Parisi
- Department of Experimental, Diagnostic and Specialty Medicine, Institute of Hematology “L. e A. Seràgnoli”, S. Orsola-Malpighi Hospital, Bologna, Italy
| | - Stefano Ratti
- Cellular Signalling Laboratory, Institute of Human Anatomy DIBINEM, University of Bologna, Bologna, Italy
| | - Sara Mongiorgi
- Cellular Signalling Laboratory, Institute of Human Anatomy DIBINEM, University of Bologna, Bologna, Italy
| | - Pann-Ghill Suh
- School of Life Sciences, UNIST, Ulsan, Republic of Korea
| | - Lucia Manzoli
- Cellular Signalling Laboratory, Institute of Human Anatomy DIBINEM, University of Bologna, Bologna, Italy
| | - James A. McCubrey
- Department of Microbiology and Immunology, Brody School of Medicine, East Carolina University, Greenville, NC, USA
| | - Lucio Cocco
- Cellular Signalling Laboratory, Institute of Human Anatomy DIBINEM, University of Bologna, Bologna, Italy
| | - Matilde Y. Follo
- Cellular Signalling Laboratory, Institute of Human Anatomy DIBINEM, University of Bologna, Bologna, Italy
| | - Carlo Finelli
- Department of Experimental, Diagnostic and Specialty Medicine, Institute of Hematology “L. e A. Seràgnoli”, S. Orsola-Malpighi Hospital, Bologna, Italy
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Abstract
INTRODUCTION Patients presenting with idiopathic cytopenia with non-diagnostic marrow morphology and a normal karyotype pose a diagnostic and therapeutic challenge. Additional diagnostic information from mutation analysis could provide important clinical insights. However, one has to be cautious during such diagnostic interpretations in view of the recent documentation of clonal somatic mutations in healthy elder individuals. Whether to regard clonality synonymous with malignant proliferation or a manifestation of ageing process is to be judged carefully. Areas covered: The review covers defining criteria and diagnostic work up for Idiopathic cytopenia of undetermined significance (ICUS), Clonal cytopenia of undetermined significance (CCUS), Clonal hematopoiesis of indeterminate potential (CHIP). It also presents the results from previous reports on this subject. In addition the evolution and potential impact of these entities is discussed. Expert commentary: Current evidence does not support the use of somatic mutations as presumptive evidence of myelodysplastic syndrome (MDS). Including CCUS under the category of MDS requires further insight on natural disease course. Longitudinal follow up study on ICUS, CCUS, CHIP may eventually identify the pathological significance of the clonal mutations. An absence of mutation however may still be useful as good predictor of not having MDS.
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Affiliation(s)
- Mili Jain
- a Pathology Department , King George's Medical University , Lucknow , Uttar Pradesh , India
| | - Anil Tripathi
- a Pathology Department , King George's Medical University , Lucknow , Uttar Pradesh , India
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15
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Valent P, Orazi A, Steensma DP, Ebert BL, Haase D, Malcovati L, van de Loosdrecht AA, Haferlach T, Westers TM, Wells DA, Giagounidis A, Loken M, Orfao A, Lübbert M, Ganser A, Hofmann WK, Ogata K, Schanz J, Béné MC, Hoermann G, Sperr WR, Sotlar K, Bettelheim P, Stauder R, Pfeilstöcker M, Horny HP, Germing U, Greenberg P, Bennett JM. Proposed minimal diagnostic criteria for myelodysplastic syndromes (MDS) and potential pre-MDS conditions. Oncotarget 2017; 8:73483-73500. [PMID: 29088721 PMCID: PMC5650276 DOI: 10.18632/oncotarget.19008] [Citation(s) in RCA: 131] [Impact Index Per Article: 18.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2017] [Accepted: 06/26/2017] [Indexed: 12/13/2022] Open
Abstract
Myelodysplastic syndromes (MDS) comprise a heterogeneous group of myeloid neoplasms characterized by peripheral cytopenia, dysplasia, and a variable clinical course with about 30% risk to transform to secondary acute myeloid leukemia (AML). In the past 15 years, diagnostic evaluations, prognostication, and treatment of MDS have improved substantially. However, with the discovery of molecular markers and advent of novel targeted therapies, new challenges have emerged in the complex field of MDS. For example, MDS-related molecular lesions may be detectable in healthy individuals and increase in prevalence with age. Other patients exhibit persistent cytopenia of unknown etiology without dysplasia. Although these conditions are potential pre-phases of MDS they may also transform into other bone marrow neoplasms. Recently identified molecular, cytogenetic, and flow-based parameters may add in the delineation and prognostication of these conditions. However, no generally accepted integrated classification and no related criteria are as yet available. In an attempt to address this challenge, an international consensus group discussed these issues in a working conference in July 2016. The outcomes of this conference are summarized in the present article which includes criteria and a proposal for the classification of pre-MDS conditions as well as updated minimal diagnostic criteria of MDS. Moreover, we propose diagnostic standards to delineate between ´normal´, pre-MDS, and MDS. These standards and criteria should facilitate diagnostic and prognostic evaluations in clinical studies as well as in clinical practice.
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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 Cluster Oncology, Medical University of Vienna, Vienna, Austria
| | - Attilio Orazi
- Department of Pathology and Laboratory Medicine, Weill Cornell Medical College, New York, NY, USA
| | - David P Steensma
- Division of Hematological Malignancies, Department of Medical Oncology, Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA, USA
| | - Benjamin L Ebert
- Division of Hematology, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Detlef Haase
- Clinic of Hematology and Medical Oncology, Universitymedicine Göttingen, Göttingen, Germany
| | - Luca Malcovati
- Department of Molecular Medicine, University of Pavia, Pavia, Italy
| | - Arjan A van de Loosdrecht
- Department of Hematology Cancer Center Amsterdam, VU University Medical Center, Amsterdam, The Netherlands
| | | | - Theresia M Westers
- Department of Hematology Cancer Center Amsterdam, VU University Medical Center, Amsterdam, The Netherlands
| | | | | | | | - Alberto Orfao
- Servicio Central de Citometría, Centro de Investigación del Cáncer (IBMCC, CSIC-USAL) and IBSAL, Universidad de Salamanca, Salamanca, Spain
| | - Michael Lübbert
- Department of Medicine I, Medical Center-University of Freiburg, Freiburg, Germany
| | - Arnold Ganser
- Department of Hematology, Hemostasis, Oncology, and Stem Cell Transplantation, Hannover Medical School, Hannover, Germany
| | - Wolf-Karsten Hofmann
- Department of Hematology and Oncology, University Hospital Mannheim, Medical Faculty Mannheim of the University of Heidelberg, Mannheim, Germany
| | - Kiyoyuki Ogata
- Metropolitan Research and Treatment Center for Blood Disorders (MRTC Japan), Tokyo, Japan
| | - Julie Schanz
- Clinic of Hematology and Medical Oncology, Universitymedicine Göttingen, Göttingen, Germany
| | - Marie C Béné
- Laboratoire d'Hématologie CHU de Nantes, Nantes, France
| | - Gregor Hoermann
- Department of Laboratory Medicine, Medical University of Vienna, Vienna, Austria
| | - Wolfgang R Sperr
- Department of Internal Medicine I, Division of Hematology & Hemostaseology, Medical University of Vienna, Vienna, Austria.,Ludwig Boltzmann Cluster Oncology, Medical University of Vienna, Vienna, Austria
| | - Karl Sotlar
- Institute of Pathology, Paracelsus Medical University Salzburg, Salzburg, Austria
| | | | - Reinhard Stauder
- Department of Internal Medicine V (Haematology and Oncology) Innsbruck Medical University, Innsbruck, Austria
| | | | - Hans-Peter Horny
- Institute of Pathology, Ludwig-Maximilians University, Munich, Germany
| | - Ulrich Germing
- Department of Hematology, Oncology, and Clinical Immunology, Heinrich-Heine-University, Düsseldorf, Germany
| | | | - John M Bennett
- Department of Pathology, Hematopathology Unit and James P Wilmot Cancer Institute, University of Rochester Medical Center, Rochester, New York, USA
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16
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Barcellini W. The relationship between idiopathic cytopenias/dysplasias of uncertain significance (ICUS/IDUS) and autoimmunity. Expert Rev Hematol 2017; 10:649-657. [PMID: 28586251 DOI: 10.1080/17474086.2017.1339597] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
INTRODUCTION This review examines the several lines of evidence that support the relationship between myelodysplasia and autoimmunity, i.e. their epidemiologic association, the existence of common immune-mediated physiopathologic mechanisms, and the response to similar immunosuppressive therapies. The same relationship is reviewed here considering idiopathic cytopenia of uncertain significance (ICUS) and idiopathic dysplasia of uncertain significance (IDUS), two recently recognized provisional conditions characterized by isolated/unexplained cytopenia and/or dysplasia in <10% bone marrow cells. Areas covered: The review focuses on alterations of cytokine profiles, telomere/telomerase and toll-like receptors, and on increased myelosuppressive mediators and apoptotic markers in both myelodysplasia and autoimmunity. In addition, the presence of an autoimmune reaction directed against marrow precursors is described in refractory/relapsing autoimmune cytopenias (autoimmune hemolytic anemia, immune thrombocytopenia, chronic idiopathic neutropenia), possibly contributing to their evolution to ICUS/IDUS/bone marrow failure syndromes. Expert commentary: The increasing availability of omics methods has fuelled the discussion on the role of somatic mutations in the pathogenesis of IDUS/ICUS, clonal hematopoiesis of indeterminate potential, and clonal cytopenias of undetermined significance, and in their possible evolution. Even more attracting is the involvement of the genetic background/accumulating somatic mutations in cytopenias with autoimmune alterations.
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Affiliation(s)
- Wilma Barcellini
- a Onco-hematology Unit , IRCCS Ca' Granda - Maggiore Policlinico Hospital Foundation , Milan , Italy
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17
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Shi J, Nie N, Huang ZD, Fan SB, Shao YQ, Zhang J, Huang JB, Li XX, Ge ML, Zheng YZ. [Diagnosis of clonal cytopenia of undetermined significance]. ZHONGHUA XUE YE XUE ZA ZHI = ZHONGHUA XUEYEXUE ZAZHI 2017; 38:65-67. [PMID: 28219229 PMCID: PMC7348399 DOI: 10.3760/cma.j.issn.0253-2727.2017.01.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/19/2016] [Indexed: 11/05/2022]
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18
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Steensma DP. New challenges in evaluating anemia in older persons in the era of molecular testing. HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2016; 2016:67-73. [PMID: 27913464 PMCID: PMC6142435 DOI: 10.1182/asheducation-2016.1.67] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
Anemia is common in older persons, and often remains unexplained despite a thorough clinical history, physical examination, and focused laboratory testing, including marrow aspiration, biopsy, and karyotyping. The advent of molecular genetic testing panels in hematology clinical practice has complicated the evaluation of older patients with unexplained anemia. While the presence of a somatic mutation provides evidence of clonal hematopoiesis and may support a diagnosis of a hematologic neoplasm such as one of the myelodysplastic syndromes (MDS), with rare exceptions, individual mutations are not strongly associated with one specific diagnosis, nor are they by themselves diagnostic of neoplasia. A clonal mutation in a patient with cytopenias and a nondiagnostic bone marrow may indicate a syndrome with a similar natural history to MDS, but at present there are no clear criteria to distinguish cytopenias coincidentally seen in association with an unrelated clonal mutation from cytopenias that are directly caused by that mutation. Ongoing and planned analyses will help define when mutation patterns alone can identify a disorder equivalent to a morphologically defined myeloid neoplasm such as MDS, further clarifying the etiology and natural history of unexplained anemia in the elderly.
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Affiliation(s)
- David P Steensma
- Dana-Farber Cancer Institute and Harvard Medical School, Boston, MA
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19
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Greenberg PL, Tuechler H, Schanz J, Sanz G, Garcia-Manero G, Solé F, Bennett JM, Bowen D, Fenaux P, Dreyfus F, Kantarjian H, Kuendgen A, Levis A, Malcovati L, Cazzola M, Cermak J, Fonatsch C, Le Beau MM, Slovak ML, Krieger O, Luebbert M, Maciejewski J, Magalhaes SMM, Miyazaki Y, Pfeilstöcker M, Sekeres M, Sperr WR, Stauder R, Tauro S, Valent P, Vallespi T, van de Loosdrecht AA, Germing U, Haase D. Cytopenia levels for aiding establishment of the diagnosis of myelodysplastic syndromes. Blood 2016; 128:2096-2097. [PMID: 27535995 PMCID: PMC5341483 DOI: 10.1182/blood-2016-07-728766] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Affiliation(s)
| | - Heinz Tuechler
- Hanusch Hospital, Boltzmann Institute for Leukemia Research, Vienna, Austria
| | | | | | | | | | - John M Bennett
- University of Rochester Medical Center, James P. Wilmot Cancer Center, Rochester, NY
| | - David Bowen
- St. James's University Hospital, Leeds, United Kingdom
| | - Pierre Fenaux
- Hôpital Avicenne, Assistance Publique-Hôpitaux de Paris(AP-HP)/University Paris XIII, Bobigny, France
| | | | | | | | | | - Luca Malcovati
- Fondazione Istituto di Ricovero e Cura a Carattere Scientifico Policlinico San Matteo and University of Pavia, Pavia, Italy
| | - Mario Cazzola
- Fondazione Istituto di Ricovero e Cura a Carattere Scientifico Policlinico San Matteo and University of Pavia, Pavia, Italy
| | - Jaroslav Cermak
- Institute of Hematology and Blood Transfusion, Praha, Czech Republic
| | | | - Michelle M Le Beau
- The University of Chicago Comprehensive Cancer Research Center, Chicago, IL
| | | | | | | | | | | | - Yasushi Miyazaki
- Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
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20
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Nakao S, Gale RP. Are mild/moderate acquired idiopathic aplastic anaemia and low-risk myelodysplastic syndrome one or two diseases or both and how should it/they be treated? Leukemia 2016; 30:2127-2130. [PMID: 27585953 DOI: 10.1038/leu.2016.206] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Affiliation(s)
- S Nakao
- Department of Haematology, Faculty of Medicine, Kanazawa University Institutes of Medical, Pharmaceutical, and Health Sciences, Kanazawa, Japan
| | - R P Gale
- Division of Experimental Medicine, Department of Medicine, Haematology Research Centre, Imperial College London, London, UK
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21
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Abstract
Application of next-generation sequencing (NGS) on myeloid neoplasms has expanded our knowledge of genomic alterations in this group of diseases. Genomic alterations in myeloid neoplasms are complex, heterogeneous, and not specific to a disease entity. NGS-based panel testing of myeloid neoplasms can complement existing diagnostic modalities and is gaining acceptance in the clinics and diagnostic laboratories. Prospective, randomized trials to evaluate the prognostic significance of genomic markers in myeloid neoplasms are under way in academic medical centers.
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Affiliation(s)
- Frank C Kuo
- Center for Advanced Molecular Diagnostics, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA 02115, USA.
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22
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Goyal H, Tilak V. Idiopathic Fatal Pancytopenia: A Case Report. J Clin Diagn Res 2016; 10:ED09-11. [PMID: 27504300 DOI: 10.7860/jcdr/2016/19230.7996] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2016] [Accepted: 04/09/2016] [Indexed: 11/24/2022]
Abstract
Pancytopenia is defined as decrease in red blood cells, white blood cells and platelets. Many disease processes involve the bone marrow primarily or secondarily resulting in pancytopenia. A 55-year-old male presented with generalized body weakness and few episodes of malena for last one year. Physical and systemic examination was unremarkable. CBC report revealed pancytopenia. Other haematological parameters were within normal limit. Stool for occult blood was positive. USG and CECT abdomen showed no abnormality. The patient was evaluated for any evidence of malignancy but no clue was found. Bone marrow examination was done as patient was having pancytopenia. Bone marrow smears, clot sections and bone marrow biopsy was normal. Immunohistochemistry and cytogenetics study was unremarkable. Patient was admitted in hospital for 1 month and his condition rapidly deteriorated. The cause of pancytopenia remained unexplained and therefore it was named as Idiopathic fatal pancytopenia. "Idiopathic Fatal Pancytopenia (IFP)" is an emerging new entity with a grave prognosis. We wish to sensitize the medical community and the scientists to this rapidly fatal condition.
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Affiliation(s)
- Hema Goyal
- Junior Resident, Department of Pathology, IMS, BHU , Varanasi, India
| | - Vijai Tilak
- Professor, Department of Pathology, IMS, BHU , Varanasi, India
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23
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Clonal hematopoiesis in acquired aplastic anemia. Blood 2016; 128:337-47. [PMID: 27121470 DOI: 10.1182/blood-2016-01-636381] [Citation(s) in RCA: 124] [Impact Index Per Article: 15.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2016] [Accepted: 04/20/2016] [Indexed: 11/20/2022] Open
Abstract
Clonal hematopoiesis (CH) in aplastic anemia (AA) has been closely linked to the evolution of late clonal disorders, including paroxysmal nocturnal hemoglobinuria and myelodysplastic syndromes (MDS)/acute myeloid leukemia (AML), which are common complications after successful immunosuppressive therapy (IST). With the advent of high-throughput sequencing of recent years, the molecular aspect of CH in AA has been clarified by comprehensive detection of somatic mutations that drive clonal evolution. Genetic abnormalities are found in ∼50% of patients with AA and, except for PIGA mutations and copy-neutral loss-of-heterozygosity, or uniparental disomy (UPD) in 6p (6pUPD), are most frequently represented by mutations involving genes commonly mutated in myeloid malignancies, including DNMT3A, ASXL1, and BCOR/BCORL1 Mutations exhibit distinct chronological profiles and clinical impacts. BCOR/BCORL1 and PIGA mutations tend to disappear or show stable clone size and predict a better response to IST and a significantly better clinical outcome compared with mutations in DNMT3A, ASXL1, and other genes, which are likely to increase their clone size, are associated with a faster progression to MDS/AML, and predict an unfavorable survival. High frequency of 6pUPD and overrepresentation of PIGA and BCOR/BCORL1 mutations are unique to AA, suggesting the role of autoimmunity in clonal selection. By contrast, DNMT3A and ASXL1 mutations, also commonly seen in CH in the general population, indicate a close link to CH in the aged bone marrow, in terms of the mechanism for selection. Detection and close monitoring of somatic mutations/evolution may help with prediction and diagnosis of clonal evolution of MDS/AML and better management of patients with AA.
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24
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25
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Cremers EMP, Westers TM, Alhan C, Cali C, Wondergem MJ, Poddighe PJ, Ossenkoppele GJ, van de Loosdrecht AA. Multiparameter flow cytometry is instrumental to distinguish myelodysplastic syndromes from non-neoplastic cytopenias. Eur J Cancer 2015; 54:49-56. [PMID: 26720403 DOI: 10.1016/j.ejca.2015.11.013] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2015] [Revised: 07/02/2015] [Accepted: 11/10/2015] [Indexed: 01/06/2023]
Abstract
Mandatory for the diagnosis of myelodysplastic syndromes (MDS) is the presence of dysplasia in >10% of cells within one or more cell lineages or presence of >15% ring sideroblasts or presence of MDS-associated cytogenetic (CG) abnormalities. Discrimination between neo-plastic and non-neoplastic causes of cytopenias can be challenging when dysplastic features by cytomorphology (CM) are minimal and CG abnormalities are absent or non-discriminating from other myeloid neoplastic disorders. This study evaluated a standard diagnostic approach in 379 patients with unexplained cytopenias and highlights the additional value of flow cytometry (FC) in patients with indeterminate CM and CG. CM reached no clear-cut diagnosis in 44% of the patients. Here, CG was able to identify two additional patients with MDS; other CG results did not reveal abnormalities or were not contributory. Based on the FC results, patients without a diagnosis by CM and CG were categorized 'no MDS-related features' (65%), 'limited number of MDS-related changes' (24%), and 'consistent with MDS' (11%). Patients were followed over time in an attempt to establish or confirm a diagnosis (median follow-up 391 d, range 20-1764). The specificity (true negative) of MDS-FC analysis calculated after follow-up was 95%. FC can aid as a valuable tool to exclude MDS when CM and additional CG are not conclusive in patients with cytopenia.
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Affiliation(s)
- Eline M P Cremers
- Department of Hematology, VU University Medical Center, Cancer Center Amsterdam (VUmc CCA), De Boelelaan 1117, 1081 HV Amsterdam, The Netherlands.
| | - Theresia M Westers
- Department of Hematology, VU University Medical Center, Cancer Center Amsterdam (VUmc CCA), De Boelelaan 1117, 1081 HV Amsterdam, The Netherlands.
| | - Canan Alhan
- Department of Hematology, VU University Medical Center, Cancer Center Amsterdam (VUmc CCA), De Boelelaan 1117, 1081 HV Amsterdam, The Netherlands.
| | - Claudia Cali
- Department of Hematology, VU University Medical Center, Cancer Center Amsterdam (VUmc CCA), De Boelelaan 1117, 1081 HV Amsterdam, The Netherlands.
| | - Mariëlle J Wondergem
- Department of Hematology, VU University Medical Center, Cancer Center Amsterdam (VUmc CCA), De Boelelaan 1117, 1081 HV Amsterdam, The Netherlands.
| | - Pino J Poddighe
- Department of Clinical Genetics, VU University Medical Center, Cancer Center Amsterdam (VUmc CCA), De Boelelaan 1117, 1081 HV Amsterdam, The Netherlands.
| | - Gert J Ossenkoppele
- Department of Hematology, VU University Medical Center, Cancer Center Amsterdam (VUmc CCA), De Boelelaan 1117, 1081 HV Amsterdam, The Netherlands.
| | - Arjan A van de Loosdrecht
- Department of Hematology, VU University Medical Center, Cancer Center Amsterdam (VUmc CCA), De Boelelaan 1117, 1081 HV Amsterdam, The Netherlands.
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26
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The shadowlands of MDS: idiopathic cytopenias of undetermined significance (ICUS) and clonal hematopoiesis of indeterminate potential (CHIP). Hematology 2015; 2015:299-307. [DOI: 10.1182/asheducation-2015.1.299] [Citation(s) in RCA: 61] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
AbstractThe WHO classification provides the best diagnostic approach to myelodysplastic syndromes (MDS). However, biologic and analytic limitations have emerged in the criteria currently adopted to establish the diagnosis and to classify MDS. The provisional category of idiopathic cytopenia of undetermined significance (ICUS) has been proposed to describe patients in whom MDS is possible but not proven. To formulate a diagnosis of ICUS, a thorough diagnostic work-up is required and repeated tests should be performed to reach a conclusive diagnosis. Recent studies provided consistent evidence of age-related hematopoietic clones (clonal hematopoiesis of indeterminate potential; CHIP), driven by mutations of genes that are recurrently mutated in myeloid neoplasms and associated with increase in the risk of hematologic cancer. A subset of mutated genes, mainly involved in epigenetic regulation, are likely initiating lesions driving the expansion of a premalignant clone. However, in a fraction of subjects the detected clone may be a small malignant clone expanding under the drive of the detected and additional undetected mutations. In addition, several experimental evidences suggest the potential relevance of an abnormal bone marrow environment in the selection and evolution of hematopoietic clones in MDS. The spreading of massively parallel sequencing techniques is offering translational opportunities in the clinical approach to myeloid neoplasms. Although several issues remain to be clarified, targeted gene sequencing may be of potential value in the dissection between clonal myelodysplasia, nonclonal cytopenia, and clonal hematopoiesis arising upon aging or in the context of acquired marrow failure.
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27
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MDS-associated somatic mutations and clonal hematopoiesis are common in idiopathic cytopenias of undetermined significance. Blood 2015; 126:2355-61. [PMID: 26429975 DOI: 10.1182/blood-2015-08-667063] [Citation(s) in RCA: 227] [Impact Index Per Article: 25.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2015] [Accepted: 09/22/2015] [Indexed: 12/24/2022] Open
Abstract
Establishing a diagnosis in patients suspected of having a myelodysplastic syndrome (MDS) can be challenging and could be informed by the identification of somatic mutations. We performed a prospective study to examine the frequency and types of mutations encountered in 144 patients with unexplained cytopenias. Based on bone marrow findings, 17% were diagnosed with MDS, 15% with idiopathic cytopenias of undetermined significance (ICUS) and some evidence of dysplasia, and 69% with ICUS and no dysplasia. Bone marrow DNA was sequenced for mutations in 22 frequently mutated myeloid malignancy genes. Somatic mutations were identified in 71% of MDS patients, 62% of patients with ICUS and some dysplasia, and 20% of ICUS patients and no dysplasia. In total, 35% of ICUS patients carried a somatic mutation or chromosomal abnormality indicative of clonal hematopoiesis. We validated these results in a cohort of 91 lower-risk MDS and 249 ICUS cases identified over a 6-month interval. Mutations were found in 79% of those with MDS, in 45% of those with ICUS with dysplasia, and in 17% of those with ICUS without dysplasia. The spectrum of mutated genes was similar with the exception of SF3B1 which was rarely mutated in patients without dysplasia. Variant allele fractions were comparable between clonal ICUS (CCUS) and MDS as were mean age and blood counts. We demonstrate that CCUS is a more frequent diagnosis than MDS in cytopenic patients. Clinical and mutational features are similar in these groups and may have diagnostic utility once outcomes in CCUS patients are better understood.
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28
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Importance of classical morphology in the diagnosis of myelodysplastic syndrome. Mediterr J Hematol Infect Dis 2015; 7:e2015035. [PMID: 25960863 PMCID: PMC4418392 DOI: 10.4084/mjhid.2015.035] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2015] [Accepted: 04/23/2015] [Indexed: 01/16/2023] Open
Abstract
Myelodysplastic syndromes (MDS) are hematopoietic stem cell disorders characterized by dysplastic, ineffective, clonal and neoplastic hematopoiesis. MDS represent a complex hematological problem: differences in disease presentation, progression and outcome have necessitated the use of classification systems to improve diagnosis, prognostication, and treatment selection. However, since a single biological or genetic reliable diagnostic marker has not yet been discovered for MDS, quantitative and qualitative dysplastic morphological alterations of bone marrow precursors and peripheral blood cells are still fundamental for diagnostic classification. In this paper, World Health Organization (WHO) classification refinements and current minimal diagnostic criteria proposed by expert panels are highlighted, and related problematic issues are discussed. The recommendations should facilitate diagnostic and prognostic evaluations in MDS and selection of patients for new effective targeted therapies. Although, in the future, morphology should be supplemented with new molecular techniques, the morphological approach, at least for the moment, is still the cornerstone for the diagnosis and classification of these disorders.
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29
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Palmblad J, Dufour C, Papadaki HA. How we diagnose neutropenia in the adult and elderly patient. Haematologica 2015; 99:1130-3. [PMID: 24986874 DOI: 10.3324/haematol.2014.110288] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Affiliation(s)
- Jan Palmblad
- Department of Medicine and Hematology, The Karolinska Institutet at Huddinge University Hospital, Stockholm, Sweden, and SWG on Granulocytes and Monocytes of the EHA
| | - Carlo Dufour
- Clinical and Exprimental Haematology Unit, G.Gaslini Children's Hospital, Genova, Italy and SWG on Granulocytes and Monocytes of the EHA
| | - Helen A Papadaki
- Department of Hematology, University of Crete Medical School, Heraklion, Greece and SWG on Granulocytes and Monocytes of the EHA
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30
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Cremers EM, Alhan C, Westers TM, Ossenkoppele GJ, van de Loosdrecht AA. Immunophenotyping for diagnosis and prognosis in MDS: Ready for general application? Best Pract Res Clin Haematol 2015; 28:14-21. [DOI: 10.1016/j.beha.2014.11.003] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2014] [Accepted: 11/04/2014] [Indexed: 11/27/2022]
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31
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Refractory thrombocytopenia and neutropenia: a diagnostic challenge. Mediterr J Hematol Infect Dis 2015; 7:e2015018. [PMID: 25745545 PMCID: PMC4344166 DOI: 10.4084/mjhid.2015.018] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2014] [Accepted: 01/28/2015] [Indexed: 11/27/2022] Open
Abstract
The 2008 WHO classification identified refractory cytopenia with unilineage dysplasia (RCUD) as a composite entity encompassing refractory anemia, refractory thrombocytopenia (RT), and refractory neutropenia (RN), characterized by 10% or more dysplastic cells in the bone marrow respective lineage. The diagnosis of RT and RN is complicated by several factors. Diagnosing RT first requires exclusion of familial thrombocytopenia, chronic auto-immune thrombocytopenia, concomitant medications, viral infections, or hypersplenism. Diagnosis of RN should also be made after ruling out differential diagnoses such as ethnic or familial neutropenia, as well as acquired, drug-induced, infection-related or malignancy-related neutropenia. An accurate quantification of dysplasia should be performed in order to distinguish RT or RN from the provisional entity named idiopathic cytopenia of unknown significance (ICUS). Cytogenetic analysis, and possibly in the future somatic mutation analysis (of genes most frequently mutated in MDS), and flow cytometry analysis aberrant antigen expression on myeloid cells may help in this differential diagnosis. Importantly, we and others found that, while isolated neutropenia and thrombocytopenia are not rare in MDS, those patients can generally be classified (according to WHO 2008 classification) as refractory cytopenia with multilineage dysplasia or refractory anemia with excess blasts, while RT and RN (according to WHO 2008) are quite rare. These results suggest in particular that identification of RT and RN as distinct entities could be reconsidered in future WHO classification updates.
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32
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Shao Y, Fu R, Liu H, Wang Y, Ding S, Wang H, Li L, Shao Z. IgG autoantibody subclasses altered in immuno-related hemocytopenia. Cell Immunol 2015; 294:13-20. [PMID: 25666506 DOI: 10.1016/j.cellimm.2015.01.013] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2014] [Revised: 01/07/2015] [Accepted: 01/20/2015] [Indexed: 11/30/2022]
Abstract
Recently, we have detected autoantibodies to bone marrow (BM) hemopoietic cells in some idiopathic cytopenia of undetermined significance (ICUS), terming as immunorelated hemocytopenia. Immunoglobulin G consists of 4 subclasses which have different biological functions in many diseases. In this study, we analyzed the alterations of IgG subclasses in 27 IRH patients compared with 20 ICUS patients and 20 normal controls. The results showed that IgG1 and IgG3 levels were increased in the bone marrow supernatant in IRH patients, and had inverse correlations with hematopoietic function. Meanwhile IgG1 level had a positive correlation with the proportion of CD5+ B lymphocytes. Using immunohistochemical staining, IgG1 were also detected on bone marrow nucleated cells in IRH patients. All these results indicated that IgG1 on bone marrow cells in some IRH patients might be involved in the destruction of hematopoietic cells leading to cytopenia and might be a novel therapeutic target in future.
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Affiliation(s)
- Yuanyuan Shao
- Department of Hematology, Tianjin Medical University General Hospital, 154 Anshan St, Heping District, Tianjin 300052, PR China
| | - Rong Fu
- Department of Hematology, Tianjin Medical University General Hospital, 154 Anshan St, Heping District, Tianjin 300052, PR China
| | - Hui Liu
- Department of Hematology, Tianjin Medical University General Hospital, 154 Anshan St, Heping District, Tianjin 300052, PR China
| | - Yihao Wang
- Department of Hematology, Tianjin Medical University General Hospital, 154 Anshan St, Heping District, Tianjin 300052, PR China
| | - Shaoxue Ding
- Department of Hematology, Tianjin Medical University General Hospital, 154 Anshan St, Heping District, Tianjin 300052, PR China
| | - Huaquan Wang
- Department of Hematology, Tianjin Medical University General Hospital, 154 Anshan St, Heping District, Tianjin 300052, PR China
| | - Lijuan Li
- Department of Hematology, Tianjin Medical University General Hospital, 154 Anshan St, Heping District, Tianjin 300052, PR China
| | - Zonghong Shao
- Department of Hematology, Tianjin Medical University General Hospital, 154 Anshan St, Heping District, Tianjin 300052, PR China.
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Fu R, Liu H, Wang Y, Liu H, He H, Chen J, Wang H, Yu H, Ding K, Huang L, Wang H, Xing L, Song J, Li L, Shao Z. Distinguishing immunorelated haemocytopenia from idiopathic cytopenia of undetermined significance (ICUS): a bone marrow abnormality mediated by autoantibodies. Clin Exp Immunol 2014; 177:412-8. [PMID: 24730511 DOI: 10.1111/cei.12347] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/03/2014] [Indexed: 12/25/2022] Open
Abstract
In recent years we have observed that some patients with idiopathic cytopenia of undetermined significance (ICUS) responded well to corticosteroid and high-dose intravenous immunoglobulin treatment, indicating that some cytopenia in ICUS might be mediated by autoantibodies. In this study, we analysed 166 ICUS cases retrospectively, some of which were autoantibodies detected on haemopoietic cells in bone marrow (BM) by BM mononuclear cell (BMMNC)-Coombs test, flow cytometry (FCM), Western blot and immunofluorescence (IF). We found that 25·9% (43 of 166) of the cases had autoantibodies positive verified with BMMNC-Coombs test or FCM analysis, 72·1% (31 of 43) of whom had immunoglobulin (Ig)G autoantibody positive by Western blot. IgG could be detected in the erythroblastic islands on the BM smear of nine (32·1%, nine of 28) ICUS patients with autoantibodies by IF. Of these 43 patients, the median percentage of reticulocytes was 1·79%. More than half the patients had hyper-BM cellularity with a higher percentage of nucleated erythroid cells in the sternum. Total response rates to immunosuppressive therapy at 6, 12, 24 and > 36 months were 46·5% (20 of 43), 75% (30 of 40), 77·4% (24 of 31) and 66·7% (16 of 24), respectively. We termed this group of ICUS cases with autoantibodies as immunorelated haemocytopenia (or BMMNC-Coombs test-positive haemocytopenia).
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Affiliation(s)
- R Fu
- Department of Haematology, Tianjin Medical University General Hospital, Tianjin, China
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Abstract
Myelodysplastic syndromes are clonal marrow stem-cell disorders, characterised by ineffective haemopoiesis leading to blood cytopenias, and by progression to acute myeloid leukaemia in a third of patients. 15% of cases occur after chemotherapy or radiotherapy for a previous cancer; the syndromes are most common in elderly people. The pathophysiology involves cytogenetic changes with or without gene mutations and widespread gene hypermethylation at advanced stages. Clinical manifestations result from cytopenias (anaemia, infection, and bleeding). Diagnosis is based on examination of blood and bone marrow showing blood cytopenias and hypercellular marrow with dysplasia, with or without excess of blasts. Prognosis depends largely on the marrow blast percentage, number and extent of cytopenias, and cytogenetic abnormalities. Treatment of patients with lower-risk myelodysplastic syndromes, especially for anaemia, includes growth factors, lenalidomide, and transfusions. Treatment of higher-risk patients is with hypomethylating agents and, whenever possible, allogeneic stem-cell transplantation.
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Affiliation(s)
- Lionel Adès
- Service d'hématologie, Hôpital St Louis (Assistance Publique Hôpitaux de Paris) and Paris 7 University, Paris, France
| | - Raphael Itzykson
- Service d'hématologie, Hôpital St Louis (Assistance Publique Hôpitaux de Paris) and Paris 7 University, Paris, France
| | - Pierre Fenaux
- Service d'hématologie, Hôpital St Louis (Assistance Publique Hôpitaux de Paris) and Paris 7 University, Paris, France.
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36
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Bennett JM. The myelodysplastic syndromes: a personal recollection of four decades of classification and prognostic scoring systems. Leuk Lymphoma 2013; 54:2588-91. [PMID: 23547832 DOI: 10.3109/10428194.2013.787615] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
In 1976 the French-American-British (FAB) Leukemia Working Group proposed the first definitions of patients with myelodysplastic syndromes (MDS), namely refractory anemia with excess blasts (RAEB) and chronic myelomonocytic leukemia (CMML). Subsequent publications resulted in additional subgroups that had prognostic significance. Incorporation of the subgroupings by the World Health Organization and additional fine tuning of the degrees of morphologic dysplasia and percentage of blasts have enhanced the classification. Several prognostic scoring systems have added degrees of cytopenia, cytogenetic aberrations and molecular genetic mutations that allow care providers to subdivide cases into lower, intermediate and higher grade categories.
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Affiliation(s)
- John M Bennett
- Departments of Pathology and Medicine, the James P. Wilmot Cancer Center, University of Rochester Medical Center , Rochester, NY , USA
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Steensma DP. Dysplasia has A differential diagnosis: distinguishing genuine myelodysplastic syndromes (MDS) from mimics, imitators, copycats and impostors. Curr Hematol Malig Rep 2013; 7:310-20. [PMID: 23015360 DOI: 10.1007/s11899-012-0140-3] [Citation(s) in RCA: 62] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Just as a pawnshop owner who is unable to distinguish a genuine Rolex™ watch from a cheap knockoff courts financial ruin, the physician who fails to discriminate between authentic myelodysplastic syndromes (MDS) and conditions resembling MDS risks misinforming or harming patients. This review summarizes minimal criteria for diagnosing MDS and discusses common diagnostic challenges. MDS needs to be separated from numerous neoplastic and non-clonal hematologic disorders that can mimic MDS, including other myeloid neoplasms, nutritional deficiencies, toxin exposures, aplastic anemia, and inherited disorders (e.g., congenital sideroblastic anemia). Some distinctions are more critical therapeutically than others; e.g., recognizing B12 deficiency is more important than parsing high-risk MDS from erythroleukemia. Diagnostically ambiguous cases may be assigned holding-pattern terms, "idiopathic cytopenia(s) of undetermined significance" (ICUS) or "idiopathic dysplasia of undetermined significance" (IDUS), while awaiting clarifying information or further clinical developments. In the future, advances in molecular pathology will improve diagnostic accuracy, especially in morphologically non-descript cases.
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Affiliation(s)
- David P Steensma
- Department of Medical Oncology, Dana-Farber Cancer Institute Harvard Medical School, 450 Brookline Ave, Suite D1B30, Mayer 1B21, Boston, MA, 02215, USA.
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38
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Tothova Z, Steensma DP, Ebert BL. New strategies in myelodysplastic syndromes: application of molecular diagnostics to clinical practice. Clin Cancer Res 2013; 19:1637-43. [PMID: 23329810 PMCID: PMC3748432 DOI: 10.1158/1078-0432.ccr-12-1251] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
An increasingly complete compendium of recurrently mutated genes in myelodysplastic syndromes (MDS) has been defined, and the application of massively parallel sequencing to identify mutations in clinical practice now promises to improve the care of patients with this disease. More than 25 recurrent MDS-associated somatic mutations have been identified, involving biologic pathways as diverse as chromatin remodeling and pre-mRNA splicing. Several of these mutations have been shown to have prognostic implications that are independent of existing risk stratification systems based on clinical and pathologic parameters. Application of these recent discoveries to diagnosis, prognosis, risk stratification, and treatment selection for patients with MDS has the potential to improve patient outcomes. Here, we review recent advances in MDS and discuss potential applications of these discoveries to clinical practice.
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Affiliation(s)
- Zuzana Tothova
- Division of Hematology, Brigham and Women's Hospital, Boston, MA, USA
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Abstract
AbstractTraditionally, cytopenias are classified as deficiency mediated, immune mediated, BM failure induced, renal, or idiopathic, with the latter including the so-called idiopathic cytopenias of undetermined significance (ICUS). Clinical findings, symptoms, blood counts, BM findings, and other laboratory parameters are usually sufficient to reveal the type and cause of a marked cytopenia. However, in patients with chronic mild cytopenia, it may be a challenge for the physician to establish a correct diagnosis. In such patients, laboratory features and findings often reflect a diagnostic interface, so that criteria that are otherwise robust may hardly be applicable or are not helpful. Even if the BM is examined, the diagnosis often remains uncertain in these patients. In addition, more than one potential cause of cytopenia may be present, especially in the elderly. A myelodysplastic syndrome (MDS) or another BM disorder, but also an overt autoimmune or other inflammatory disease, may develop during follow-up in these patients. A key problem is that in an early phase of MDS, most laboratory and clinical signs are “nonspecific.” One of the very few reliable peripheral blood parameters distinguishing between an early or “pre-phase” of MDS and most other causes of a mild cytopenia are the numbers of circulating colony-forming progenitor cells. In addition, flow cytometric and molecular investigations may sometimes assist in the delineation between clonal and reactive conditions underlying mild cytopenias. This review provides an overview of diagnostic approaches and algorithms for patients with mild unexplained cytopenia(s).
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van de Loosdrecht AA, Ireland R, Kern W, Della Porta MG, Alhan C, Balleisen JS, Bettelheim P, Bowen DT, Burbury K, Eidenschink L, Cazzola M, Chu SSC, Cullen M, Cutler JA, Dräger AM, Feuillard J, Fenaux P, Font P, Germing U, Haase D, Hellström-Lindberg E, Johansson U, Kordasti S, Loken MR, Malcovati L, te Marvelde JG, Matarraz S, Milne T, Moshaver B, Mufti GJ, Nikolova V, Ogata K, Oelschlaegel U, Orfao A, Ossenkoppele GJ, Porwit A, Platzbecker U, Preijers F, Psarra K, Richards SJ, Subirá D, Seymour JF, Tindell V, Vallespi T, Valent P, van der Velden VHJ, Wells DA, de Witte TM, Zettl F, Béné MC, Westers TM. Rationale for the clinical application of flow cytometry in patients with myelodysplastic syndromes: position paper of an International Consortium and the European LeukemiaNet Working Group. Leuk Lymphoma 2012; 54:472-5. [PMID: 22916713 DOI: 10.3109/10428194.2012.718341] [Citation(s) in RCA: 59] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
An international working group within the European LeukemiaNet gathered, aiming to determine the role of flow cytometry (FC) in myelodysplastic syndromes (MDS). It was agreed that FC has a substantial application in disease characterization, diagnosis and prognosis. FC may also be useful in predicting treatment responses and monitoring novel and standard therapeutic regimens. In this article the rationale is discussed that flow cytometry should be integrated as a part of diagnostic and prognostic scoring systems in MDS.
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Abstract
Sustained clinical cytopenia is a frequent laboratory finding in ambulatory and hospitalized patients. For pathologists and hematopathologists who examine the bone marrow (BM), a diagnosis of cytopenia secondary to an infiltrative BM process or acute leukemia can be readily established based on morphologic evaluation and flow cytometry immunophenotyping. However, it can be more challenging to establish a diagnosis of myelodysplastic syndrome (MDS). In this article, the practical approaches for establishing or excluding a diagnosis of MDS (especially low-grade MDS) in patients with clinical cytopenia are discussed along with the current diagnostic recommendations provided by the World Health Organization and the International Working Group for MDS.
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42
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Valent P, Bain BJ, Bennett JM, Wimazal F, Sperr WR, Mufti G, Horny HP. Idiopathic cytopenia of undetermined significance (ICUS) and idiopathic dysplasia of uncertain significance (IDUS), and their distinction from low risk MDS. Leuk Res 2011; 36:1-5. [PMID: 21920601 DOI: 10.1016/j.leukres.2011.08.016] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2011] [Revised: 08/01/2011] [Accepted: 08/18/2011] [Indexed: 10/17/2022]
Abstract
It is now generally appreciated that hematologic neoplasms can develop over many years if not decades, often being initially occult or showing minimal (subdiagnostic) abnormalities. However, whereas such early neoplastic conditions have been defined in some detail in lymphoproliferative neoplasms, little is known about minimal lesions preceding the manifestation of an overt myeloid neoplasm, about underlying mechanisms, the clinical course and outcome, and the prognostic significance of such conditions. Members of several groups have recently described two 'premalignant' myeloid conditions, namely idiopathic cytopenia of undetermined significance (ICUS) and idiopathic bone marrow dysplasia of uncertain significance (IDUS). At least in some patients these are neoplastic conditions. Both conditions may progress to an overt myelodysplastic syndrome (MDS), but may also progress to another myeloid neoplasm such as acute myeloid leukemia, a myeloproliferative neoplasm (MPN), or a mast cell disorder (mastocytosis). In ICUS the dysplasia is mild and does not fulfill the WHO criteria for MDS but cytopenias can be severe. In IDUS the dysplasia is prominent but cytopenias, if detectable, are mild. In both conditions it is possible that a neoplastic clone has already replaced most or all of normal bone marrow cells when ICUS or IDUS is detected, but evidence to support this possibility is not necessarily available. For both groups of patients we recommend a thorough hematologic follow up because of the potential of disease-manifestation and the unpredictable form and time of progression. In the present review, we discuss current concepts relating to ICUS and IDUS as well as diagnostic approaches and available criteria.
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Affiliation(s)
- Peter Valent
- Department of Internal Medicine I, Division of Hematology & Hemostaseology, Medical University of Vienna, Vienna, Austria.
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43
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Yun GW, Yang YJ, Song IC, Baek SW, Lee KS, Lee HJ, Yun HJ, Kwon KC, Kim S, Jo DY. Long-term outcome of isolated thrombocytopenia accompanied by hypocellular marrow. THE KOREAN JOURNAL OF HEMATOLOGY 2011; 46:128-34. [PMID: 21747886 PMCID: PMC3128894 DOI: 10.5045/kjh.2011.46.2.128] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/09/2011] [Revised: 03/06/2011] [Accepted: 05/17/2011] [Indexed: 11/23/2022]
Abstract
Background Hypocellularity of bone marrow (BM), not associated with significant dyshematopoiesis, is often found in patients with isolated thrombocytopenia, but its clinical implications have not been studied. We prospectively studied the clinical features and natural history of these patients. Methods Adults with isolated thrombocytopenia (platelet counts <100×109/L) in the absence of dyshematopoiesis, cytogenetic abnormalities, or megakaryocytic hyperplasia and who had BM hypocellularity (below 30% in patients aged less than 60 years; below 20% in patients aged 60 years or more) were enrolled at Chungnam National University Hospital between January 2002 and December 2006. They were monitored regularly for changes in platelet counts or development of additional cytopenia. Results Twenty patients (17 men and 3 women) were enrolled in the study. The median age was 29 years (range, 18-70 years). At initial presentation, the platelet counts ranged from 12×109/L to 99×109/L (median, 63×109/L) and were >50×109/L in 16 patients (80%). BM cellularity ranged from 5% to 25% (median, 15%) and was ≤10% in 6 patients (30%). During the median 48-month follow-up (range, 12-90 months), platelet counts of 3 of the 20 patients recovered to normal levels (>150×109/L) after 12, 56 and 66 months. Three patients developed pancytopenia after 11, 70 and 90 months. Two patients were consistent with moderate aplastic anemia, and 1 was confirmed as having refractory cytopenia with multilineage dysplasia. In the remainder of the patients, platelet counts remained unchanged. Conclusion Isolated thrombocytopenia accompanied by hypocellular marrow encompasses a group of heterogeneous conditions.
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Affiliation(s)
- Gak-Won Yun
- Department of Internal Medicine, School of Medicine, Chungnam National University, Daejeon, Korea
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44
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Steensma DP. ASH 2010 meeting report-Top 10 clinically-oriented abstracts in myelodysplastic syndromes (MDS). Am J Hematol 2011. [DOI: 10.1002/ajh.21975] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
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45
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Abstract
Sustained clinical cytopenia is a frequent laboratory finding in ambulatory and hospitalized patients. For pathologists and hematopathologists who examine the bone marrow (BM), a diagnosis of cytopenia secondary to an infiltrative BM process or acute leukemia can be readily established based on morphologic evaluation and flow cytometry immunophenotyping. However, it can be more challenging to establish a diagnosis of myelodysplastic syndrome (MDS). In this article, the practical approaches for establishing or excluding a diagnosis of MDS (especially low-grade MDS) in patients with clinical cytopenia are discussed along with the current diagnostic recommendations provided by the World Health Organization and the International Working Group for MDS.
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Affiliation(s)
- Sa A Wang
- Department of Hematopathology, University of Texas, MD Anderson Cancer Center, Unit 72, 1515 Holcombe Boulevard, Houston, TX 77030-4009, USA.
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46
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Ando K, Tanaka Y, Hashimoto Y, Ohyashiki JH, Sugimori N, Nakao S, Ohyashiki K. correspondence: PNH-phenotype cells in patients with idiopathic cytopenia of undetermined significance (ICUS) with megakaryocytic hypoplasia and thrombocytopenia. Br J Haematol 2010; 150:705-7. [DOI: 10.1111/j.1365-2141.2010.08257.x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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47
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Gupta G, Singh R, Kotasthane DS, Kotasthane VD. Myelodysplastic syndromes/neoplasms: recent classification system based on World Health Organization Classification of Tumors - International Agency for Research on Cancer for Hematopoietic and Lymphoid Tissues. J Blood Med 2010; 1:171-82. [PMID: 22282696 PMCID: PMC3262332 DOI: 10.2147/jbm.s12257] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2010] [Indexed: 11/23/2022] Open
Abstract
The myelodysplastic Syndromes (MDS) are a group of clonal hematopoietic stem cell diseases characterized by cytopenia(s), dysplasia in one or more of the major myeloid cell lines, ineffective hematopoiesis, and increased risk of development of acute myeloid leukemia. The classification and the diagnostic criteria have been redefined by the recent World Health Organization Classification of Tumors – International Agency for Research on Cancer for Hematopoietic and Lymphoid Tissues. The myelodysplastic syndromes are now classified into the following categories – refractory cytopenia with unilineage dysplasia, refractory anemia with ring sideroblasts, refractory cytopenia with multilineage dysplasia, refractory anemia with excess blasts, myelodysplastic syndrome associated with isolated del (5q), myelodysplastic syndrome – unclassifiable, and childhood myelodysplastic syndrome. The clinicopathologic features, morphology, differential diagnosis, immunophenotyping, cytogenetics, prognosis and predictive factors are presented in the light of recent World Health Organization Classification of Tumors – International Agency for Research on Cancer.
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Affiliation(s)
- Geetanjali Gupta
- Department of Pathology, Mahatma Gandhi Medical College and Research Institute, Puducherry-607402, India
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48
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Schroeder T, Ruf L, Bernhardt A, Hildebrandt B, Aivado M, Aul C, Gattermann N, Haas R, Germing U. Distinguishing myelodysplastic syndromes (MDS) from idiopathic cytopenia of undetermined significance (ICUS): HUMARA unravels clonality in a subgroup of patients. Ann Oncol 2010; 21:2267-2271. [PMID: 20439346 DOI: 10.1093/annonc/mdq233] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND Patients not fulfilling minimal criteria for myelodysplastic syndromes (MDS) but presenting with persisting cytopenia(s) not attributable to a haematological or non-haematological disease are defined as 'idiopathic cytopenia of undetermined significance' (ICUS). DESIGN AND METHODS We retrospectively analysed 67 of 3504 patients from our MDS Registry fulfilling the criteria for ICUS. Furthermore, we used the human androgen receptor gene-based assay (HUMARA) to look for clonality. RESULTS Of all 67 patients, 66% had unilineage, 18% bilineage and 12% trilineage cytopenias. The majority of patients (67%) presented with anaemia. Median overall survival was 44 months (range: 1-199 months). In the entire group, eight patients (12%) developed acute myeloid leukaemia (AML). Of the 23 patients eligible for HUMARA, 17 had non-clonal X-chromosome inactivation patterns, while 6 patients showed clonal patterns. Two of these six patients developed AML indicating that a clonal stem cell disorder was the reason for the anteceding cytopenia, while there was no AML observed among the 17 patients with non-clonal patterns (P = 0.013). CONCLUSIONS Since some of the ICUS patients had a clonal bone marrow disease when presenting with cytopenia(s) and 8 of 67 patients with ICUS later developed AML, we recommend to follow these patients thoroughly. As demonstrated here, HUMARA can facilitate the discrimination between ICUS and a 'manifest' MDS.
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Affiliation(s)
- T Schroeder
- Department of Haematology, Oncology and Clinical Immunology.
| | - L Ruf
- Department of Haematology, Oncology and Clinical Immunology
| | - A Bernhardt
- Department of Haematology, Oncology and Clinical Immunology
| | - B Hildebrandt
- Institute of Human Genetics and Anthropology, Heinrich-Heine University, Düsseldorf, Germany
| | - M Aivado
- Department of Haematology, Oncology and Clinical Immunology; Global Clinical Development Oncology GlaxoSmithKline, Collegeville, PA, USA
| | - C Aul
- Department of Haematology, Oncology and Clinical Immunology, St Johannes Hospital, Duisburg, Germany
| | - N Gattermann
- Department of Haematology, Oncology and Clinical Immunology
| | - R Haas
- Department of Haematology, Oncology and Clinical Immunology
| | - U Germing
- Department of Haematology, Oncology and Clinical Immunology
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Ando K, Kodama A, Iwabuchi T, Ohyashiki JH, Ohyashiki K. Idiopathic neutropenia with fewer than 5% dysplasia may be a distinct entity of idiopathic cytopenia of undetermined significance. Ann Hematol 2009; 89:733-5. [DOI: 10.1007/s00277-009-0845-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2009] [Accepted: 09/28/2009] [Indexed: 12/01/2022]
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50
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Sperr WR, El-Samahi A, Kundi M, Girschikofsky M, Winkler S, Lutz D, Endler G, Rumpold H, Agis H, Sillaber C, Jäger U, Valent P. Elevated tryptase levels selectively cluster in myeloid neoplasms: a novel diagnostic approach and screen marker in clinical haematology. Eur J Clin Invest 2009; 39:914-23. [PMID: 19522836 DOI: 10.1111/j.1365-2362.2009.02184.x] [Citation(s) in RCA: 71] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
BACKGROUND Recent data suggest that tryptase, a mast cell enzyme, is expressed in neoplastic cells in myeloid leukaemias. In several of these patients, increased serum tryptase levels are detectable. MATERIALS AND METHODS We have determined serum tryptase levels in 914 patients with haematological malignancies, including myeloproliferative disorders (n = 156), myelodysplastic syndromes (MDS, n = 241), acute myeloid leukaemia (AML, n = 317), systemic mastocytosis (SM, n = 81), non-Hodgkin's lymphoma (n = 59) and acute lymphoblastic leukaemia (n = 26). Moreover, tryptase was measured in 136 patients with non-neoplastic haematological disorders, 102 with non-haematological disorders and 164 healthy subjects. RESULTS In healthy subjects, the median serum tryptase was 5.2 ng mL(-1). Elevated serum tryptase levels were found to cluster in myeloid neoplasm, whereas almost all patients with lymphoid neoplasms exhibited normal tryptase. Among myeloid neoplasms, elevated tryptase levels (> 15 ng mL(-1)) were recorded in > 90% of patients with SM, 38% with AML, 34% with CML and 25% with MDS. The highest tryptase levels, often > 1000 ng mL(-1), were found in advanced SM and core-binding-factor leukaemias. In most patients with non-neoplastic haematological disorders and non-haematological disorders analysed in our study, tryptase levels were normal, the exception being a few patients with end-stage kidney disease and helminth infections, in whom a slightly elevated tryptase was found. CONCLUSIONS In summary, tryptase is a new diagnostic marker of myeloid neoplasms and a useful test in clinical haematology.
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Affiliation(s)
- W R Sperr
- Medical University of Vienna, A-1090 Vienna, Austria.
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