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Young DJ, Fan X, Groarke EM, Patel B, Desmond R, Winkler T, Larochelle A, Calvo KR, Young NS, Dunbar CE. Long-term eltrombopag for bone marrow failure depletes iron. Am J Hematol 2022; 97:791-801. [PMID: 35312200 DOI: 10.1002/ajh.26543] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2022] [Revised: 03/16/2022] [Accepted: 03/17/2022] [Indexed: 11/09/2022]
Abstract
Eltrombopag (EPAG) has been approved for the treatment of aplastic anemia and for immune thrombocytopenia, and a subset of patients require long-term therapy. Due to polyvalent cation chelation, prolonged therapy leads to previously underappreciated iron depletion. We conducted a retrospective review of patients treated at the NIH for aplastic anemia, myelodysplastic syndrome, and unilineage cytopenias, comparing those treated with EPAG to a historical cohort treated with immunosuppression without EPAG. We examined iron parameters, duration of therapy, response assessment, relapse rates, and common demographic parameters. We included 521 subjects treated with (n = 315) or without EPAG (n = 206) across 11 studies with multiyear follow-up (3.6 vs. 8.5 years, respectively). Duration of EPAG exposure correlated with ferritin reduction (p = 4 × 10-14 ) regardless of response, maximum dose, or degree of initial iron overload. Clearance followed first-order kinetics with faster clearance (half-life 15.3 months) compared with historical responders (47.5 months, p = 8 × 10-10 ). Risk of iron depletion was dependent upon baseline ferritin and duration of therapy. Baseline ferritin did not correlate with response of marrow failure to EPAG or to relapse risk, and timing of iron clearance did not correlate with disease response. In conclusion, EPAG efficiently chelates total body iron comparable to clinically available chelators. Prolonged use can deplete iron and ultimately lead to iron-deficiency anemia mimicking relapse, responsive to iron supplementation.
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Affiliation(s)
- David J. Young
- Translational Stem Cell Biology Branch National Heart, Lung, and Blood Institute, NIH Bethesda Maryland USA
| | - Xing Fan
- Translational Stem Cell Biology Branch National Heart, Lung, and Blood Institute, NIH Bethesda Maryland USA
| | - Emma M. Groarke
- Hematology Branch National Heart, Lung, and Blood Institute, NIH Bethesda Maryland USA
| | - Bhavisha Patel
- Hematology Branch National Heart, Lung, and Blood Institute, NIH Bethesda Maryland USA
| | - Ronan Desmond
- Hematology Branch National Heart, Lung, and Blood Institute, NIH Bethesda Maryland USA
- Department of Haematology (Laboratory) Tallaght University Hospital Dublin Ireland
| | - Thomas Winkler
- Translational Stem Cell Biology Branch National Heart, Lung, and Blood Institute, NIH Bethesda Maryland USA
| | - Andre Larochelle
- Cellular and Molecular Therapeutics Branch National Heart, Lung, and Blood Institute, NIH Bethesda Maryland USA
| | - Katherine R. Calvo
- Department of Laboratory Medicine Clinical Center, NIH Bethesda Maryland USA
| | - Neal S. Young
- Hematology Branch National Heart, Lung, and Blood Institute, NIH Bethesda Maryland USA
| | - Cynthia E. Dunbar
- Translational Stem Cell Biology Branch National Heart, Lung, and Blood Institute, NIH Bethesda Maryland USA
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2
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Samara A, Shapira S, Lubin I, Shpilberg O, Avigad S, Granot G, Raanani P. Deferasirox induces cyclin D1 degradation and apoptosis in mantle cell lymphoma in a reactive oxygen species- and GSK3β-dependent mechanism. Br J Haematol 2021; 192:747-760. [PMID: 33521925 DOI: 10.1111/bjh.17284] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2020] [Revised: 11/12/2020] [Accepted: 11/24/2020] [Indexed: 01/29/2023]
Abstract
Mantle cell lymphoma (MCL) is a difficult-to-treat B-cell malignancy characterized by cyclin D1 (CD1) overexpression. Targeting CD1 in MCL has been shown to be of therapeutic significance. However, treatment of MCL remains challenging since patients are still subject to early and frequent relapse of the disease. To ensure their high proliferation rate, tumour cells have increased iron needs, making them more susceptible to iron deprivation. Indeed, several iron chelators proved to be effective anti-cancer agents. In this study, we demonstrate that the clinically approved iron chelator deferasirox (DFX) exerts an anti-tumoural effect in MCL cell lines and patient cells. The exposure of MCL cells to clinically feasible concentrations of DFX resulted in growth inhibition, cell cycle arrest and induction of apoptosis. We show that DFX unfolds its cytotoxic effect by a rapid induction of reactive oxygen species (ROS) that leads to oxidative stress and severe DNA damage and by triggering CD1 proteolysis in a mechanism that requires its phosphorylation on T286 by glycogen synthase kinase-3β (GSK3β). Moreover, we demonstrate that DFX mediates CD1 proteolysis by repressing the phosphatidylinositol 3-kinase (PI3K)/AKT/GSK3β pathway via ROS generation. Our data suggest DFX as a potential therapeutic option for MCL and paves the way for more treatment options for these patients.
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Affiliation(s)
- Aladin Samara
- Felsenstein Medical Research Center, Beilinson Hospital, Rabin Medical Center, Petah Tikva, Israel
| | - Saar Shapira
- Felsenstein Medical Research Center, Beilinson Hospital, Rabin Medical Center, Petah Tikva, Israel
| | - Ido Lubin
- Felsenstein Medical Research Center, Beilinson Hospital, Rabin Medical Center, Petah Tikva, Israel
| | - Ofer Shpilberg
- Institute of Hematology, Assuta Medical Center, and School of Medicine, Ariel University, Ariel, Israel
| | - Smadar Avigad
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Galit Granot
- Felsenstein Medical Research Center, Beilinson Hospital, Rabin Medical Center, Petah Tikva, Israel
| | - Pia Raanani
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel.,Institute of Hematology, Davidoff Cancer Center, Beilinson Hospital, Rabin Medical Center, Petah Tikva, Israel
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3
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Leitch HA, Gattermann N. Hematologic improvement with iron chelation therapy in myelodysplastic syndromes: Clinical data, potential mechanisms, and outstanding questions. Crit Rev Oncol Hematol 2019; 141:54-72. [DOI: 10.1016/j.critrevonc.2019.06.002] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2018] [Revised: 11/25/2018] [Accepted: 06/03/2019] [Indexed: 12/25/2022] Open
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4
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Tataranni T, Mazzoccoli C, Agriesti F, De Luca L, Laurenzana I, Simeon V, Ruggieri V, Pacelli C, Della Sala G, Musto P, Capitanio N, Piccoli C. Deferasirox drives ROS-mediated differentiation and induces interferon-stimulated gene expression in human healthy haematopoietic stem/progenitor cells and in leukemia cells. Stem Cell Res Ther 2019; 10:171. [PMID: 31196186 PMCID: PMC6567456 DOI: 10.1186/s13287-019-1293-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2019] [Revised: 05/15/2019] [Accepted: 05/31/2019] [Indexed: 12/11/2022] Open
Abstract
Background Administration of the iron chelator deferasirox (DFX) in transfusion-dependent patients occasionally results in haematopoiesis recovery by a mechanism remaining elusive. This study aimed to investigate at a molecular level a general mechanism underlying DFX beneficial effects on haematopoiesis, both in healthy and pathological conditions. Methods Human healthy haematopoietic stem/progenitor cells (HS/PCs) and three leukemia cell lines were treated with DFX. N-Acetyl cysteine (NAC) and fludarabine were added as antioxidant and STAT1 inhibitor, respectively. In vitro colony-forming assays were assessed both in healthy and in leukemia cells. Intracellular and mitochondrial reactive oxygen species (ROS) as well as mitochondrial content were assessed by cytofluorimetric and confocal microscopy analysis; mtDNA was assessed by qRT-PCR. Differentiation markers were monitored by cytofluorimetric analysis. Gene expression analysis (GEA) was performed on healthy HS/PCs, and differently expressed genes were validated in healthy and leukemia cells by qRT-PCR. STAT1 expression and phosphorylation were assessed by Western blotting. Data were compared by an unpaired Student t test or one-way ANOVA. Results DFX, at clinically relevant concentrations, increased the clonogenic capacity of healthy human CD34+ HS/PCs to form erythroid colonies. Extension of this analysis to human-derived leukemia cell lines Kasumi-1, K562 and HL60 confirmed DFX capacity to upregulate the expression of specific markers of haematopoietic commitment. Notably, the abovementioned DFX-induced effects are all prevented by the antioxidant NAC and accompanied with overproduction of mitochondria-generated reactive oxygen species (ROS) and increase of mitochondrial content and mtDNA copy number. GEA unveiled upregulation of genes linked to interferon (IFN) signalling and tracked back to hyper-phosphorylation of STAT1. Treatment of leukemic cell lines with NAC prevented the DFX-mediated phosphorylation of STAT1 as well as the expression of the IFN-stimulated genes. However, STAT1 inhibition by fludarabine was not sufficient to affect differentiation processes in leukemic cell lines. Conclusions These findings suggest a significant involvement of redox signalling as a major regulator of multiple DFX-orchestrated events promoting differentiation in healthy and tumour cells. The understanding of molecular mechanisms underlying the haematological response by DFX would enable to predict patient’s ability to respond to the drug, to extend treatment to other patients or to anticipate the treatment, regardless of the iron overload. Electronic supplementary material The online version of this article (10.1186/s13287-019-1293-y) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Tiziana Tataranni
- Laboratory of Pre-Clinical and Translational Research, IRCCS-CROB, Referral Cancer Center of Basilicata, Rionero in Vulture, PZ, Italy
| | - Carmela Mazzoccoli
- Laboratory of Pre-Clinical and Translational Research, IRCCS-CROB, Referral Cancer Center of Basilicata, Rionero in Vulture, PZ, Italy
| | - Francesca Agriesti
- Laboratory of Pre-Clinical and Translational Research, IRCCS-CROB, Referral Cancer Center of Basilicata, Rionero in Vulture, PZ, Italy
| | - Luciana De Luca
- Laboratory of Pre-Clinical and Translational Research, IRCCS-CROB, Referral Cancer Center of Basilicata, Rionero in Vulture, PZ, Italy
| | - Ilaria Laurenzana
- Laboratory of Pre-Clinical and Translational Research, IRCCS-CROB, Referral Cancer Center of Basilicata, Rionero in Vulture, PZ, Italy
| | - Vittorio Simeon
- Department of Public, Clinical and Preventive Medicine, Medical Statistics Unit, University of Campania Luigi Vanvitelli, Caserta, Italy
| | - Vitalba Ruggieri
- Laboratory of Pre-Clinical and Translational Research, IRCCS-CROB, Referral Cancer Center of Basilicata, Rionero in Vulture, PZ, Italy
| | - Consiglia Pacelli
- Department of Clinical and Experimental Medicine, University of Foggia, Foggia, Italy
| | - Gerardo Della Sala
- Laboratory of Pre-Clinical and Translational Research, IRCCS-CROB, Referral Cancer Center of Basilicata, Rionero in Vulture, PZ, Italy
| | - Pellegrino Musto
- Hematology Department of Basilicata, IRCCS-CROB Referral Cancer Center of Basilicata, Rionero in Vulture, Italy
| | - Nazzareno Capitanio
- Department of Clinical and Experimental Medicine, University of Foggia, Foggia, Italy
| | - Claudia Piccoli
- Laboratory of Pre-Clinical and Translational Research, IRCCS-CROB, Referral Cancer Center of Basilicata, Rionero in Vulture, PZ, Italy. .,Department of Clinical and Experimental Medicine, University of Foggia, Foggia, Italy.
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5
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Jiménez-Solas T, López-Cadenas F, Aires-Mejía I, Caballero-Berrocal JC, Ortega R, Redondo AM, Sánchez-Guijo F, Muntión S, García-Martín L, Albarrán B, Alonso JM, Del Cañizo C, Hernández-Hernández Á, Díez-Campelo M. Deferasirox reduces oxidative DNA damage in bone marrow cells from myelodysplastic patients and improves their differentiation capacity. Br J Haematol 2019; 187:93-104. [PMID: 31172513 DOI: 10.1111/bjh.16013] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2019] [Accepted: 04/11/2019] [Indexed: 12/12/2022]
Abstract
Patients with low-risk myelodysplastic syndromes (MDS) usually develop iron overload. This leads to a high level of oxidative stress in the bone marrow (BM) and increases haematopoietic cell dysfunction. Our objective was to analyse whether chelation with deferasirox (DFX) alleviates the consequences of oxidative stress and improves BM cell functionality. We analysed 13 iron-overloaded MDS patients' samples before and 4-10 months after treatment with DFX. Using multiparametric flow cytometry analysis, we measured intracellular reactive oxygen species (ROS), DNA oxidation and double strand breaks. Haematopoietic differentiation capacity was analysed by colony-forming unit (CFU) assays. Compared to healthy donors, MDS showed a higher level of intracellular ROS and DNA oxidative damage in BM cells. DNA oxidative damage decreased following DFX treatment. Furthermore, the clonogenic assays carried out before treatment suggest an impaired haematopoietic differentiation. DFX seems to improve this capacity, as illustrated by a decreased cluster/CFU ratio, which reached values similar to controls. We conclude that BM cells from MDS are subject to higher oxidative stress conditions and show an impaired haematopoietic differentiation. These adverse features seem to be partially rectified after DFX treatment.
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Affiliation(s)
- Tamara Jiménez-Solas
- Servicio de Hematología, Hospital Universitario de Salamanca, Salamanca, Spain.,Instituto de Investigación Biomédica de Salamanca (IBSAL), Salamanca, Spain
| | - Félix López-Cadenas
- Servicio de Hematología, Hospital Universitario de Salamanca, Salamanca, Spain.,Instituto de Investigación Biomédica de Salamanca (IBSAL), Salamanca, Spain
| | - Irene Aires-Mejía
- Servicio de Hematología, Hospital Universitario de Salamanca, Salamanca, Spain.,Instituto de Investigación Biomédica de Salamanca (IBSAL), Salamanca, Spain
| | - Juan Carlos Caballero-Berrocal
- Servicio de Hematología, Hospital Universitario de Salamanca, Salamanca, Spain.,Instituto de Investigación Biomédica de Salamanca (IBSAL), Salamanca, Spain
| | - Rebeca Ortega
- Instituto de Investigación Biomédica de Salamanca (IBSAL), Salamanca, Spain
| | - Alba María Redondo
- Servicio de Hematología, Hospital Universitario de Salamanca, Salamanca, Spain.,Instituto de Investigación Biomédica de Salamanca (IBSAL), Salamanca, Spain
| | - Fermín Sánchez-Guijo
- Servicio de Hematología, Hospital Universitario de Salamanca, Salamanca, Spain.,Instituto de Investigación Biomédica de Salamanca (IBSAL), Salamanca, Spain
| | - Sandra Muntión
- Servicio de Hematología, Hospital Universitario de Salamanca, Salamanca, Spain.,Instituto de Investigación Biomédica de Salamanca (IBSAL), Salamanca, Spain
| | - Luís García-Martín
- Servicio de Hematología, Hospital Universitario de Salamanca, Salamanca, Spain.,Instituto de Investigación Biomédica de Salamanca (IBSAL), Salamanca, Spain
| | - Beatriz Albarrán
- Servicio de Hematología, Complejo Asistencial Universitario de Palencia, Palencia, Spain
| | - José María Alonso
- Servicio de Hematología, Complejo Asistencial Universitario de Palencia, Palencia, Spain
| | | | - Ángel Hernández-Hernández
- Instituto de Investigación Biomédica de Salamanca (IBSAL), Salamanca, Spain.,Departamento de Bioquímica y Biología Molecular, Universidad de Salamanca, Salamanca, Spain
| | - María Díez-Campelo
- Servicio de Hematología, Hospital Universitario de Salamanca, Salamanca, Spain.,Instituto de Investigación Biomédica de Salamanca (IBSAL), Salamanca, Spain
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6
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Di Veroli A, Campagna A, De Muro M, Maurillo L, Trawinska MM, LeonettiCrescenzi S, Petriccione L, Romano A, D'Addosio A, Cenfra A, Montanaro M, Felici S, Andriani A, Carmosino I, Niscola P, Montefusco E, Breccia M, Latagliata R. Deferasirox in the treatment of iron overload during myeloproliferative neoplasms in fibrotic phase: does ferritin decrement matter? Leuk Res 2018; 76:65-69. [PMID: 30578958 DOI: 10.1016/j.leukres.2018.11.012] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2018] [Revised: 11/21/2018] [Accepted: 11/22/2018] [Indexed: 11/30/2022]
Abstract
Few data are available on the treatment with DFX in patients with transfusion dependent Ph- Myeloproliferative Neoplasms in fibrotic phase. Here we report 48MPNpatients and iron overload treated with DFX. Starting DFX dose was 20 mg/Kg in 23 patients, 15 mg/Kg in 20 patientsand 10 mg/Kg in 5 patients. After a median treatment of 27.6 months, 5 patients achieved ferritin<500 ng/ml, 11 < 1000 ng/ml and 3 a reduction >50% of basal ferritin with a global response rate of 41%. As to hematological improvement, 9/47 patients (19.1%) showed a persistent rise of Hb>1.5 g/dl, with disappearance of transfusion requirement in 6 cases. The median OS from DFX initiation in patients with chelation response was 61.0 months compared to 15.8 months in patients without chelation efficacy. Treatment with DFX is feasible and effective in MPN with iron overload and a hematological improvement can occur in a sizeable rate of patients.
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Affiliation(s)
| | | | | | | | | | | | | | - Atelda Romano
- Ematologia, Istituto Nazionale dei Tumori Regina Elena, Roma, Italy
| | | | | | | | - Stefano Felici
- Ematologia, Ospedale Nuovo Regina Margherita, Roma, Italy
| | | | - Ida Carmosino
- Dipartimento di Biotecnologie Cellulari ed Ematologia, Università Sapienza, Roma, Italy
| | | | | | - Massimo Breccia
- Dipartimento di Biotecnologie Cellulari ed Ematologia, Università Sapienza, Roma, Italy
| | - Roberto Latagliata
- Dipartimento di Biotecnologie Cellulari ed Ematologia, Università Sapienza, Roma, Italy
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7
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Tuning the Anti(myco)bacterial Activity of 3-Hydroxy-4-pyridinone Chelators through Fluorophores. Pharmaceuticals (Basel) 2018; 11:ph11040110. [PMID: 30347802 PMCID: PMC6316862 DOI: 10.3390/ph11040110] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2018] [Revised: 10/17/2018] [Accepted: 10/18/2018] [Indexed: 02/08/2023] Open
Abstract
Controlling the sources of Fe available to pathogens is one of the possible strategies that can be successfully used by novel antibacterial drugs. We focused our interest on the design of chelators to address Mycobacterium avium infections. Taking into account the molecular structure of mycobacterial siderophores and considering that new chelators must be able to compete for Fe(III), we selected ligands of the 3-hydroxy-4-pyridinone class to achieve our purpose. After choosing the type of chelating unit it was also our objective to design chelators that could be monitored inside the cell and for that reason we designed chelators that could be functionalized with fluorophores. We didn’t realize at the time that the incorporation a fluorophore, to allow spectroscopic detection, would be so relevant for the antimycobacterial effect or to determine the affinity of the chelators towards biological membranes. From a biophysical perspective, this is a fascinating illustration of the fact that functionalization of a molecule with a particular label may lead to a change in its membrane permeation properties and result in a dramatic change in biological activity. For that reason we believe it is interesting to give a critical account of our entire work in this area and justify the statement “to label means to change”. New perspectives regarding combined therapeutic approaches and the use of rhodamine B conjugates to target closely related problems such as bacterial resistance and biofilm production are also discussed.
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8
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Rose C, Lenoir C, Gyan E, Hacini M, Amé S, Corront B, Beyne-Rauzy O, Adiko D, Loppinet E, Ali-Ammar N, Laribi K, Wattel E, Dreyfus F, Roué CS, Cheze S. Prospective evaluation of the effect of deferasirox on hematologic response in transfusion-dependent patients with low-risk MDS and iron overload. Eur J Haematol 2018; 101:165-173. [PMID: 29719933 DOI: 10.1111/ejh.13088] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/19/2018] [Indexed: 12/26/2022]
Abstract
OBJECTIVES To assess the reduction of transfusions rate in transfusion-dependent patients with low-risk myelodysplastic syndrome (MDS) with iron overload treated with deferasirox. METHODS Prospective observational study. Primary endpoint was reduction in transfusion requirements (RTR) at 3 months, (assessed on 8-week period). Secondary endpoints were hematologic improvement according to International Working Group (IWG) 2006 criteria at 3, 6, and 12 months. RESULTS Fifty-seven patients were evaluable. After 3 months of chelation, no effect was seen on transfusion requirement (5.9 packed red blood cells (PRBC) vs 5.8 before chelation). According to the Kaplan-Meier analysis, the probability of RTR at 3, 6, and 12 months was assessed as 3.5%, 9.1%, and 18.7%, respectively. Median duration of RTR was 182 days. However, during the 12-month follow-up after deferasirox initiation, 17 patients (31.5%) achieved minor erythroid response [HI-E] according to IWG criteria, 10 of whom having achieved Hb improvement at month 12. CONCLUSION After 3 months of treatment, deferasirox had no impact on transfusion requirement in regularly transfused patients with low-risk MDS. However, deferasirox could induce 31% of erythroid response during the 12-month follow-up period thus suggesting that iron chelation therapy with deferasirox may induce an effect on hematopoiesis in a subset of patients with MDS and iron overload.
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Affiliation(s)
- Christian Rose
- Hospital Saint Vincent de Paul, Catholic University of Lille, Lille, France
| | | | - Emmanuel Gyan
- Hospital Bretonneau, University of Tours, Tours, France
| | | | - Shanti Amé
- Hospital Hautepierre, University of Strasbourg, Strasbourg, France
| | | | | | | | | | | | | | - Eric Wattel
- Hospital Lyon-Sud, University of Lyon, Pierre-Bénite, France
| | | | | | - Stephane Cheze
- Hospital Côte de Nacre, University of Caen, Caen, France
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9
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Zhang Y, Han S, Guo C, Zhang QX, Chang CK. [Effect of iron chelation therapy on EPO-Stat5 signaling pathway and Treg expression in IPSS low risk/medium risk-1 group myelodysplastic syndrome patients]. ZHONGHUA XUE YE XUE ZA ZHI = ZHONGHUA XUEYEXUE ZAZHI 2018; 39:336-338. [PMID: 29779334 PMCID: PMC7342130 DOI: 10.3760/cma.j.issn.0253-2727.2018.04.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Download PDF] [Subscribe] [Scholar Register] [Received: 11/01/2017] [Indexed: 11/08/2022]
Affiliation(s)
| | | | | | | | - C K Chang
- Department of Hematology, The Sixth People's Hospital, Shanghai Jiaotong University, Shanghai 201306, China
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10
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Ohara Y, Chew SH, Shibata T, Okazaki Y, Yamashita K, Toyokuni S. Phlebotomy as a preventive measure for crocidolite-induced mesothelioma in male rats. Cancer Sci 2018; 109:330-339. [PMID: 29193587 PMCID: PMC5797813 DOI: 10.1111/cas.13460] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2017] [Revised: 11/17/2017] [Accepted: 11/26/2017] [Indexed: 12/13/2022] Open
Abstract
Malignant mesothelioma (MM) is a rare but socially important neoplasm due to its association with asbestos exposure. Malignant mesothelioma is difficult to diagnose at an early stage, yet there are no particularly effective treatments available at the advanced stage, thus necessitating efficient strategies to prevent MM in individuals already exposed to asbestos. We previously showed that persistent oxidative damage caused by foreign body reaction and affinity of asbestos both to hemoglobin and histones is one of the major pathogeneses. Accordingly, as an effective strategy to prevent asbestos‐induced MM, we undertook the use of an iron chelator, deferasirox, which decreased the epithelial–mesenchymal transition in a crocidolite‐induced rat MM model. However, this agent may show adverse effects. Here, we studied the effects of iron removal by phlebotomy as a realistic measure on the same rat model. We injected a total of 5 mg crocidolite i.p. to F1 hybrid rats between the Fischer‐344 and Brown‐Norway strains at the age of 6 weeks. We repeated weekly or biweekly phlebotomy of 6‐8 mL/kg/time from 10 to 60 weeks of age. The animals were observed until 120 weeks. In male rats, phlebotomy significantly decreased the weight and nuclear grade of MM, and modestly reduced the associated ascites and the fraction of more malignant sarcomatoid subtype. Weekly phlebotomy prolonged long‐term survival. Our results indicate that appropriate phlebotomy may be a practical preventive measure to attenuate the initiation and promotion capacity of asbestos towards MM by reducing iron in individuals exposed to asbestos.
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Affiliation(s)
- Yuuki Ohara
- Department of Pathology and Biological Responses, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Shan-Hwu Chew
- Department of Pathology and Biological Responses, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Takahiro Shibata
- Department of Pathology and Biological Responses, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Yasumasa Okazaki
- Department of Pathology and Biological Responses, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Kyoko Yamashita
- Department of Pathology and Biological Responses, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Shinya Toyokuni
- Department of Pathology and Biological Responses, Nagoya University Graduate School of Medicine, Nagoya, Japan.,Sydney Medical School, The University of Sydney, Sydney, NSW, Australia
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11
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12
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Giagounidis A. Current treatment algorithm for the management of lower-risk MDS. HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2017; 2017:453-459. [PMID: 29222293 PMCID: PMC6142548 DOI: 10.1182/asheducation-2017.1.453] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/30/2023]
Abstract
Lower risk myelodysplastic syndromes (MDS), defined as MDS with a Revised International Prognostic Scoring System score ≤3.5 points, will remain a challenging entity in 2018. Supportive care continues to be the linchpin of treatment, although the options to reduce transfusion needs are broadening. To achieve red blood cell transfusion independence in non-del(5q) patients, erythropoiesis-stimulating agents remain a mainstay of therapy as long as endogenous erythropoietin levels are <500 U/L (and preferably <200 U/L). Experimental strategies for patients ineligible for erythropoiesis-stimulating agents or relapsing after gaining transfusion independence include immunosuppressive agents, transforming growth factor β inhibitors, and lenalidomide. All these alternatives have shown reasonable response rates in selected patient populations with lower risk MDS. Patients with del(5q) disease can derive long-term benefit from lenalidomide, and some patients remain transfusion free for extended periods even after discontinuation of the drug. In rare cases in which thrombocytopenia is the main clinical problem leading to clinically significant bleeding events, thrombopoietin receptor analogues may alleviate bleeding, increase platelet counts, and rarely lead to trilineage responses. It seems prudent to use these drugs only in patients with confirmed bone marrow blast counts <5%. Allogeneic stem cell transplantation is reasonable for patients with high molecular risk of progression and those failing several lines of treatment with signs of progression toward higher-risk MDS.
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Affiliation(s)
- Aristoteles Giagounidis
- Department of Hematology, Oncology and Palliative Care, Marien Hospital Düsseldorf, Düsseldorf, Germany
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13
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Meunier M, Ancelet S, Lefebvre C, Arnaud J, Garrel C, Pezet M, Wang Y, Faure P, Szymanski G, Duployez N, Preudhomme C, Biard D, Polack B, Cahn JY, Moulis JM, Park S. Reactive oxygen species levels control NF-κB activation by low dose deferasirox in erythroid progenitors of low risk myelodysplastic syndromes. Oncotarget 2017; 8:105510-105524. [PMID: 29285268 PMCID: PMC5739655 DOI: 10.18632/oncotarget.22299] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2017] [Accepted: 08/26/2017] [Indexed: 11/25/2022] Open
Abstract
Anemia is a frequent cytopenia in myelodysplastic syndromes (MDS) and most patients require red blood cell transfusion resulting in iron overload (IO). Deferasirox (DFX) has become the standard treatment of IO in MDS and it displays positive effects on erythropoiesis. In low risk MDS samples, mechanisms improving erythropoiesis after DFX treatment remain unclear. Herein, we addressed this question by using liquid cultures with iron overload of erythroid precursors treated with low dose of DFX (3μM), which corresponds to DFX 5 mg/kg/day, an unusual dose used for iron chelation. We highlight a decreased apoptosis rate and an increased proportion of cycling cells, both leading to higher proliferation rates. The iron chelation properties of low dose DFX failed to activate the Iron Regulatory Proteins and to support iron depletion, but low dose DFX dampers intracellular reactive oxygen species. Furthermore low concentrations of DFX activate the NF-κB pathway in erythroid precursors triggering anti-apoptotic and anti-inflammatory signals. Establishing stable gene silencing of the Thioredoxin (TRX) 1 genes, a NF-κB modulator, showed that fine-tuning of reactive oxygen species (ROS) levels regulates NF-κB. These results justify a clinical trial proposing low dose DFX in MDS patients refractory to erythropoiesis stimulating agents.
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Affiliation(s)
- Mathieu Meunier
- CHU Grenoble Alpes, University Clinic of Hematology, Grenoble, France.,Université Grenoble Alpes, CNRS UMR 5525, Grenoble INP, CHU Grenoble Alpes, TIMC-IMAG ThEREx, Grenoble, France
| | - Sarah Ancelet
- Université Grenoble Alpes, CNRS UMR 5525, Grenoble INP, CHU Grenoble Alpes, TIMC-IMAG ThEREx, Grenoble, France
| | | | - Josiane Arnaud
- Unité de Biochimie Hormonale et Nutritionnelle, Département de Biologie - Toxicologie - Pharmacologie, CHU Grenoble Alpes, Grenoble, France
| | - Catherine Garrel
- Unité de Biochimie Hormonale et Nutritionnelle, Département de Biologie - Toxicologie - Pharmacologie, CHU Grenoble Alpes, Grenoble, France
| | - Mylène Pezet
- Plateforme de Microscopie Photonique - Cytométrie en Flux, Institut Albert Bonniot, La Tronche, France
| | - Yan Wang
- Université Grenoble Alpes, CNRS UMR 5525, Grenoble INP, CHU Grenoble Alpes, TIMC-IMAG ThEREx, Grenoble, France
| | - Patrice Faure
- Unité de Biochimie Hormonale et Nutritionnelle, Département de Biologie - Toxicologie - Pharmacologie, CHU Grenoble Alpes, Grenoble, France
| | | | - Nicolas Duployez
- Laboratory of Hematology and Tumor Bank, INSERM UMR-S 1172, Cancer Research Institute of Lille, CHRU of Lille, University Lille Nord de France, Lille, France
| | - Claude Preudhomme
- Laboratory of Hematology and Tumor Bank, INSERM UMR-S 1172, Cancer Research Institute of Lille, CHRU of Lille, University Lille Nord de France, Lille, France
| | - Denis Biard
- CEA, Institut de Biologie François Jacob, SEPIA, Team Cellular Engineering and Human Syndromes, Université Paris-Saclay, Fontenay-aux-Roses, France
| | - Benoit Polack
- Université Grenoble Alpes, CNRS UMR 5525, Grenoble INP, CHU Grenoble Alpes, TIMC-IMAG ThEREx, Grenoble, France.,Laboratory of Hematology, CHU Grenoble Alpes, Grenoble, France
| | - Jean-Yves Cahn
- CHU Grenoble Alpes, University Clinic of Hematology, Grenoble, France.,Université Grenoble Alpes, CNRS UMR 5525, Grenoble INP, CHU Grenoble Alpes, TIMC-IMAG ThEREx, Grenoble, France
| | - Jean Marc Moulis
- Université Grenoble Alpes, Laboratory of Fundamental and Applied Bioenergetics, and Environmental and Systems Biology, Grenoble, France.,INSERM U1055, Grenoble, France.,CEA-Grenoble, Bioscience and Biotechnology Institute, Grenoble, France
| | - Sophie Park
- CHU Grenoble Alpes, University Clinic of Hematology, Grenoble, France.,Université Grenoble Alpes, CNRS UMR 5525, Grenoble INP, CHU Grenoble Alpes, TIMC-IMAG ThEREx, Grenoble, France
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14
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Shen JC, Zhang YC, Zhao MF. Protective effects of deferasirox and N-acetyl-L-cysteine on iron overload-injured bone marrow. ACTA ACUST UNITED AC 2017; 50:e6087. [PMID: 29069221 PMCID: PMC5649863 DOI: 10.1590/1414-431x20176087] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2017] [Accepted: 07/20/2017] [Indexed: 01/13/2023]
Abstract
Using an iron overload mouse model, we explored the protective effect of deferasirox (DFX) and N-acetyl-L-cysteine (NAC) on injured bone marrow hematopoietic stem/progenitor cells (HSPC) induced by iron overload. Mice were intraperitoneally injected with 25 mg iron dextran every 3 days for 4 weeks to establish an iron overload (Fe) model. DFX or NAC were co-administered with iron dextran in two groups of mice (Fe+DFX and Fe+NAC), and the function of HSPCs was then examined. Iron overload markedly decreased the number of murine HSPCs in bone marrow. Subsequent colony-forming cell assays showed that iron overload also decreased the colony forming capacity of HSPCs, the effect of which could be reversed by DFX and NAC. The bone marrow hematopoiesis damage caused by iron overload could be alleviated by DFX and NAC.
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Affiliation(s)
- J C Shen
- Department of Hematology, Affiliated Hospital of Logistics University of People's Armed Police Forces, Tianjin, China
| | - Y C Zhang
- Department of Biotherapy, Affiliated Hospital of Logistics University of People's Armed Police Forces, Tianjin, China
| | - M F Zhao
- Department of Hematology, The First Central Hospital, Tianjin, China
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15
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Du Y, Long Z, Chen M, Han B, Hou B, Feng F. Observational Monitoring of Patients with Aplastic Anemia and Low/Intermediate-1 Risk of Myelodysplastic Syndromes Complicated with Iron Overload. Acta Haematol 2017; 138:119-128. [PMID: 28866669 DOI: 10.1159/000479422] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2017] [Accepted: 07/10/2017] [Indexed: 01/19/2023]
Abstract
BACKGROUND This study focuses on the iron overload (IOL) of patients with transfused aplastic anemia (AA) or a low/intermediate-1 risk of myelodysplastic syndrome (MDS). METHODS Ninety-two AA or MDS patients with IOL were prospectively recruited. Clinical data were collected every 6 months, and organ magnetic resonance imaging T2* values were collected annually. Patients with IOL were chelated. RESULTS Serum ferritin was correlated with liver T2* and pancreatic T2* in the AA and MDS groups. Transfusion amounts were correlated with serum ferritin values, liver T2*, and pancreatic T2* in the AA group. At the 6-month and 1-year evaluations, patients with sufficient chelation experienced significant decreases in serum ferritin, and those with decreased serum ferritin experienced an obvious increase in hemoglobin. At their 1-year-follow-up, patients with adequate chelation showed significant increases in hepatic T2*, cardiac T2*, and left ventricular ejection fraction (LVEF). Patients with decreased serum ferritin (including those without chelation) experienced an increase in hemoglobin, hepatic T2*, cardiac T2*, and LVEF. CONCLUSION The transfusion amount was more reliable at predicting IOL in patients with AA than in those with MDS. Adequate iron chelation can decrease serum ferritin levels and may improve hepatic T2*, cardiac T2*, and LVEF levels. A decrease in serum ferritin, even in the absence of chelation, may also benefit patients.
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Affiliation(s)
- Yali Du
- Department of Hematology, Chinese Academy of Medical Sciences, Peking Union Medical College, Peking Union Medical College Hospital, Beijing, China
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16
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Coates TD, Carson S, Wood JC, Berdoukas V. Management of iron overload in hemoglobinopathies: what is the appropriate target iron level? Ann N Y Acad Sci 2017; 1368:95-106. [PMID: 27186942 DOI: 10.1111/nyas.13060] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2015] [Revised: 03/04/2016] [Accepted: 03/09/2016] [Indexed: 01/19/2023]
Abstract
Patients with thalassemia become iron overloaded from increased absorption of iron, ineffective erythropoiesis, and chronic transfusion. Before effective iron chelation became available, thalassemia major patients died of iron-related cardiac failure in the second decade of life. Initial treatment goals for chelation therapy were aimed at levels of ferritin and liver iron concentrations associated with prevention of adverse cardiac outcomes and avoidance of chelator toxicity. Cardiac deaths were greatly reduced and survival was much longer. Epidemiological data from the general population draw clear associations between increased transferrin saturation (and, by inference, labile iron) and early death, diabetes, and malignant transformation. The rate of cancers now seems to be significantly higher in thalassemia than in the general population. Reduction in iron can reverse many of these complications and reduce the risk of malignancy. As toxicity can result from prolonged exposure to even low levels of excess iron, and survival in thalassemia patients is now many decades, it would seem prudent to refocus attention on prevention of long-term complications of iron overload and to maintain labile iron and total body iron levels within a normal range, if expertise and resources are available to avoid complications of overtreatment.
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Affiliation(s)
- Thomas D Coates
- Section of Hematology, Children's Center for Cancer, Blood Diseases and Bone Marrow Transplantation
| | - Susan Carson
- Section of Hematology, Children's Center for Cancer, Blood Diseases and Bone Marrow Transplantation
| | - John C Wood
- Division of Cardiology, Children's Hospital Los Angeles, University of Southern California, Keck School of Medicine, Los Angeles, California
| | - Vasilios Berdoukas
- Section of Hematology, Children's Center for Cancer, Blood Diseases and Bone Marrow Transplantation
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17
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Maximova N, Gregori M, Boz G, Simeone R, Zanon D, Schillani G, Zennaro F. MRI-based evaluation of multiorgan iron overload is a predictor of adverse outcomes in pediatric patients undergoing allogeneic hematopoietic stem cell transplantation. Oncotarget 2017; 8:79650-79661. [PMID: 29108345 PMCID: PMC5668078 DOI: 10.18632/oncotarget.19021] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2016] [Accepted: 06/19/2017] [Indexed: 01/11/2023] Open
Abstract
The medical records of 44 pediatric patients who underwent allogeneic transplantation from 2011 to 2015 were retrospectively reviewed. Magnetic resonance imaging was used to measure iron concentrations in the liver, spleen, pancreas and bone. These patients were divided into two groups, 18 with non-elevated (< 100 μmol/g; Group 1) liver iron concentration before transplantation and 26 with elevated (> 100 μmol/g; Group 2) concentration . We compared transplant-related outcomes in the two groups. Iron overload was a negative prognostic risk factor for sinusoidal obstruction syndrome (OR = 17), osteoporosis (OR = 6.8), pancreatic insufficiency (OR = 17) and metabolic syndrome (OR = 15.1). No statistically significant differences in overall survival, disease-free survival, relapse incidence and incidence of acute or chronic graft-versus host disease were observed between the two groups. Mean times to engraftment of platelets (43.0 ± 35.3 days vs. 22.1 ± 9.5 days, p < 0.05) and neutrophils (23.1 ± 10.4 days vs. 17.8 ± 4.6 days, p < 0.05) appear significantly longer in Group 2 than in Group 1. Time to platelet engraftment showed statistically significant correlation with pre-transplant liver (r = 0.5775; p < 0.001) and bone iron concentration (r = 0.7305; p < 0.001). Post-transplant evaluation pointed out that iron concentration analyzed at the first follow-up peaked in all tissues. The iron accumulation was highest in bone, followed by the spleen, liver and pancreas. One year post transplant 9 of 18 (50%) patients in Group 1 and 6 of 22 (27%) in Group 2 presented with bone and/or spleen iron overload, but not with liver overload. Liver iron concentration is not always a reliable indicator of systemic siderosis or of the efficacy of chelation therapy.
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Affiliation(s)
- Natalia Maximova
- Bone Marrow Transplant Unit, Institute for Maternal and Child Health-IRCCS Burlo Garofolo, 34137 Trieste, Italy
| | - Massimo Gregori
- Department of Radiology, Institute for Maternal and Child Health-IRCCS Burlo Garofolo, 34137 Trieste, Italy
| | - Giulia Boz
- University of Trieste, Piazzale Europa, 34128 Trieste, Italy
| | - Roberto Simeone
- Department of Transfusion Medicine, Institute for Maternal and Child Health-IRCCS Burlo Garofolo, 34137 Trieste, Italy
| | - Davide Zanon
- Pharmacy, Institute for Maternal and Child Health-IRCCS Burlo Garofolo, 34137 Trieste, Italy
| | - Giulia Schillani
- Bone Marrow Transplant Unit, Institute for Maternal and Child Health-IRCCS Burlo Garofolo, 34137 Trieste, Italy
| | - Floriana Zennaro
- Department of Radiology, Institute for Maternal and Child Health-IRCCS Burlo Garofolo, 34137 Trieste, Italy
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18
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Musto P, Maurillo L, Simeon V, Poloni A, Finelli C, Balleari E, Ricco A, Rivellini F, Cortelezzi A, Tarantini G, Villani O, Mansueto G, Milella MR, Scapicchio D, Marziano G, Breccia M, Niscola P, Sanna A, Clissa C, Voso MT, Fenu S, Venditti A, Santini V, Angelucci E, Levis A. Iron-chelating therapy with deferasirox in transfusion-dependent, higher risk myelodysplastic syndromes: a retrospective, multicentre study. Br J Haematol 2017; 177:741-750. [PMID: 28419408 DOI: 10.1111/bjh.14621] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2016] [Accepted: 12/27/2016] [Indexed: 01/19/2023]
Abstract
Iron chelation is controversial in higher risk myelodysplastic syndromes (HR-MDS), outside the allogeneic transplant setting. We conducted a retrospective, multicentre study in 51 patients with transfusion-dependent, intermediate-to-very high risk MDS, according to the revised international prognostic scoring system, treated with the oral iron chelating agent deferasirox (DFX). Thirty-six patients (71%) received azacitidine concomitantly. DFX was given at a median dose of 1000 mg/day (range 375-2500 mg) for a median of 11 months (range 0·4-75). Eight patients (16%) showed grade 2-3 toxicities (renal or gastrointestinal), 4 of whom (8%) required drug interruption. Median ferritin levels decreased from 1709 μg/l at baseline to 1100 μg/l after 12 months of treatment (P = 0·02). Seventeen patients showed abnormal transaminase levels at baseline, which improved or normalized under DFX treatment in eight cases. One patient showed a remarkable haematological improvement. At a median follow up of 35·3 months, median overall survival was 37·5 months. The results of this first survey of DFX in HR-MDS are comparable, in terms of safety and efficacy, with those observed in lower-risk MDS. Though larger, prospective studies are required to demonstrate real clinical benefits, our data suggest that DFX is feasible and might be considered in a selected cohort of HR-MDS patients.
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Affiliation(s)
- Pellegrino Musto
- Scientific Direction, IRCCS-CROB, "Referral Cancer Centre of Basilicata", Rionero In Vulture (Pz), Italy
| | - Luca Maurillo
- Haematology, Department of Biomedicine and Prevention, "Tor Vergata" University, Rome, Italy
| | - Vittorio Simeon
- Laboratory of Pre-clinical and Translational Research, IRCCS-CROB, "Referral Cancer Centre of Basilicata", Rionero In Vulture (Pz), Italy
| | - Antonella Poloni
- Haematology Clinic, Department of Clinic and Molecular Sciences, "Università Politecnica delle Marche", Ancona, Italy
| | - Carlo Finelli
- "Seràgnoli Institute of Haematology", University School of Medicine, Bologna, Italy
| | - Enrico Balleari
- Department of Haematology and Oncology, IRCCS AOU San Martino - IST, Genova, Italy
| | - Alessandra Ricco
- Department of Emergency and Organ Transplantation, Haematology Section, University of Bari, Bari, Italy
| | | | - Agostino Cortelezzi
- Department of Oncology and Haemato-Oncology, University of Milan and Haematology Unit, "Fondazione IRCCS Ca' Granda, Ospedale Maggiore" Policlinico, Milan, Italy
| | | | - Oreste Villani
- Department of Onco-Haematology, IRCCS-CROB, "Referral Cancer Centre of Basilicata", Rionero in Vulture (Pz), Italy
| | - Giovanna Mansueto
- Department of Onco-Haematology, IRCCS-CROB, "Referral Cancer Centre of Basilicata", Rionero in Vulture (Pz), Italy
| | - Maria R Milella
- Pharmacy Unit, IRCCS-CROB, "Referral Cancer Centre of Basilicata", Rionero In Vulture (Pz), Italy
| | - Daniele Scapicchio
- Management Control Unit, IRCCS-CROB, "Referral Cancer Centre of Basilicata", Rionero In Vulture (Pz), Italy
| | - Gioacchino Marziano
- Scientific Direction, IRCCS-CROB, "Referral Cancer Centre of Basilicata", Rionero In Vulture (Pz), Italy
| | - Massimo Breccia
- Department of Cellular Biotechnologies and Haematology, "La Sapienza" University, Rome, Italy
| | | | - Alessandro Sanna
- Haematology, University of Florence, AOU Careggi, Florence, Italy
| | - Cristina Clissa
- Haematology and Haematopoietic Stem Cell Transplant Centre, AORMN, Pesaro, Italy
| | - Maria T Voso
- Haematology, Department of Biomedicine and Prevention, "Tor Vergata" University, Rome, Italy
| | - Susanna Fenu
- Haematology, "San Giovanni" Hospital, Rome, Italy
| | - Adriano Venditti
- Haematology, Department of Biomedicine and Prevention, "Tor Vergata" University, Rome, Italy
| | - Valeria Santini
- Haematology, University of Florence, AOU Careggi, Florence, Italy
| | - Emanuele Angelucci
- Department of Haematology and Oncology, IRCCS AOU San Martino - IST, Genova, Italy
| | - Alessandro Levis
- FISM, Fondazione Italiana Sindromi Mielodisplastiche, Alessandria, Italy
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19
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Kostos L, Chai KL, Tam CS, Bazargan A. The positive effect of deferasirox on erythropoiesis in a patient with a dual diagnosis of myelofibrosis and diffuse large B-cell lymphoma. Leuk Lymphoma 2017; 58:2720-2723. [DOI: 10.1080/10428194.2017.1281414] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Affiliation(s)
- Louise Kostos
- Department of Haematology, St Vincent’s Hospital, Melbourne, Australia
| | - Khai Li Chai
- Department of Haematology, St Vincent’s Hospital, Melbourne, Australia
| | - Constantine S. Tam
- Department of Haematology, St Vincent’s Hospital, Melbourne, Australia
- Department of Haematology, Peter MacCallum Cancer Centre, Melbourne, Australia
- University of Melbourne, Parkville, Victoria, Australia
| | - Ali Bazargan
- Department of Haematology, St Vincent’s Hospital, Melbourne, Australia
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20
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Iron-induced epigenetic abnormalities of mouse bone marrow through aberrant activation of aconitase and isocitrate dehydrogenase. Int J Hematol 2016; 104:491-501. [DOI: 10.1007/s12185-016-2054-7] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2016] [Revised: 06/24/2016] [Accepted: 06/24/2016] [Indexed: 12/19/2022]
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21
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Ye L, Jing L, Peng G, Zhou K, Li Y, Li Y, Li J, Fan H, Yang W, Zhang F, Zhang L. [Effects of pre-immunosupressive therapy iron overload on hematologic response of severe aplastic anemia]. ZHONGHUA XUE YE XUE ZA ZHI = ZHONGHUA XUEYEXUE ZAZHI 2016; 37:324-8. [PMID: 27093997 PMCID: PMC7343093 DOI: 10.3760/cma.j.issn.0253-2727.2016.04.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Download PDF] [Subscribe] [Scholar Register] [Received: 11/19/2015] [Indexed: 11/15/2022]
Abstract
OBJECTIVE To explore the effects of serum ferritin (SF) and iron overload (IO) pre-immunosupressive treatment (IST) on hematologic response of severe aplastic anemia (SAA/VSAA) patients treated with IST. METHODS 257 SAA/VSAA patients who underwent first-line IST from Feb, 2003 to Dec, 2011 in Anemia Therapeutic Centre, Institute of Hematology and Blood Diseases Hospital were retrospectively analyzed, the status of SF before IST and the IO-affected factors were studied. The effects of IO on hematologic response of SAA/VSAA patients were evaluated as well. RESULTS The median level of SF of 257 patients was 387 (6-2 004) μg/L. 36 patients (14%) had IO, including 20 SAA and 16 VSAA patients. According to univariate logistical regression analyses, IO was influenced by age>14 years (P=0.010) and blood transfusion (P<0.001). The multivariate logistic regression analysis showed that blood transfusion [P=0.001, OR=0.218 (95% CI 0.092-0.520)] was the only independent prognostic factor. SAA (but not for VSAA) patients with IO had much lower hematologic response rate in 6 month after IST (P=0.037). Absolute reticulocyte count and IO correlated with response at 6 month by univariate logistical regression analysis (P=0.014, 0.037). The multivariate logistic regression analysis showed that IO [P=0.021, OR=4.092 (95% CI 1.235-13.563)], ARC ≥20×10(9)/L [P=0.040, OR=2.743 (95% CI 1.049-7.175)] were independent prognostic factors. CONCLUSION 84.8% patients had high serum ferritin before IST, and 14.0% reached IO. Adult and more blood transfusion caused IO more likely. IO correlated with response at 6 month, and was independent prognostic factor.
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Affiliation(s)
- Lei Ye
- Anemia Therapeutic Centre, Institute of Hematology and Blood Diseases Hospital, CAMS & PUMC, Tianjin 300020, China
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22
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Latagliata R, Montagna C, Porrini R, Di Veroli A, Leonetti SC, Niscola P, Ciccone F, Spadea A, Breccia M, Maurillo L, Rago A, Spirito F, Cedrone M, De Muro M, Montanaro M, Andriani A, Bagnato A, Montefusco E, Alimena G. Chelation efficacy and erythroid response during deferasirox treatment in patients with myeloproliferative neoplasms in fibrotic phase. Eur J Haematol 2015; 96:643-9. [PMID: 26277477 DOI: 10.1111/ejh.12674] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/10/2015] [Indexed: 12/12/2022]
Abstract
At present, very few data are available on deferasirox (DFX) in the treatment of patients with Philadelphia-negative myeloproliferative neoplasms in fibrotic phase (FP-MPN) and transfusion dependence. To address this issue, a retrospective analysis of 28 patients (22 male and 6 female) with FP-MPN and iron overload secondary to transfusion dependence was performed, based on patients enrolled in the database of our regional cooperative group who received treatment with DFX. DFX was started after a median interval from diagnosis of 12.8 months (IR 7.1-43.1) with median ferritin values of 1415 ng/mL (IR 1168-1768). Extra-hematological toxicity was reported in 16 of 28 patients (57.1%), but only two patients discontinued treatment due to toxicity. Among 26 patients evaluable for response (≥6 months of treatment), after a median treatment period of 15.4 months (IR 8.1-22.3), 11 patients (42.3%) achieved a stable and consistent reduction in ferritin levels <1000 ng/mL. As for hematological improvement, 6 of 26 patients (23%) showed a persistent (>3 months) rise of Hb levels >1.5 g/dL, with disappearance of transfusion dependence in four cases. Treatment with DFX is feasible and effective in FP-MPN with iron overload. Moreover, in this setting, an erythroid response can occur in a significant proportion of patients.
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Affiliation(s)
- Roberto Latagliata
- Department of Cellular Biotechnologies and Hematology, University "Sapienza", Rome, Italy
| | - Chiara Montagna
- Department of Cellular Biotechnologies and Hematology, University "Sapienza", Rome, Italy
| | | | | | | | | | | | | | - Massimo Breccia
- Department of Cellular Biotechnologies and Hematology, University "Sapienza", Rome, Italy
| | | | - Angela Rago
- Hematology, Polo Universitario Pontino, Latina, Italy
| | | | | | | | | | | | | | | | - Giuliana Alimena
- Department of Cellular Biotechnologies and Hematology, University "Sapienza", Rome, Italy
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23
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Nolte F, Angelucci E, Breccia M, Gattermann N, Santini V, Vey N, Hofmann WK. Updated recommendations on the management of gastrointestinal disturbances during iron chelation therapy with Deferasirox in transfusion dependent patients with myelodysplastic syndrome - Emphasis on optimized dosing schedules and new formulations. Leuk Res 2015; 39:1028-33. [PMID: 26293555 DOI: 10.1016/j.leukres.2015.06.008] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2015] [Revised: 06/04/2015] [Accepted: 06/16/2015] [Indexed: 11/29/2022]
Abstract
Myelodysplastic syndromes (MDS) are oligoclonal hematopoietic disorders characterized by peripheral cytopenias with anemias being the most prevalent feature. The majority of patients will depend on regular transfusions of packed red blood cells (PRBC) during the course of the disease. Particularly patients with MDS and low risk for transformation into acute myeloid leukemia and low risk of early death will receive PRBC transfusions on a regular basis, which puts them at high risk for transfusional iron overload. Transfusion dependence has been associated with negative impact on organ function and reduced life expectancy. Recently, several retrospective but also some prospective studies have indicated, that transfusion dependent patients with MDS might benefit from consequent iron chelation with regard to morbidity and mortality. However, low treatment adherence due to adverse events mainly gastrointestinal in nature is an important obstacle in achieving sufficient iron chelation in MDS patients. Here, we will summarize and discuss the existing data on Deferasirox in low risk MDS published so far and provide recommendations for optimal management of gastrointestinal adverse events during iron chelation aiming at improving treatment compliance and, hence, sufficiently removing excess iron from the patients.
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Affiliation(s)
- Florian Nolte
- Department of Hematology and Oncology, University Hospital Mannheim, Medical Faculty Mannheim of the University of Heidelberg, Germany.
| | - Emanuele Angelucci
- Hematology and Bone Marrow Transplant Unit, and Medical Oncology Department, Ospedale Oncologico "Armando Businco", Cagliari, Italy
| | - Massimo Breccia
- Department of Cellular Biotechnologies and Hematology, "La Sapienza" University, Rome, Italy
| | - Norbert Gattermann
- Comprehensive Cancer Center and Department of Hematology, Oncology, and Clinical Immunology, Heinrich Heine University, Düsseldorf, Germany
| | - Valeria Santini
- Division of Hematology, University of Florence, Florence, Italy
| | - Norbert Vey
- Department of Hematology, Institute Paoli Calmettes, Marseille, France
| | - Wolf-Karsten Hofmann
- Department of Hematology and Oncology, University Hospital Mannheim, Medical Faculty Mannheim of the University of Heidelberg, Germany
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Effect of combined deferasirox and 5-azacytidine treatment on human leukemia cells in vitro. Ann Hematol 2015; 94:1601-2. [PMID: 26044890 DOI: 10.1007/s00277-015-2417-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2015] [Accepted: 05/30/2015] [Indexed: 01/10/2023]
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Durable Red Blood Cell Transfusion Independence in a Patient with an MDS/MPN Overlap Syndrome Following Discontinuation of Iron Chelation Therapy. Case Rep Hematol 2015; 2015:253294. [PMID: 25918650 PMCID: PMC4396885 DOI: 10.1155/2015/253294] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2014] [Revised: 01/11/2015] [Accepted: 03/06/2015] [Indexed: 01/14/2023] Open
Abstract
Background. Hematologic improvement (HI) occurs in some patients with acquired anemias and transfusional iron overload receiving iron chelation therapy (ICT) but there is little information on transfusion status after stopping chelation. Case Report. A patient with low IPSS risk RARS-T evolved to myelofibrosis developed a regular red blood cell (RBC) transfusion requirement. There was no response to a six-month course of study medication or to erythropoietin for three months. At 27 months of transfusion dependence, she started deferasirox and within 6 weeks became RBC transfusion independent, with the hemoglobin normalizing by 10 weeks of chelation. After 12 months of chelation, deferasirox was stopped; she remains RBC transfusion independent with a normal hemoglobin 17 months later. We report the patient's course in detail and review the literature on HI with chelation. Discussion. There are reports of transfusion independence with ICT, but that transfusion independence may be sustained long term after stopping chelation deserves emphasis. This observation suggests that reduction of iron overload may have a lasting favorable effect on bone marrow failure in at least some patients with acquired anemias.
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Tataranni T, Agriesti F, Mazzoccoli C, Ruggieri V, Scrima R, Laurenzana I, D'Auria F, Falzetti F, Di Ianni M, Musto P, Capitanio N, Piccoli C. The iron chelator deferasirox affects redox signalling in haematopoietic stem/progenitor cells. Br J Haematol 2015; 170:236-46. [DOI: 10.1111/bjh.13381] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2014] [Accepted: 02/04/2015] [Indexed: 01/19/2023]
Affiliation(s)
- Tiziana Tataranni
- Laboratory of Pre-Clinical and Translational Research; IRCCS-CROB; Referral Cancer Centre of Basilicata; Rionero in Vulture (Pz) Italy
| | - Francesca Agriesti
- Laboratory of Pre-Clinical and Translational Research; IRCCS-CROB; Referral Cancer Centre of Basilicata; Rionero in Vulture (Pz) Italy
| | - Carmela Mazzoccoli
- Laboratory of Pre-Clinical and Translational Research; IRCCS-CROB; Referral Cancer Centre of Basilicata; Rionero in Vulture (Pz) Italy
| | - Vitalba Ruggieri
- Laboratory of Pre-Clinical and Translational Research; IRCCS-CROB; Referral Cancer Centre of Basilicata; Rionero in Vulture (Pz) Italy
| | - Rosella Scrima
- Department of Clinical and Experimental Medicine; University of Foggia; Foggia Italy
| | - Ilaria Laurenzana
- Laboratory of Pre-Clinical and Translational Research; IRCCS-CROB; Referral Cancer Centre of Basilicata; Rionero in Vulture (Pz) Italy
| | - Fiorella D'Auria
- Laboratory of Clinical Research and Advanced Diagnostics; IRCCS-CROB; Referral Cancer Centre of Basilicata; Rionero in Vulture (PZ) Italy
| | - Franca Falzetti
- Haematology and Clinical Immunology Section; University of Perugia; Perugia Italy
| | - Mauro Di Ianni
- Department of Internal Medicine and Public Health; University of L'Aquila; L'Aquila Italy
| | - Pellegrino Musto
- Scientific Direction; IRCCS-CROB; Referral Cancer Centre of Basilicata; Rionero in Vulture (PZ) Italy
| | - Nazzareno Capitanio
- Department of Clinical and Experimental Medicine; University of Foggia; Foggia Italy
| | - Claudia Piccoli
- Laboratory of Pre-Clinical and Translational Research; IRCCS-CROB; Referral Cancer Centre of Basilicata; Rionero in Vulture (Pz) Italy
- Department of Clinical and Experimental Medicine; University of Foggia; Foggia Italy
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Zhang Y, Zhai W, Zhao M, Li D, Chai X, Cao X, Meng J, Chen J, Xiao X, Li Q, Mu J, Shen J, Meng A. Effects of iron overload on the bone marrow microenvironment in mice. PLoS One 2015; 10:e0120219. [PMID: 25774923 PMCID: PMC4361683 DOI: 10.1371/journal.pone.0120219] [Citation(s) in RCA: 53] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2014] [Accepted: 01/20/2015] [Indexed: 12/11/2022] Open
Abstract
OBJECTIVE Using a mouse model, Iron Overload (IO) induced bone marrow microenvironment injury was investigated, focusing on the involvement of reactive oxygen species (ROS). METHODS Mice were intraperitoneally injected with iron dextran (12.5, 25, or 50 mg) every three days for two, four, and six week durations. Deferasirox(DFX)125 mg/ml and N-acetyl-L-cysteine (NAC) 40 mM were co-administered. Then, bone marrow derived mesenchymal stem cells (BM-MSCs) were isolated and assessed for proliferation and differentiation ability, as well as related gene changes. Immunohistochemical analysis assessed the expression of haematopoietic chemokines. Supporting functions of BM-MSCs were studied by co-culture system. RESULTS In IO condition (25 mg/ml for 4 weeks), BM-MSCs exhibited proliferation deficiencies and unbalanced osteogenic/adipogenic differentiation. The IO BM-MSCs showed a longer double time (2.07±0.14 days) than control (1.03±0.07 days) (P<0.05). The immunohistochemical analysis demonstrated that chemokine stromal cell-derived factor-1, stem cell factor -1, and vascular endothelial growth factor-1 expression were decreased. The co-cultured system demonstrated that bone marrow mononuclear cells (BMMNCs) co-cultured with IO BM-MSCs had decreased colony forming unit (CFU) count (p<0.01), which indicates IO could lead to decreased hematopoietic supporting functions of BM-MSCs. This effect was associated with elevated phosphatidylinositol 3 kinase (PI3K) and reduced of Forkhead box protein O3 (FOXO3) mRNA expression, which could induce the generation of ROS. Results also demonstrated that NAC or DFX treatment could partially attenuate cell injury and inhibit signaling pathway striggered by IO. CONCLUSION These results demonstrated that IO can impair the bone marrow microenvironment, including the quantity and quality of BM-MSCs.
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Affiliation(s)
- Yuchen Zhang
- Department of Hematology, Tianjin First Central Hospital, Tianjin, China
| | - Wenjing Zhai
- Department of Stem Cells Transplantation, Blood Disease Hospital of Chinese Academy of Medical Sciences, Tianjin, China
| | - Mingfeng Zhao
- Department of Hematology, Tianjin First Central Hospital, Tianjin, China
- * E-mail:
| | - Deguan Li
- Key Lab of Radiation Medicine and Molecular Nuclear Medicine, Institute of Radiation Medicine, Academy of Medical Science and Peking Union Medical College, Tianjin, China
| | - Xiao Chai
- Department of Hematology, Tianjin First Central Hospital, Tianjin, China
| | - Xiaoli Cao
- Department of Hematology, Tianjin First Central Hospital, Tianjin, China
| | - Juanxia Meng
- Department of Hematology, Tianjin First Central Hospital, Tianjin, China
| | - Jie Chen
- Department of Hematology, Tianjin First Central Hospital, Tianjin, China
| | - Xia Xiao
- Department of Hematology, Tianjin First Central Hospital, Tianjin, China
| | - Qing Li
- Department of Hematology, Tianjin First Central Hospital, Tianjin, China
| | - Juan Mu
- Department of Hematology, Tianjin First Central Hospital, Tianjin, China
| | - Jichun Shen
- Department of Hematology, Affiliated Hospital of Logistics University of People’s Armed Police Force, Tianjin, China
| | - Aimin Meng
- Key Lab of Radiation Medicine and Molecular Nuclear Medicine, Institute of Radiation Medicine, Academy of Medical Science and Peking Union Medical College, Tianjin, China
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An increase in hemoglobin, platelets and white blood cells levels by iron chelation as single treatment in multitransfused patients with myelodysplastic syndromes: clinical evidences and possible biological mechanisms. Ann Hematol 2015; 94:771-7. [DOI: 10.1007/s00277-015-2341-z] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2014] [Accepted: 02/16/2015] [Indexed: 12/16/2022]
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Puliyel M, Mainous AG, Berdoukas V, Coates TD. Iron toxicity and its possible association with treatment of Cancer: lessons from hemoglobinopathies and rare, transfusion-dependent anemias. Free Radic Biol Med 2015; 79:343-51. [PMID: 25463277 DOI: 10.1016/j.freeradbiomed.2014.10.861] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2014] [Revised: 10/22/2014] [Accepted: 10/30/2014] [Indexed: 01/19/2023]
Abstract
Exposure to elevated levels of iron causes tissue damage and organ failure, and increases the risk of cancer. The toxicity of iron is mediated through generation of oxidants. There is also solid evidence indicating that oxidant stress plays a significant role in a variety of human disease states, including malignant transformation. Iron toxicity is the main focus when managing thalassemia. However, the short- and long-term toxicities of iron have not been extensively considered in children and adults treated for malignancy, and only recently have begun to draw oncologists' attention. The treatment of malignancy can markedly increase exposure of patients to elevated toxic iron species without the need for excess iron input from transfusion. This under-recognized exposure likely enhances organ toxicity and may contribute to long-term development of secondary malignancy and organ failure. This review discusses the current understanding of iron metabolism, the mechanisms of production of toxic free iron species in humans, and the relation of the clinical marker, transferrin saturation (TS), to the presence of toxic free iron. We will present epidemiological data showing that high TS is associated with poor outcomes and development of cancer, and that lowering free iron may improve outcomes. Finally, we will discuss the possible relation between some late complications seen in survivors of cancer and those due to iron toxicity.
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Affiliation(s)
- Mammen Puliyel
- Section of Hematology, Childrens Center for Cancer, Blood Disease and Bone Marrow Transplantation, Children's Hospital Los Angeles, University of Southern California Keck School of Medicine, Los Angeles California, USA
| | - Arch G Mainous
- Department of Health Services Research, Management and Policy, University of Florida, Gainesville, Fla. USA
| | - Vasilios Berdoukas
- Section of Hematology, Childrens Center for Cancer, Blood Disease and Bone Marrow Transplantation, Children's Hospital Los Angeles, University of Southern California Keck School of Medicine, Los Angeles California, USA
| | - Thomas D Coates
- Section of Hematology, Childrens Center for Cancer, Blood Disease and Bone Marrow Transplantation, Children's Hospital Los Angeles, University of Southern California Keck School of Medicine, Los Angeles California, USA.
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Vallejo C, Batlle M, Vázquez L, Solano C, Sampol A, Duarte R, Hernández D, López J, Rovira M, Jiménez S, Valcárcel D, Belloch V, Jiménez M, Jarque I. Phase IV open-label study of the efficacy and safety of deferasirox after allogeneic stem cell transplantation. Haematologica 2014; 99:1632-7. [PMID: 24997153 PMCID: PMC4181261 DOI: 10.3324/haematol.2014.105908] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2014] [Accepted: 07/02/2014] [Indexed: 01/19/2023] Open
Abstract
This is the first prospective study of deferasirox in adult allogeneic hematopoietic stem cell transplant recipients with transfusional iron overload in hematologic malignancies. Patients at least six months post transplant were treated with deferasirox at a starting dose of 10 mg/kg/day for 52 weeks or until serum ferritin was less than 400 ng/mL on two consecutive occasions. Thirty patients were enrolled and 22 completed the study. A significant reduction from baseline in median serum ferritin and in liver iron concentration at 52 weeks was observed in the overall population: from 1440 to 755.5 ng/mL (P=0.002) and from 14.5 to 4.6 mg Fe/g dw (P=0.0007), respectively. Reduction in serum ferritin in patients who did not discontinue deferasirox therapy was significantly greater than that found in those who prematurely discontinued the treatment (from 1541 to 581 ng/mL vs. from 1416 to 1486 ng/mL; P=0.008). Drug-related adverse events, reported in 17 patients (56.7%), were mostly mild to moderate in severity. There were no drug-related serious adverse events. Twelve patients (40.0%) showed an increase of over 33% in serum creatinine compared to baseline and greater than the upper limit of normal on two consecutive visits. Two patients (6.7%) with active graft-versus-host disease showed an increase in alanine aminotransferase exceeding 10 times upper limit of normal; both resolved. In this prospective study, deferasirox provided a significant reduction in serum ferritin and liver iron concentration over one year of treatment in allogeneic hematopoietic stem cell transplant recipients with iron overload. In addition, the majority of adverse events related to deferasirox were mild or moderate in severity. (clinicaltrials.gov identifier:01335035).
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Affiliation(s)
- Carlos Vallejo
- Hospital Universitario Central de Asturias, Oviedo, Spain
| | | | | | - Carlos Solano
- Hospital Clínico Universitario-INCLIVA, Valencia, Spain
| | | | - Rafael Duarte
- Catalan Institute of Oncology-Idibell, L'Hospitalet de Llobregat, Spain
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Coates TD. Physiology and pathophysiology of iron in hemoglobin-associated diseases. Free Radic Biol Med 2014; 72:23-40. [PMID: 24726864 PMCID: PMC4940047 DOI: 10.1016/j.freeradbiomed.2014.03.039] [Citation(s) in RCA: 101] [Impact Index Per Article: 10.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2014] [Revised: 03/26/2014] [Accepted: 03/27/2014] [Indexed: 01/19/2023]
Abstract
Iron overload and iron toxicity, whether because of increased absorption or iron loading from repeated transfusions, can be major causes of morbidity and mortality in a number of chronic anemias. Significant advances have been made in our understanding of iron homeostasis over the past decade. At the same time, advances in magnetic resonance imaging have allowed clinicians to monitor and quantify iron concentrations noninvasively in specific organs. Furthermore, effective iron chelators are now available, including preparations that can be taken orally. This has resulted in substantial improvement in mortality and morbidity for patients with severe chronic iron overload. This paper reviews the key points of iron homeostasis and attempts to place clinical observations in patients with transfusional iron overload in context with the current understanding of iron homeostasis in humans.
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Affiliation(s)
- Thomas D Coates
- Children׳s Center for Cancer and Blood Diseases, Children׳s Hospital Los Angeles, University of Southern California Keck School of Medicine, Los Angeles, CA 90027, USA.
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Finelli C, Clissa C, Stanzani M. Use of deferasirox in transfusion-dependent myelodysplastic syndromes with iron overload. Int J Hematol Oncol 2014. [DOI: 10.2217/ijh.14.19] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
SUMMARY In myelodysplastic syndromes (MDS), transfusion-dependent anemia has been established as an independent risk factor for decreased survival. Although evidence from prospective studies is still lacking, several guidelines recommend iron-chelating therapy in MDS patients with a longer life expectancy. With the recent introduction of deferasirox, an oral active iron-chelating drug, which has shown dose-dependent efficacy and acceptable tolerability, this therapeutic option has become feasible even in the elderly. Several retrospective and prospective studies showed that in MDS patients deferasirox is effective in reducing iron burden and in maintaining the circulating toxic iron fraction within the normal range. Moreover, in a substantial fraction of patients treated with deferasirox a significant improvement of peripheral cytopenias may occur.
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Affiliation(s)
- Carlo Finelli
- Institute of Hematology, “Seràgnoli”, Sant’Orsola-Malpighi University Hospital, Via Massarenti 9 – 40138 Bologna, Italy
| | - Cristina Clissa
- Institute of Hematology, “Seràgnoli”, Sant’Orsola-Malpighi University Hospital, Via Massarenti 9 – 40138 Bologna, Italy
| | - Marta Stanzani
- Institute of Hematology, “Seràgnoli”, Sant’Orsola-Malpighi University Hospital, Via Massarenti 9 – 40138 Bologna, Italy
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Merkel DG, Nagler A. Toward resolving the unsettled role of iron chelation therapy in myelodysplastic syndromes. Expert Rev Anticancer Ther 2014; 14:817-29. [PMID: 24641787 DOI: 10.1586/14737140.2014.896208] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Transfusion dependent low risk myelodysplastic syndromes (MDS) patients, eventually develop iron overload. Iron toxicity, via oxidative stress, can damage cellular components and impact organ function. In thalassemia major patients, iron chelation therapy lowered iron levels with recovery of cardiac and liver functions and significant improvement in survival. Several noncontrolled studies show inferior survival in MDS patients with iron overload, including an increase in transplant-related mortality and infection risk while iron chelation appears to improve survival in both lower risk MDS patients and in stem cell transplant settings. Collated data are presented on the pathophysiological impact of iron overload; measuring techniques and chelating agents' therapy positive impact on hematological status and overall survival are discussed. Although suggested by retrospective analyses, the lack of clear prospective data of the beneficial effects of iron chelation on morbidity and survival, the role of iron chelation therapy in MDS patients remains controversial.
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Affiliation(s)
- Drorit G Merkel
- Division of Hematology, Chaim Sheba Medical Center, Tel Aviv University, Tel-Hashomer, Israel
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Moreno de Gusmão B, Guinea de Castro JM, Perez-Persona E, Oiartzabal I. Independencia transfusional en un paciente con anemia refractaria con exceso de blastos tipo 2 refractario a 5-azacitidina tratado con deferasirox y agentes estimuladores de colonias. Med Clin (Barc) 2014; 142:91-2. [DOI: 10.1016/j.medcli.2013.04.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2013] [Revised: 04/09/2013] [Accepted: 04/11/2013] [Indexed: 10/26/2022]
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Steensma DP, Gattermann N. When is iron overload deleterious, and when and how should iron chelation therapy be administered in myelodysplastic syndromes? Best Pract Res Clin Haematol 2013; 26:431-44. [DOI: 10.1016/j.beha.2013.09.009] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
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Abstract
Few people expected that asbestos, a fibrous mineral, would be carcinogenic to humans. In fact, asbestos is a definite carcinogen in humans, causing a rare but aggressive cancer called malignant mesothelioma (MM). Mesothelial cells line the three somatic cavities and thus do not face the outer surface, but reduce the friction among numerous moving organs. MM has several characteristics: extremely long incubation period of 30-40 years after asbestos exposure, difficulty in clinical diagnosis at an early stage, and poor prognosis even under the current multimodal therapies. In Japan, 'Kubota shock' attracted considerable social attention in 2005 for asbestos-induced mesothelioma and, thereafter, the government enacted a law to provide the people suffering from MM a financial allowance. Several lines of recent evidence suggest that the major pathology associated with asbestos-induced MM is local iron overload, associated with asbestos exposure. Preclinical studies to prevent MM after asbestos exposure with iron reduction are in progress. In addition, novel target genes in mesothelial carcinogenesis have been discovered with recently recognized mesothelioma-prone families. Development of an effective preventive strategy is eagerly anticipated because of the long incubation period for MM.
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Mayor erythropoietic response after deferasirox treatment in a transfusion-dependent anemic patient with primary myelofibrosis. Case Rep Hematol 2013; 2013:520712. [PMID: 24307957 PMCID: PMC3836304 DOI: 10.1155/2013/520712] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2013] [Accepted: 08/31/2013] [Indexed: 01/12/2023] Open
Abstract
Primary myelofibrosis (PMF) is a myeloproliferative neoplasm frequently complicated by transfusion dependent anemia. Both anemia and transfusion-dependence are associated with a poor outcome, at least in part because of toxic effects of iron overload (IOL). Iron-chelating therapy (ICT) is increasingly used in order to prevent IOL in this setting. Here, we describe the case of a 73-year-old man affected by PMF and severe transfusion-dependent anemia who experienced a dramatic erythroid response after being treated with deferasirox to prevent IOL.
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Deferasirox treatment improved hematopoiesis and led to complete remission in a patient with pure red cell aplasia. Int J Hematol 2013; 98:719-22. [DOI: 10.1007/s12185-013-1455-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2013] [Revised: 09/18/2013] [Accepted: 10/16/2013] [Indexed: 01/07/2023]
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Improta S, Villa MR, Volpe A, Lombardi A, Stiuso P, Cantore N, Mastrullo L. Transfusion-dependent low-risk myelodysplastic patients receiving deferasirox: Long-term follow-up. Oncol Lett 2013; 6:1774-1778. [PMID: 24260074 PMCID: PMC3834329 DOI: 10.3892/ol.2013.1617] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2013] [Accepted: 09/20/2013] [Indexed: 11/06/2022] Open
Abstract
Myelodysplastic syndromes (MDSs) are characterized by ineffective hematopoiesis that results in peripheral cytopenias. Anemia is the most common symptom of MDS and the majority of patients become transfusion-dependent with the risk of iron overload, which may lead to cardiac, hepatic and endocrine complications. Deferasirox is an orally available iron chelator administered once-daily in transfusion-dependent patients with various chronic anemias. Its efficacy has been established in controlled clinical trials. In the present study, we describe our experience with 55 consecutive MDS patients [International Prognostic Scoring System risk score of low (n=32) or intermediate-1 (n=23)] treated with deferasirox in a routine clinical setting following Consensus Guidelines on Iron Chelation Therapy. According to WHO classifications, patients had refractory anemia (n=30), refractory anemia with ringed sideroblasts (n=16), refractory cytopenia with multilineage dysplasia (n=8) or refractory cytopenia with multilineage dysplasia and ringed sideroblasts (n=1). The median monthly transfusion requirement at baseline was 3 units. Patients received a starting dosage of 10 mg/kg/day, subsequently titrated according to serum ferritin (SF) levels which were measured monthly. Safety assessment included monitoring of liver and renal parameters and recording adverse events (AE) during treatment. At the baseline, the mean ± SD SF level was 2,362±172 ng/ml and after 24 months, the mean ± SD decrease in SF was 1,679±209 ng/ml. Sixteen patients had sustained hematological improvement meeting International Working Group 2006 criteria. One patient became transfusion-independent. No severe AE were reported. In conclusion, deferasirox therapy was effective and safe in reducing transfusional iron overload and it reduces transfusion requirement in a subset of patients.
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Affiliation(s)
- Salvatore Improta
- Hematology Division, P.O. San Gennaro ASL NA1 Centro, Naples I-80136, Italy
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Nagai H, Okazaki Y, Chew SH, Misawa N, Yasui H, Toyokuni S. Deferasirox Induces Mesenchymal–Epithelial Transition in Crocidolite-Induced Mesothelial Carcinogenesis in Rats. Cancer Prev Res (Phila) 2013; 6:1222-30. [DOI: 10.1158/1940-6207.capr-13-0244] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Abstract
Anemia leading to transfusion dependency (TD) and iron overload (IO) is commonly observed in patients with myelodysplastic syndromes (MDS). In MDS, TD and IO have been retrospectively associated with inferior survival and worse clinical outcomes, including cardiac, hepatic and endocrine dysfunction, and, in some analyses, with leukemic progression and infectious complications. Although suggested by retrospective analyses, clear prospective documentation of the beneficial effects of iron chelation therapy (ICT) on organ function and survival in MDS patients with TD and IO is currently lacking. Consequently, the role of ICT in MDS patients with TD and IO remains a very controversial aspect in the management of MDS. In this review, the authors summarize the current knowledge regarding IO in MDS and the role of ICT.
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Affiliation(s)
- Mhairi Mitchell
- School of Medicine and Dentistry, University of Aberdeen, Aberdeen, UK
| | - Steven D Gore
- The Sidney Kimmel Comprehensive Cancer Center at the Johns Hopkins University, Department of Oncology, 1650 Orleans Street, CRB1 building, Room 186, Baltimore, MD 21287, USA
| | - Amer M Zeidan
- The Sidney Kimmel Comprehensive Cancer Center at the Johns Hopkins University, Department of Oncology, 1650 Orleans Street, CRB1 building, Room 186, Baltimore, MD 21287, USA
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Lu W, Zhao M, Rajbhandary S, Xie F, Chai X, Mu J, Meng J, Liu Y, Jiang Y, Xu X, Meng A. Free iron catalyzes oxidative damage to hematopoietic cells/mesenchymal stem cells in vitro and suppresses hematopoiesis in iron overload patients. Eur J Haematol 2013; 91:249-261. [PMID: 23772810 DOI: 10.1111/ejh.12159] [Citation(s) in RCA: 70] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/12/2013] [Indexed: 12/01/2022]
Abstract
OBJECTIVES Transfusional iron overload is of major concern in hematological disease. Iron-overload-related dyserythropoiesis and reactive oxygen species (ROS)-related damage to hematopoietic stem cell (HSC) function are major setbacks in treatment for such disorders. We therefore aim to investigate the effect of iron overload on hematopoiesis in the patients and explore the role of ROS in iron-induced oxidative damage in hematopoietic cells and microenvironment in vitro. PATIENTS AND METHODS The hematopoietic colony-forming capacity and ROS level of bone marrow cells were tested before and after iron chelation therapy. In vitro, we first established an iron overload model of bone marrow mononuclear cells (BMMNC) and umbilical cord-derived mesenchymal stem cells (UC-MSC). ROS level, cell cycle, and apoptosis were measured by FACS. Function of cells was individually studied by Colony-forming cell (CFC) assay and co-culture system. Finally, ROS-related signaling pathway was also detected by Western blot. RESULTS After administering deferoxamine (DFO), reduced blood transfusion, increased neutrophil, increased platelet, and improved pancytopenia were observed in 76.9%, 46.2%, 26.9%, and 15.4% of the patients, respectively. Furthermore, the colony-forming capacity of BMMNC from iron overload patient was deficient, and ROS level was higher, which were partially recovered following iron chelation therapy. In vitro, exposure of BMMNC to ferric ammonium citrate (FAC) for 24 h decreased the ratio of CD34(+) cell from 0.91 ± 0.12% to 0.39 ± 0.07%. Excessive iron could also induce apoptosis, arrest cell cycle, and decrease function of BMMNC and UC-MSC, which was accompanied by increased ROS level and stimulated p38MAPK, p53 signaling pathway. More importantly, N-acetyl-L-cysteine (NAC) or DFO could partially attenuate cell injury and inhibit the signaling pathway induced by excessive iron. CONCLUSIONS Our study shows that iron overload injures the hematopoiesis by damaging hematopoietic cell and hematopoietic microenvironment, which is mediated by ROS-related signaling proteins.
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Affiliation(s)
- Wenyi Lu
- The First Central Clinical College of Tianjin Medical University, Tianjin First Central Hospital, Tianjin, China
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Bedford MR, Ford SJ, Horniblow RD, Iqbal TH, Tselepis C. Iron chelation in the treatment of cancer: a new role for deferasirox? J Clin Pharmacol 2013; 53:885-91. [PMID: 23740857 DOI: 10.1002/jcph.113] [Citation(s) in RCA: 56] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2013] [Accepted: 05/08/2013] [Indexed: 01/19/2023]
Abstract
Iron plays a crucial role in a number of metabolic pathways including oxygen transport, DNA synthesis, and ATP generation. Although insufficient systemic iron can result in physical impairment, excess iron has also been implicated in a number of diseases including ischemic heart disease, diabetes, and cancer. Iron chelators are agents which bind iron and facilitate its excretion. Experimental iron chelators have demonstrated potent anti-neoplastic properties in a number of cancers in vitro. These agents have yet to be translated into clinical practice, however, largely due to the significant side effects encountered in pre-clinical models. A number of licensed chelators, however, are currently in clinical use for the treatment of iron overload associated with certain non-neoplastic diseases. Deferasirox is one such agent and the drug has shown significant anti-tumor effects in a number of in vitro and in vivo studies. Deferasirox is orally administered and has demonstrated a good side effect profile in clinical practice to date. It represents an attractive agent to take forward into clinical trials of iron chelators as anti-cancer agents.
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Affiliation(s)
- Matthew R Bedford
- School of Cancer Studies, Department of Medical and Dental Sciences, University of Birmingham, Birmingham, United Kingdom
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Adams RLC, Bird RJ. Safety and efficacy of deferasirox in the management of transfusion-dependent patients with myelodysplastic syndrome and aplastic anaemia: a perspective review. Ther Adv Hematol 2013; 4:93-102. [PMID: 23610617 DOI: 10.1177/2040620712472355] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
Deferasirox is an orally administered, once-daily iron chelator with a generally good safety and efficacy profile. Reported adverse events in the older myelodysplastic population are somewhat different to the more intensively investigated and younger thalassaemic population. Renal impairment is the most concerning adverse event, but this is reversible if identified and the drug is withdrawn early. Gastrointestinal effects, particularly diarrhoea, can be troublesome for older patients, but can be minimized with tailored therapy. Negative iron balance can be achieved in most patients with a median dose of 20 mg/kg/day, and doses up to 40 mg/kg are possible in patients with severe iron overload, who are at risk of cardiac decompensation.
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Haematological improvement as a beneficial effect during deferasirox treatment in transfusion-dependent patients with myelodysplastic syndrome. BLOOD TRANSFUSION = TRASFUSIONE DEL SANGUE 2013; 12 Suppl 1:s162-3. [PMID: 23736908 DOI: 10.2450/2013.0005-13] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Subscribe] [Scholar Register] [Received: 01/07/2013] [Accepted: 02/06/2013] [Indexed: 11/21/2022]
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Lee JW, Yoon SS, Shen ZX, Ganser A, Hsu HC, El-Ali A, Habr D, Martin N, Porter JB. Hematologic responses in patients with aplastic anemia treated with deferasirox: a post hoc analysis from the EPIC study. Haematologica 2013; 98:1045-8. [PMID: 23585526 DOI: 10.3324/haematol.2012.077669] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
Reports are emerging of hematologic responses associated with iron chelation therapy; however, studies are limited in aplastic anemia patients. Deferasirox reduced iron overload in aplastic anemia patients enrolled in the EPIC (Evaluation of Patients' Iron Chelation with Exjade(®)) study (n=116). A post hoc analysis of hematologic responses was conducted on 72 patients with evaluable hematologic parameters (according to UK guideline criteria), 24 of whom received deferasirox without concomitant immunosuppressive treatment. Partial hematologic responses were observed in 11 of 24 (45.8%) patients; all became transfusion-independent. One patient had an additional platelet response and one patient had an additional platelet and hemoglobin response. Mean serum ferritin levels at end of study were significantly reduced in partial hematologic responders (n=11; -3948 ± 4998 ng/mL; baseline 6693 ± 7014 ng/mL; percentage change from baseline -45.7%; P=0.0029). In non-responders, the reduction in serum ferritin was less pronounced (n=13; -2021 ± 3242 ng/mL; baseline 4365 ± 3063 ng/mL; % change from baseline -27.6%; P=0.0171). Alongside reduction in iron overload, deferasirox may, therefore, improve hematologic parameters in a subset of aplastic anemia patients. Further investigation is required to elucidate the mechanisms involved.
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Affiliation(s)
- Jong Wook Lee
- The Catholic University of Korea, Seoul, South Korea.
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Forni GL, Podestà M, Musso M, Piaggio G, Musallam KM, Balocco M, Pozzi S, Rosa A, Frassoni F. Differential effects of the type of iron chelator on the absolute number of hematopoietic peripheral progenitors in patients with β-thalassemia major. Haematologica 2012; 98:555-9. [PMID: 23242593 DOI: 10.3324/haematol.2012.076240] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Abstract
Several studies have established an association between iron chelation therapy with deferasirox and hematopoietic improvement in patients with myelodysplastic syndromes. There are no data from patients with β-thalassemia major. In a cross-sectional study, we evaluated the absolute number of several hematopoietic peripheral progenitors (colony-forming unit-granulocyte/macrophage, erythroid burst-forming units, colony-forming unit-granulocyte/erythrocyte/macrophage/megakaryocyte, and long-term culture-initiating cells) in 30 patients with β-thalassemia major (median age 29.5 years, 40% males) and 12 age-matched controls. For the β-thalassemia major patients, data on splenectomy status, the type of iron chelator used, and serum ferritin levels reflecting changes in iron status on the chelator were also retrieved. All patients had to be using the same iron chelator for at least 6 months with >80% compliance. The absolute number of all hematopoietic peripheral progenitors was higher in β-thalassemia major patients than in controls, and varied between splenectomized and non-splenectomized patients (lower number of erythroid burst-forming units and higher numbers of colony-forming unit-granulocyte/macrophage, colony-forming unit-granulocyte/erythrocyte/macrophage/megakaryocyte, and long-term culture-initiating cells). The number of erythroid burst-forming units was significantly higher in patients taking deferasirox (n=10) than in those taking either deferoxamine (n=10) or deferiprone (n=10) (P<0.05). After adjusting for age, sex, splenectomy status, and serum ferritin changes, the association between a higher absolute number of erythroid burst-forming units in deferasirox-treated patients than in patients taking deferoxamine or deferiprone remained statistically significant (P=0.011). In conclusion, in β-thalassemia major patients, compared with other iron chelators, deferasirox therapy is associated with higher levels of circulating erythroid burst-forming units. This variation is independent of iron status changes and is more likely to be due to the type of chelator.
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Affiliation(s)
- Gian Luca Forni
- Ematologia-Centro della Microcitemia e delle Anemie Congenite, Ospedale Galliera, Genoa, Italy.
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Lee SE, Yahng SA, Cho BS, Eom KS, Kim YJ, Lee S, Min CK, Kim HJ, Cho SG, Kim DW, Min WS, Park CW, Lee JW. Improvement in hematopoiesis after iron chelation therapy with deferasirox in patients with aplastic anemia. Acta Haematol 2012; 129:72-7. [PMID: 23154600 DOI: 10.1159/000342772] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2012] [Accepted: 08/20/2012] [Indexed: 11/19/2022]
Abstract
Iron overload due to regular transfusions of packed red cells can cause multiple organ damage. Iron chelation therapy (ICT) is important in patients with aplastic anemia (AA) who require blood transfusions as supportive management. With the introduction of the oral iron chelator deferasirox, ICT has become more widely available and feasible. We studied 4 adult AA patients who had transfusion-induced iron overload and showed hematological improvement after ICT with oral deferasirox. Following deferasirox treatment, hemoglobin increased and serum ferritin levels decreased, and the patients subsequently became transfusion independent. Our experience raises the possibility of the potential benefit of ICT on hematopoiesis. Further long-term studies in larger patient cohorts are needed to clarify the effect of the restoration of hematopoiesis after iron chelation therapy.
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Affiliation(s)
- Sung-Eun Lee
- Department of Hematology, Catholic Blood and Marrow Transplantation Center, Seoul St. Mary's Hospital, College of Medicine, Catholic University of Korea, Seoul, Korea
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