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Díez-Campelo M, López-Cadenas F, Xicoy B, Lumbreras E, González T, Del Rey González M, Sánchez-García J, Coll Jordà R, Slama B, Hernández-Rivas JÁ, Thepot S, Bernal T, Guerci-Bresler A, Bargay J, Amigo ML, Preudhomme C, Fenwarth L, Platzbecker U, Götze KS, Arar A, Toribio S, Del Cañizo C, Hernández-Rivas JM, Fenaux P. Low dose lenalidomide versus placebo in non-transfusion dependent patients with low risk, del(5q) myelodysplastic syndromes (SintraREV): a randomised, double-blind, phase 3 trial. Lancet Haematol 2024; 11:e659-e670. [PMID: 39033767 DOI: 10.1016/s2352-3026(24)00142-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2024] [Revised: 05/02/2024] [Accepted: 05/05/2024] [Indexed: 07/23/2024]
Abstract
BACKGROUND Lenalidomide is the standard of care for patients who are transfusion dependent with chromosome 5q deletion (del[5q]) myelodysplastic syndromes. In the SintraREV trial, we aimed to investigate whether an early intervention of low lenalidomide doses for 2 years could delay transfusion dependency in patients with anaemia who were not transfusion dependent. METHODS This randomised, double-blind, phase 3 trial, was conducted at 22 sites (University Hospitals) in Spain, France, and Germany. Eligible patients were aged 18 years or older diagnosed with low-risk or intermediate-1-risk del(5q) myelodysplastic syndromes with non-transfusion-dependent anaemia (according to the IPSS), were erythropoietin-stimulating agents naive, and had an ECOG performance status of 2 or less. Patients were randomly assigned (2:1) by means of a telephone system to receive lenalidomide 5 mg daily in 28-day cycles versus placebo for 2 years. The primary endpoint was time to transfusion dependency based on blinded independent central review. Analysis were by intent-to-treat (ITT) and evaluable population. Safety analyses included all participants who received at least one dose of treatment. This trial is registered with ClinicalTrials.gov (NCT01243476) and EudraCT (2009-013619-36) and is complete. FINDINGS Between Feb 15, 2010, and Feb 21, 2018, 61 patients were randomly assigned to receive lenalidomide (n=40; two did not receive treatment) or placebo (n=21). The median age was 72·2 (IQR 65·4-81·9) years, 50 (82%) patients were female, and 11 (18%) were male. The median follow-up time was 60·6 (IQR 32·1-73·9) months. Regarding primary endpoint, median time to transfusion dependency was not reached (95% CI not applicable) in the lenalidomide group versus 11·6 months (95% CI 0·00-30·11) in the placebo group (p=0·0027). Lenalidomide significantly reduced the risk of transfusion dependency by 69·8% (hazard ratio 0·302, 95% CI 0·132-0·692; p=0·0046). The most frequent treatment-related adverse event was neutropenia, occurring in 24 (63%) of 38 patients in the lenalidomide group (grade 3 and 4 in 17 [45%] patients and one [3%], respectively) and in four (19%) of 21 patients in the placebo group (grade 3 in one [5%] patient). Thrombocytopenia was detected in seven (18%) of 38 patients receiving lenalidomide (grade 3 in two [5%] patients). Regarding the non-haematological toxicity, skin disorders (rash nine [23%] of 38 patients) were the most frequently described toxicities among patients receiving lenalidomide, being grade 3 in one (3%) of 38 patients. 19 serious adverse events were reported in 13 patients, 18 in the lenalidomide group and one in the placebo group, five of which were potentially related to the study drug. No treatment-related deaths were identified. INTERPRETATION An early approach with low doses of lenalidomide across two years delays the time to transfusion dependency and improves the rate and quality of the responses, with a manageable safety profile in patients who are non-transfusion dependent with del(5q) low-risk myelodysplastic syndromes. FUNDING Bristol Myers Squibb.
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Affiliation(s)
- María Díez-Campelo
- Department of Hematology, Hospital Universitario de Salamanca, Salamanca, Spain; IBSAL, Instituto de investigación Biomédica de Salamanca, Salamanca, Spain.
| | - Félix López-Cadenas
- Department of Hematology, Hospital Universitario de Salamanca, Salamanca, Spain; IBSAL, Instituto de investigación Biomédica de Salamanca, Salamanca, Spain
| | - Blanca Xicoy
- Department of Clinical Hematology, Institut Català d'Oncologia, Hospital Germans Trias i Pujol, Barcelona, Spain; Josep Carreras Leukemia Research Institute, Myeloid Neoplasm Group Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Eva Lumbreras
- IBSAL, Instituto de investigación Biomédica de Salamanca, Salamanca, Spain
| | - Teresa González
- IBSAL, Instituto de investigación Biomédica de Salamanca, Salamanca, Spain
| | | | - Joaquín Sánchez-García
- Department of Hematology, Hospital Universitario Reina Sofía, Córdoba, Spain; Instituto Maimónides de Investigación Biomédica de Córdoba (IMIBIC), Córdoba, Spain; Universidad de Córdoba, Córdoba, Spain
| | - Rosa Coll Jordà
- Department of Hematology, Hospital Josep Trueta, Institut Català d'Oncologia, Girona, Spain
| | - Bohrane Slama
- Department of Clinical Hematology, CH Avignon, Avignon, France
| | - Jose-Ángel Hernández-Rivas
- Department of Hematology, Hospital Universitario Infanta Leonor, Universidad Complutense de Madrid, Madrid, Spain
| | - Sylvain Thepot
- Department of Clinical Hematology, Angers University Hospital, Angers, France
| | - Teresa Bernal
- Department of Hematology, Hospital Universitario Central de Asturias, Oviedo, Spain
| | | | - Joan Bargay
- Department of Hematology, Hospital Universitario Son Llatzer, Palma de Mallorca, Spain; Institut d'Investigacio Illes Balears (IdISBa), Palma de Mallorca, Spain
| | - María Luz Amigo
- Department of Hematology, Hospital Universitario Jose María Morales Meseguer, Murcia, Spain
| | - Claude Preudhomme
- Cancer Heterogeneity Plasticity and Resistance to Therapies (CANTHER), UMR9020-U1277, University of Lille, Lille, France; Laboratory of Hematology, CHU Lille, Lille, France
| | - Laurene Fenwarth
- Cancer Heterogeneity Plasticity and Resistance to Therapies (CANTHER), UMR9020-U1277, University of Lille, Lille, France; Laboratory of Hematology, CHU Lille, Lille, France
| | - Uwe Platzbecker
- Department for Hematology, Cell Therapy, Hemostaseology, and Infectious Medicine, University Hospital Leipzig, Leipzig, Germany
| | - Katharina S Götze
- Department of Medicine III, Technical University of Munich, Munich, Germany
| | - Ali Arar
- Department of Hematology, CHR Orleans, Orléans, France
| | - Sofía Toribio
- IBSAL, Instituto de investigación Biomédica de Salamanca, Salamanca, Spain
| | - Consuelo Del Cañizo
- Department of Hematology, Hospital Universitario de Salamanca, Salamanca, Spain; IBSAL, Instituto de investigación Biomédica de Salamanca, Salamanca, Spain
| | - Jesús María Hernández-Rivas
- Department of Hematology, Hospital Universitario de Salamanca, Salamanca, Spain; IBSAL, Instituto de investigación Biomédica de Salamanca, Salamanca, Spain; Department of Medicine, University of Salamanca, Salamanca, Spain
| | - Pierre Fenaux
- Département (DMU) d'hématologie et immunologie, Service d'hématologie Seniors, Hôpital St Louis, Université de Paris, APHP Nord Paris, France
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Buesche G, Teoman H, Schneider RK, Ribezzo F, Ebert BL, Giagounidis A, Göhring G, Schlegelberger B, Bock O, Ganser A, Aul C, Germing U, Kreipe H. Evolution of severe (transfusion-dependent) anaemia in myelodysplastic syndromes with 5q deletion is characterized by a macrophage-associated failure of the eythropoietic niche. Br J Haematol 2022; 198:114-130. [PMID: 35362549 DOI: 10.1111/bjh.18163] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2021] [Revised: 02/16/2022] [Accepted: 03/13/2022] [Indexed: 01/01/2023]
Abstract
Evolution of erythrocyte transfusion-dependent (RBC-TD) anaemia associated with haploinsufficiency of the ribosomal protein subunit S14 gene (RPS14) is a characteristic complication of myelodysplastic syndromes (MDS) with del(5q) [MDS.del(5q)]. Evaluating 39 patients with MDS.del(5q), <5% of anaemia progression was attributable to RPS14-dependent alterations of normoblasts, pro-erythroblasts, or CD34+ CD71+ precursors. Ninety-three percent of anaemia progression and 70% of the absolute decline in peripheral blood Hb value were attributable to disappearance of erythroblastic islands (Ery-Is). Ery-Is loss occurred independently of blast excess, TP53 mutation, additional chromosome aberrations and RPS14-dependent alterations of normoblasts and pro-erythroblasts. It was associated with RPS14-dependent intrinsic (S100A8+ ) and extrinsic [tumour necrosis factor α (TNF-α)-overproduction] alterations of (CD169+ ) marrow macrophages (p < 0.00005). In a mouse model of RPS14 haploinsufficiency, Ery-Is disappeared to a similar degree: approximately 70% of Ery-Is loss was related to RPS14-dependent S100A8 overexpression of marrow macrophages, less than 20% to that of CD71high Ter119- immature precursors, and less than 5% to S100A8/p53 overexpression of normoblasts or pro-erythroblasts. Marked Ery-Is loss predicted reduced efficacy (erythrocyte transfusion independence) of lenalidomide therapy (p = 0.0006). Thus, erythroid hypoplasia, a characteristic complication of MDS.del(5q), seems to result primarily from a macrophage-associated failure of the erythropoietic niche markedly reducing the productive capacity of erythropoiesis as the leading factor in anaemia progression and evolution of RBC-TD in MDS.del(5q).
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Affiliation(s)
- Guntram Buesche
- Institute of Pathology, Hannover Medical School, Hannover, Germany
| | - Huesniye Teoman
- Institute of Pathology, Hannover Medical School, Hannover, Germany
| | - Rebekka K Schneider
- Department of Hematology, Erasmus MC Cancer Institute, Rotterdam, The Netherlands
| | - Flavia Ribezzo
- Department of Hematology, Oncology, Hemostaseology, and Stem Cell Transplantation, RWTH Aachen University, Aachen, Germany
| | - Benjamin L Ebert
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
| | - Aristoteles Giagounidis
- Department of Oncology, Hematology, and Palliative Treatment, Marien-Hospital, Düsseldorf, Germany
| | - Gudrun Göhring
- Institute of Human Genetics, Hannover Medical School, Hannover, Germany
| | | | - Oliver Bock
- Institute of Pathology, Hannover Medical School, Hannover, Germany
| | - Arnold Ganser
- Department of Hematology, Hemostasis, Oncology, and Stem Cell Transplantation, Hannover Medical School, Hannover, Germany
| | - Carlo Aul
- Department 2, Oncology and Hematology, St. Johannes Hospital, Duisburg, Germany
| | - Ulrich Germing
- Department of Hematology, Oncology and Clinical Immunology, Heinrich-Heine-University, Duesseldorf, Germany
| | - Hans Kreipe
- Institute of Pathology, Hannover Medical School, Hannover, Germany
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Magalhães SMM, Velloso EDRP, Buzzini R, Bernardo WM. Part 4: Myelodysplastic syndromes-Treatment of low-risk patients with the 5q deletion. Hematol Transfus Cell Ther 2018; 40:274-277. [PMID: 30128438 PMCID: PMC6098185 DOI: 10.1016/j.htct.2018.05.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2018] [Accepted: 05/22/2018] [Indexed: 11/17/2022] Open
Affiliation(s)
| | - Elvira Deolinda Rodrigues Pereira Velloso
- Hospital das Clinicas, Faculdade de Medicina, Universidade de São Paulo (HC FMUSP), São Paulo, SP, Brazil; Hospital Israelita Albert Einstein, São Paulo, SP, Brazil
| | - Renata Buzzini
- Associação Médica Brasileira (AMB), São Paulo, SP, Brazil
| | - Wanderley Marques Bernardo
- Hospital das Clinicas, Faculdade de Medicina, Universidade de São Paulo (HC FMUSP), São Paulo, SP, Brazil; Associação Médica Brasileira (AMB), São Paulo, SP, Brazil
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Harnan S, Ren S, Gomersall T, Everson-Hock ES, Sutton A, Dhanasiri S, Kulasekararaj A. Association between Transfusion Status and Overall Survival in Patients with Myelodysplastic Syndromes: A Systematic Literature Review and Meta-Analysis. Acta Haematol 2016; 136:23-42. [PMID: 27160308 DOI: 10.1159/000445163] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2015] [Accepted: 03/02/2016] [Indexed: 02/06/2023]
Abstract
INTRODUCTION Multiple studies show that transfusion independence (TI) in myelodysplastic syndrome (MDS) has a positive impact on overall survival (OS). To assess this, a systematic review and meta-analysis of the association between TI and OS in patients with MDS was conducted (PROSPERO ID: CRD42014007264). METHODS Comprehensive searches of 5 key bibliographic databases were conducted and supplemented with additional search techniques. Included were studies that had recruited adults aged >18 years with MDS and had examined the impact of transfusion status on OS. RESULTS Fifty-five studies (89 citations) were included. The vast majority reported a statistically significant hazard ratio (HR) for OS in favor of TI patients or in patients who acquired TI after treatment. A random-effects meta-analysis was conducted. Patients classed as TI at baseline showed a 59% decrease in the risk of death compared with transfusion-dependent (TD) patients [HR 0.41; 95% credible interval (CrI) 0.29-0.56], and this effect did not appear to interact significantly with illness severity (interaction coefficient HR 1.38; 95% CrI 0.62-3.41). A meta-analysis of studies where patients acquired TI was not possible, but those studies consistently reported a survival benefit for those who acquired TI. CONCLUSION The findings revealed a 59% pooled reduction in mortality among TI patients when compared with TD patients.
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Affiliation(s)
- Sue Harnan
- Health Economics and Decision Science, School of Health and Related Research, University of Sheffield, Sheffield, UK
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